The Rationale for Continuing Open Repair of Ruptured Abdominal Aortic Aneurysm

Abstract

Mortality after open repair of ruptured abdominal aortic aneurysms (RAAAs) remains high. The purpose of this study is to present the results of open RAAA treatment observing 2 different 10-year periods in a single high-volume center and to consider the possibilities of result improvement in the future. Retrospective analysis of 729 RAAA patients who were treated through 1991-2001 (229 patients, Group A) and 2002-2011 (500 patients, Group B) was performed. Variables significantly associated with mortality were defined and analyzed. Overall 30-day mortality in Group A was 53.7% (123/229 patients) with intraoperative mortality of 13.5% (31/229 patients), while in Group B it was 37.4% (187/500 patients) with intraoperative mortality of 12.4% (62/500 patients). Overall 30-day mortality was significantly lower in Group B (P=0.012). There was no difference regarding intraoperative mortality (P=0.797). Preoperative severe hemodynamic instability (P<0.01, P<0.001), cardiac arrest (P<0.01, P<0.001), consciousness deterioration (P<0.05, P<0.001), renal malfunction (P<0.01, P<0.001), and significant anemia (P<0.01, P<0.001) were associated with increased mortality in both A and B groups, respectively. Aortic cross-clamping level in Group A was predominantly infrarenal (68%) while in Group B it was mostly supraceliac (53%) (P<0.001). Cross-clamping time, duration of surgery, and type of aortic reconstruction had no influence on survival in Group B (P>0.05). Intraoperative hemodynamic instability (P<0.01, P<0.001), significant bleeding (P<0.05, P<0.01), and low urine output (P<0.05, P<0.001) remained parameters that favored lethal outcome in both A and B groups, respectively. Cell saving was used only in Group B. The multivariate logistic regression applied on the complete sample of patients presented several significant predictors of lethal outcome: congestive heart failure on admission (odds ratio [OR] 1.954, 95% confidence interval [CI] 1.103-3.460), intraperitoneal rupture (OR 3.009, 95% CI 1.771-5.423), aortofemoral reconstruction (OR 1.928, 95% CI 1.044-3.563), and total operative time (OR 1.005, 95% CI 1.001-1.010). Postoperative multisystem organ failure (P<0.01, P<0.001), respiratory (P<0.01, P<0.001) and renal (P<0.05, P<0.001) failure, postoperative bleeding (P<0.05), and cerebrovascular incidents (P<0.05, P<0.01) significantly increased mortality in both A and B groups. Although unselective, aggressive surgical approach in RAAA performed by teams experienced in open repair can improve patient's survival. Short admission/surgery time, supraceliac aortic cross-clamping, and the use of intraoperative cell saving are recommended.