Different Preoperative Factors Affect Early Versus Late Mortality After Repair of Ruptured Abdominal Aortic Aneurysm

Abstract

Outcomes after endovascular aneurysm repair (EVAR) or open repair of ruptured abdominal aortic aneurysms (RAAA) are dependent on both intraoperative and postoperative care of this patient population. We sought to characterize perioperative RAAA care and determine the effect of patient characteristics and interventions, including the role of perioperative blood product administration, on survival. We reviewed demographic, comorbidity, perioperative, and transfusion data for patients who underwent treatment of RAAA at a single institution between 2003 and 2018. The primary outcomes were 30-day and early (48-hour) mortality. Use of EVAR and perioperative blood product administration over time were measured as secondary outcomes. We identified 466 patients (age 74.5 ± 0.44, 74.3% male). EVAR was utilized in 29.6% of patients overall, increasing to 50% over the last 5 years as we shifted to an EVAR-first approach over time (Fig 1). Median time from arrival to the operating room was 63 minutes (interquartile range [IQR], 41-124 minutes). The proportion of crystalloid to total fluid (65.1 ± 28.4%) and blood to total fluid (23.7 ± 21%) did not change over time. The proportion of plasma to blood was 51% (IQR, 0%-91%) and increased over time. Mortality at 30 days was 34.1% (39.3% open, 21.7% EVAR) and did not change over time despite low EVAR mortality, due to increasing open surgical mortality after the introduction of EVAR (Fig 2). Blood product resuscitation ratios did not affect 30-day, early, or late mortality on adjusted analysis. Multivariable logistic regression showed that age >76 years (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.70-4.26; P < .001), creatinine >2 mg/dL (OR, 3.09; 95% CI, 1.77-5.39; P < .001), systolic blood pressure 2 mg/dL (OR, 4.82; 95% CI, 2.53-9.20 P < .001) with nonsignificant impact from systolic blood pressure and cardiopulmonary resuscitation. Mortality rates for RAAA have not improved despite increasing use and low perioperative mortality of EVAR over time as mortality for open surgery has increased. Increasing perioperative plasma to blood ratios have not demonstrated any mortality benefit in our study. Early mortality is strongly associated with the shock-based factors of hypotension and need for cardiopulmonary resuscitation, while late mortality is more strongly associated with elevated creatinine suggesting multiple organ failure despite hemodynamic stability.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)