Preoperative risk score accuracy confirmed in a modern ruptured abdominal aortic aneurysm experience

Validation of Harborview Risk Score for Ruptured Abdominal Aortic Aneurysms in a 22-Year Retrospective Single- Centre Experience

BACKGROUND

Among all the published risk scores, the Harborview Risk Score (HRS) is the only one that relies exclusively on preoperative variables that can be easily assessed at the bedside (age >76 years, creatinine concentration >2.0 mg/dL, systolic blood pressure ever <70 mm Hg and pH < 7.2 or international normalized ratio >1.8). This study has the aim of retrospectively evaluating the population of the ASST Grande Ospedale Metropolitano Niguarda (Milan) the accuracy of the HRS in Italy and of the modified Harborview Risk Score (mHRS) for the first time in Italy.

METHODS

A single-center, retrospective, observational study was performed. Information on patients treated for ruptured abdominal aortic aneurysms (rAAAs) between January 2002 and March 2024 at the ASST Grande Ospedale Metropolitano Niguarda, Milan (Italy) were collected.

RESULTS

Of the 180 patients treated for rAAA in our hospital during the 22-year study period, 158 met inclusion criteria for the HRS and 145 for the mHRS. Observed 30-day mortality using the HRS was 8.3%, 24.1%, 47%, 54.5%, and 100%, respectively, for a score from 0 to 4 (P value < 0.001). For the mHRS the 30-day mortality observed was 13.2%, 26.7%, 36.4%, 58.8%, and 100%, respectively, for a score from 0 to 4 (P value < 0.001). Receiver operating characteristic analysis revealed a slightly higher ability of the HRS to predict 30-day death (area under the curve = 0.732) than the mHRS (area under the curve = 0.682).

CONCLUSION

The HRS can accurately predict 30-day mortality after repair of rAAAs, with a higher accuracy for the HRS than the mHRS. These scores represent valuable tools that may guide the clinical decision-making process and help predict futility in the preoperative setting for this morbid disease.

The Modified Harborview Risk Score Successfully Predicts Mortality after Ruptured Abdominal Aortic Aneurysm Repair

BACKGROUND

The traditional Harborview Risk Score uses 4 criteria to predict mortality after surgical repair of ruptured abdominal aortic aneurysms (rAAAs): preoperative minimum systolic blood pressure <70 mm Hg, creatinine >2.0 mg/dL, age >76 years and preoperative arterial pH < 7.2. Difficulties obtaining arterial pH values limit the clinical utility of this score. The international normalized ratio (INR > 1.8) has been proposed as an acceptable substitution when arterial blood gases are not available preoperatively. Preliminary studies have shown that the accuracy of the score is not compromised when using this modified criterion. The objective of this study is to validate the modified Harborview Risk Score (mHRS).

METHODS

We conducted a retrospective analysis of all patients presenting with rAAA at a single tertiary-care center from 2011 to 2022. The Vascular Study Group of New England (VSGNE) score was used for comparison. The primary outcome was 30-day mortality. Logistic regression and receiver operating characteristic curves were used to evaluate the predictability of each score. Categorical and continuous data were compared using Chi-squared and Student's t-tests, respectively.

RESULTS

Of the 91 patients identified during the study period, 69 patients met inclusion criteria. Fifty patients underwent endovascular repairs and 19 patients received open repairss. All 69 patient records had documented INR values, and 62 patients (89.8%) had documented arterial pH values. The 30-day mortality rate was 38% overall (30% for endovascular repair vs. 58% for open repairs, P = 0.030). There was a stronger linear relationship between the mHRS and 30-day mortality (R2 = 0.97) than the VSGNE score (R2 = 0.94). There was no significant difference in the areas under the receiver operating characteristic curves between the mHRS and VSGNE scores (0.70 [0.56-0.83], P = 0.007 vs. 0.69 [0.56-0.82], P = 0.01, respectively). Logistic regression analysis showed a significant correlation between creatinine (4.0 [1.2-13.8], P = 0.03), systolic blood pressure (3.8 [1.3-11.1], P = 0.02), and age (1.7 [1.1-7.4], P = 0.04) and 30-day mortality.

CONCLUSION

The mHRS accurately predicted 30-day mortality after rAAA repair using INR > 1.8. By using easily obtainable preoperative variables, the mHRS has broader clinical utility, making it a superior scoring system to the traditional Harborview Risk Score and VSGNE scores.

External Validation of Traditional and Modified Harborview Risk Scores for Ruptured Abdominal Aortic Aneurysm 30-day Mortality Prediction

BACKGROUND

A critical issue in the preoperative assessment of a patient with a ruptured abdominal aortic aneurysm (rAAA) is death risk prediction. The traditional and modified Harborview Risk Score (tHRS and mHRS) consider readily available variables to estimate 30-day mortality. The aim of the study was to validate tHRS and mHRS in a rAAA external population.

METHODS

Consecutive patients undergoing rAAA repair from January 2012 to January 2024 at a tertiary Vascular Surgery Center were retrospectively reviewed. The scores were calculated for each patient; receiver operating characteristic curves (ROC), area under the curve (AUC) with 95% confidence intervals (CIs) and calibration plots were built to evaluate discrimination and calibration. Furthermore, the relationship of mortality with score variables was updated running a multivariate logistic model, and then applied to one thousand bootstrap samples.

RESULTS

One hundred and five patients treated for rAAA (97 males, 92.4%) were included in the study (77 ± 8.5 years). An endovascular repair (rEVAR) was performed in 35 patients (3 women, 80 ± 9.0 years) while an open repair (rOAR) in 70 patients (5 women, 75 ± 8.0 years). The 30-day mortality rate was 31.4%, (33/105), 25.7% (9/35), and 34.3% (24/70) for rEVAR and rOAR, respectively (p 0.5). Eight patients (7.6%) were on therapy with warfarin at the time of admission. AUC for tHRS was 0.56 while AUC for mHRS was 0.68 (DeLong test = 0.29). The tHRS' calibration showed underestimation for patients with predicted mortality <25% and overestimation for the remaining; for mHRS, the predictions were well calibrated for patients with estimated mortality <40% with overprediction afterward. The model update demonstrated that the wider effects are due to the interaction between the HRS factors.

CONCLUSIONS

tHRS and mHRS showed limited prediction capability with 30-day mortality overestimation in an external validation, raising many concerns about their extended and systematic application. Interaction between factors should be taken into account to enhance the score's performance, especially in high risk patients.

Review of Scoring Systems for Predicting 30-Day Mortality in Ruptured Abdominal Aortic Aneurysm

BACKGROUND

Ruptured abdominal aortic aneurysms (rAAAs) are a serious disease that can lead to high mortality; thus, their early prediction can save patients' lives. The aim of this study was to compare the accuracies of various models for predicting rAAA mortality-including the Glasgow Aneurysm Score, Vancouver Scoring System, Dutch Aneurysm Score, Edinburgh Ruptured Aneurysm Score (ERAS), and Hardman index-based on rAAA treatment outcomes at our institution.

METHODS

Between 2016 and 2022, we retrospectively analyzed the early outcome data-including 30-day mortality-of patients who underwent emergency surgery for rAAA at our institution. Receiver operating characteristic curve analysis was performed to compare the aneurysm scoring systems for mortality using the area under the receiver operating characteristic curve (AUC).

RESULTS

The AUC was better for the ERAS (0.718; 95% confidence interval, 0.601-0.817) than for the other scoring systems. Significant differences were observed between ERAS and Hardman indices (difference: 0.179; P = 0.016). No significant differences were found among the Glasgow Aneurysm Score, Vancouver Scoring System, and Dutch Aneurysm Score predictive risk models.

CONCLUSIONS

Among the models for predicting mortality in patients with rAAA, the ERAS model demonstrated the highest AUC value; however, significant differences were only observed between ERAS and Hardman indices. This study may help develop strategies for improving rAAA prediction.

Predicting 30-day Mortality after Ruptured Abdominal Aortic Aneurysms: Validation of the Harborview Risk Score in a Single-Center Dutch Study Population

BACKGROUND

The Harborview Risk Score (HRS) was recently proposed as scoring tool to predict 30-day mortality in patients with ruptured abdominal aortic aneurysms (rAAAs). The HRS assigns 1 point for each of the following preoperative characteristics: age > 76 years, pH < 7.2, creatinine level > 2 mg/dL (> 176.8 μmol/L), and systolic blood pressure < 70 mm Hg, resulting in scores from 0 to 4. The 30-day mortality risk increases with every point. Primarily, we aimed to validate the HRS for the first time in a Dutch study population. A second objective was to identify other clinically relevant predictors for 30-day mortality after repair of rAAA.

METHODS

Retrospective data from patients who underwent open repair or endovascular aortic repair for a rAAA between January 2009 and February 2022 were reviewed. Patients were grouped by HRS category (score 0-4). The 30-day mortality rate was calculated for each HRS category. Determinants for 30-day mortality were tested for significance and validated for HRS.

RESULTS

In total, data from 135 patients were included. Open repair was performed in 95 patients and 40 patients underwent endovascular aortic repair. Univariate logistic regression identified pH < 7.2, systolic blood pressure < 70 mm Hg, female sex, performance status, and increase per HRS unit as significant determinants for 30-day mortality. After adjusting for sex and performance status in the multivariate analysis, the association between the HRS per-unit increase and 30-day mortality remained significant (odds ratio 2.532 (95% confidence interval: 1.437-4.461)). The 30-day mortality rate for HRS score 0 was 15.2%, while for HRS score 3 and 4 the mortality was 80% and 100% respectively.

CONCLUSIONS

The Harborview Risk Score was validated in this single-center Dutch population. Results were concordant with data presented in earlier studies. Therefore, the HRS seems accurate and accessible as preoperative tool. For now, the HRS should guide as an insightful tool to indicate the chances of postoperative mortality during the preoperative conversations in the emergency room, rather than as a decision-making tool whether to operate or not. Our results suggest that female sex and performance status are also relevant predictors that should be assessed in other populations to improve preoperative scoring systems.

Transition from Open Repair to Endovascular Aneurysm Repair for Rupture Aortic Aneurysms throughout a 16-Year Period of Time in a Single Tertiary Center

BACKGROUND

Endovascular aneurysm repair (EVAR) is recommended as the first option for both elective and ruptured abdominal aortic aneurysms (rAAAs) with suitable anatomy. The aim of this study was to evaluate the outcomes of the gradual adoption of ruptured EVAR (rEVAR) as first option in the management of rAAAs in a reference tertiary center over a 16 year-period.

METHODS

A retrospective analysis of prospectively collected clinical data was undertaken, including all patients that were treated for rAAA infrarenal or juxtarenal either with open surgical repair (OSR) or EVAR from 2006-2023. Three periods were identified and analyzed: Initial (2006-2011); intermediate (2012-2017); and current (2018-2023). The primary outcomes were the 30-day mortality rate in relation to the changing pattern of treatment. Secondary outcomes were re-intervention and mortality during the follow up period.

RESULTS

Two hundred patients were treated for rAAA; 52% by endovascular means [EVAR (94), Ch-EVAR (9), and branched endovascular aneurysm repair (1)] and 48% by OSR (96). In the initial period, 61 patients were treated for rAAA (21% EVAR vs. 79% OSR), 68 in intermediate patients (47% EVAR vs. 53% OSR), and 71 in current period (83% EVAR vs. 17% OSR). Only in the current period juxta -renal rAAAs were treated by endovascular means (14%). The 30-day mortality rate was 46% in initial period (31% for EVAR vs. 50% for OSR), 64% in second period (46% in EVAR vs. 80% for OSR), and 35% in third period (25% for EVAR vs. 83% for OSR). The mean follow up did not differ between the groups, (EVAR 28.3 ± 2 months, vs. OSR 33.1 ± 3 months, P = 0.56). The survival rate did not differ between the groups; in rEVAR was 82% (SE 5%), 74% (SE 6%), 68% (SE 6.5%), and 63% (SE 7.7%) at 12, 24, 36, and 48 months, respectively, and in OSR was 76% (SE 7%), 66% (SE 8%), and 56% (SE 9.5%) at 6, 24, and 48 months, respectively (P = 0.544).

CONCLUSIONS

Through a 16-year period, the implementation of EVAR as treatment of choice for rAAAs over OSR resulted in a noticeable reduction in the 30-day mortality. rEVAR was feasible in over 80% of rAAA patients.

Modified Harborview Risk Score accurately predicts mortality for patients with ruptured abdominal aortic aneurysm

OBJECTIVE

The modified Harborview Risk Score (HRS) is a simple measure initially derived from a single institutional dataset used to predict ruptured abdominal aortic aneurysm (rAAA) repair survival preoperatively using basic labs and vital signs collected upon presentation. However, validation of this widely applicable scoring system has not been performed. This study aims to validate this scoring system using a large multi-institutional database.

METHODS

All patients who underwent repair of an rAAA from 2011 to 2018 in the National Surgical Quality Improvement Program (NSQIP) and at a single academic medical center were included. The modified HRS was calculated by assigning 1 point for each of the following: age >76 years, creatinine >2 mg/dL, international normalized ratio >1.8, and any systolic blood pressure less than 70 mmHg. Assessment of the prediction model was then completed. Using a primary outcome measure of 30-day mortality, the receiver operating characteristic area under the curve was calculated. The discrimination between datasets was compared using a Delong test. Mortality rates for each score were compared between datasets using the Pearson χ2 test. Comparative analysis for patients with a score of 4 was limited due to a small sample size.

RESULTS

A total of 1536 patients were identified using NSQIP, and 163 patients were assessed in the institutional dataset. There were 518 patients with a score of 0 (455 NSQIP, 63 institutional), 676 patients with a score of 1 (617 NSQIP, 59 institutional), 391 patients with a score of 2 (364 NSQIP, 27 institutional), 106 with a score of 3 (93 NSQIP, 13 institutional), and 8 patients with a score of 4 (7 NSQIP, 1 institutional). No difference was found in the receiver operating characteristic area under the curves between datasets (P = .78). Thirty-day mortality was 10% NSQIP vs 22% institutional for a score of 0; 28% NSQIP vs 36% institutional for a score of 1; 41% NSQIP vs 44% institutional for a score of 2; 45% NSQIP vs 69% institutional for a score of 3; and 57% NSQIP vs 100% institutional for a score of 4. Score 0 was the only score with a significant mortality rate difference between datasets (P = .01).

CONCLUSIONS

The modified HRS is confirmed to be broadly applicable as a clinical decision-making tool for patients presenting with rAAAs. Therefore, this easily applicable model should be applied for all patients presenting with rAAAs to assist with provider and patient decision-making prior to proceeding with repair.

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.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Modern management of ruptured abdominal aortic aneurysm

Ruptured abdominal aortic aneurysms (rAAA) remain one of the most clinically challenging and technically complex emergencies in contemporary vascular surgery practice. Over the past 30 years, a variety of changes surrounding the treatment of rAAA have evolved including improvements in diagnosis, development of coordinated referral networks to transfer patients more efficiently to higher volume centers, deliberate de-escalation of pre-hospital resuscitation, modification of patient and procedure selection, implementation of clinical pathways, as well as enhanced awareness of certain high-impact postoperative complications. Despite these advances, current postoperative outcomes remain sobering since morbidity and mortality rates ranging from 25%-50% persist among modern published series. Some of the most impactful variation in rAAA management has been fostered by the rapid proliferation of endovascular repair (EVAR) along with service alignment at selected centers to improve timely revascularization. Indeed, clinical care pathways and emergency response networks are now increasingly utilized which has led to improved outcomes contemporaneously. Moreover, evolution in pre- and post-operative physiologic resuscitation has also contributed to observed improvements in rAAA outcomes. Due to different developments in care provision over time, the purpose of this review is to describe the modern management of rAAA, while providing historical perspectives on patient, procedure and systems-based practice elements that have evolved care delivery paradigms in this complex group of patients.

The Management of Ruptured Abdominal Aortic Aneurysms: An Ongoing Challenge

BACKGROUND

despite improvements in the diagnosis and treatment of elective AAAs, ruptured abdominal aortic aneurysms (RAAAs) continue to cause a substantial number of deaths. The choice between an open or endovascular approach remains a challenge, as does postoperative complications in survivors. The aim of this manuscript is to offer an overview of the contemporary management of RAAA patients, with a focus on preoperative and intraoperative factors that could help surgeons provide more appropriate treatment.

METHODS

we performed a search on MEDLINE, Embase, and Scopus from 1 January 1985 to 1 May 2023 and reviewed SVS and ESVS guidelines. A total of 278 articles were screened, but only those with data available on ruptured aneurysms' incidence and prevalence, preoperative scores, and mortality rates after emergency endovascular or open repair for ruptured AAA were included in the narrative synthesis. Articles were not restricted due to the designs of the studies.

RESULTS

the centralization of RAAAs has improved outcomes after both surgical and endovascular repair. Preoperative mortality risk scores and knowledge of intraoperative factors influencing mortality could help surgeons with decision-making, although there is still no consensus about the best treatment. Complications continue to be an issue in patients surviving intervention.

CONCLUSIONS

RAAA still represents a life-threatening condition, with high mortality rates. Effective screening and centralization matched with adequate preoperative risk-benefit assessment may improve outcomes.

Risk Prediction Models for Peri-Operative Mortality in Patients Undergoing Major Vascular Surgery with Particular Focus on Ruptured Abdominal Aortic Aneurysms: A Scoping Review

PURPOSE

The present scoping review aims to describe and analyze available clinical data on the most commonly reported risk prediction indices in vascular surgery for perioperative mortality, with a particular focus on ruptured abdominal aortic aneurysm (rAAA).

MATERIALS AND METHODS

A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English in PubMed, Cochrane and EMBASE databases (last queried, 30 March 2023) were systematically reviewed and analyzed. The Population, Intervention, Comparison, Outcome (PICO) framework used to construct the search strings was the following: in patients with aortic pathologies, in particular rAAA (population), undergoing open or endovascular surgery (intervention), what different risk prediction models exist (comparison), and how well do they predict post-operative mortality (outcomes)?

RESULTS

The literature search and screening of all relevant abstracts revealed a total of 56 studies in the final qualitative synthesis. The main findings of the scoping review, grouped by the risk score that was investigated in the original studies, were synthetized without performing any formal meta-analysis. A total of nine risk scores for major vascular surgery or elective AAA, and 10 scores focusing on rAAA, were identified. Whilst there were several validation studies suggesting that most risk scores performed adequately in the setting of rAAA, none reached 100% accuracy. The Glasgow aneurysm score, ERAS and Vancouver score risk scores were more frequently included in validation studies and were more often used in secondary studies. Unfortunately, the published literature presents a heterogenicity of results in the validation studies comparing the different risk scores. To date, no risk score has been endorsed by any of the vascular surgery societies.

CONCLUSIONS

The use of risk scores in any complex surgery can have multiple advantages, especially when dealing with emergent cases, since they can inform perioperative decision making, patient and family discussions, and post hoc case-mix adjustments. Although a variety of different rAAA risk prediction tools have been published to date, none are superior to others based on this review. The heterogeneity of the variables used in the different scores impairs comparative analysis which represents a major limitation to understanding which risk score may be the "best" in contemporary practice. Future developments in artificial intelligence may further assist surgical decision making in predicting post-operative adverse events.

Intraoperative predictors of in-hospital mortality after open repair of ruptured abdominal aortic aneurysms

BACKGROUND

Several models and scores have been released to predict early mortality in patients undergoing surgery for a ruptured abdominal aortic aneurysm (rAAA). These scores included above all preoperative factors and they could be useful to deny surgical repair. The aim of the study was to evaluate intraoperative predictors of in-hospital mortality in patients undergoing open surgical repair (OSR) for a rAAA.

METHODS

Between January 2007 and December 2020, 265 patients were admitted at our tertiary referral hospital for a rAAA. Two-hundred-twenty-two patients underwent OSR. Intra-operative factors were analyzed by means of univariate analysis (step 1). Associations of procedure variables with in-hospital mortality rates were sought based on a multivariate Cox regression analysis (step 2).

RESULTS

Overall, in-hospital mortality rate was 28.8% (64 cases). Multivariate Cox regression analysis reported that operation time >240 minutes (P=0.032, OR 2.155, CI 95% 1.068-4.349), and hemoperitoneum (P<0.001, OR 3.582, CI 95% 1.749-7.335) were negative predictive factors for in-hospital mortality. Patency of at least one hypogastric artery (P=0.010; OR 0.128, CI 95% 0.271-0.609), and infrarenal clamping (P=0.001; OR 0.157, CI 95% 0.052-0.483) had a protective role in reducing in-hospital mortality rate.

CONCLUSIONS

Operation time >240 minutes, and hemoperitoneum affected in-hospital mortality in patients undergoing OSR for rAAA. Patency of at least one hypogastric artery, and infrarenal clamping had a protective role. Further studies are needed to validate these outcomes. A validated predictive model could be useful to help the physicians in communication with patients' relatives.

The role of big data, risk prediction, simulation, and centralization for emergency vascular problems: Lessons learned and future directions

Vascular specialists remain in high demand in current practice and commonly oversee care delivery for a variety of clinical emergencies. Accordingly, the contemporary vascular surgeon must be facile with treating a spectrum of problems, including a complex, heterogeneous group of acute arteriovenous thromboembolic and bleeding diatheses. It has been documented previously that there are substantial current workforce limitations placing constraints on vascular surgical care provision. Moreover, with the aging at-risk population, there remains a considerable national urgency to improve timely diagnoses, specialty consultation, and appropriate transfer of patients to centers of excellence capable of providing a comprehensive compendium of emergency vascular services. Clinical decision aids, simulation training, and regionalization of nonelective vascular problems are all strategies that have been increasingly recognized to address these service gaps. Notably, clinical research in vascular surgery has traditionally focused on identification of patient- and procedure-related factors that influence outcomes by using resource-intensive causal inference methodology. By comparison, large data sets have only more recently been recognized to be a valuable tool that can provide heuristic algorithms to address more complex health care problems. Such data can be manipulated to generate clinical risk scores and decision aids, as well as robust outcome descriptions, which stand to inform stakeholders regarding best practice. The purpose of this review was to provide a robust overview of the lessons derived from the application of big data, risk prediction, and simulation in the management of vascular emergencies.

Emergency vascular surgical care in populations with unique physiologic characteristics: Pediatric, pregnant, and frail populations

Vascular surgical emergencies are common in vascular surgical care and require complex decision making and multidisciplinary care. They are especially challenging when they occur in patients with unique physiological characteristics, such as pediatric, pregnant, and frail patients. Among the pediatric and pregnant population, vascular emergencies are rare. This rarity challenges accurate and timely diagnosis of the vascular emergency. This landscape review summarizes these three unique populations' epidemiology and emergency vascular considerations. Understanding the epidemiology is the foundation for accurate diagnosis and subsequent management. Considering each population's unique characteristics is crucial to the emergent vascular surgical interventions decision making. Collaborative and multidisciplinary care is vital in gaining expertise in managing these special populations and achieving optimal patient outcomes.

Association of Genetic Polymorphisms and Serum Levels of miR-1-3p with Postoperative Mortality following Abdominal Aortic Aneurysm Repair

BACKGROUND

Several miRNAs have been implicated in the clinical outcomes of cardiovascular disorders, but the role of miR-1-3p in abdominal aortic aneurysm (AAA) prognosis remains unclear. This study aimed to investigate the correlation of single nucleotide polymorphisms (SNPs) in pri-miR-1-3p and mature miR-1-3p expression with postoperative mortality of AAA patients.

METHODS

A total of 230 AAA patients who received AAA repair were recruited and followed up for 5 years. SNP genotyping was carried out using KASP method and relative expression of serum miR-1-3p was measured with qRT-PCR.

RESULTS

Multivariate Cox regression analyses showed that both rs2155975 and rs4591246 variant genotypes were associated with increased all-cause mortality of postoperative AAA patients after adjusting possible confounders. Patients who died tended to have lower baseline miR-1-3p expression (overall and for age < 65 years, aneurysm-related death or cardiac death subgroup) when compared to alive patients; further Cox regression yielded an independent relationship of preoperative low serum miR-1-3p levels with incidents of all-cause death. Patients carrying rs2155975 AG + GG or rs4591246 AG + AA genotype had a higher ratio of low miR-1-3p levels in contrast to those with AA or GG genotype, respectively. The Kaplan-Meier survival curves suggested that the combined genotype in rs2155975 or rs4591246 and low miR-1-3p levels could decrease the overall survival of AAA patients during 5-year follow-up.

CONCLUSIONS

This pilot study demonstrated the importance of rs2155975 and rs4591246 polymorphisms and baseline serum miR-1-3p levels as promising markers to predict mortality among patients following AAA repair.