Ruptured abdominal aortic aneurysms: the excessive mortality rate of conventional repair

Abstract

Objective: Rupture of abdominal aortic aneurysms (AAAs) remains lethal. In a report of patients treated in the 1980s, we recommended aggressive management. Our continued experience prompted us to reevaluate this policy.

Methods: We reviewed clinical variables affecting outcome, morbidity, mortality, and trends in mortality of all patients managed at our institution with ruptured AAAs between January 2, 1980, and November 30, 1998.

Results: The study group included 413 consecutive patients, 339 men and 74 women. The mean age was 74.3 years (range, 49-96); 116 (28%) patients were older than 80 years. AAA was diagnosed before rupture in 119 (29%) patients. Eighty (19%) patients had preoperative cardiac arrest. Twenty-nine (7%) patients died before operation; 65 (17%) died during the operation. The surgical mortality rate (30-day) was 37%; the overall mortality rate was 45% and was higher in women (68%) than in men (40%) (P <.001). Advanced age, APACHE (Acute Physiology and Chronic Health Evaluation) II score, initial hematocrit, and preoperative cardiac arrest were associated multivariately with 30-day mortality rates by means of stepwise logistic regression (P <.05). Twelve (23%) of 53 patients with cardiac arrest survived the operation. Logistic regression, adjusted for age, sex, and APACHE II score, demonstrated a decrease in overall and 30-day mortality rates (P <.001) over 18 years. The mean overall mortality rate was 51% from 1980 to 1984 and 42% from 1994 to 1998.

Conclusions: The mortality rate of ruptured AAAs remains excessive, despite improvement over 18 years. Patients older than 80 years with shock or cardiac arrest have the highest mortality rate and should be evaluated for possible endovascular treatment. Because the diagnosis of AAA was unknown in more than 70% of patients, screening of the high-risk population and elective repair are recommended.