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Deaths from ruptured abdominal aortic aneurysm in Wales
Abstract
The aim was to determine the true incidence and operative mortality rate of patients with ruptured abdominal aortic aneurysm (AAA) who reach hospital alive in Wales.
Patients presenting with a ruptured AAA between September 1996 and August 1997 were analysed. The data were collected prospectively by an independent body, observing strict confidentiality.
Two hundred and thirty-three patients with confirmed ruptured AAA were identified. One hundred and thirty-three patients (57 per cent) underwent attempted operative repair. Eighty-five (64 per cent) died within 30 days. All 100 patients who received no operation died. Of the 233 patients, 92 were admitted under vascular surgeons (VSs) and 141 under non-vascular surgeons (NVSs). VSs operated on 82 patients (89 per cent) of whom 50 (61 per cent) died; NVSs operated on 51 (36 per cent) of whom 35 (69 per cent) died.
This study is the only independent prospective study of death among patients with ruptured AAA who reached hospital alive. Some 57 per cent of the patients with a ruptured AAA were operated on. The operative mortality rate was 64 per cent and the overall mortality rate was 79 per cent. VSs were significantly more aggressive (89 per cent) in the management of ruptured AAA (i.e. more likely to operate) than NVSs (36 per cent) (P < 0·0001). Despite this, the operative mortality rate for VSs was 61 per cent, whereas for NVSs it was 69 per cent (P = 0·372). The overall mortality rate (including operated and non-operated patients) for NVSs (89 per cent) was significantly higher than that for VSs (65 per cent) (P < 0·0001). In Conclusion, ruptured AAA is common in Wales and associated with a high mortality rate even when managed by VSs. © 1999 British Journal of Surgery Society Ltd
... Fixed risk factors include advancing age, with risk increasing by 40% every 5 years after the age of 65 years, being male (male to female ratio, 6:1) and having a positive family history, notably first degree male family members. Modifiable risk factors include smoking, hypertension and hypercholesterolaemia (Basnyat et al. 1999). Approximately 2–20% of AAAs are classified as juxtarenal (JR) if their proximal extent is close to the origin of the renal arteries but does not involve them (Crawford et al. 1986). ...
... The natural history of AAAs is gradual expansion, with spontaneous rupture accounting for ß8,000 deaths per year in the UK (Thompson, 2003) and 15,000 in the USA (Gillum, 1995). Surgical or endovascular intervention is recommended for all symptomatic and asymptomatic AAAs >55 mm in diameter, with the mortality rate for elective repair <5% compared with 65–85% for rupture (Basnyat et al. 1999). The majority of open IR AAA repairs can be treated safely by IR clamping, whereas JR AAA repair for more technically challenging lesions in patients with short or absent aortic necks can be achieved only by clamping at the suprarenal (SR) or supracoeliac (SC) levels to enable optimal anastomosing of the graft. ...
... Fixed risk factors include advancing age, with risk increasing by 40% every 5 years after the age of 65 years, being male (male to female ratio, 6:1) and having a positive family history, notably first degree male family members. Modifiable risk factors include smoking, hypertension and hypercholesterolaemia ( Basnyat et al. 1999). Approximately 2-20% of AAAs are classified as juxtarenal (JR) if their proximal extent is close to the origin of the renal arteries but does not involve them ( Crawford et al. 1986). ...
New Findings
What is the central question of this study?
To what extent focal abdominal aortic aneurysmal (AAA) disease is associated with systemic remodelling of the vascular tree remains unknown. The present study examined whether anatomical differences exist between distances of the intervisceral artery origins and AAA location/size in patients with disease compared with healthy patients.
What is the main finding and its importance?
Intervisceral artery distances were shown to be consistently greater in AAA patients, highlighting the systemic nature of AAA disease that extends proximally to the abdominal aorta and its branches. The anatomical description of the natural variation in visceral artery origins has implications for the design of stent grafts and planning complex open aortic surgery.
The initial histopathology of abdominal aortic aneurysmal (AAA) disease is atherosclerotic, later diverting towards a distinctive dilating rather than occlusive aortic phenotype. To what extent focal AAA disease is associated with systemic remodelling of the vascular tree remains unknown. The present study examined whether anatomical differences exist between the intervisceral artery origins and AAA location/size in patients with AAA disease (AAA+) relative to those without (AAA−). Preoperative contrast‐enhanced computerized tomograms were reviewed in 90 consecutive AAA+ patients scheduled for open repair who underwent an infrarenal ( n = 45), suprarenal ( n = 26) or supracoeliac clamp ( n = 19). These were compared with 39 age‐matched AAA− control patients. Craniocaudal measurements were recorded from the distal origin of the coeliac artery to the superior mesenteric artery and from the origin of the superior mesenteric artery to both renal artery origins. Serial blood samples were obtained for estimation of the glomerular filtration rate before and after surgery. Intervisceral artery origins were shown to be consistently greater in AAA+ patients ( P < 0.05 versus AAA−), although unrelated to AAA diameter ( P > 0.05). Postoperative renal function became progressively more impaired the more proximal the clamp placement (estimated glomerular filtration rate for supracoeliac < suprarenal < infrarenal clamps, P < 0.05). These findings highlight the systemic nature of AAA disease that extends proximally to the abdominal aorta and its branches. The anatomical description of the natural variation in visceral artery origins has implications for the design of stent grafts and planning complex open aortic surgery.
... The operative mortality rate overlooks the actual hospital mortality and does not reflect the vascular service of the area. The proportion of RAAA patients who arrive alive at the hospital, but who are considered unfit for surgery, varied from 7–43% (weighted mean 24%) in numerious series (Table 4) (Hardman et al. 1996, Bradbury et al. 1997, Basnyat et al. 1999, Evans et al. 2000, Kantonen et al. 1999b, Noel et al. 2001, Heikkinen et al. 2002, Neary et al. 2003, Dueck et al. 2004a, Tambyraja et al. 2005d). In the Finnvasc study Kantonen et al. found huge variations in the selection criteria between hospitals in Finland, resulting in the exclusion of 12–63% RAAA patients from emergency repair (Kantonen et al. 1999b) The weighted mean operative mortality rate for RAAA was 42% (range 29–64%) in the recent studies (Table 4) (Chen et al. 1996, Hardman et al. 1996, Rutledge et al. 1996, Bradbury et al. 1997, Koskas and Kieffer 1997, Dardik et al. 1998, van Dongen et al. 1998, Basnyat et al. 1999, Kantonen et al. 1999b, Sasaki et al. 1999, Evans et al. 2000, Noel et al. 2001, Heikkinen et al. 2002, Neary et al. 2003, Roddy et al. 2003, Dueck et al. 2004a, Stenbaek et al. 2004, Davidovic et al. 2005, Hadjianastassiou et al. 2005, Tambyraja et al. 2005d, Visser et al. 2005, Rigberg et al. 2006). ...
... The proportion of RAAA patients who arrive alive at the hospital, but who are considered unfit for surgery, varied from 7–43% (weighted mean 24%) in numerious series (Table 4) (Hardman et al. 1996, Bradbury et al. 1997, Basnyat et al. 1999, Evans et al. 2000, Kantonen et al. 1999b, Noel et al. 2001, Heikkinen et al. 2002, Neary et al. 2003, Dueck et al. 2004a, Tambyraja et al. 2005d). In the Finnvasc study Kantonen et al. found huge variations in the selection criteria between hospitals in Finland, resulting in the exclusion of 12–63% RAAA patients from emergency repair (Kantonen et al. 1999b) The weighted mean operative mortality rate for RAAA was 42% (range 29–64%) in the recent studies (Table 4) (Chen et al. 1996, Hardman et al. 1996, Rutledge et al. 1996, Bradbury et al. 1997, Koskas and Kieffer 1997, Dardik et al. 1998, van Dongen et al. 1998, Basnyat et al. 1999, Kantonen et al. 1999b, Sasaki et al. 1999, Evans et al. 2000, Noel et al. 2001, Heikkinen et al. 2002, Neary et al. 2003, Roddy et al. 2003, Dueck et al. 2004a, Stenbaek et al. 2004, Davidovic et al. 2005, Hadjianastassiou et al. 2005, Tambyraja et al. 2005d, Visser et al. 2005, Rigberg et al. 2006). Interestingly, the total weighted mean mortality rates of 30-day operative and operative hospital mortality did not differ, but this was due to the fact that the mortality rates were collected from different publications. ...
... Some studies have shown that hospital volume has no effect on mortality, but that high-volume surgeons or vascular surgeons had better outcome rates than general surgeons (Ouriel et al. 1990, Dardik et al. 1998, Dueck et al. 2004c). Basnyat et al. (1999) found operative mortality to be similar between vascular surgeons and non-vascular surgeons, but vascular surgeons turned down significantly fewer patients. In Finland high-volume hospitals (>15 elective AAA procedures per year) had lower overall hospital mortality than low-volume hospitals, indicating that more RAAA patients were defin ...
Ruptured abdominal aortic aneurysm (RAAA) is a life-threatening event, and without operative treatment the patient will die. The overall mortality can be as high as 80-90%; thus repair of RAAA should be attempted whenever feasible. The quality of life (QoL) has become an increasingly important outcome measure in vascular surgery. Aim of the study was to evaluate outcomes of RAAA and to find out predictors of mortality. In Helsinki and Uusimaa district 626 patients were identified to have RAAA in 1996-2004. Altogether 352 of them were admitted to Helsinki University Central Hospital (HUCH). Based on Finnvasc Registry, 836 RAAA patients underwent repair of RAAA in 1991-1999. The 30-day operative mortality, hospital and population-based mortality were assessed, and the effect of regional centralisation and improving in-hospital quality on the outcome of RAAA. QoL was evaluated by a RAND-36 questionnaire of survivors of RAAA. Quality-adjusted life years (QALYs), which measure length and QoL, were calculated using the EQ-5D index and estimation of life expectancy. The predictors of outcome after RAAA were assessed at admission and 48 hours after repair of RAAA. The 30-day operative mortality rate was 38% in HUCH and 44% nationwide, whereas the hospital mortality was 45% in HUCH. Population-based mortality was 69% in 1996-2004 and 56% in 2003-2004. After organisational changes were undertaken, the mortality decreased significantly at all levels. Among the survivors, the QoL was almost equal when compared with norms of age- and sex-matched controls; only physical functioning was slightly impaired. Successful repair of RAAA gave a mean of 4.1 (0-30.9) QALYs for all RAAA patients, although non-survivors were included. The preoperative Glasgow Aneurysm Score was an independent predictor of 30-day operative mortality after RAAA, and it also predicted the outcome at 48- hours for initial survivors of repair of RAAA. A high Glasgow Aneurysm Score and high age were associated with low numbers of QALYs to be achieved. Organ dysfunction measured by the Sequential Organ Failure Assessment (SOFA) score at 48 hours after repair of RAAA was the strongest predictor of death. In conclusion surgery of RAAA is a life-saving and cost-effective procedure. The centralisation of vascular emergencies improved the outcome of RAAA patients. The survivors had a good QoL after RAAA. Predictive models can be used on individual level only to provide supplementary information for clinical decision-making due to their moderate discriminatory value. These results support an active operation policy, as there is no reliable measure to predict the outcome after RAAA. Revenneen vatsa-aortan pullistuman leikkaushoito pelastaa ihmishenkiä, on kustannustehokasta eikä huononna elämänlaatua Vatsa-aortan pullistuman repeämä (ruptured abdominal aortic aneurysm = RAAA) on välittömästi henkeä uhkaava kirurginen hätätilanne. Potilaan hengen voi pelastaa vaativa leikkaus ja sitä seuraava onnistunut tehohoito. Vatsa-aortan pullistuma on yleinen sairaus, miehillä se aiheuttaa jopa 2% kaikista kuolemista teollistuneissa maissa. Repeämä on usein ensimmäinen oire pullistumasta. Helsingin ja Uudenmaan sairaanhoitopiirissä vuosittain noin 70 potilaalla todetaan RAAA (ilmaantuvuus 5,4/100 000 henkilöä/vuosi). Noin kolmannes näistä potilaista kuolee heti ja noin puolet ehtii sairaalaan. RAAA -potilaat ovat yleensä iäkkäitä ja hoidon mielekkyyttä on arvosteltu, etenkin kun elämänlaatua ja laatupainotettuja elinvuosia RAAA hoidon jälkeen ei ole Suomessa aiemmin mitattu. Tutkimuksessa RAAA-potilaiden keski-ikä oli 71 vuotta (vaihteluväli 43-94 vuotta). Tutkimuksessa todettiin, että toivuttuaan vaikeasta leikkauksesta ja usein pitkästä sairaalahoidosta potilaiden elämänlaatu on lähes yhtä hyvä kuin suomalaisessa ikä- ja sukupuolivakioidussa väestössä. Laatupainotettujen elinvuosien määrän avulla voitiin laskea kustannustehokkuus, ja todettiin, että leikkaushoito on kustannustehokasta myös yli 80-vuotiailla. Hoidon lopputulosta pyrittiin ennustamaan erilaisten menetelmien avulla hoidon eri vaiheissa, kuten päivystyspoliklinikalla ennen leikkausta (Glasgow Aneurysm Score) tai teho-osastolla 48 tuntia leikkauksen jälkeen (Sequential Organ Failure Assessment). Menetelmät ennustavat elossa säilymistä ja antavat näin hoitaville lääkäreille lisäinformaatiota päätöksentekoon. Helsingin ja Uudenmaan sairaanhoitopiirissä verisuonikirurgiset hätätilanteet on keskitetty Meilahden sairaalaan ja tämä on parantanut RAAA-potilaiden ennustetta tehohoidon ja päivystysjärjestelmän tehostamisen ohella. Kuolleisuus on laskenut merkitsevästi sairaala- ja väestötasolla organisatoristen muutosten jälkeen. Sairaalakuolleisuus oli 45% ja kuolleisuus väestötasolla 69% vuosina 1996-2004. Vuosina 2003-2004 sairaalakuolleisuus oli 28% ja väestötasolla 56%. Leikkaushoito on ainoa mahdollisuus pelastaa RAAA-potilaan henki. RAAA-potilaiden hoidon lopputuloksen ennustamiseen ei ole luotettavia menetelmiä yksilötasolla, joten leikkaushoitoa tulee tarjota alkuvaiheessa lähes kaikille RAAA-potilaille. Hoidon keskittämisellä on saatu hyviä tuloksia aikaan ja leikkaus on todettu kustannustehokkaaksi myös iäkkäillä.
... Rupture of aortic aneurysms is the 16t h leading cause of adult death in the Unites States and accounts for more than 10,000 deaths in the USA annually [2]. AAA rupture risk increases with increasing aortic diameter and this catastrophic event is associated with a mortality of 50 to 80% [3] [4] [5]. The most important risk factors for the development of a AAA are smoking, advanced age, male sex and a family history of AAA [6] [7] [8] [9] [10]. ...
Abdominal aortic aneurysm (AAA) is a complex, multifactorial disease with a strong genetic component. About 20% of AAA patients have at least one relative with this condition. Since the first candidate gene studies were published 20 years ago, nearly 100 genetic association studies using single nucleotide polymorphisms (SNPs) in biologically relevant genes have been reported on AAA. The most significant results from candidate gene studies are for sortilin-1 (SORT1), interleukin 6 receptor (IL6R), and apolipoprotein(a) (LPA). Unbiased genome-wide approaches such as family-based DNA linkage studies and genome-wide association studies have been carried out by international consortia to identify susceptibility loci for AAA. The chromosomal regions in the human genome with the strongest supporting evidence of contribution to the genetic risk for AAA are: 1) CDKN2BAS gene (located on chromosome 9p21), also known as ANRIL, which encodes an antisense RNA that regulates expression of the cyclin-dependent kinase inhibitors CDKN2A and CDKN2B; 2) DAB2 interacting protein (DAB2IP; located on chromosome 9q33), which encodes an inhibitor of cell growth and survival; 3) low density lipoprotein receptor-related protein 1 (LRP1; located on chromosome 12q13.3), a plasma membrane receptor involved in vascular smooth muscle and macrophage endocytosis, 4) low density lipoprotein receptor (LDLR; located on chromosome 19p13.2), and 5) contactin-3 (CNTN3; located on chromosome 3p12.3), which demonstrated the strongest association in smokers and yet its function remains unclear. These five loci were identified in genome-wide association studies. Using a different approach, DNA linkage analysis with affected relative-pairs, two additional loci containing several plausible candidate genes, located on chromosomes 4q31 and 19q13, were discovered. On-going and future studies to find additional risk loci include large meta-analyses and whole genome sequencing. Furthermore, functional studies are needed to establish the mechanisms by which these genes contribute to AAA pathogenesis. In the long-term, these discoveries will result in important translational applications to the prevention, diagnosis and management of AAAs.
... AAA rupture risk increases with increasing aortic diameter and this catastrophic event is associated with a mortality of 50% to 80%. [2][3][4] Due to the excessive mortality associated with emergent repair, the mainstay of AAA management is early diagnosis and elective repair prior to rupture. The traditional open surgical repair involves a large incision in the abdomen and exclusion/replacement of the aneurysm with a synthetic fabric graft. ...
The introduction of endovascular abdominal aortic aneurysm (AAA) repair has revolutionized the therapeutic approach to patients with AAA. Due to an on-going and prolific collaboration between vascular interventionalists and biomedical engineers, the devices used to perform endovascular AAA repair have also changed dramatically. The purpose of this publication is to provide an overview of the currently available and upcoming options for endovascular AAA repair.
... AAA prevalence increases with age, and even though the incidence has declined in the past ten years [14], rupture of AAA is still a significant cause of death with 10– 15% of AAAs presenting as ruptured AAAs (rAAA) in the emergency room. AAA rupture risk increases with increasing aortic diameter and this catastrophic event is associated with a mortality of 50 to 80%151617. Due to the excessive mortality associated with emergent repair, the mainstay of AAA management is early diagnosis and elective repair prior to rupture. In an effort to reduce the number of AAArelated deaths, the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act was approved by the United States Congress in January 2007. ...
An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta with a diameter of at least 3.0 cm. AAAs are often asymptomatic and are discovered as incidental findings in imaging studies or when the AAA ruptures leading to a medical emergency. AAAs are more common in males than females, in individuals of European ancestry, and in those over 65 years of age. Smoking is the most important environmental risk factor. In addition, a positive family history of AAA increases the person's risk for AAA. Interestingly, diabetes has been shown to be a protective factor for AAA in many large studies. Hallmarks of AAA pathogenesis include inflammation, vascular smooth muscle cell apoptosis, extracellular matrix degradation, and oxidative stress. Autoimmunity may also play a role in AAA development and progression. In this Outlook paper, we summarize our recent studies on AAA including clinical studies related to surgical repair of AAA and genetic risk factor and large-scale gene expression studies. We conclude with a discussion on our research projects using large data sets available through electronic medical records and biobanks.
... Rupture of aortic aneurysms is the 16t h leading cause of adult death in the Unites States and accounts for more than 10,000 deaths in the USA annually [2]. AAA rupture risk increases with increasing aortic diameter and this catastrophic event is associated with a mortality of 50 to 80% [3] [4] [5]. The most important risk factors for the development of a AAA are smoking, advanced age, male sex and a family history of AAA [6] [7] [8] [9] [10]. ...
... Rupture of aortic aneurysms is the 16t h leading cause of adult death in the Unites States and accounts for more than 10,000 deaths in the USA annually [2]. AAA rupture risk increases with increasing aortic diameter and this catastrophic event is associated with a mortality of 50 to 80% [3] [4] [5]. The most important risk factors for the development of a AAA are smoking, advanced age, male sex and a family history of AAA [6] [7] [8] [9] [10]. ...
... Law (1998) 11 referiu que o AAA é responsável por 2% das mortes da população masculino acima dos 60 anos. Basnyat et al. (1999) 44 estimaram que a incidência anual de ruptura do AAA é de 8 por 100000 habitantes. ...
Definição Aneurisma é uma palavra é de origem grega, significa dilatação circunscrita de um vaso ou da parede do coração. 1 Podemos definir que o aneurisma é uma dilatação localizada de um vaso em mais de 50% do seu diâmetro normal presumido. 2 Aceita-se também que um vaso é aneurismático quando o diâmetro transversal (laterolateral e ou anteroposterior) de um segmento do mesmo vaso tiver mais ou menos dois desvios padrão. 3 Arteriomegalia é uma dilatação difusa (não localizada) envolvendo vários segmentos da artéria com aumento do diâmetro em mais de 50% do seu diâmetro normal presumido. 2 Ectasia é caracterizada por dilatação da artéria menor que 50% do seu diâmetro normal presumido. 2 Pseudoaneurisma ou falso aneurisma é a lesão de todas camadas de um vaso, sendo contido por um hematoma pulsátil, ou também quando tem lesão da íntima e da média, preservando-se a adventícia. Aneurisma infeccioso (micótico) é uma dilatação segmentar sacular do vaso devida à infecção bacteriana, freqüentemente por êmbolo séptico.
... The risk of AAA rupture increases with increasing aortic diameter [9]. Mortality after AAA rupture is about 80% for those who reach hospital and w50% for those who undergo surgery [10,11]. There is no established therapy for small AAAs [12]. ...
Abdominal aortic aneurysm (AAA) affects ∼5% men aged over 65 years and is an important cause of death in this population. Research into AAA pathogenesis has been fuelled by the need to identify new diagnostic biomarkers and therapeutic targets for this disease. One animal model of AAA involves peri-vascular application of calcium chloride (CaCl(2)) onto the infra-renal aorta of mice and rats to induce extracellular matrix remodelling. Twenty-three studies assessing CaCl(2)-induced AAA and six studies assessing AAA induced by a modified CaCl(2) method were identified. In the current report the preparation and pathological features of this AAA model are discussed. We also compared this animal model to human AAA. CaCl(2)-induced AAA shows the following pathological characteristics typically found in human AAA: calcification, inflammatory cell infiltration, oxidative stress, neovascularisation, elastin degradation and vascular smooth muscle cell apoptosis. A number of mechanisms involved in CaCl(2)-induced AAA have been identified which may be relevant to the pathogenesis of human AAA. Key molecules include c-Jun N-terminal kinase, peroxisome proliferator-activated receptor-γ, chemokine (C-C motif) receptor 2, group x secretory phospholipase A2 and plasminogen. CaCl(2)-induced AAA does not display aortic thrombus, atherosclerosis and rupture which are classical features of human AAA. Advantages of the CaCl(2)-induced AAA technique include (1) it can be applied to wild type mice making assessment of transgenic rodent models more straight forward and rapid; and (2) CaCl(2)-induced AAAs are usually developed in the infra-renal abdominal aorta, which is the most common location of human AAA. Currently findings obtained from the CaCl(2)-induced AAA model or other animal models of AAA have not been translated into the human situation. It is hoped that this deficiency will be corrected over the next decade with a number of clinical trials currently examining novel treatment options for AAA patients.
... Most patients with ruptured AAA die before they come to surgery and the overall mortality is about 80%, compared to a reported mortality during elective surgery of 0-9%[90,96979899100101102103104105106107108109110111112. Due to this difference in outcome, early detection by screening has been advocated113114115116117. However, a screening program for AAA would be associated with substantial costs, and the objective of this study was therefore to analyse the cost-effectiveness of screening for AAA from a societal perspective in Sweden. ...
Includes six papers co-authored by author. Diss. (Ph. D.)--Karolinska institutet, 2005.
... A recent report from Wales had a similar study design in the respect that all conventional saline pHi-monitoring in the stomach, 33 studies are in progress at our department to validate patients reaching hospital alive, and evaluated by a surgeon, were included in the results. 30 Vascular it in the sigmoid colon. Though described already in ...
to determine whether sigmoid-pHi diagnose colon ischaemia after aortoiliac surgery?Design: single-centre, non-randomised, prospective study.
of 83 patients operated on between 1994 and 1998, 41 with risk factors for the development of colon ischaemia were monitored peri- and/or postoperatively with sigmoid-pHi. Peri-operative mortality was 26% (8/31) after operation for a ruptured abdominal aortic aneurysm (AAA), nil after operation for non-ruptured AAA. Thirty-five postoperative colonoscopies were performed. All non-survivors were examined post-mortem.
of six patients developing colon ischaemia after emergency operations (five for ruptured AAA) all had pHi-values <7.1 for 16-80 h. In two patients with transmural gangrene, and who had pHi-values below 6.6, pHi-monitoring permitted early diagnosis, colectomy and recovery. Three patients with mucosal gangrene were treated conservatively and recovered. Nine patients without ischaemic lesions had pHi-values <7.1, during 1-5 h, without adverse outcome. Bilateral ligation of the internal iliac arteries increased the risk of colon ischaemia (p<0.0001).
pHi-monitoring was diagnostic for colon ischaemia. Mucosal and transmural gangrene were distinguished. The importance of the internal iliac circulation was demonstrated. The low mortality rate, and the fact that no patient died from bowel ischaemia, suggests that sigmoid pHi-monitoring may improve survival after ruptured AAA.
New findings:
What is the central question of this study? To what extent cardiorespiratory fitness (CRF) is impaired in patients with abdominal aortic aneurysmal (AAA) disease and corresponding implications for postoperative survival requires further investigation. What is the main finding and its importance? Cardiorespiratory fitness is impaired in patients with AAA disease. Patients with peak oxygen uptake < 13.1 mL O2 .kg-1 .min-1 and ventilatory equivalent for carbon dioxide at anaerobic threshold ≥ 34 are associated with increased risk of post-operative mortality at 2 years. These findings demonstrate that CRF can predict mid-term postoperative survival in AAA patients which may help direct care provision.
Abstract:
Preoperative cardiopulmonary exercise testing (PCPET) is a standard assessment used for the assessment of cardiorespiratory fitness (CRF) and risk stratification. However, to what extent CRF is impaired in patients undergoing surgical repair of abdominal aortic aneurysm (AAA) disease and corresponding implications for postoperative outcome requires further investigation. We measured CRF during an incremental exercise test to exhaustion using online respiratory gas analysis in patients with AAA disease (n = 124, aged 72 ± 7 years) and healthy sedentary controls (n = 104, aged 70 ± 7 years). Postoperative survival was examined for association with CRF and threshold values calculated for independent predictors of mortality. Patients who underwent PCPET prior to surgical repair had lower CRF [age-adjusted mean difference of 12.5 mL O2 .kg-1 .min-1 for peak oxygen uptake (V̇O2 peak), P < 0.001 vs. controls]. Following multivariable analysis, both V̇O2 peak and the ventilatory equivalent for carbon dioxide at anaerobic threshold (V̇E /V̇CO2 -AT) were independent predictors of mid-term postoperative survival (2 years). Hazard ratios of 5.27 (95% confidence interval (CI) 1.62 to 17.14, P = 0.006) and 3.26 (95% CI 1.00 - 10.59, P = 0.049) were observed for V̇O2 peak < 13.1 mL O2 .kg-1 .min-1 and V̇E /V̇CO2 -AT ≥ 34 respectively. Thus, CRF is lower in patients with AAA and those with a V̇O2 peak < 13.1 mL O2 .kg-1 .min-1 and V̇E /V̇CO2 -AT ≥ 34 are associated with a markedly increased risk of post-operative mortality. Collectively, our findings demonstrate that CRF can predict mid-term postoperative survival in AAA patients which may help direct care provision. This article is protected by copyright. All rights reserved.
The lifetime incidence of abdominal aortic aneurysm (AAA) is 8.9% in males and 2.2% in females, with the peak incidence occurring in males during their ninth decade of life. The main concern with AAA is rupture. Saccular aneurysms are localised and may occur on any surface of an otherwise normal appearing aorta. This chapter describes an effective examination which can be performed at the point-of-care (POC), to identify the presence or absence of an AAA. On ultrasound, an aneurysm appears as an abnormal dilatation of the artery. It also presents a brief on ultrasound appearances of open repair and endovascular aortic repair (EVAR) stent grafts. The absence of free abdominal fluid does not exclude acute AAA. If an AAA is detected in a patient in shock, it should be presumed to be ruptured or leaking until proven otherwise.
Contexte : Un patient avec des douleurs lombaires. Objectif de l'article: Présenter une démarche de diagnostic clinque d'un anévrisme de l'aorte abdominale (AAA). Plan de rédaction : Nous décrivons la démarche d'examen puis des données sur cette pathologie et son diagnostic clinique. Discussion : Un diagnostic clinique éclairé permet d'exclure un AAA. Conclusion : Des tests cliniques permettent de dépister un anévrisme de l'aorte abdominale. Niveau de preuve : étude d'un cas isolé, niveau de preuve 5. Mots-clés : Lombalgie, Diagnostic différentiel, Anévrisme aortique abdominal.
Abdominal aortic aneurysm (AAA) disease is multifactorial with both environmental and genetic risk factors. The current research in AAA revolves around genetic profiles and expression studies in both human and animal models. Variants in genes involved in extracellular matrix degradation, inflammation, the renin-angiotensin system, cell growth and proliferation and lipid metabolism have been associated with AAA using a variety of study designs. However, the results have been inconsistent and without a standard animal model for validation. Thus, despite the growing body of knowledge, the specific variants responsible for AAA development, progression and rupture have yet to be determined. This review explores some of the more significant genetic studies to provide an overview of past studies that have influenced the current understanding of AAA etiology. Expanding our understanding of disease pathogenesis will inform research into novel diagnostics and therapeutics and ultimately to improve outcomes for patients with AAA.
Colin G Stirrat,1 Alex T Vesey,1 Olivia MB McBride,1 Jennifer MJ Robson,1 Shirjel R Alam,1 William A Wallace,2 Scott I Semple,1,3 Peter A Henriksen,1 David E Newby1 1British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; 2Department of Pathology, University of Edinburgh, Edinburgh, UK; 3Clinical Research Imaging Centre, University of Edinburgh, Edinburgh, UK Abstract: Ultra-small superparamagnetic particles of iron oxide (USPIO) are iron-oxide based contrast agents that enhance and complement in vivo magnetic resonance imaging (MRI) by shortening T1, T2, and T2* relaxation times. USPIO can be employed to provide immediate blood pool contrast, or to act as subsequent markers of cellular inflammation through uptake by inflammatory cells. They can also be targeted to specific cell-surface markers using antibody or ligand labeling. This review will discuss the application of USPIO contrast in MRI studies of cardiovascular disease. Keywords: cardiac, aortic, MRI, USPIO, carotid, vascular, molecular imaging
The objective of the Amsterdam Acute Aneurysm Trial is to study the combined outcome of conventional emergency surgery versus endovascular treatment for ruptured abdominal aortic aneurysms. The design used was a multicenter randomized clinical trial conducted in two university hospitals and one teaching hospital in the Amsterdam region. The study included all patients with a ruptured abdominal aneurysm who were eligible for enclovascular and conventional surgery. The primary end points were combined mortality and severe morbidity. The secondary end points were quality of life and cost-effectiveness. The background, design, and methods of this trial are presented, and the ethical and legal issues of this type of research are discussed.
This research seeks to improve the understanding of the mechanisms accounting for the growth of abdominal aortic aneurysms (AAA), by quantifying the role that mechanical stimuli play in the disease processes. In recent years, the development of vascular diseases has been associated with the formation of disturbed patterns of wall shear stresses (WSS) and gradients of wall shear stresses (GWSS). They have been shown to affect the wall structural integrity, primarily via the changes induced on the morphology and functions of the endothelial cells (EC) and circulating blood cells. Particle Image Velocimetry measurements of the pulsatile blood flow have been performed in aneurysm models, while changing systematically their geometric
parameters. The parametric study shows that the flow separates from the wall even at early stages of the disease (dilatation ≤ 50%). A large vortex ring forms in symmetric aneurysms, followed by internal shear layers. Two regions with distinct patterns of WSS have been identified: a region of flow detachment, with low oscillatory WSS, and a downstream region of flow reattachment, where large negative WSS and sustained GWSS are produced as a result of the impact of the vortex ring.
The loss of symmetry in the models engenders a helical flow pattern due to the non-symmetric vortex shedding. The dominant vortex, whose strength increases with the asymmetry parameter, is shed from the most bulged wall (anterior). It results in the formation of a large recirculating region, where ECs are subjected to quasi-steady reversed WSS of low magnitude, while the posterior wall is exposed to quasi-healthy WSS. GWSS are generated at the necks and around the point of impact of the vortex.
Lagrangian tracking of blood cells inside the different models of aneurysms shows a dramatic increase in the cell residence time as the aneurysm grows. While recirculating, cells experience high shear stresses close to the walls and inside the shear layers, which may lead to cell activation. The vortical structure of the flow also convects the cells towards the wall, increasing the probability for cell deposition and ipso facto for the formation of an intraluminal thrombus.
Contexte : Un patient avec des douleurs lombaires. Objectif de l'article: Présenter une démarche de diagnostic clinque d'un anévrisme de l'aorte abdominale (AAA). Plan de rédaction : Nous décrivons la démarche d'examen puis des données sur cette pathologie et son diagnostic clinique. Discussion : Un diagnostic clinique éclairé permet d'exclure un AAA. Conclusion : Des tests cliniques permettent de dépister un anévrisme de l'aorte abdominale. Niveau de preuve : étude d'un cas isolé, niveau de preuve 5. Mots-clés : Lombalgie, Diagnostic différentiel, Anévrisme aortique abdominal.
Definição Aneurisma é uma palavra é de origem grega, significa dilatação circunscrita de um vaso ou da parede do coração 1 . Podemos definir que o aneurisma é uma dilatação localizada de um vaso em mais de 50% do seu diâmetro normal presumido 2 . Aceita-se também que um vaso é aneurismático quando o diâmetro transversal (laterolateral e ou anteroposterior) de um segmento do mesmo vaso tiver mais ou menos dois desvios padrão 3 . Arteriomegalia é uma dilatação difusa (não localizada) envolvendo vários segmentos da artéria com aumento do diâmetro em mais de 50% do seu diâmetro normal presumido 2 . Ectasia é caracterizada por dilatação da artéria menor que 50% do seu diâmetro normal presumido 2 . Pseudoaneurisma ou falso aneurisma é a lesão de todas camadas de um vaso, sendo contido por um hematoma pulsátil, ou também quando tem lesão da íntima e da média, preservando-se a adventícia. Aneurisma infeccioso (micótico) é uma dilatação segmentar sacular do vaso devida à infecção bacteriana, freqüentemente por êmbolo séptico. Introdução O aneurisma da aorta abdominal (AAA) tem chamado a atenção do médico desde a antigüidade. Galeno descreveu dois tipos de aneurisma: um em que havia uma dilatação expontânea da artéria, e outro que surgia após trauma da artéria. No terceiro século A C, Antyllus descreveu a ligadura proximal e distal do aneurisma, e em 1924, Halsted escreveu: the moment of tying the ligature is indeed a dramatic one. The monstrous, booming tumor is stilled by tiny trhead....(Halsted 1924) 4 . No Brasil em 1845, Monteiro 5 descreveu sua técnica revolucionária de ligadura do AAA, tendo grande repercussão internacional. Rudolph Matas (1903) 6 descreveu a técnica do endoaneurismorrafia . Em 1951, Charles Dubost 7 na França foi o primeiro a descrever a ressecção do AAA e reconstrução da aorta abdominal com enxerto homólogo de aorta preservada de cadáver, por via extraperitoneal. Em 1952, DeBakey & Cooley 8 publicaram uma série de 7 casos de correção de aneurisma da aorta abdominal através de aneurismectomia e restauração da circulação com aorta homóloga. No Brasil, Coutinho em 1964 9 realizou a primeira correção de AAA.
BACKGROUND: Infrarenal abdominal aortic aneurysm (AAA) is a vascular disease requiring continuous attention both in terms of screening and therapeutic improvement. Infrarenal AAA is a major condition because of its high mortality rate due to AAA rupture, as opposite to the low mortality rate related to elective surgical repair conducted in specialized facilities. In the metropolitan area of Salvador there are no data concerning the identification of patients with infrarenal AAA. Such lack of information prompted this study.OBJECTIVE: (1) to determine the prevalence of infrarenal AAA in patients with risk factors; (2) to identify risk factors; and (3) to determine whether the population at risk should be routinely screened.METHODS: In a study for AAA screening conducted by the Department of Vascular Surgery of Hospital Geral Roberto Santos and Hospital Geral de Camaçari from September 2008 to October 2009, 1,350 individuals aged 50 years or older with risk factors for aortic aneurysm were selected. Screening included completion of protocol and performance of color Doppler ultrasound.RESULTS: AAA prevalence in this sample was 3.9%. The most frequent risk factors associated with aneurysm were mean age of 72 years, male gender, smoking, and patients with peripheral obstructive arterial disease, coronary failure, and chronic obstructive lung disease. AAA screening should be considered in men aged over 65 years, mainly when one of these risk factors are present.
Background
Ultrasonography is increasingly used by clinicians to identify abdominal aortic aneurysms (AAA). We performed a systematic review and meta-analysis comparing the accuracy of non-radiologist performed ultrasound (NRPUS) for AAA disease to the ‘gold standard’ of radiologist performed aortic imaging (RPI), intra-operative findings or postmortem findings.Methods
Cochrane Library, MEDLINE, EMBASE, SCOPUS-V.4, trial registries, conference proceedings, and article reference lists were searched to identify studies comparing NRPUS with RPI as the reference standard. Data abstracted from eligible studies was used to generate 2 × 2 contingency tables allowing calculation of pooled sensitivity and specificity values.Results11 studies (944 patients) evaluated NRPUS for AAA detection. NRPUS had a pooled sensitivity of 0.975 [95% confidence interval (CI), 0.942–0.992] for AAA detection and a pooled specificity of 0.989 (95% CI, 0.979–0.995).Conclusions
Non-radiologist performed ultrasound achieves acceptable sensitivity and specificity for both detection and measurement of AAA. There was no evidence of significant heterogeneity with respect to pooled sensitivity or specificity.
The outcome of patients with ruptured abdominal aortic aneurysm (rAAA) varies by country. Study of practice differences might allow the formulation of pathways to improve care.
We compared data from the Hospital Episode Statistics for England and the Nationwide Inpatient Sample for the USA for patients admitted to hospital with rAAA from 2005 to 2010. Primary outcomes were in-hospital mortality, mortality after intervention, and decision to follow non-corrective treatment. In-hospital mortality and the rate of non-corrective treatment were analysed by binary logistic regression for each health-care system, after adjustment for age, sex, year, and Charlson comorbidity index.
The study included 11,799 patients with rAAA in England and 23,838 patients with rAAA in the USA. In-hospital mortality was lower in the USA than in England (53·05% [95% CI 51·26-54·85] vs 65·90%; p<0·0001). Intervention (open or endovascular repair) was offered to a greater proportion of cases in the USA than in England (19,174 [80·43%] vs 6897 [58·45%]; p<0·0001) and endovascular repair was more common in the USA than in England (4003 [20·88%] vs 589 [8·54%]; p<0·0001). Postintervention mortality was similar in both countries (41·77% for England and 41·65% for USA). These observations persisted in age-matched and sex-matched comparisons. In both countries, reduced mortality was associated with increased use of endovascular repair, increased hospital caseload (volume) for rAAA, high hospital bed capacity, hospitals with teaching status, and admission on a weekday.
In-hospital survival from rAAA, intervention rates, and uptake of endovascular repair are lower in England than in the USA. In England and the USA, the lowest mortality for rAAA was seen in teaching hospitals with larger bed capacities and doing a greater proportion of cases with endovascular repair. These common factors suggest strategies for improving outcomes for patients with rAAA.
None.
To evaluate the risk of aortic aneurysm in patients with giant cell arteritis (GCA) compared with age-, gender- and location-matched controls.
A UK General Practice Research Database (GPRD) parallel cohort study of 6999 patients with GCA and 41 994 controls, matched on location, age and gender, was carried out. A competing risk model using aortic aneurysm as the primary outcome and non-aortic-aneurysm-related death as the competing risk was used to determine the relative risk (subhazard ratio) between non-GCA and GCA subjects, after adjustment for cardiovascular risk factors.
Comparing the GCA cohort with the non-GCA cohort, the adjusted subhazard ratio (95% CI) for aortic aneurysm was 1.92 (1.52 to 2.41). Significant predictors of aortic aneurysm were being an ex-smoker (2.64 (2.03 to 3.43)) or a current smoker (3.37 (2.61 to 4.37)), previously taking antihypertensive drugs (1.57 (1.23 to 2.01)) and a history of diabetes (0.32 (0.19 to 0.56)) or cardiovascular disease (1.98 (1.50 to 2.63)). In a multivariate model of the GCA cohort, male gender (2.10 (1.38 to 3.19)), ex-smoker (2.20 (1.22 to 3.98)), current smoker (3.79 (2.20 to 6.53)), previous antihypertensive drugs (1.62 (1.00 to 2.61)) and diabetes (0.19 (0.05 to 0.77)) were significant predictors of aortic aneurysm.
Patients with GCA have a twofold increased risk of aortic aneurysm, and this should be considered within the range of other risk factors including male gender, age and smoking. A separate screening programme is not indicated. The protective effect of diabetes in the development of aortic aneurysms in patients with GCA is also demonstrated.
CONTEXTO: O tratamento cirúrgico convencional do aneurisma da aorta abdominal (AAA) infra-renal pode resultar em complicações graves. A fim de otimizar os resultados na evolução do tratamento, é importante que sejam identificados os pacientes predispostos a determinadas complicações e instituídas condutas preventivas. OBJETIVOS: Avaliar a taxa de mortalidade operatória precoce, analisar as complicações pós-operatórias e identificar os fatores de risco relacionados com a morbimortalidade. MÉTODO: Foram analisados 134 pacientes com AAA infra-renal submetidos a correção cirúrgica eletiva no período de fevereiro de 2001 a dezembro de 2005. RESULTADOS: A taxa de mortalidade foi de 5,2%, sendo secundária principalmente a infarto agudo de miocárdio (IAM) e isquemia mesentérica. As complicações cardíacas foram as mais freqüentes, seguidas das pulmonares e renais. A presença de diabetes melito (DM), insuficiência cardíaca congestiva (ICC), insuficiência coronariana (ICO) e cintilografia miocárdica positiva para isquemia estiveram associadas às complicações cardíacas. A idade avançada, a doença pulmonar obstrutiva crônica (DPOC) e a capacidade vital forçada reduzida aumentaram os riscos de atelectasia e pneumonia. História de nefropatia, tempo de pinçamento aórtico prolongado e níveis de uréia elevados aumentaram os riscos de insuficiência respiratória aguda (IRA). A isquemia dos membros inferiores esteve associada ao tabagismo e à idade avançada, e a maior taxa de mortalidade, à presença de coronariopatia, tempos prolongados de pinçamento aórtico e de cirurgia. CONCLUSÃO: A taxa de morbimortalidade esteve compatível com a literatura nacional e internacional, sendo secundária às complicações cardíacas, respiratórias e renais. Os fatores de risco identificados no pré e transoperatório estiveram relacionados com essas complicações.
The aorta is the largest artery in the human body, transporting oxygenized blood directly from the left ventricle of the heart
to the rest of the body. An aortic aneurysm is a local dilation in the aorta of more than 1.5 times the original diameter
[27]. Although aneurysms can be present in every part of the aorta, the majority of the aortic aneurysms are situated in the
abdominal aorta (AAA, Fig. 6.1), below the level of the renal arteries and above the aortic bifurcation to the common iliac arteries [7]. A diameter of 3 cm or more is generally used as indication for an AAA (abdominal aortic aneurysm). In most AAAs, thrombus
is found between the perfused flow lumen and the aortic wall. Thrombus is a fibrin structure with mainly blood cells, platelets,
and blood proteins, which is deposited onto the vessel wall [21].
StudienzielUntersuchungen ber den Stellenwert der notfallmigen endovaskulren Behandlung von Patienten mit gedeckten Rupturen im Bereich der Aorta descendens sowie im infrarenalen Aortenabschnitt.Studiendesign.Prospektive, nichtrandomisierte Studie in einer Universittsklinik.Material und MethodenIm Zeitraum zwischen 1995 und 2003 wurde bei insgesamt 338Patienten eine stentgesttzte aortale Rekonstruktion durchgefhrt. 274Eingriffe erfolgten elektiv (81%). In 64Fllen (19%) wurde die endovaskulre Versorgung notfallmig im Stadium der Ruptur durchgefhrt. Bei 29Patienten handelte es sich um ein gedeckt rupturiertes infrarenales Aortenaneurysma, bei 11Patienten um ein rupturiertes Aneurysma im Bereich der Aorta descendens, bei 3Patienten um eine Ruptur eines thorakoabdominalen Aortenaneurysmas, bei 5Patienten um eine Ruptur im ersten Segment der Aorta descendens bei akuter Typ-B Dissektion und bei weiteren 16Patienten um eine traumatische thorakale Aortenruptur loco typico. Die Diagnose wurde bei allen 64Patienten jeweils durch eine properative Spiral-CT-Untersuchung gesichert.ErgebnisseDer rupturierte Aortenabschnitt konnte bei 62Patienten endovaskulr sicher versorgt werden. Eine primre Konversion zum offenen Eingriff wurde bei 2Patienten (3,1%) notwendig. Die postoperative 30-Tage-Letalitt betrug bei 7Todesfllen 10,9%. Keiner der Patienten entwickelte postoperativ ein vorbergehendes oder dauerhaftes neurologisches Defizit. Bei 8Patienten (12,5%) waren Zweiteingriffe zum Verschluss primrer Endoleaks erforderlich und 6Patienten (9,3%) bedurften eines zweiten chirurgischen oder kombinierten endovaskulren und offenchirurgischen Vorgehens. Die mittlere Nachbeobachtungszeit (Follow-up) betrug 37Monate (1–93).SchlussfolgerungUnsere Ergebnisse zeigen, dass die stentgesttzte Rekonstruktion bei Patienten mit rupturierten Aortenlsionen technisch durchfhrbar ist und diese Technik zudem mit einer ausreichenden Sicherheit angewandt werden kann. Angesichts der im Vergleich zum offenen Vorgehen reduzierten Morbiditt und Letalitt stellt das endovaskulre stentgesttzte Verfahren bei Patienten, die anatomisch und pathomorphologisch fr eine Stentbehandlung geeignet erscheinen, ein alternatives, viel versprechendes Behandlungskonzept dar. Unsere Ergebnisse lassen zudem vermuten, dass bei rupturiertem mykotischem Aneurysma bzw. bei aortobronchialen und aortointestinalen Fisteln die endovaskulre Therapie nur als "Bridging"-Manahme angewandt werden sollte.ObjectivesTo evaluate endovascular repair in ruptured aortic lesions.DesignProspective nonrandomized study in a university hospital.Material and methodsOf 338 endovascular aortic repairs, 64 (19%) procedures were conducted as emergencies (29 ruptured infrarenal aortic aneurysms, 11 ruptured descending thoracic aortic aneurysms, 3 ruptured thoracoabdominal aortic aneurysm, 5 patients with descending aortic rupture due to acute type B dissection, and 16 patients with acute descending aortic transection). Preoperative spiral computed tomography was performed in each patient, and based on these findings the feasibility of endovascular treatment and appropriate size of stent grafts were determined.ResultsEndovascular operations were completed successfully in 96.8% (62 patients). The primary conversion rate to open repair was 3.1% (two patients). The 30-day mortality rate was 10.9% (seven deaths). In no patient did temporary or permanent paraplegia result. Of the primary endoleaks, 12.5% (eight patients) required additional intervention and 9.3% (six patients) required secondary surgical procedures. The mean follow-up was 37months (1–93months); three deaths occurred within 3months after stent graft placement. Six patients (9.3%) required secondary conversion to open repair.ConclusionEndoluminal treatment of ruptured aortic lesions is feasible and safe and may offer the best means of therapy in selected cases. Compared with open repair, endoluminal treatment holds tremendous potential in terms of reduced morbidity and mortality and confers protection against secondary aortic rupture. Continued surveillance is essential.
Background
Ruptured abdominal aortic aneurysm (RAAA) presents with increased frequency in the winter and spring months. Seasonal changes in atmospheric pressure mirrors this pattern.
Aim
To establish if there was a seasonal variation in the occurrence of RAAA and to determine if there was any association with atmospheric pressure changes.
Methods
A retrospective cohort-based study was performed. Daily atmospheric pressure readings for the region were obtained.
Results
There was a statistically significant monthly variation in RAAA presentation with 107 cases (52.5%) occurring from November to March. The monthly number of RAAA and the mean atmospheric pressure in the previous month were inversely related (r = 0.752, r
2 = 0.566, P = 0.03), and there was significantly greater daily atmospheric pressure variability on days when patients with RAAA were admitted.
Conclusion
These findings suggest a relationship between atmospheric pressure and RAAA.
The role of open repair in the management of ruptured abdominal aortic aneurysm (RAAA) in patients>80 years old is questioned by the perceived high operative risk of these patients. This issue has been investigated in the present meta-analysis of observational studies.
Studies on open repair of RAAA in patients>80 years old were identified in July 2010. The immediate and intermediate results were expressed as pooled proportions with 95% confidence interval (95% CI). Linear regression and meta-regression were performed to evaluate the impact of variables on the immediate postoperative mortality.
Pooled analysis of 29 studies showed that the risk of immediate postoperative mortality in patients>80 years old was significantly higher than in younger patients (risk ratio 1.440, 95%CI 1.365-1.519, I2 36.8%, P=0.002; risk difference 19.4%, 95% CI 16.4-22.4%, I2 38.8%, P=0.019). Pooled analysis of 36 studies showed an immediate postoperative mortality rate of 59.2% (95% CI 55.7-62.5, I2 35.62). Immediate postoperative mortality in patients<80 years old positively correlated with that of patients>80 years old (rho: 0.686, P<0.0001). Intermediate survival data of 111 operative survivors were available from six studies, and their pooled survival rates at 1-, 2-, and 3-year were 82.4, 75.6, and 68.7%, respectively.
Immediate and intermediate survival rates of patients>80 years old after open repair of RAAA are acceptable. These findings suggest a more confident approach toward emergency repair of RAAA in the very elderly.
Currently the transverse diameter is the primary decision criterion to assess rupture risk in patients with an abdominal aortic aneurysm (AAA). To obtain a measure for more patient-specific risk assessment, aneurysm wall stress, calculated using finite element analysis (FEA), has been evaluated in literature. In many cases, initial stress, present in the AAA wall during image acquisition, is not taken into account. In the current study the effect of initial stress incorporation (ISI) is determined by directly comparing wall displacements extracted from FEA and dynamic MRI. Ten patients with an aneurysm diameter >5.5 cm were scanned with cardiac triggered MRI. Semi-automatic segmentation of the AAA was performed on the diastolic phase. The segmented in-slice contours were propagated through the remaining cardiac phases using an active contour model as to track wall displacements on MRI. Consequently, FEA with and without ISI (no-ISI) was performed using the diastolic geometry with simultaneously measured intra-aneurysm pressure values as boundary condition. Contours extracted from FEA were compared with MRI contours at corresponding cardiac phases by distance and relative area differences. The wall displacements from FEA with ISI show significant better correspondence with wall motion from MRI data in comparison with the no-ISI FEA (deviation in wall displacement 1.7% vs. 12.4%; p<0.001). Based on these results it can be concluded that incorporation of initial stress significantly improves wall displacement accuracy of FEA and therefore it should be incorporated in future analyses.
In a cross-sectional, population-based study in Tromsø, Norway, the authors investigated correlations between lumen diameter in the right common carotid artery (CCA) and the diameters of the femoral artery and abdominal aorta and whether CCA lumen diameter was a risk factor for abdominal aortic aneurysm (AAA). Ultrasonography was performed in 6,400 men and women aged 25-84 years during 1994-1995. An AAA was considered present if the aortic diameter at the level of renal arteries was greater than or equal to 35 mm, the infrarenal aortic diameter was greater than or equal to 5 mm larger than the diameter of the level of renal arteries, or a localized dilation of the aorta was present. CCA lumen diameter was positively correlated with abdominal aortic diameter (r = 0.3, P < 0.01) and femoral artery diameter (r = 0.2, P < 0.01). In a multivariable adjusted model, CCA lumen diameter was a significant predictor of AAA in both men and women (for the fifth quintile vs. the third, odds ratios were 1.9 (95% confidence interval: 1.2, 2.9) and 4.1 (95% confidence interval: 1.5, 10.8), respectively). Thus, CCA lumen diameter was positively correlated with femoral and abdominal aortic artery diameter and was an independent risk factor for AAA.
The study defined the selection criteria used for treatment of ruptured abdominal aortic aneurysms (RAAAs) and reviewed results during a 5-year period.
From 2002 on, our tertiary referral center adopted a protocol of selective use of endovascular repair for RAAAs. The study included all patients with a proven RAAA who were admitted to our hospital from 2002 to 2006. The primary outcome measure was surgical mortality.
A total of 187 patients were admitted with an acute AAA, and an RAAA was confirmed 135 (72%) by computed tomography scanning or at laparotomy, and 125 (93%) were treated, 89 by open means and 36 by endovascular means. The overall mortality rate was 24% and the mortality rate was 13.9% for endovascular repair. Endovascular repair was consistently used more often in patients with favorable anatomy and in patients who were hemodynamically more stable. There were considerable differences in approach between the four consultant vascular surgeons. The overall evaluation and inclusion for endovascular treatment increased during the study period.
A strict protocol for admission, evaluation, and treatment of RAAA, with selective use of endovascular repair, resulted in low mortality rates in our center.
In a population-based study of 6,386 men and women aged 25--84 years in Tromsø, Norway, in 1994--1995, the authors assessed the age- and sex-specific distribution of the abdominal aortic diameter and the prevalence of and risk factors for abdominal aortic aneurysm. Renal and infrarenal aortic diameters were measured with ultrasound. The mean infrarenal aortic diameter increased with age. The increase was more pronounced in men than in women. The age-related increase in the median diameter was less than that in the mean diameter. An aneurysm was present in 263 (8.9%) men and 74 (2.2%) women (p < 0.001). The prevalence of abdominal aortic aneurysm increased with age. No person aged less than 48 years was found with an abdominal aortic aneurysm. Persons who had smoked for more than 40 years had an odds ratio of 8.0 for abdominal aortic aneurysm (95% confidence interval: 5.0, 12.6) compared with never smokers. Low serum high density lipoprotein cholesterol was associated with an increased risk for abdominal aortic aneurysm. Other factors associated with abdominal aortic aneurysm were a high level of plasma fibrinogen and a low blood platelet count. Antihypertensive medication (ever use) was significantly associated with abdominal aortic aneurysm, but high systolic blood pressure was a risk factor in women only. This study indicates that risk factors for atherosclerosis are also associated with increased risk for abdominal aortic aneurysm.
Aortic inflammation and the genes that regulate the immune response play an important role in abdominal aortic aneurysm pathogenesis. However, the modulating effects of such genetic and other environmental factors on the severity on aneurysm inflammation is not known. The objective of this study was to determine the influence of the human leukocyte antigen (HLA) class II genes, gender, and environmental factors on degree of abdominal aortic aneurysm tissue inflammation.
Aneurysm specimens were obtained at the time of operation from 96 consecutive patients who underwent abdominal aortic aneurysm repair and were graded for degree of histologic inflammation. Multivariate analysis was used to determine the association of genetic and environmental factors with degree of inflammation and to determine the HLA-associated disease risk for aneurysm.
Active cigarette smoking and female gender were independently associated with high-grade tissue inflammation identified histologically (odds ratio [OR], confidence interval [CI]: 5.6, 1.6 to 19.3; and 6.0, 1.4 to 26.2, respectively), and a specific HLA allele (DR B1(*)01) was inversely associated with inflammation (OR, CI: 0.2, 0.04 to 0.7). Overall, the HLA-DR B1(*)02 and B1(*)04 alleles were significantly associated with disease risk, more than doubling risk for abdominal aortic aneurysm (OR, CI: 2.5, 1.4 to 4.3; and 2.1, 1.2 to 3.7, respectively).
Active cigarette smoking and female gender are significant disease-modulating factors associated with increased abdominal aortic aneurysm inflammation. In addition, the HLA class II immune response genes possess both disease modulating and disease risk properties, which may be useful in early aneurysm detection and surveillance.
Operative repair of ruptured abdominal aortic aneurysm (RAAA) is associated with a high mortality rate but reported figures vary widely. The aim of this study was to estimate the operative mortality of RAAA repair and determine how it has changed over time.
A meta-analysis of all English language literature quoting figures for operative mortality of RAAA repair.
The pooled estimate for the overall operative mortality rate of RAAA repair from 1955 to 1998 was 48 (95 per cent confidence interval 46 to 50) per cent. Meta-regression analysis of operative mortality over time demonstrated a constant reduction of approximately 3.5 per cent per decade (1954-1997) with an operative mortality rate estimate for the year 2000 of 41 per cent. Seventy-seven studies reported intraoperative mortality but, while this appears to have remained constant over time, there was evidence of the presence of publication bias in the subgroup of papers reporting this outcome. There was no evidence of publication bias for the overall operative mortality outcome.
Contrary to the conclusion of recent studies, this paper demonstrates a gradual reduction with time in the operative mortality rate of RAAA repair.
To report the initial experience with endovascular aortic repair (EVAR) in patients with ruptured or symptomatic abdominal aortic aneurysms (AAA) and to compare the results with conventional open surgery.
Between May 1999 and December 2001, 24 patients (21 men; mean age 75 years, range 56-89) with ruptured or symptomatic AAA underwent EVAR using a specially designed aortomonoiliac endograft. Six patients were selected based on device and operator availability; the subsequent 18 patients were treated under a modified management protocol that offered stent-graft repair to all symptomatic AAA patients. The results of this new treatment protocol were analyzed on an intention-to-treat basis for the last 8 months of the study. The 30-day outcomes in all patients treated with emergency EVAR were compared with 40 consecutive, contemporaneous patients undergoing open surgery for symptomatic or ruptured AAA.
No early conversions to open surgery were performed. Significantly decreased operative blood loss and intensive care stay (p<0.05 for both) were observed in EVAR patients. The mortality rate for EVAR patients was 17% compared to 32% in conventionally treated patients (NS). Among patients with ruptured AAA, the 30-day mortality rates were 24% (4/17) and 41% (12/29) for EVAR and open surgery, respectively (NS). Of 26 unselected patients who were treated prospectively under the modified protocol, the majority (81%, 21/26) had anatomy suitable for endovascular repair; however, only 18 (69%) underwent EVAR owing to a short infrarenal neck (n=2) or device/operator unavailability (n=6).
EVAR is a feasible treatment in the majority of patients with ruptured or symptomatic AAA. The 30-day mortality appears to be similar between conventionally treated patients and those undergoing endovascular repair.
A retrospective review of urgently operated aortic or iliac aneurysms over a 13 1/2 year period identified 51 patients (50 male, one female). In our consecutive series, 45 patients underwent an emergency operation for an abdominal aortic aneurysm (AAA) and six patients for an iliac aneurysm (IA). Mean age was 69 years. All patients had prominent symptoms: acute low abdominal pain or low back pain in 20 patients, shock in six patients, shock and pain in 25 patients. Free rupture was found in 28 cases, retroperitoneal rupture in 14 cases, fissurisation in seven and arterio-venous fistulisation in two cases. All reconstructions were done by the same vascular surgeon using Dacron prostheses. Intra-operative mortality rate was 3.9% (n = 2), 30-day mortality was 21.6% (n = 11) and cumulative hospital mortality was 23.5% (n = 12). The morbidity was 59%.
Between 1985 and 2000, a total of 871 patients underwent surgical treatment for infrarenal abdominal aortic aneurysm (AAA), including 98 (11.2%) presenting with ruptured abdominal aortic aneurysms (RAAA). An optimized operative protocol was used to treat 77 RAAA starting in January 1989. The main features of the optimized protocol are routine use of intraoperative autotransfusion, revascularization by aortoaortic bypass, absence of systemic heparinization, and use of a collagen-impregnated prosthesis. Intraoperative mortality (IOM) was 3.8%. Postoperative mortality at 1 month (POM1) was 25.9% and postoperative mortality at 3 months (POM3) was 33.7%. Heart failure (p <0.001), hemodynamic shock (p <0.001), and hemorrhage (p = 0.04) were the only complications correlated with POM1. Pneumonia (p = 0.01) and sepsis (p = 0.01) were the only complications correlated with POM3. Isolated acute renal insufficiency was not a significant risk factor for postoperative mortality. Using a cutoff of 75 years, there was a significant age-related difference (p = 0.025) for POM1 but not for IOM and POM3. The findings of this study show that optimizing the operative protocol decreases mortality related to RAAA. The main predictor of POM1 was hemodynamic status while the main predictor of POM3 was infection. Isolated acute renal insufficiency was not a risk factor for mortality. Age should not be considered a contraindication for operative treatment.
Outcome of treatment of patients with ruptured or symptomatic non-ruptured aneurysm (rAAA and snrAAA), preferentially treated by emergency endovascular repair was assessed. The outcome was compared with a historical group of patients treated by open repair.
Two groups of patients presenting with acute symptomatic AAA were compared. Group I (study group) consisted of 40 consecutive prospectively enrolled patients from May 2001 until June 2002, in whom emergency endovascular abdominal aortic aneurysm repair (e-EVAR) was the preferential management. Short or wide neck or profound hypovolemic shock were exclusion criteria for e-EVAR. Group II (control group) consisted of 28 patients, retrospectively analysed, all treated by conventional surgical repair between January 1999 and May 2001. In group I, 26 patients had rAAA and in group II 22 patients. The other patients had snrAAA.
In group I, 14 patients were treated by open repair. Unsuitable anatomy or profound hypovolemia was the cause of open repair in eight patients, while logistic reasons were the reasons for use of open repair in six patients (off-protocol use of open surgery). Thus, in this prospective series the feasibility of EVAR was 80% (32/40). Patient characteristics, proportion rAAA or hemodynamically unstable patients were comparable in group I and II. Volume of blood loss and need for fluid transfusion were significantly less in group I compared to group II. The perioperative mortality in group I was significantly less than in group II (20% vs. 43%, respectively, p = 0.04). If patients with rAAA were considered the mortality was 31% in group I and 50% in group II, which difference did not reach the level of statistical significance.
e-EVAR was a feasible treatment in the majority of patients with rAAA and snrAAA. Blood loss and the requirements of fluid transfusion were significantly decreased. Most importantly in this institutional series significantly lower first-month mortality was observed in the group with preferential e-EVAR compared to a control group. A multi-center study assessing the outcome of preferential use of e-EVAR in patients with acute symptomatic AAA is required.
Recombinant FVIIa (rFVIIa/NovoSeven) is a novel hemostatic agent originally developed to treat patients with hemophilia who had developed inhibitors. Several case reports have suggested that rFVIIa may be effective in treating patients without a pre-existing bleeding disorder who have uncontrolled bleeding.
Data on the efficacy and safety of rFVIIa in the treatment of massive hemorrhage were obtained retrospectively from the NovoSeven extended-use data collection system.
A total of 40 patients received rFVIIa for uncontrolled bleeding, and in these patients, bleeding stopped or decreased in 32 (80%). Blood product usage was significantly decreased after rFVIIa administration. Thromboembolic events occurred in three patients with additional risk factors for thrombosis. Of 40 patients, 23 (57.5%) died. Bleeding was the direct cause of death in seven cases (all within 24 hr of administration of rFVIIa). The remaining 16 deaths were the result of sepsis, multi-organ failure, or the underlying disease.
In this retrospective study of data voluntarily submitted to a web-based drug surveillance program, we present preliminary results on the use of rFVIIa in nonhemophilia patients with bleeding. Although some efficacy is suggested, there was a high mortality rate from nonhemorrhagic causes. Randomized controlled trials are needed to properly assess the role of rFVIIa in the management of hemorrhage.
This study was undertaken to determine the effect of the preoperative diameter of abdominal aortic aneurysms on the midterm outcome after endovascular abdominal aneurysm repair (EVAR).
The data for 4392 patients who had undergone EVAR were analyzed. Patients were enrolled over 6 years to June 2002 in the EUROSTAR database. Outcomes were compared between three groups defined by the preoperative diameter of the aneurysm: group A (n = 1962), 4.0 to 5.4 cm; group B (n = 1528), 5.5 to 6.4 cm; and group C (n = 902), 6.5 cm or larger. Patient characteristics, details of aortoiliac anatomy, operative procedures, old or current device generation, and postoperative complications in the three patient groups were compared. Outcome events included aneurysm-related death, unrelated death, conversion, and post-EVAR rupture of the aneurysm. Life table analysis and log-rank tests were used to compare outcome in the three study groups. Multivariate Cox models were used to determine whether baseline and follow-up variables were independently associated with adverse outcome events.
Patients in group C were significantly older than patients in groups A and B (73 years vs 70 and 72 years, respectively; P =.003 - P <.0001 for different group comparisons), and more frequently were at higher operative risk (American Society of Anesthesiologists classification >or=3; 63% vs 48% and 54%; P =.0002-P <.0001). Device-related (type I) endoleaks were more frequently observed at early postoperative arteriography in group C compared with groups A and B (9.9% vs 3.7% and 6.8%; P =.01-P <.0001). Postoperatively systemic complications were more frequently present in group C (17.4% vs 12.0% in group A and 12.6% in group B; P <.0001 and.001). The first-month mortality was approximately twice as high in group C compared with the other groups combined (4.1% vs 2.1%; P <.0001). Late rupture was most frequent in group C. Follow-up results at midterm were less favorable in groups C and B compared with group A (freedom from rupture, 90%, 98%, and 98% at 4 years in groups C, B, and A, respectively; P <.0001 for group C vs groups A and B). Aneurysm-related death was highest in group C (88% freedom at 4 years, compared with 95% in group B and 97% in A; P =.001 and P <.0001, respectively; group B vs A, P =.004). The annual rate of aneurysm-related death in group C was 1% in the first 3 years, but accelerated to 8.0% in the fourth year. Incidence of unrelated death also was higher in groups C and B than in group A (76% and 82% freedom at 4 years vs 87%; P <.0001 for both comparisons). Ratio of aneurysm-related to unrelated death was 23%, 21%, and 50% in groups A, B, and C, respectively. Cox models demonstrated that the correlation between large aneurysms (group C) and all assessed outcome events was independent and highly significant. Older generation devices had an independent association with aneurysm-related and unrelated deaths (P =.02 and P =.04, respectively). However, this correlation was less strong than large aneurysm diameter (P =.0001 and P =.0009, respectively).
The midterm outcome of large aneurysms after EVAR was associated with increased rates of aneurysm-related death, unrelated death, and rupture. Reports of EVAR should stratify their outcomes according to the diameter of the aneurysm. Large aneurysms need a more rigorous post-EVAR surveillance schedule than do smaller aneurysms. In small aneurysms EVAR was associated with excellent outcome. This finding may justify reappraisal of currently accepted management strategies.
Purpose
To determine the anatomical suitability and the range of endografts required to undertake an endovascular repair (EVR) program for ruptured abdominal aortic aneurysms.
Methods
The morphology of ruptured and nonruptured AAAs were compared by retrospective review of computed tomographic scans from 51 patients (47 men; mean age 76 years, range 55–90) with ruptured AAAs and 50 patients (37 men; mean age 74 years, range 57–75) with nonruptured AAAs. Three experienced clinicians reviewed the scans for EVR suitability based on a generic trimodular endograft with suprarenal fixation. Endograft oversizing was assumed to be 10% to 20%.
Results
Interobserver agreement was high, with a mean kappa of 0.78 (range 0.75–0.83, p<0.001). In all, 41% of ruptured and 68% of nonruptured AAAs were suitable for EVR (p=0.009). Ruptured AAAs had shorter mean neck lengths (17±12 versus 22±11 mm, p=0.031) and larger mean aneurysm diameters (75±15 versus 63±9 mm, p>0.001). Neck length and neck diameter were significantly correlated for ruptured AAAs (r=–0.34, p= 0.018). The main contraindication to EVR was hostile neck morphology. A range of endografts with aortic components from 24 to 32 mm and iliac components from 12 to 22 mm would be required to stent 41% of ruptured AAAs.
Conclusions
Ruptured AAAs are less suitable for EVR due to differing neck morphology. An EVR program for ruptured AAA requires an inventory of endografts with appropriate aortic and iliac components.
The primary objective of this study was to develop a simulation model to assess the cost-effectiveness of different screening strategies for abdominal aortic aneurysms (AAAs) in men.
A systematic review of the literature was conducted for different screening strategies in terms of age (60, 65, or 70 years) and risk profiles (all men or specific high-risk groups) of the screened population, and rescreening after 5 or 10 years. These data were analyzed in a Markov simulation cohort model.
The cost per life year gained for different screening strategies ranged from US 8,309 dollars to US 14,084 dollars and was estimated at US 10,474 dollars when 65-year-old men were screened once. Screening 60-year-old men was equally cost-effective, with the advantage of more life years gained. We demonstrated a trade-off between high prevalence of AAA and lower life expectancy, eliminating the expected benefits of screening high-risk groups such as smokers (US 10,695 dollars) or cardiovascular patients (US 10,392 dollars). Assuming general population utility resulted in a cost per quality-adjusted life year (QALY) gained of US 13,900 dollars, whereas a hypothetical 5% reduction in utility among men with a screening-detected AAA raised the cost per QALY gained to US 75,100 dollars.
This Markov model, which was based on a systematic review of the literature, supplied information on the estimated cost-effectiveness of different screening strategies. Screening men for AAA may be cost-effective in the long-term. Different screening strategies and quality-of-life effects related to screening for AAA need to be evaluated in future clinical studies.
Purpose
To compare endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (rAAA) to the results with open surgery.
Methods
Between May 2001 and January 2004, 50 patients were diagnosed with rAAA. Fifteen (30%) patients (14 men; median age 73 years, range 58–85) underwent EVAR, while 26 (52%) patients (23 men; median age 75 years, range 60–84) had open surgery. Nine (18%) patients (5 men; median age 86 years, range 77–91) were not operated upon. Circulatory shock was defined as systolic blood pressure < 80 mmHg. Mortality was defined as death within 30 days after operation; in cases where hospital stay exceeded 30 days, in-hospital mortality was registered. Five risk factors (age >76 years, loss of consciousness, hemoglobin < 90 g/L, creatinine >190 μmol/L, and electrocardiographic ischemia) were analyzed.
Results
In the EVAR group, 93% (14/15) of the aneurysms were excluded from the blood-stream; there were 2 (13%) conversions: 1 intraoperatively for stent-graft migration and another owing to dissection prior to hospital discharge. Mortality after open surgery was 46% (12/26) versus 13% (2/15) in the EVAR group (p>0.05). Univariate analysis without considering variables other than mortality resulted in OR 5.4 (95% CI 0.9 to 58; p=0.07). Considering risk factors and shock, multivariate analysis resulted in OR 6.5 (95% CI 0.8 to 96; p=0.08). In the EVAR group, 60% (9/15) had complications; in the group with open surgery, the complication rate was 85% (22/26; p=0.13).
Conclusions
It is possible to treat rAAA with EVAR. Hypotensive patients can, at least initially, be operated under local anesthesia to stabilize blood pressure utilizing a percutaneously inserted occlusion balloon. There was a trend in our study for reduced mortality and morbidity with EVAR, but further studies are required to conclude whether EVAR significantly increases survival and reduces complications.
Background:
Spinal cord ischemia is a rare complication after open surgical repair for ruptured abdominal aortic aneurysms (rAAA). The use of emergency endovascular aortic aneurysm repair (eEVAR) is increasing, and paraplegia has been observed in a few patients. The objective of this study was to assess the incidence and pathogenesis of spinal cord ischemia after eEVAR in greater detail.
Methods:
This was a retrospective analysis of patients who had eEVAR for rAAA in three hospitals in The Netherlands and Belgium during a 3-year study period that ended in February 2004. The use of aortouniiliac devices combined with a femorofemoral crossover bypass was the preferred technique. Patients with postoperative symptoms of spinal cord ischemia were identified and the influence of potential risk factors was assessed. These factors included the presence of common iliac artery aneurysms necessitating device limb extension to the external iliac artery with associated overlapping the hypogastric artery, the prolonged interruption of bilateral hypogastric artery arterial inflow during the procedure (defined "functional aortic occlusion time" >30 minutes), and the occurrence of preoperative hemodynamic shock.
Results:
Thirty-five patients were treated by EVAR and they constituted the study group. The first-month mortality in the study group with EVAR was 23%. Four patients (11.5%) with EVAR developed paraplegia postoperatively; the unilateral or bilateral hypogastric artery in all four patients became occluded during the procedure. In the other 31 patients who did not have paraplegia, the unilateral or bilateral hypogastric arteries became occluded in 14 patients (45%). This constituted a significant difference in the prevalence of hypogastric artery occlusion in patients with or without paraplegia (P = .04). The functional aortic occlusion time was prolonged in all four patients with paraplegia and in five without spinal cord ischemia (P = .0003). All four patients with spinal cord ischemia presented with hemodynamic shock. This factor did not reach a significant difference from nonparaplegic patients.
Conclusion:
Emergency EVAR continues to be a promising approach to reduce the high mortality of rAAA, but the incidence of spinal cord ischemia after endovascular treatment of rAAA was worrisome. Although the pathogenesis is most likely multifactorial, interruption of the hypogastric artery inflow appeared to have significant influence. In patients with aneurysmatic common iliac arteries, any effort should be made to minimize hypogastric occlusion time during the procedure and to maintain hypogastric artery inflow afterwards, either by the use of a bell-bottom iliac extension or by electing open repair.
Operative survival is as high as 96% for elective abdominal aortic aneursym (AAA) repair but as low as 10% for emergency repair. Our primary aim was to compare elective AAA repair in octogenarians with nonoperative management. Our secondary aim was to compare octogenarians with their younger counterparts.
From 1998 to 2003, 180 patients with AAA were treated operatively or nonoperatively. Factors determining treatment included American Society of Anesthesiologists grade ≥ 4, inoperable malignancy, New York Heart Association class III, forced expiratory volume in 1 second < 35%, creatinine > 6.0 mg/dL, and patient and family choice. A parallel-group observational study was performed to assess age and treatment effects on outcome.
Seventy (39%) patients were repaired electively, 68 (38%) were managed nonoperatively, and 42 (23%) underwent emergency repair. Fifty-nine (33%) were octogenarians.
The octogenarian 5-year survival rate was 20% following emergency repair, 42% if treated nonoperatively, and 83% following elective repair. Younger cohort rates were 55% (emergency), 44% (nonoperative), and 76% (elective).
The octogenarian mean expansion rate was 0.26 cm/yr in those treated nonoperatively and 1.04 cm/yr in confirmed rupture. Rupture rate was related to expansion rate (95% confidence interval [CI] 0.06–0.59, r = .35, p = .01). The rates in the younger subgroup were 0.32 cm/yr and 1.14 cm/yr (95% CI −0.021–0.672}, r = .37, p = .03).
The octogenarian survival rate was highest following elective repair. Rupture was closely correlated with aneurysm expansion. Screening should reduce the incidence of octogenarian rupture of AAA and identify those patients most suitable for nonoperative management.
In the absence of formal screening abdominal aortic aneurysms (AAA) are detected in an opportunistic manner. Many remain asymptomatic and undetected until they rupture. Incidentally discovered small AAAs are entered into a surveillance programme until they reach a suitable size for repair. The aim of this study was to examine trends in the management of AAA and whether the method of presentation had an effect on subsequent mortality.
Observational study in UK district general hospital.
This study reports a single surgeon case series identified using a prospectively maintained database. Data on mode of presentation, management and mortality were retrieved from case notes, PIMS hospital database and the Office of National Statistics.
Two hundred and five patients were referred with AAAs between 1992 and 2004, 78% presenting in elective circumstances. The surveillance programme fed 33% of the operated cases. Two aneurysms ruptured whilst under surveillance. Overall elective operative mortality was 11.8% and has progressively decreased over time. Thirty-day operated mortality was significantly lower in patients having a period of surveillance than those having immediate elective repair (2.3 vs. 16.3%, p=0.018). A slight reduction in emergency AAA repairs was noted over the study period (r2=0.6) although registered aneurysm deaths continue to increase (r2=0.83).
Elective mortality following AAA surgery decreased over the study period. Outcome was better in those patients who had surgery for aneurysms that had been under surveillance. Despite opportunistic screening the population adjusted mortality rate of aortic aneurysms showed a progressive increase. A reduction in deaths from aneurysms is unlikely without a formal screening programme.
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