Emergency Abdominal Aortic Aneurysm Repair: Factors Affecting Survival and Long-Term Results

Elective surgery for abdominal aortic aneurysm (AAA) has become a safe operation, although the mortality related to ruptured AAA remains considerably high. Factors affecting survival of 32 consecutive patients with ruptured AAAs were evaluated. The postoperative mortality was 50% (16/32) compared with 1.9% for 103 elective AAA patients. Factors associated with poor prognosis were systolic blood pressure of less than 90 mmHg and severe metabolic acidosis on arrival to the hospital, size of the aneurysm, and massive blood transfusion. The high mortality and morbidity rates of the ruptured AAA patients emphasize the need for early and aggressive treatment of AAA in the elective setting in the patient at high risk. In follow-up study, however, the actuarial survival following ruptured AAA surgery, excluding hospital mortality, was 77% at five years. It did not differ statistically from that of patients who had elective AAA surgery. The quality of life survey following surgery showed no discernible differences between ruptured and elective AAA surgery.

Prediction of outcome after abdominal aortic aneurysm rupture

BACKGROUND

Most vascular surgeons practice a selective policy of operative intervention for patients with ruptured abdominal aortic aneurysm (AAA). The evidence on which to justify operative selection remains uncertain. This review examines the prediction of outcome after attempted open repair of ruptured AAA.

METHODS

The Medline and EMBASE databases and Cochrane Database of Systematic Reviews were searched for clinical studies relating to the prediction of outcome after ruptured AAA. Reference lists of relevant articles were also reviewed.

RESULTS

The last 20 years has seen >60 publications considering variables predictive of outcome after AAA rupture. Four predictive scoring systems are reported: Hardman Index, Glasgow Aneurysm Score, Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM), and the Vancouver Scoring System. No scoring system has been shown to have consistent or absolute validity. Of the remaining data, there are no individual or combination of variables that can accurately and consistently predict outcome.

CONCLUSIONS

Little robust evidence is available on which to base preoperative outcome prediction in patients with ruptured AAA. Experienced clinical judgement will remain of foremost importance in the selection of patients for ruptured AAA repair.

Determinants of postoperative and long-term survival of patients with ruptured abdominal aortic aneurysms

To compare the surgical results of patients with ruptured (rAAA) and nonruptured abdominal aortic aneurysms (NrAAA), 267 consecutive patients surgically treated for abdominal aortic aneurysms (AAA) were reviewed. The patients' characteristics, preexistent risk factors, perioperative factors, and postoperative early and long-term survival were compared between the rAAA group (n = 27) and the NrAAA group (n = 240). A multivariate analysis to predict postoperative survival was also conducted in the rAAA group. The hospital mortality rate was 3.3% (8/232) for the NrAAA group and 22.2% (6/27) for the rAAA group (P < 0.001). The maximum size of aneurysms, period of preoperative hypotension, and intraoperative bleeding volume were significantly higher in the rAAA group than in the NrAAA group. The 5- and 10-year cumulative survival rates in the rAAA group were 88.1% and 42.0%, which were comparable to those in the NrAAA group. The incremental risk factors for hospital death in the rAAA group included advanced age, preoperative hypotension (< 80 mmHg), and postoperative renal failure requiring dialysis. These findings showed that the interval from rupture to cross-clamping must be shortened, maintaining hemodynamic stability to avoid prolonged hypotension. Reducing risk factors and minimizing deterioration of organ functions postoperatively would be essential to improve the prognosis of patients with rAAA.