Risk-scoring methods in predicting the immediate outcome after emergency open repair of ruptured abdominal aortic aneurysm

doi:10.1016/j.amjsurg.2006.01.026

The American Journal of Surgery

Volume 192, Issue 1, July 2006, Pages 19-23

https://doi.org/10.1016/j.amjsurg.2006.01.026 Get rights and content

Abstract

Background

Rupture of an abdominal aortic aneurysm (RAAA) is associated with a risk of death approaching 80%. Prediction of immediate postoperative death in this condition assumes obvious relevance because it may be helpful in preoperative risk stratification.

Methods

One hundred fourteen patients underwent emergency open repair of RAAA. Data were retrospectively collected, and preoperative risk assessment was done according to the Glasgow aneurysm score, the Hardman index, and the Chen calculated risk.

Results

Fifty-one patients (44.7%) died during the immediate postoperative period. The area under the receiver operating characteristics curve for the Glasgow aneurysm score, the Hardman index, and the Chen calculated risk was 0.906, 0.834, and 0.672, respectively. The mortality rate among patients with a Glasgow aneurysm score >85 was 88.9%, whereas in those with a lower score it was 15.9% (P < .0001). The mortality rate among patients with a Hardman index ≥2 was 81.1%, whereas it was 27.3% in those with a lower score (P < .0001). The mortality rate in patients with a Chen calculated mortality risk >37% was 62.0%, whereas it was 31.3% in those with a calculated risk ≤37% (P = .001).

Conclusions

The present study showed that the Glasgow aneurysm score and, to a somewhat lower extent, the Hardman score are valuable predictors of immediate postoperative death after emergency open repair of RAAA.

Section snippets

Patients and Methods

From January 1996 to September 2004, 114 consecutive patients underwent open repair of RAAA at the Division of Vascular Surgery, Department of Cardiovascular Sciences, St. Camillo–Forlanini Hospital, Rome, Italy. Their records were retrospectively reviewed for data collection. Patients who underwent emergency surgery for symptomatic, unruptured AAA were excluded from the study. Clinical data are listed in Table 1. Ninety-six patients (84.2%) underwent aortoaortic, 11 patients (9.6%) underwent

Results

No intraoperative death occurred, and 51 patients (44.7%) died during the immediate postoperative period, a mean of .02 days after the operation. Postoperative complications are listed in Table 2. Twenty-five reoperations were performed in 20 patients. Ten patients underwent Hartmann operation, 2 underwent splenectomy, and 1 underwent cholecystectomy. Another patient underwent small-bowel resection. Because of acute lower limb ischemia, 1 patient underwent bilateral lower limb amputation, 1

Comments

Multivariable analysis showed that the only 2 independent risk factors associated with adverse outcome—ie, the main variables of the Glasgow aneurysm score—were preoperative serum creatinine concentration and shock. This is the reason why this risk-scoring method has proven to be highly predictive of postoperative death as shown by a rather large area under the ROC curve and its relevant accuracy compared with the Hardman index and the Chen calculated risk. The Chen calculated mortality risk

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Available methods for determining outcomes in vascular surgery patients are often subjective or not applicable in nonambulatory patients. The purpose of the present study was to assess the association between vascular surgery outcomes and a previously validated upper-extremity function (UEF) method, which incorporates wearable motion sensors for the physical frailty assessment.
Patients (≥50 y old) undergoing vascular surgery were recruited. Participants performed the 20-s UEF test, which involved rapid elbow flexion. This technology quantifies physical frailty features including slowness, weakness, exhaustion, and flexibility, which allows grouping individuals into nonfrail, prefrail, and frail categories. Surgical outcomes included length of hospital stay, discharged disposition, and 30-d mortality, complications, readmission, and reintervention(s). Associations between outcomes and frailty were assessed using nominal logistic regression models, adjusted for age, gender, body mass index, and wound classification.
Thirty-seven participants were recruited: eight nonfrail (age = 62.0 ± 10.6); 22 prefrail (age = 65.6 ± 11.6); and seven frail (age = 68.0 ± 8.0). Significant associations were observed between frailty and length of hospital stay (three times longer among frail participants, P = 0.03), mortality after surgery (two incidents among frail participants, P < 0.01), and adverse discharge disposition (all nonfrail patients were discharged home, whereas only 43% of frail patients discharged home, P = 0.01).
This is the first study to validate the utility of UEF among patients undergoing any vascular surgery. Findings suggest that UEF may provide an objective and simple approach for assessing frailty to predict adverse events after vascular surgery, especially for nonambulatory patients.
Retroperitoneal hematoma volume is a good predictor of perioperative mortality after endovascular aneurysm repair for ruptured abdominal aortic aneurysm
2018, Journal of Vascular Surgery
The objective of this study was to validate the usefulness of retroperitoneal hematoma volume as a predictor of perioperative mortality after endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA).
We retrospectively reviewed consecutive patients with rAAA who underwent the unified EVAR first protocol between 2012 and 2016 at any one of three participating institutions in Japan and were prospectively registered in a dedicated database. Only patients with preoperative computed tomography scans adequate for three-dimensional volumetric analysis were included. Volumetry was used to measure the retroperitoneal hematoma volume. To adjust for body size differences between patients, the retroperitoneal hematoma volume was divided by the abdominal cavity volume, and the predictive power of this ratio was validated using appropriate statistical methods.
Of 114 patients with rAAA managed during the study period, 101 (88.6%) underwent EVAR, 9 (7.9%) underwent open surgical repair, and 4 (3.5%) did not undergo any repair. Finally, 82 of 101 patients treated with EVAR were included in the analysis. Within 30 days after EVAR, the mortality rates for the 82 patients included in the analysis and the 19 excluded patients were 24.4% and 31.6%, respectively, without statistically significant differences (P = .518). The retroperitoneal hematoma volume ratio was 3.59% ± 2.46% and 7.63% ± 3.45% in survivors and nonsurvivors, respectively (P < .001). Univariate analysis of other preoperative demographic and anatomic factors revealed that a Glasgow Aneurysm Score >85, systolic blood pressure <90 mm Hg, loss of consciousness, and mean minimum right external iliac artery diameter were statistically significant. Receiver operating characteristic curve analysis for the prediction of perioperative mortality revealed that retroperitoneal hematoma volume ratio was the best predictor of perioperative mortality in patients with rAAA of type >III in the Fitzgerald classification (area under the curve: retroperitoneal hematoma volume ratio, 0.880; Glasgow Aneurysm Score, 0.587; P < .001). Based on the Youden index, the optimal cutoff for the retroperitoneal hematoma volume ratio was 6.97%, providing a sensitivity of 0.833 and specificity of 0.860.
Our study suggests that retroperitoneal hematoma volume may be a good predictor of perioperative mortality after EVAR for rAAA, especially for patients with Fitzgerald classification >III and a best cutoff value of 6.97%.
Modern Anesthetic Management of Ruptured Abdominal Aortic Aneurysms
2016, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
These patients often are elderly with premorbid conditions that contribute significantly to perioperative risk.18 In some clinical scenarios, attempted surgical intervention would be futile, and in an attempt to stratify perioperative risk, scoring systems have been developed (Table 1), including the following:19 Glasgow Aneurysm Score (GAS).
Editor's choice - External validation of models predicting survival after ruptured abdominal aortic aneurysm repair
2015, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
The Vancouver score discriminated sufficiently accurately, but even after recalibration its predictions still overestimated the death rate considerably. These results are in accordance with previous disappointing results on discrimination,27 but in conflict with previous fairly accurate results on calibration.23 Therefore, the accuracy of the Vancouver score has not yet been proven and the present authors prefer the updated GAS.
Prediction of survival after intervention for ruptured abdominal aortic aneurysms (RAAA) may support case mix comparison and tailor the prognosis for patients and relatives. The objective of this study was to assess the performance of four prediction models: the updated Glasgow Aneurysm Score (GAS), the Vancouver scoring system, the Edinburgh Ruptured Aneurysm Score (ERAS), and the Hardman index.
This was a retrospective cohort study in 449 patients in ten hospitals with a RAAA (intervention between 2004 and 2011). The primary endpoint was combined 30 day or in hospital death. The accuracy of the prediction models was assessed for discrimination (area under the curve [AUC]). An AUC >0.70 was considered sufficiently accurate. In studies with sufficiently accurate discrimination, correspondence between the predicted and observed outcomes (i.e. calibration) was recalculated.
The AUC of the updated GAS was 0.71 (95% confidence interval [CI] 0.66–0.76), of the Vancouver score was 0.72 (95% CI 0.67–0.77), and of the ERAS was 0.58 (95% CI 0.52–0.65). After recalibration, predictions by the updated GAS slightly overestimated the death rate, with a predicted death rate 60% versus observed death rate 54% (95% CI 44–64%). After recalibration, predictions by the Vancouver score considerably overestimated the death rate, with a predicted death rate 82% versus observed death rate 62% (95% CI 52–71%). Performance of the Hardman index could not be assessed on discrimination and calibration, because in 57% of patients electrocardiograms were missing.
Concerning discrimination and calibration, the updated GAS most accurately predicted death after intervention for a RAAA. However, the updated GAS did not identify patients with a ≥95% predicted death rate, and therefore cannot reliably support the decision to withhold intervention.
Regarding "derivation and validation of a practical risk score for prediction of mortality after open repair of ruptured abdominal aortic aneurysms in a U.S. regional cohort and comparison to existing scoring systems"
2013, Journal of Vascular Surgery
Risk factors for predicting postoperative complications after open infrarenal abdominal aortic aneurysm repair: Results from a single vascular center in China
2013, Journal of Clinical Anesthesia
To identify the risk factors of, and develop a prediction model for, postoperative complications of patients undergoing infrarenal abdominal aortic aneurysm (IAAA) repair.
Retrospective analysis.
Vascular surgery center of a university hospital.
The clinical data of 316 IAAA cases were collected from January 2004 to October 2010 at a single vascular center in China. Postoperative complications were observed within 30 days after surgery. Patient-specific and operation-specific characteristics were analyzed in relation to postoperative complications using multiple logistic regression analysis.
Overall incidence of postoperative complications and overall 30-day mortality of IAAA repair patients were 48.4% (153/316) and 8.8% (28/316), respectively. Postoperative complications involved pulmonary (18.9%), cardiac (14.2%), renal (7.3%), gastrointestinal (5.4%), neurologic (1.3%), and hepatic (0.9%) systems, and acute arterial embolism of the lower limb occurred in 1.3% of cases. Risk factors were age [> 65 yrs; odds ratio (OR) 1.6], aortic occlusion time (> 90 min; OR 2.4), history of chronic obstructive pulmonary disease (COPD; OR 4.4), emergency operation (OR 6.1), and history of cardiac dysfunction (OR 2.1).
A combination of age, COPD, emergency operation, history of cardiac dysfunction and aortic occlusion time has significant impact on postoperative complications after open IAAA repair.

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Clinical surgery–internationalRisk-scoring methods in predicting the immediate outcome after emergency open repair of ruptured abdominal aortic aneurysm

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comments

J Vasc Surg

J Vasc Surg

J Vasc Surg

Am J Surg

Eur J Vasc Endovasc Surg

Eur J Vasc Endovasc Surg

Eur J Vasc Endovasc Surg

Eur J Vasc Endovasc Surg

Clinical surgery–international
Risk-scoring methods in predicting the immediate outcome after emergency open repair of ruptured abdominal aortic aneurysm