Annals of Vascular Surgery
Volume 23, Issue 2 , Pages 159-166, March 2009

Open Repair for Ruptured Abdominal Aortic Aneurysm: Is It Possible to Predict Survival?

  • M. Antonello

      Affiliations

    • Department of Cardiac, Thoracic, and Vascular Sciences, Vascular and Endovascular Surgery Section, University of Padua, Padua, Italy
    • Corresponding Author InformationCorrespondence to: Michele Antonello, MD, PhD, Department of Cardiac, Thoracic, and Vascular Sciences, Vascular and Endovascular Surgery Section, University of Padua, Via Giustiniani 2, 35100 Padua, Italy
    • ,
  • P. Frigatti

      Affiliations

    • Department of Cardiac, Thoracic, and Vascular Sciences, Vascular and Endovascular Surgery Section, University of Padua, Padua, Italy
    • ,
  • C. Maturi

      Affiliations

    • Department of Cardiac, Thoracic, and Vascular Sciences, Vascular and Endovascular Surgery Section, University of Padua, Padua, Italy
    • ,
  • S. Lepidi

      Affiliations

    • Department of Cardiac, Thoracic, and Vascular Sciences, Vascular and Endovascular Surgery Section, University of Padua, Padua, Italy
    • ,
  • F. Noventa

      Affiliations

    • Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
    • ,
  • G. Pittoni

      Affiliations

    • Department of Anesthesiology and Reanimation, Azienda Ospedaliera di Padova, Padua, Italy
    • ,
  • G.P. Deriu

      Affiliations

    • Department of Cardiac, Thoracic, and Vascular Sciences, Vascular and Endovascular Surgery Section, University of Padua, Padua, Italy
    • ,
  • F. Grego

      Affiliations

    • Department of Cardiac, Thoracic, and Vascular Sciences, Vascular and Endovascular Surgery Section, University of Padua, Padua, Italy

published online 01 October 2008.

Article Outline

The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAAA) and to assess the accuracy of the Glasgow Aneurysm Score (GAS) and the Acute Physiology Chronic Health Evaluation II (APACHE-II). From January 1998 to July 2006, 103 patients underwent operations for RAAA. For each patient, 44 variables were retrospectively recorded in a database. Data were analyzed with univariate and multivariate methods. In the univariate analysis significant predictors of death were hypotension (p = 0.001), preexisting peripheral vascular disease (p < 0.001), renal insufficiency (p = 0.037), chronic obstructive pulmonary disease (p = 0.028), level of HCO3- (p < 0.001), intraperitoneal rupture (p = 0.001), blood transfused (p < 0.001), cardiac complications (p < 0.001), and APACHE-II score (p = 0.001). Multivariate analysis confirmed statistical significance for coexisting peripheral vascular disease (p < 0.001), diastolic blood pressure at admission <60 mm Hg (p = 0.039), APACHE-II score >18.5 (p = 0.025), HCO3- <21 mg/dL (p < 0.001), and intraperitoneal rupture of the aneurysm (p = 0.011) as predictors of death. Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. APACHE-II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAAA.

 

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Introduction 

Despite the increase in numbers of elective abdominal aortic aneurysm (AAA) repair, the number of patients with ruptured AAA (RAAA) has not been significantly reduced.1, 2, 3 Whereas the surgical mortality rate for elective repair of AAA has steadily improved by about 5%, the mortality rates after repair of RAAA have not significantly changed in the literature in the last three decades, still ranging 30-50% in the most recent reports.4, 5, 6, 7, 8, 9

Many different factors have been advocated to be predictive of death, including age, comorbidity, medical condition, preoperative shock or hypotension, increased creatinine level, low hemoglobin/hematocrit level, and technical and postoperative complications; but none of these was really able to predict correctly the outcome of these patients.5, 8, 10, 11, 12 Scoring systems have been developed to identify those patients who are at high risk of postoperative mortality or morbidity; however, most of them are complex and not usable in the emergent setting. The Glasgow Aneurysm Score (GAS) has been proved to be a simple and effective method to identify preoperatively patients at high risk for emergent AAA repair.13, 14 The Acute Physiology Chronic Health Evaluation II (APACHE-II) model is the only available model specifically developed for predicting outcome in the postoperative period for patients managed in the intensive unit care (IUC).15, 16 The aim of this retrospective study was to determine significant variables that could be used to predict survival in patients who underwent emergent repair for RAAA and to evaluate the accuracy of GAS and APACHE-II as models of prediction of in-hospital mortality.

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Patients And Methods 

Data of all patients admitted to the Department of Vascular and Endovascular Surgery of the University of Padua for RAAA between January 1998 and July 2006 were retrospectively collected in a database and thereafter analyzed.

RAAA was defined as a defect in the aneurysmal wall that had allowed extravasation of a quantity of blood. Patients with ruptured thoracoabdominal aneurysm, isolated iliac artery aneurysm, or pseudoaneurysm and symptomatic patients who had surgery without retroperitoneal hematoma were excluded. In all patients diagnosis was obtained with clinical presentation, physical examination, and ultrasonography confirmation. Angio-computed tomography (CT) was performed only when doubt existed about the diagnosis of rupture in stable patients or in situations where the condition responsible for presentation was unclear. Once the diagnosis of RAAA was made, patients were transferred to the operating theater as rapidly as possible for preoperative resuscitation and operation. For each patient, 44 variables were recorded analyzed and divided into three subgroups: preoperative, intraoperative, and postoperative (Table I).

Table I. Variables of the study
Preoperative variablesIntraoperative variablesPostoperative variables
Male sexClamping siteImpairment of renal function
PulmonaryDuration of suprarenal clampingRespiratory complication
CardiacTotal amount of blood transfusedCardiac events
Peripheral vascularTotal fluids at operationNeurological complications
HypertensionUrine outputLower extremity ischemia
Cerebrovascular diseasesDuration of surgeryIntestinal ischemia
Days on ventilation
Diabetes mellitus ICU stay (days)
Previous abdominal surgery APACHE-AAA
Arrival systemic blood pressure
Cardiac arrest
Loss of consciousness
Renal function impairment
Hematocrit level
Electrocardiographic ischemic changes
Abdominal pain
Back pain
Time from emergency department to operating theater
HCO3-
Body temperature (°C)
PaO2
Arterial pH
Na (mEq/L)
K (mEq/L)
Azotemia
Creatinemia
White blood cells
GAS

The analysis was completed with the GAS in the preoperative subgroup and with the APACHE-II in the postoperative subgroup.

The GAS was calculated according to the following formula: risk score = age in years + 7 points for myocardial disease + 10 points for cerebrovascular disease + 14 points for renal disease.13 “Myocardial disease” refers to previously documented myocardial infarctions, coronary artery disease, or ongoing angina pectoris. “Cerebrovascular disease” refers to all grades of strokes including transient ischemic attacks. “Renal disease” refers to history of chronic or acute renal failure and/or creatinine >2 mg/dL at admission.

The APACHE-II score was calculated using the program found on the web site of the Société Française d'Anesthésie et de Réanimation (French Society of Anesthesia and Intensive Care, http://www.sfar.org).

Regarding data collection on the postoperative status of the patients, a renal complication was considered as serum creatinine concentration >2 mg/dL or renal failure requiring dialysis. Respiratory complications were regarded as pulmonary murmurs on auscultation, findings of atelectasia or pleural effusion on chest X-rays, as well as pneumonia. Diagnosis of myocardial infarction was made in the presence of characteristic changes on electrocardiogram (inversion of T waves, ST segment depression or elevation, appearance of pathological Q waves) and when serum troponin I concentration was >0.15 mg/L.

“Postoperative mortality” refers to 30-day or in-hospital mortality.

Statistical Analysis 

All statistical tests were two-sided, with an alpha level of 0.05. Data were analyzed by both univariate and multivariate methods and performed using SPSS software, version 13.0 (SPSS Inc., Chicago, IL).

To compare dead versus alive patients, we used Student's t-test for continuous variables and Fisher's exact test for categorical ones.

Stepwise logistic regression was used to estimate the independent odds ratio and confidence interval of an optimized subset of predictor variables significantly associated with death in univariate analysis.

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Results 

From January 1998 to July 2006, 1,141 patients underwent AAA repair at the Department of Vascular Surgery of Padua University. There were 1,008 elective procedures, and 251 (24.9%) of these were endovascular treatment; 169 (16.7%) patients underwent emergency operations for symptomatic AAA, 127 of whom had evidence of rupture. Of these, 11 patients (8.6%) were considered unfit for surgery due to prohibitive comorbidity; six were men and five were women, of median age 87 (range 80-95) years. Four patients were deemed unsuitable for surgery because they were previously judged unfit for elective repair. The primary reasons for nonoperative management in the remainder were malignancy (n = 3), age-related comorbidity (n = 3), and cardiorespiratory comorbidity (n = 1).

Thirteen patients were excluded from the study, despite knowing their outcome, due to missing data for most of the prognostic variables considered, especially in those patients for whom the GAS and APACHE-II scores were not assessable.

There were 82 men and 21 women. The mean age was 72.9 years (range 47-91). The intraoperative mortality rate was 6.8% (seven out of 103 patients), and deaths were the result of continued hemorrhage and irreversible shock in the majority of cases. The 30-day mortality rate was 29.1% (30 out of 103 patients). The overall in-hospital mortality rate was of 39.5% (37 patients). The mean age of those who died (group A) was only slightly higher than that of survivors (group B)—74.0 and 72.5, respectively—but did not reach statistical significance. At admission, all patients complained of pain: 49.5% had some form of back pain and 88.3% had abdominal pain. A systolic blood pressure <80 mm Hg was registered in 13.6% of cases, and all of these underwent preoperative ultrasonographic examination only. The hematocrit was 25% or less in 17.5% of cases (18 out of 103 patients). Nine patients (8.7%) at admission were anuric, 49 (47.6%) presented a diuresis contraction, and the renal status of the remaining was normal. Only six (5.8%) patients sustained a preoperative cardiac arrest and 25 (24.3%), loss of consciousness. The comparison of the preoperative variables between the two groups is given in Table II. Univariate significant predictors of early death were preexisting chronic obstructive pulmonary disease (p = 0.028), coronary artery disease (p = 0.013), peripheral vascular disease (p < 0.001), cerebrovascular disease (p = 0.046), diabetes mellitus (p = 0.032), renal insufficiency (p = 0.037), hypotension (p = 0.001), cardiac arrest on admission in the emergency department (p = 0.002), and level of HCO3- (p < 0.001). No evidence of a predictive value was observed for the GAS.

Table II. Univariate analysis of preoperative variables
n (%) or mean ± SD
Preoperative variablesGroup A (73 alive)Group B (30 dead)p
Age (years)72.5 ± 6.974.0 ± 7.50.318
Male sex56 (76.6)26 (86.7)0.255
COPD20 (27.4)15 (50.0)0.028
CAD29 (39.7)20 (66.7)0.013
PAOD7 (9.6)15 (50.0)<0.001
Hypertension50 (68.5)21 (70.0)0.881
Cerebrovascular disease12 (16.4)10 (33.3)0.046
Diabetes mellitus9 (12.3)9 (30.0)0.032
Previous abdominal surgery22 (30.1)7 (23.3)0.485
Arrival systemic blood pressure
Systolic107.1 ± 26.190.3 ± 16.00.001
Diastolic65 ± 17.455.3 ± 10.80.002
Cardiac arrest1 (1.4)5 (16.7)0.002
Loss of consciousness15 (20.5)10 (33.3)0.169
RI (serum creatinine >2.0 mg/dL)
Oliguric32 (43.8)17 (56.7)0.037
Anuric4 (5.5)5 (16.7)
Hematocrit level32.0 ± 6.029.7 ± 4.40.071
ECG ischemic changes16 (21.9)10 (33.3)0.225
Abdominal pain64 (87.7)27 (90.0)0.737
Back pain36 (49.3)15 (50.0)0.949
Time from emergency department to operating room (min)169 ± 234101 ± 71.70.118
HCO3-23.9 ± 2.216.5 ± 5.2<0.001
GAS78.7 ± 14.584.0 ± 15.50.328

COPD, chronic obstructive pulmonary disease; CAD, coronary artery disease; PAOD, peripheral arterial obstructive disease (history of PAOD defined on the basis of data collected directly from the patient or patient's relative and on clinical finding of peripheral pulses); cerebrovascular disease, previous carotid revascularization, transient ischemic attack, or stroke; RI, renal insufficiency (anuric if diuresis <100 mL/24 hr, oliguric if diuresis 100-600 mL/24 hr); ECG, electrocardiogram (ischemic changes defined as inversion of T waves, ST segment depression or elevation, appearance of pathological Q waves).

Median time between hospital admission and entrance into the operating theater was 100 min.

Aortic control was obtained in two-thirds of patients within 40 min of entering the operating room. The rest of the patients required over 1 hr resuscitation time. All procedures were performed through a midline laparotomy. The extent of rupture was retroperitoneal in 58 (56.3%) cases and extended into the peritoneal cavity in 45 (43.7%) patients. Three patients (2.9%) with retroperitoneal rupture also had an aortocaval fistula. In 99 patients (96.1%) the location of the AAA was infrarenal, and in five cases (4.9%) suprarenal involvement was noticed. In 15 (14.5%) patients with critical hypotension or difficult identification of the infrarenal aortic neck, a supraceliac clamp was temporarily placed before the infrarenal control.

Five patients with a suprarenal aneurysm and a renal exclusion of over 40 min needed a temporary renal revascularization. The intraoperative blood recovery system was used in each case, and the mean blood transfusion requirements were 5.39 ± 2.2 units, including red cells and autologous blood.

The mean intraoperative crystalloid infusion was 3,810 ± 1,165 mL. The comparison of the intraoperative variables between the two groups is given in Table III. Univariate significant predictors of early death were rupture location (worse if intraperitoneal, p = 0.001), suprarenal cross-clamping (p = 0.024), total amount of blood transfused (p < 0.001), intraoperative fluid infusion (p < 0.001), and intraoperative diuresis (p < 0.001).

Table III. Univariate analysis of intraoperative variables
n (%) or mean ± SD
Intraoperative variablesGroup A(73 alive)Group B(30 dead)p
Intraperitoneal rupture25 (34.2)20 (66.7)0.001
Clamping site
Infrarenal64 (87.7%)14 (46.7%)<0.001
Suprarenal9 (12.3%)16 (53.3%)
Total amount of blood transfused4.7 ± 1.86.9 ± 2.2<0.001
Total fluids at operation3,393 ± 8404,823 ± 1235<0.001
Urine output
Anuric0 (0)6 (20.0)<0.001
>50 mL/hr53 (72.6)1 (3.3)
<50 mL/hr20 (27.4)23 (76.7)
Duration of surgery (min)176.6 ± 36.8197.0 ± 65.20.530

The most common postoperative complications among the 96 patients surviving at least 1 day after surgery were tracheal intubation for more than 3 days (17 patients, 17.7. %), in three of whom a tracheostomy was necessary; serum creatinine elevation >3.0 mg/dL (17 patients, 17.7%); and renal failure requiring dialysis (10 patients, 9.8%). Six died and four had dialytic support, two of whom continued after discharge. Cardiac ischemia occurred in five patients (6.8%) of group B, and in one of these cases an emergency myocardial revascularization was performed. Six patients needed a new operation for lower limb ischemia (two in group A and four in group B), and nine patients (six in group A and three in group B) underwent a second laparotomy for suspected intestinal ischemia, with bowel resection being necessary in only four cases (three in group A and one in group B). Table IV shows the comparison of the postoperative variables between the two groups. Univariate significant predictors of early death were cardiac (p < 0.001) and renal (p = 0.035) complications, intestinal ischemia (p = 0.005), days on ventilation (p < 0.001), and APACHE-II score >15.6 (p = 0.001) (Table IV).

Table IV. Univariate analysis of postoperative variables
n (%) or mean ± SD
Postoperative variablesGroup A(73 alive)Group B(30 dead)p
Renal
Dialysis support4 (5.5)6 (20.0)0.035
RI12 (16.4)5 (16.7)
Respiratory4 (5.5)6 (20.0)0.169
Cardiac
Heart failure6 (8.2)9 (30.0)<0.001
Acute myocardial infarction5 (6.8)0 (0.0)
Cardiac arrest0 (0.0)11 (36.7)
Neurological0 (0.0)3 (10.0)0.004
Lower extremity ischemia4 (5.5)2 (6.7)0.709
Intestinal ischemia3 (4.1)6 (20.0)0.005
Days on ventilation2.2 ± 2.16.0 ± 7.8<0.001
ICU stay (days)5.3 ± 3.76.0 ± 7.80.530
APACHE-II15.6 ± 6.523.7 ± 12.90.001

Renal: renal insufficiency (RI) if postoperative creatinine >2 mg/dL. Respiratory: pulmonary murmurs on auscultation, atelectasia, or pleural effusion on chest X-rays, pneumonia. Cardiac: changes on electrocardiogram (inversion of T waves, ST segment depression or elevation, appearance of pathological Q waves) and serum troponin >0.15 mg/L.

Multivariate analysis confirmed the statistical significance of coexisting peripheral vascular disease (p < 0.001), diastolic blood pressure at admission <60 mm Hg (p = 0.039), APACHE-II score >18.5 (p = 0.025), HCO3- <21 mg/dL (p < 0.001), and intraperitoneal rupture of the aneurysm (p = 0.011) as predictors of death (Table V).

Table V. Significant variables in multivariate analysis
Variablesp
Peripheral vascular disease<0.001
Intraperitoneal rupture0.011
Diastolic blood pressure at admission <60 mm Hg0.039
HCO3- <21 mmol/L<0.001
APACHE-II >18.50.025

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Discussion 

The mortality rate of ruptured aneurysms remains remarkably high. With the exception of a few series,17, 18 this is from 30% to more than 70% in most reports.19 If patients who died at home or during transport to a hospital are included, the mortality rate approaches 90%.20, 21 This excessively high operative mortality rate could be explained because patient selection is usually impossible and the majority already suffer the consequences of hypovolemic shock at admission. A report by Johansen et al.19 demonstrated a mortality rate of 70% in 186 patients treated in a single hospital for RAAA. This poor survival was observed despite specialized prehospital management and transport, short emergency department diagnostic evaluation, aneurysm repair by an operating vascular surgery team, and sophisticated postoperative care. Considering the high mortality rate combined with associated high hospital costs, other authors22 suggested that certain preoperative variables (preoperative cardiac arrest, age >80 years, male gender, persistent preoperative hypotension despite aggressive crystalloid and blood replacement, admission hematocrit <25, transfusion requirements exceeding 15 units) might be used to select patients who are most likely to die and, thus, would be best treated without operation. This approach may have some justification in this age of cost-effective therapy but could have significant ethical and legal implications. The decision to deny operative treatment to a patient with RAAA should be taken while considering each patient individually and can only be justified in those cases with poor quality of life due to precarious general medical status or mental condition. Rather than using predictive variables to identify patients who will not survive, several studies, including ours, have tried to identify which surgical tactics and anesthesiological procedures can improve the survival rate and identify patients in whom preoperative conditions and other clinical factors make conventional repair inopportune.

Even if several authors have found higher mortality rates for elderly patients,11, 19, 22, 23 we have not found advanced age to be a significant predictor of outcome. Once elderly patients have survived the operation, they can enjoy a long-term life expectancy similar to their contemporaries of the general population.23, 24 Thus, it seems reasonable to consider that physiological age is more relevant than chronological age even if older patients are exposed to increased surgical risk in the case of aneurysm rupture. Factors intrinsic to the patient were most important in predicting survival after RAAA. Most significant among these circumstances was the presence of chronic renal insufficiency. No patients with a baseline creatinine >3.0 mg/dL survived the perioperative period. Markers of cardiac and coronary disease would have been logically expected to be significant predictors of early death. Even among elective patients, cardiac comorbidity may be difficult to detect;25 this is even higher among emergency patients and explains an underestimation of cardiac predictors, as we recorded in our series. Associated peripheral vascular disease, a great marker of the severity of systemic arteriosclerosis, is simple to detect and seems to be a significant preoperative predictor of early death, reaching statistical significance in this report. There is agreement that the preoperative clinical variables reflecting the severity of bleeding, such as hypotension, shock, or loss of consciousness, are associated with a higher mortality rate. In order to define the hypotension variable better, it would have been necessary to register not only the absolute level but also the duration of the hypotensive episode. When we considered the level of HCO3- as a marker of inadequate organ system perfusion and its correlate acidosis, this was a significant predictor of early death in both univariate and multivariate analyses. In this series, the GAS scoring system was not able to predict postoperative death after surgery for RAAA. In agreement with our finding is the report by Tambyraja et al.,26 who described a single-unit experience of prospective validation of a prognostic scoring system in 84 patients who underwent surgery for RAAA over 26 months in which the GAS was found to be a poor predictor of postoperative mortality. The low capability of the GAS as a predictor of death in RAAA found in our study and in the study by Tambyraja et al.26 could be related to the small sample size of the studies. In fact, a larger retrospective study performed by the Finnvasc Study Group27 that included 836 patients during a 9-year period found that the GAS was predictive of postoperative death after repair for RAAA, but they were not able to find a cut-off value for patients at extreme risk. Thus, data from the literature are still lacking to determine the capability of the GAS to predict postoperative mortality after repair for RAAA, and further, larger prospective studies will be necessary.

Excessive transfusions or blood loss had a high correlation with death. These complications were correlated with technical problems at the time of operation, such as difficult aortic control in cases of suprarenal aortic aneurysm associated with free rupture. Immediate supraceliac aortic control is advisable also in cases of intraperitoneal bleeding because it is difficult to localize a safe place for clamping in the renal area. Retroperitoneal or peritoneal cavity ruptures have been considered important factors influencing outcome. It has been estimated that around 50% of all patients with RAAA died before admission to hospital and the majority of those had a free rupture.28 It has been recently reported that bifurcated grafting was associated with greater early death risk.12 The choice between bifurcated grafting or a tube graft, the conditions of iliac arteries, the time of operation, global bleeding, and the preservation of at least one hypogastric artery or patency of the mesenteric artery (reimplantation) must be considered. A tube graft with larger iliac arteries is recommended rather than a bifurcated grafting with a longer surgical time.

The majority of postoperative complications reflect, or could be related at least to a certain degree to, the consequences of hypovolemic shock on diverse organs or systems. As should be expected and in concordance with the previous discussion, cardiac complications represented the most frequent comorbidity (66.7%) after emergency AAA repair. Respiratory failure was present in a high percentage (20%) of our patients who died late in their hospital stay but in the majority of cases was associated with renal failure and a massive intraoperative crystalloid infusion. Postoperative renal insufficiency was identified as being a predictor of mortality (p = 0.035). Ischemic colitis is another postoperative complication and, in our experience, has been related to death after RAAA surgery (p = 0.005).29, 30

The APACHE-II scoring system appears to be predictive of postoperative mortality in patients who underwent surgery for RAAA managed in the ICU with a cut-off value of 18.5 in multivariate analysis. In recent years a more specific and complex model for predicting outcome in the postoperative AAA patient, the APACHE AAA31 based on the principles of the APACHE-II methodology, has been developed using data from 24 general ICUs in North Thames, United Kingdom, collected over a period of 9 years (1992-2000). The multilevel methodology used to develop the model enables it to adjust for the structure and process of care in individual ICUs as well as the patient case mix.

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Conclusion 

Despite the large number of recent reports that have studied this subject, controversy remains; and in accordance with some authors, we conclude that there are no preoperative characteristics or scoring system that allow us to withhold emergency surgical repair for RAAA. The ideal treatment of RAAA remains its prevention and, when not possible, to identify the patients in whom preoperative conditions and other preoperative clinical factors make conventional repair inopportune.

The role of endovascular ruptured aneurysm repair (EVRAR) in these patients is interesting and still a matter of debate. In fact, whereas most of the published data, drawn from nonrandomized studies,32, 33 suggest that EVRAR is feasible in selected patients and in institutions with experience in endovascular techniques, the only published randomized control study, by Hinchliffe et al.,34 showed no benefit in terms of mortality or complications. Moreover, long-term data are needed in order to truly assess if EVRAR is a durable treatment in relation to endoleak, stent-graft integrity, and late rupture risk. In a recent manuscript by Hinchliffe and Braithwaite,35 in which the authors analyzed their experience from 1994 to 2004 in 54 patients, EVRAR did not appear to confer any overall survival advantage in the long term compared to open repair. Nevertheless, the potential advantages of EVRAR with respect to open repair, such as reduction in blood loss, transfusion, length of ICU stay (which can be attributed to a reduction in the physiological insult to the patient as EVRAR obviates the need for laparotomy), exposure and handling of abdominal contents, and aortoiliac clamping, make this procedure attractive and potentially helpful in reducing the mortality rate of RAAA.36 The major concerns regarding endovascular treatment in emergency situations are the hemodynamic condition of the patient and the time delays during the preoperative work-up. The Montefiore RAAA Management Protocol37 seems to have overcome these problems by foreseeing the use of endovascular approaches in all patients with presumed ruptured aortoiliac aneurysms, thus reaching a better mortality rate than expected.

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PII: S0890-5096(08)00215-X

doi:10.1016/j.avsg.2008.05.011

Annals of Vascular Surgery
Volume 23, Issue 2 , Pages 159-166, March 2009

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