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Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age.

ABSTRACT: Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA.We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between January 2005 and December 2011 in the vascular surgery department at Amphia Hospital, the Netherlands. The outcome in patients treated for rAAA by eEVAR or OPEN repair was investigated. Special attention was paid to patients who were admitted and did not receive operative intervention due to serious comorbidity, extremely advanced age, or poor physical condition. We calculated the 30-day rAAA-related mortality for all rAAA patients admitted to our hospital.Twelve patients did not receive operative emergency repair due to extreme fragility (mean age 87 years, median time to mortality 27 hours). Twenty-three patients had eEVAR and 82 had OPEN surgery. The 30-day mortality rate in operated patients was 30% (7/23) in the eEVAR group versus 26% (21/82) in the OPEN group (P=0.64). No difference in mortality was noted between eEVAR and OPEN over 5 years of follow-up. There were more cardiac adverse events in the OPEN group (n=25, 31%) than in the eEVAR group (n=2, 9%; P=0.035). Reintervention after discharge was more frequent in patients who received eEVAR (35%) than in patients who had OPEN (6%, P<0.001). Advancing age was associated with increasing mortality (hazard ratio 1.05 [95% confidence interval 1.01-1.09]) per year for patients who received operative repair, with a 67%, 76%, and 100% 5-year mortality rate in the 34 patients aged <70 years, 59 patients aged 70-79 years, and 12 octogenarians, respectively; 30-day rAAA-related mortality was also associated with increasing age (21%, 30%, and 61%, respectively; P=0.008).The 30-day and 5-year mortality in patients who survived rAAA was equal between the treatment options of eEVAR and OPEN. Particularly fragile and very elderly patients did not receive operative repair. The decision to intervene in rAAA should not be made on the basis of patient age alone, but also in relation to comorbidity and patient preference.

SUBMITTER: Raats JW

PROVIDER: S-EPMC4206251 | biostudies-literature | 2014

REPOSITORIES: biostudies-literature

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Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age.

Raats Jelle W JW Flu Hans C HC Ho Gwan H GH Veen Eelco J EJ Vos Louwerens D LD Steyerberg Ewout W EW van der Laan Lijckle L

Clinical interventions in aging 20141013

<h4>Background</h4>Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA.<h4>Methods</h4>We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between Januar ...[more]

PMID: 25342890

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Project description:ObjectiveRecent data indicate social determinants of health (SDOH) have a great impact on prevention and treatment outcomes across a broad variety of disease states, especially cardiovascular diseases. The area deprivation index (ADI) is a validated measure of neighborhood level disadvantage capturing key social determinate factors. Abdominal aortic aneurysm rupture (rAAA) is highly morbid, but also preventable through evidence-based screening. However, the association between rAAA and SDOH is poorly characterized. Our objective is to study the association of SDOH with rAAA and screening age.MethodsThis retrospective study included patients who underwent operative repair of a rAAA at a multihospital healthcare system (2003-2019). Deprivation was measured by the ADI (scale 1-100), grouped into quintiles for simplicity, with higher quintiles indicating greater deprivation. Patients with the highest quintile ADI (89-100) were categorized as the most deprived. We investigated the association between neighborhood deprivation with the odds of (i) undergoing repair for rAAA before screening age 65 and (ii) undergoing endovascular aortic repair (EVAR) using logistic regression, sequentially modeling nonmodifiable then both nonmodifiable and modifiable confounding variables.ResultsThere were 632 patients who met the inclusion criteria (aged 74.2 ± 9.4 years; 174 women [27.6%]; 564 White [89.2%]; ADI 66.8 ± 22.3). Those from the most deprived neighborhoods (n = 118) were younger (71.7 ± 10.0 years vs 74.8 ± 9.2 years; P = .002), more likely to be female (36% vs 26%; P = .031), more likely to be Black (5.9% vs 0.4%; P = .007), and fewer underwent EVAR (28% vs 39.5%; P = .020) compared with those from other neighborhoods. On sequential modeling, residing in the most deprived neighborhoods was associated with undergoing rAAA repair before age 65 after adjusting for nonmodifiable factors (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.39-2.95; P < .001), and nonmodifiable as well as modifiable factors (OR, 2.22; 95% CI, 1.56-3.16; P < .001). Those in the most deprived neighborhoods had a lower odds of undergoing EVAR compared with open repair after adjusting for nonmodifiable factors (OR, 0.64; 95% CI, 0.41-0.98; P = .042), and nonmodifiable as well as modifiable factors (OR, 0.61; 95% CI, 0.37-0.99; P = .047).ConclusionsAmong patients who underwent rAAA, residing in the most deprived neighborhoods was associated with greater adjusted odds of presenting under age 65 and undergoing an open repair. These neighborhoods represent tangible geographic targets that may benefit from a younger screening age, enhanced education, and access to care. These findings stress the importance of developing strategies for early prevention and diagnosis of cardiovascular diseases among patients with disadvantageous SDOH.

Project description:BackgroundMultiple organ failure (MOF) is associated with poor outcomes and increased mortality in sepsis and trauma. There are limited data regarding MOF in patients after ruptured abdominal aortic aneurysm (rAAA) repair. We aimed to identify the contemporary prevalence and characteristics of patients with rAAA with MOF.MethodsWe retrospectively reviewed patients with rAAA who underwent repair (2010-2020) at our multihospital institution. Patients who died within the first 2 days after repair were excluded. MOF was quantified by modified (excluding hepatic system) Denver, Sequential Organ Failure Assessment (SOFA) score, and Multiple Organ Dysfunction Score (MODS) for postoperative days 3 to 5 to determine the prevalence of MOF. MOF was defined as a Denver score of >3, dysfunction in two or more organ systems by SOFA score, or a MODS score of >8. Kaplan-Meier curves and log-rank testing were used to evaluate differences in 30-day mortality between multiple organ failure and patients without MOF. Logistic regression was used to assess predictors of MOF.ResultsOf 370 patients with rAAA, 288 survived past two days (mean age, 73±10.1 years; 76.7% male; 44.1% open repair), and 143 had data for MOF calculation recorded. From postoperative days 3 to 5, 41 (14.24%) had MOF by Denver, 26 (9.03%) by SOFA, and 39 (13.54%) by MODS criteria. Among these scoring systems, pulmonary and neurological systems were impacted most commonly. Among patients with MOF, pulmonary derangement occurred in 65.9% (Denver), 57.7% (SOFA), and 56.4% (MODS). Similarly, neurological derangement occurred in 92.3% (SOFA) and 89.7% (MODS), but renal derangement occurred in 26.8% (Denver), 23.1% (SOFA), and 10.3% (MODS). MOF by all three scoring systems was associated with increased 30-day mortality (Denver: 11.3% vs 41.5% [P < .01]; DOFA: 12.6% vs 46.2% [P < .01]; MODS: 12.5% vs 35.9% [P < .01]), as was MOF by any criteria (10.8% vs 35.7 %; P < .01). Patients with MOF were more likely to have a higher body mass index (55.9±26.6 vs 49.0±15.0; P = .011) and to have had a preoperative stroke (17.9% vs 6.0%; P = .016). Patients with MOF were less likely to have undergone endovascular repair (30.4% vs 62.1%; P < .001). Endovascular repair was protective against MOF (any criteria) on multivariate analysis (odds ratio, 0.23; 95% confidence interval, 0.08-0.64; P = .019) after adjusting for age, gender, and presenting systolic blood pressure.ConclusionsMOF occurred in only 9% to 14% of patients after rAAA repair, but was associated with a three-fold increase in mortality. Endovascular repair was associated with a reduced MOF incidence.

Project description:BackgroundRandomized trials and observational studies have shown that perioperative morbidity and mortality are lower with endovascular repair of abdominal aortic aneurysm than with open repair, but the survival benefit is not sustained. In addition, concerns have been raised about the long-term risk of aneurysm rupture or the need for reintervention after endovascular repair.MethodsWe assessed perioperative and long-term survival, reinterventions, and complications after endovascular repair as compared with open repair of abdominal aortic aneurysm in propensity-score-matched cohorts of Medicare beneficiaries who underwent repair during the period from 2001 through 2008 and were followed through 2009.ResultsWe identified 39,966 matched pairs of patients who had undergone either open repair or endovascular repair. The overall perioperative mortality was 1.6% with endovascular repair versus 5.2% with open repair (P<0.001). From 2001 through 2008, perioperative mortality decreased by 0.8 percentage points among patients who underwent endovascular repair (P=0.001) and by 0.6 percentage points among patients who underwent open repair (P=0.01). The rate of conversion from endovascular to open repair decreased from 2.2% in 2001 to 0.3% in 2008 (P<0.001). The rate of survival was significantly higher after endovascular repair than after open repair through the first 3 years of follow-up, after which time the rates of survival were similar. Through 8 years of follow-up, interventions related to the management of the aneurysm or its complications were more common after endovascular repair, whereas interventions for complications related to laparotomy were more common after open repair. Aneurysm rupture occurred in 5.4% of patients after endovascular repair versus 1.4% of patients after open repair through 8 years of follow-up (P<0.001). The rate of total reinterventions at 2 years after endovascular repair decreased over time (from 10.4% among patients who underwent procedures in 2001 to 9.1% among patients who underwent procedures in 2007).ConclusionsEndovascular repair, as compared with open repair, of abdominal aortic aneurysm was associated with a substantial early survival advantage that gradually decreased over time. The rate of late rupture was significantly higher after endovascular repair than after open repair. The outcomes of endovascular repair have been improving over time. (Funded by the National Institutes of Health.).

Project description:ObjectiveTo determine whether there is a relation between aortic diameter and morbidity and mortality in men screened for abdominal aortic aneurysm.DesignProspective cohort study.SettingHighland and Western Isles (a large, sparsely populated area of Scotland).Participants8146 men aged 65-74.Main outcome measuresMorbidity and mortality in relation to presence of abdominal aortic aneurysm and three categories of aortic diameter (≤ 24 mm, 25-29 mm, and ≥ 30 mm).ResultsWhen screened, 414 men (5.1%) had an aneurysm (diameter ≥ 30 mm), 669 (8.2%) an aortic diameter of 25-29 mm, and 7063 (86.7%) an aortic diameter of ≤ 24 mm. The cohort was followed up for a median of 7.4 (interquartile range 6.9-8.2) years. Mortality was significantly associated with aortic diameter: 512 (7.2%) men in the ≤ 24 mm group died compared with 69 (10.3%) in the 25-29 mm group and 73 (17.6%) in the ≥ 30 mm group. The mortality risk in men with an aneurysm or with an aorta measuring 25-29 mm was significantly higher than in men with an aorta of ≤ 24 mm. The increased mortality risk in the 25-29 mm group was reduced when taking confounders such as smoking and known heart disease into account. After adjustment, compared with men with an aortic diameter of ≤ 24 mm, the risk of hospital admission for cardiovascular disease and chronic obstructive pulmonary disease was significantly higher in men with aneurysm and those with aortas measuring 25-29 mm. Men with an aneurysm also had an increased risk of hospital admission for cerebrovascular disease, atherosclerosis, peripheral arterial disease, and respiratory disease. In men with aortas measuring 25-29 mm, the risk of hospital admission with abdominal aortic aneurysm was significantly higher than in men with an aorta of ≤ 24 mm (adjusted hazard ratio 6.7, 99% confidence interval 3.4 to 13.2) and this increased risk became apparent two years after screening.ConclusionsMen with abdominal aortic aneurysm and those with aortic diameters measuring 25-29 mm have an increased risk of mortality and subsequent hospital admissions compared with men with an aorta diameter of ≤ 24 mm. Consideration should be given to control of risk factors and to rescreening men with aortas measuring 25-29 mm at index scanning.

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Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age.

Publications

Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age.

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