Predictors of postoperative mortality of ruptured abdominal aortic aneurysm: a retrospective clinical study

[Diagnosis and Management of Perioperative Myocardial Ischemia after Elective Aortic Aneurysm Surgery]

INTRODUCTION

Perioperative myocardial ischemia (PMI) is a serious postoperative complication. Aortic operations represent an especially high-risk surgery concerning cardiac complications. This aim of this study was to analyse the clinical features of PMI after elective aortic aneurysm surgery.

PATIENTS AND METHODS

This study is a retrospective analysis of 863 patients who underwent elective aortic aneurysm surgery between 2005 and 2012 in the Department of Vascular and Endovascular Surgery of Heidelberg University Hospital with regard to PMI. The PMI diagnosis was based on a positive serum troponin diagnostic test. We evaluated the clinical course, time point of the diagnosis and features of diagnostics to characterise PMI. Moreover, we analysed the treatment options and management of the patients' discharge.

RESULTS

Thirty-one patients (3.6% of 863) with PMI after elective aortic aneurysm surgery were identified. Of these, 21 patients (67.7%) underwent open surgery and 10 patients (32.3%) received endovascular treatment. PMI was diagnosed in 24 patients (77%) during the first 3 days. More than half of these patients (16/31) were clinically asymptomatic. Electrocardiogram did not show pathological findings in 24 cases (77.4%). The first troponin measurement was not elevated in eight patients (25.8%). Drug therapy alone was used in 17 cases (54.8%) of PMI, coronary catheterisation was performed in 12 patients (38.7%) and two patients (6.5%) received aortocoronary bypass. Fourteen patients (45.1%) were discharged home and another 14 patients (44.1%) were transferred to another hospital or to a rehabilitation institution. Two patients died because of multi-organ failure.

CONCLUSION

PMI is not a rare complication after elective aortic surgery. The diagnosis of PMI can be challenging because of occult symptoms especially in a perioperative setting. Due to the potentially serious consequences, cardiac enzyme diagnostics should be initiated immediately if there is suspicion of PMI or routinely in defined at-risk patients after aortic surgery.

Intraoperative Predictors and Proposal for a Novel Prognostic Risk Score for In-Hospital Mortality after Open Repair of Ruptured Abdominal Aortic Aneurysms (SPARTAN Score)

(1) Background: Several mortality risk scores have been developed to predict mortality in ruptured abdominal aortic aneurysms (rAAAs), but none focused on intraoperative factors. The aim of this study is to identify intraoperative variables affecting in-hospital mortality after open repair and develop a novel prognostic risk score. (2) Methods: The analysis of a retrospectively maintained dataset identified patients who underwent open repair for rAAA from January 2007 to October 2023 in three Italian tertiary referral centers. Multinomial logistic regression was used to calculate the association between intraoperative variables and perioperative mortality. Independent intraoperative factors were used to create a prognostic score. (3) Results: In total, 316 patients with a mean age of 77.3 (SD ± 8.5) were included. In-hospital mortality rate was 30.7%. Hemoperitoneum (p < 0.001), suprarenal clamping (p = 0.001), and operation times of >240 min (p = 0.008) were negative predictors of perioperative mortality, while the patency of at least one hypogastric artery had a protective role (p = 0.008). Numerical values were assigned to each variable based on the respective odds ratio to create a risk stratification for in-hospital mortality. (4) Conclusions: rAAA represents a major cause of mortality. Intraoperative variables are essential to estimate patients' risk in surgically treated patients. A prognostic risk score based on these factors alone may be useful to predict in-hospital mortality after open repair.

Relationship between intraoperative dopamine infusion and postoperative acute kidney injury in patients undergoing open abdominal aorta aneurysm repair

Background

Acute kidney injury (AKI) is one of the most common complications in patients undergoing open abdominal aortic aneurysm (AAA) repair. Dopamine has been frequently used in these patients to prevent AKI. We aimed to clarify the relationship between intraoperative dopamine infusion and postoperative AKI in patients undergoing open AAA repair.

Methods

We analyzed 294 patients who underwent open AAA repair at a single tertiary center from 2009 to 2018, retrospectively. The primary outcome was the incidence of postoperative AKI, determined by the Kidney Disease Improving Global Outcomes definition, after open AAA repair. Secondary outcomes included survival outcome, hospital and intensive care unit length of stay, and postoperative renal replacement therapy (RRT).

Results

Postoperative AKI occurred in 21.8% (64 out of 294 patients) The risk of postoperative AKI by intraoperative dopamine infusion was greater after adjusting for risk factors (odds ratio [OR] 2.56; 95% confidence interval [CI], 1.09–5.89; P = 0.028) and after propensity score matching (OR 3.22; 95% CI 1.12–9.24; P = 0.030). On the contrary, intraoperative norepinephrine use was not associated with postoperative AKI (use vs. no use; 19.3 vs. 22.4%; P = 0.615). Patients who used dopamine showed higher requirement for postoperative RRT (6.8 vs. 1.2%; P = 0.045) and longer hospital length of stay (18 vs. 16 days, P = 0.024).

Conclusions

Intraoperative dopamine infusion was associated with more frequent postoperative AKI, postoperative RRT, and longer hospital length of stay in patients undergoing AAA repair, when compared to norepinephrine. Further prospective randomized clinical trial may be necessary for this topic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01624-6.

Systematic review of plasma/packed red blood cell ratio on survival in ruptured abdominal aortic aneurysms

BACKGROUND

The ideal perioperative fluid resuscitation for patients with ruptured abdominal aortic aneurysms (rAAAs) is unknown. It has been shown in trauma studies that a higher ratio of plasma and platelets to packed red blood cells confers a mortality benefit. Controversy remains whether this is true also in the rAAA population. The objective of the present study was to investigate the benefit of a greater ratio of plasma/packed red blood cells in patients with rAAAs.

METHODS

A health sciences librarian searched four electronic databases, including PubMed, Embase, Cochrane, and ClinicalTrials.gov, using concepts for the terms "fluid resuscitation," "survival," and "ruptured abdominal aortic aneurysm." Two reviewers independently screened the studies that were identified through the search strategy and read in full any study that was potentially relevant. Studies were included if they had compared the mortality of patients with rAAAs who had received a greater ratio of plasma to other component therapy with that of patients who had received a lower ratio. The risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions) validated tool, and evidence quality was rated using the GRADE (grades of recommendation assessment, development, and evaluation) profile. No data synthesis or meta-analysis was planned or performed, given the anticipated paucity of research on this topic and the high degree of heterogeneity of available studies.

RESULTS

Our search identified seven observational studies for inclusion in the present review. Of these seven studies, three found an associated decrease in mortality with a greater ratio of plasma to packed red blood cells. The remaining four found no significant differences. The overall risk of bias was serious, and the evidence quality was very low.

CONCLUSIONS

Overall, the findings from the available studies would suggest that for patients who have undergone open surgery for a rAAA, mortality tends to be decreased when the amount of plasma transfused perioperatively is similar to the amount of packed red blood cells. However, the included studies reported very low-quality evidence based solely on highly heterogeneous observational studies, and further research is warranted.

Open Surgery for Ruptured Abdominal Aortic Aneurysm - 38 Years Experience at an Academic Center in Chile

BACKGROUND

Few series of ruptured abdominal aortic aneurysm (RAAA) from Latin America have been published.

OBJECTIVES

To report the outcomes of RAAA treated with open surgical repair (OSR) in a University Hospital in Chile. Secondary objectives are the identification of prognostic factors and survival rates.

METHODS

Retrospective review of consecutive RAAA patients treated with OSR between September 1979 and December 2017. Medical records, diagnostic images, and follow-up details were obtained. Statistical methods include multiple logistic regression analysis.

RESULTS

One hundred and sixteen patients underwent OSR for RAAA. The average age was 72.3 years (54-95), 62.9% ≥ 70 years, and 81.9% male. Preoperative systolic pressure <90 mm Hg was present in 74 patients (63.8%), and 10 (8.6%) experienced cardiac arrest before surgery. Only 30.2% were known to have an AAA before rupture. The mean aortic diameter was 7.9 cm. Sixteen patients had juxtarenal aneurysms (13.8%). The rupture was intra or retroperitoneal in 111 cases (95.7%), there were 4 fistulas to neighboring veins and one into the duodenum. Reconstruction included tubular graft in 39.7% and bifurcated in 58.6%. The estimated mean blood loss was 3,456 ± 2,768 mL (median 3,000). Mean mechanical ventilation was 7.4 ± 12.0 days and hemodialysis requirement in 21.8%. Six patients died during surgery and other 24 during the first postoperative month or in hospital, for an overall mortality rate of 25.9%. Age ≥70 years (P < 0.01), blood pressure less than 90 mm Hg (P = 0.03) and dialysis (P < 0.01) were associated with higher 30-day mortality rates. The survival rate was 68.0, 65.3, 44.3, and 25.2% at 1, 2, 5, and 10 years, respectively.

CONCLUSIONS

EVAR for RAAA is not affordable in every country. Outcomes of open RAAA repair at our institution are similar to results reported recently for OSR by the USA and European Medical centers.

Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair

OBJECTIVE

Outcomes after repair of ruptured abdominal aortic aneurysm (RAAA) have improved in the last decade. It is unknown whether this has resulted in a reduction of postoperative bowel ischemia (BI). The primary objective was to determine BI prevalence after RAAA repair. Secondary objectives were to determine its major sequelae and differences between open repair (OR) and endovascular aneurysm repair (EVAR).

METHODS

This systematic review (PROSPERO CRD42017055920) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. MEDLINE and Embase were searched for studies published from 2005 until 2018. The methodologic quality of observational studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) tool. The quality of the randomized controlled trials (RCTs) was assessed with the Cochrane Collaboration's tool for assessing risk of bias. BI prevalence and rates of BI as cause of death, reoperation, and bowel resection were estimated with meta-analyses with a random-effects model. Differences between OR and EVAR were estimated with pooled risk ratios with 95% confidence intervals (CIs). Changes over time were assessed with Spearman rank test (ρ). Publication bias was assessed with a funnel plot analysis.

RESULTS

A total of 101 studies with 52,670 patients were included; 72 studies were retrospective cohort studies, 14 studies were prospective cohort studies, 12 studies were retrospective administrative database studies, and 3 studies were RCTs. The overall methodologic quality of the RCTs was high, but that of observational studies was low. The pooled prevalence of BI ranged from of 0.08 (95% CI, 0.07-0.09) in database studies to 0.10 (95% CI, 0.08-0.12) in cohort studies. The risk of BI was higher after OR than after EVAR (risk ratio, 1.79; 95% CI, 1.25-2.57). The pooled rate of BI as cause of death was 0.04 (95% CI, 0.03-0.05), and that of BI as cause of reoperation and bowel resection ranged between 0.05 and 0.07. BI prevalence did not change over time (ρ, -0.01; P = .93). The funnel plot analysis was highly suggestive of publication bias.

CONCLUSIONS

The prevalence of clinically relevant BI after RAAA repair is approximately 10%. Approximately 5% of patients undergoing RAAA repair suffer from severe consequences of BI. BI is less prevalent after EVAR than after OR.

Application of Clinical Intelligence to Streamline Care in Aortic Emergencies

This article discusses the lessons learned by an interdisciplinary team in a large metropolitan specialty hospital during the implementation of the Code Aorta protocol for aortic emergencies and the subsequent application of technological enhancements to improve data transfer. Aortic dissections require rapid diagnosis and surgical treatment; thus, in order to optimize patient outcomes, clinicians must be accessible, data must be readily available, and proper prompts and notifications must be made to alert and ready teams. An interdisciplinary team reviewed our hospital's processes and architecture of systems to define how we provide care during aortic emergencies. Based on this insight into patient flow, we ultimately developed a Code Aorta protocol to streamline provision of care during aortic emergencies. This process focused on protocol development, human-technology interfaces, and outcome-oriented metrics. The team also aimed to heighten awareness of the emergent process and to understand relevant outcomes data. After introduction of the Code Aorta protocol, a 78% reduction was achieved in time-to-treatment from the previous year's average time. In addition, the average length of stay was reduced by 2.4 days (18%). The team's efforts focused on clinical communication, aiming to link technology to maximize clinical efficiency. The initial results of our Code Aorta protocol show promise that continual refinement of patient care processes during aortic emergencies will improve outcomes for patients suffering aortic dissection.

The beneficial place for the treatment of ruptured abdominal aortic aneurysms

OBJECTIVE

To study the beneficial place for the treatment of ruptured abdominal aortic aneurysms (RAAAs).

METHOD

A retrospective chart review of consecutive RAAA patients was performed. Patients were divided into two groups: direct group and transfer group. We retrospectively reviewed patients' hospital charts and recorded various clinical factors apparent on presentation. The primary consequence was mortality during hospitalization, and some other parameters such as duration of intensive care unit (ICU). All patients were followed up at 1 month, 3 months, 6 months and one year after discharge.

RESULTS

During 4-year period, 56 RAAA patients were treated (24 in direct group, and 32 in transfer group). Significant differences were shown for systolic blood pressure, pulse oxygen saturation, hemoglobin, the time interval from diagnosis to operation et al. There was no difference concerning age and comorbidity among two groups. All the patients were treated by open surgical aneurysm repair. The mortality rate was 68.8% ((6 + 16)/32) in transfer group and 33.3% (8/24) in direct group (P = 0.00067). Both the duration of ICU stay and entire hospitalization were a bit longer in the transfer group, but there was no significant difference. The mean follow-up time was 25.2 ± 12.9 months. The cumulative survival difference was significant (P = 0.042) between the two groups.

CONCLUSION

It is beneficial that we treat RAAAs in the diagnosed hospital. The reasons are: 1) to avoid the development of unstable state of aneurysm after rupturing of stable state; 2) the time interval from initial symptoms to operation will be shortened.

Ruptured Abdominal Aortic Aneurysm: Prediction of Mortality From Clinical Presentation and Glasgow Aneurysm Score

OBJECTIVE

To examine association of presenting clinical acuity and Glasgow Aneurysm Score (GAS) with perioperative and 1-year mortality.

DESIGN

Retrospective chart review.

SETTING

Major tertiary care facility.

PARTICIPANTS

Patients with ruptured abdominal aortic aneurysm (rAAA) from 2003 through 2013.

INTERVENTIONS

Emergency repair of rAAA.

MEASUREMENTS AND MAIN RESULTS

The authors reviewed outcomes after stable versus unstable presentation and by GAS. Unstable presentation included hypotension, cardiac arrest, loss of consciousness, and preoperative tracheal intubation. In total, 125 patients (40 stable) underwent repair. Perioperative mortality rates were 41% and 12% in unstable and stable patients, respectively (p<0.001). Unstable status had 88% sensitivity and 41% specificity for predicting perioperative mortality. Using logistic regression, higher GAS was associated with perioperative mortality (p<0.001). Using receiver operating characteristic analysis, the area under the curve was 0.72 (95% CI, 0.62-0.82) and cutoff GAS≥96 had 63% and 72% sensitivity and specificity, respectively. Perioperative mortality for GAS≥96 was 51% (25/49), whereas it was 20% (15/76) for GAS≤95. The estimated 1-year survival (95% CI) was 75% (62%-91%) for stable patients and 48% (38%-60%) for unstable patients. Estimated 1-year survival (95% CI) was 23% (13%-40%) for GAS≥96 and 77% (67%-87%) for GAS≤95.

CONCLUSIONS

Clinical presentation and GAS identified patients with rAAA who were likely to have a poor surgical outcome. GAS≥96 was associated with poor long-term survival, but>20% of these patients survived 1 year. Thus, neither clinical presentation nor GAS provided reliable guidance for decisions regarding futility of surgery.