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Results of 101 Ruptured Abdominal Aortic Aneurysm Repairs From a Single Surgical Practice
Sachinder Singh Hans, MD;
Raywin R. Huang, PhD
Arch Surg. 2003;138:898-901.
ABSTRACT
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Hypotheses The results of ruptured abdominal aortic aneurysm repairs from a solo community hospital–based practice are comparable to those reported from large university referral medical centers. Patients younger than 70 years, arriving in the emergency department with stable hemodynamics, and undergoing prompt operation have better outcome.
Design A retrospective review from an ongoing vascular surgery registry.
Setting Two midsized (300-bed) community hospitals. One hundred one consecutive patients with ruptured abdominal aortic aneurysms who were undergoing open surgical repair by a single surgeon (S.S.H.) during a 21-year period were reviewed.
Main Outcome Measures Operative mortality; cardiac, pulmonary, renal, and gastrointestinal complications; and coagulation abnormalities were recorded. Iatrogenic complications and length of hospital stay were noted. Preoperative and intraoperative factors affecting mortality were studied.
Results Fifty-three patients survived ruptured abdominal aortic aneurysm repair (operative mortality, 47.5%). A favorable outcome was observed in patients (1) younger than 70 years, (2) with a hematocrit of more than 35% at presentation, and (3) with emergency department to operating room times of less than 120 minutes. Increasing experience of the surgeon did not result in improved survival.
Conclusion The results of ruptured abdominal aortic aneurysm repairs from community-based practice are comparable to those reported from university referral medical centers.
INTRODUCTION
A RUPTURED abdominal aortic aneurysm (RAAA) is associated with excessive mortality, even in patients who are fortunate enough to reach a hospital and undergo immediate repair. Early transportation to an emergency department (ED), prompt diagnosis, resuscitation (preferably in an operating room [OR]), immediate operation by an experienced surgeon, and associated technical considerations may impact the outcome of an RAAA.1-11 Previous studies12-13 regarding surgeons' experiences in influencing the mortality associated with an RAAA repair have yielded conflicting results. Most of the outcome data for an RAAA repair have been reported from large university referral medical centers. There are relatively few reports1, 14 of an RAAA repair from surgeons practicing in community hospitals. An individual surgeon's experience with an RAAA repair is limited by small numbers.1, 14 The experience of a single surgeon (S.S.H.) with 101 RAAA repairs performed at a community hospital–based practice is reported herein.
METHODS
One hundred one consecutive patients with RAAAs who were undergoing open surgical repair by a single surgeon (S.S.H.) during a 21-year period were reviewed. Data were collected from an ongoing vascular surgery registry. Age, sex, OR time, ED to OR time, lowest blood pressure at presentation to the ED, and initial hematocrit (Hct) were analyzed. Blood transfusion requirements, lowest blood pressure in the OR, and iatrogenic complications (renal, cardiac, pulmonary, gastrointestinal, and coagulation abnormalities) were recorded. Follow-up data (range, 1-21 years) were available for 53 patients (2 patients were lost to follow-up—one 2 years and the other 5 years after the RAAA repair). Patient outcome measures were analyzed using the  2 test and the Fisher exact test. A univariate analysis and multiple logistic regression analyses were performed. Continuous variables were reported as mean ± SD. All analyses were conducted using Statistical Product and Service Solutions, version 10 (SPSS Inc, Chicago, Ill).
One hundred patients were operated on via a midline abdominal incision. One patient with a leaking AAA had extension of the aneurysm up to the superior mesenteric artery and underwent a thoracoabdominal retroperitoneal approach for repair. In 3 patients, a medial visceral rotation was performed (for a ruptured type IV thoracoabdominal aneurysm in 2 and for an RAAA with a ureteroileostomy in 1).
Three patients had free rupture of an AAA. Ninety-eight patients had a retroperitoneal hematoma. Proximal control was obtained by supraceliac clamping of the aorta at the diaphragm in 4 patients. Intraluminal control with a large Foley balloon catheter (30-mL balloon capacity) passed through an aneurysmal sac was obtained through the infrarenal AAA in 16 patients. Suprarenal clamping between the superior mesenteric and the renal artery was performed in 20 patients. After obtaining proximal control, the clamp was applied below the renal arteries. An infrarenal clamp was placed in the remaining 61 patients. Two patients had a rupture associated with an inflammatory aortic aneurysm.
RESULTS
Ninety-five patients experienced an infrarenal rupture of an AAA. Three patients experienced a rupture of the iliac aneurysm, but these patients had an associated large unruptured AAA. Three patients had a suprarenal AAA; in 1 patient, the upper extent of the aneurysm was up to the superior mesenteric artery, and in the remaining 2 patients, there was involvement of the celiac, superior mesenteric, and renal arteries (Crawford type IV thoracoabdominal aneurysm). Forty-eight patients died during the perioperative period, including 5 in whom the repair of the RAAA could not be completed (operative mortality, 47.5%). Perioperative morbidity was high, with a predominance of pulmonary complications (60 patients [59.4%]), renal failure (41 patients [40.6%]), and coagulation abnormalities (32 patients [31.7%]). There were also cardiac (25 patients [24.8%]), gastrointestinal (25 patients [24.8%]), neurological (2 patients [2.0%; paraparesis in one and basilar artery stroke in the other]), and iatrogenic (9 patients [8.9%]) complications. The length of hospital stay was 14.97 ± 14.42 days, and the OR time was 3.88 ± 0.63 hours.
Certain preoperative and intraoperative factors were significant in relation to perioperative mortality (Table 1 and Table 2). Patients younger than 70 years had a significantly better outcome by univariate and multiple regression analyses. Female patients did not have a worse outcome than their male counterparts. Patients with an Hct of more than 35% at presentation to the ED had a significantly better outcome. The presence of chronic obstructive pulmonary disease, the presence of coronary artery disease, and a history of congestive heart failure did not influence the outcome of the RAAA repair. Patients taken to the OR within 120 minutes of presenting in the ED had a much better outcome (P = .02). Patients whose lowest blood pressure was higher than 90 mm Hg, either in the ED or the OR, had a better outcome by univariate analysis. When the data were analyzed by a stepwise multiple logistic regression analysis, however, this did not have any influence on mortality rate. Patients receiving less than 17 U of packed cells during the operative procedure did not have better outcomes.
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Table 1. Univariate Analysis of Preoperative and Intraoperative Variables and Their Association With Mortality
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Table 2. Multiple Logistic Regression Analysis of Variables Associated With Mortality of RAAA Repair
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One hundred one patients were divided into 2 categories: the early group (July 1980 to December 1990 [n = 46]) and the late group (January 1991 to February 2001 [n = 55]). There was no statistical difference in the mortality between the 2 groups (P = .88), although the operative time was significantly shorter in the late group vs the early group (3.73 ± 0.58 vs 4.05 ± 0.67 hours; P = .01) (Table 3). The 9 iatrogenic complications included a laceration to the right renal artery (n = 1), injury to the right common iliac vein (n = 1), injury to the left renal vein (n = 2), right renal artery occlusion (n = 1), ureter necrosis (n = 1), tearing of the suprarenal aorta from a clamp injury (n = 1), a splenic laceration (n = 1), and tension pneumothorax from a central line insertion (n = 1). There was no difference in iatrogenic complications between the early and late groups.
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Table 3. Analysis of Morbidity and Mortality in 2 Groups*
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There were 13 patients who were younger than 70 years, had a presenting Hct of more than 35%, and had ED to OR times of less than 120 minutes. Eleven survived the RAAA repair, but 2 died (the first of multiple organ failure secondary to a descending colon infarction, and the second of renal failure [in a patient who underwent renal artery reimplantation with a solitary kidney associated with an RAAA]).
Thirty-four patients died during the late follow-up period (follow-up, 7.93 ± 0.98 years). Late graft-related complications occurred in 3 patients. Graft infection occurred in 2 patients at 6 months and 3 years following RAAA repair. Graft removal and axillobifemoral reconstruction resulted in perioperative mortality. A left-sided iliac limb–ileum fistula developed in one patient 3 years following the RAAA repair. The graft limb was excised, the small intestine was resected, and a crossover femoral-femoral graft was placed. The patient died 1 year later of metastatic carcinoma of the bile duct.
Tube grafts were used sparingly (in 7 patients). In the remaining patients, most of the grafts were aortoiliac; a few aortofemoral grafts were used.
COMMENT
The morbidity and mortality of an RAAA remain prohibitive, despite immediate surgical repair and aggressive postoperative management. The mortality rates of patients arriving at the hospital have ranged from 32% to 80%.1-11 Such a wide range in reported mortality is due to significant variations in the hemodynamic status of the patient at presentation. In view of the high mortality rate associated with the repair of RAAAs, several studies have tried to identify factors predictive of a fatal outcome. A mortality of more than 92% was identified in patients older than 80 years; the rate was 68% in patients 80 years and younger.11 Donaldson et al4 observed that the mortality was higher in patients older than 76 years. The presence of cardiac disease, chronic obstructive pulmonary disease, and chronic renal failure (creatinine levels >3.0 mg/dL) correlated with poor outcome.4-5 Mortality was also higher in those with a free intraperitoneal rupture and in those with suprarenal extension of the aneurysm.4-5 Hypotension on arrival in the ED (blood pressure <80 mm Hg) and a low Hct correlated with poor outcome as well.15-16 A delay in making the correct diagnosis in the ED and preoperative cardiac arrest were associated with fatal outcome in many patients.6 The mortality was reported to be 47% by Wakefield et al5 if the operative procedure took more than 5 hours, and 33% when the repair could be completed in less than 4 hours. In our series, the operative time was shorter in the late group, without any improvement in mortality in this group (P = .02). Intraoperative blood loss of more than 11 000 mL, an intraoperative transfusion of more than 17 U of packed cells, and the administration of more than 7000 mL of fluid in the OR was associated with a mortality of 57%4; however, we did not find any difference in the outcome among patients receiving 17 U or less vs those receiving more than 17 U of packed cells intraoperatively. Chen et al,17 using a multivariate stepwise logistic regression analysis, found that coagulopathy, ischemic colitis, persistent shock, delayed transfer to the OR, advanced age, a perioperative myocardial infarction, and renal failure were independent predictors for postoperative death. Bradbury et al18 observed that a low platelet count at the completion of the operation was associated with a poor prognosis. By stepwise multiple regression analysis, we observed that age younger than 70 years, an Hct of more than 35%, and an ED to OR time of less than 120 minutes were associated with improved survival rates; however, the presence of a chronic obstructive or a cardiac disease or female sex was not associated with an adverse outcome. Rutledge et al,12 from a statewide review of patients in North Carolina, reported a mortality of 54% for RAAA repair, and found that the survival rate was better in larger hospitals with more than a 100-bed capacity. They also reported an improved patient survival rate with increasing surgeon experience (determined by number of cases). Katz et al19 reported a mortality of 49.8% from a statewide report of RAAAs in Michigan. Dardik et al13 reported an operative mortality of 47.4% from a database of 527 patients in Maryland from 1990 to 1995. Operative mortality rates increased significantly with advancing age; however, the operative mortality was lower when the repair was performed by high-volume surgeons (ie, those performing >10 RAAA repairs in 5 years).13 Ouriel et al9 reported that the surgeon's experience (5 years of practice and 2 aneurysm resections per year) did not affect the mortality associated with an RAAA repair; however, chronic renal failure, chronic obstructive pulmonary disease, and unstable hemodynamic status correlated with poor prognosis. Katz and Kohl1 reported an overall in-hospital mortality of 57% from 3 primary care hospitals in a community setting, and concluded that surgical experience and avoidance of technical errors significantly impacted the survival of patients with an RAAA. They identified 15 major technical errors (6 venous injuries, 4 juxtarenal aortic injuries, 4 intraoperative anastomotic failures, and 1 intraoperative graft occlusion), and noted a 43% mortality.
In conclusion, age younger than 70 years, hemodynamic stability, and prompt surgical repair were factors associated with a successful outcome following an RAAA repair. Although an increase in the surgeon's experience decreased the operative time for the RAAA repair, it did not result in improved morbidity and mortality.
AUTHOR INFORMATION
Corresponding author and reprints: Sachinder Singh Hans, MD, Department of Surgery, St John Macomb Hospital, 28411 Hoover Rd, Warren, MI 48093 (e-mail: sshans{at}comcast.net).
Accepted for publication January 25, 2003.
We thank Alexander Shepard, MD, and Michael Dahn, MD, PhD, for their assistance in the preparation of the manuscript.
From the Department of Surgery, St John Macomb Hospital, Warren (Dr Hans), and William Beaumont Hospital Research Institute, Royal Oak (Dr Huang), Mich.
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