Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality.
OBJECTIVE
The purpose of this study is to evaluate contemporary results of ruptured aortoiliac aneurysms (RAAA) and identify the role of surgeons' annual aortic volume and other prognostic indicators for early outcome.


METHODS
A retrospective review identified 213 consecutive patients who presented with an atherosclerotic RAAA without thoracic extension over 6.5 years ending in June 2007. Excluded were 31 ruptures treated by endovascular repair (EVAR) or following previous EVAR, also excluded were two chronic asymptomatic hemodynamically stable ruptures. Ten patients were not treated due to either patient's refusal or prohibitive surgical risk. Demographic, preoperative, intraoperative, and postoperative variables were collected. Log rank test and Cox proportional hazard model analyses were utilized to identify factors contributing to mortality and morbidity in these patients. Survival rates were estimated by Kaplan-Meier method.


RESULTS
One hundred thirty-one males and 39 females with a mean age of 74.5 +/- 8.1 years underwent consecutive RAAA repairs. The operative mortality rate was 38.2% (65/170), including 29 intraoperative deaths. Using multivariate analysis, surgeon's average annual AAA volume (<20/y), advanced age, and postoperative intestinal ischemia were independent predictors of perioperative deaths. Shock on presentation, preoperative cardiopulmonary resuscitation or free rupture were not. High-volume surgeons (>20 average annual AAA cases/y) had a higher 30-day survival rates (78.4% vs 57.9%, P = .024). Octogenarians had a lower 30-day survival rate of 49.0% vs 70.5% (P = .012). Patients who developed postoperative intestinal ischemia had a lower 30-day survival rate compared with patients without (48.1% vs 15.3%, P = .002). Increased intraoperative fluid and blood product usage was associated with bowel ischemia (P < .05).


CONCLUSIONS
RAAA remains a highly lethal problem. The improved early outcomes of surgeons with high-volume AAA have strong implications for training, emergency staffing needs and alternative treatment strategies.
Cho
Jae-Sung
JS
Division of Vascular Surgery, University of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA. chojs@upmc.edu
Kim
Jang Yong
JY
Rhee
Robert Y
RY
Gupta
NavYash
N
Marone
Luke K
LK
Dillavou
Ellen D
ED
Makaroun
Michel S
MS
D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality* / Q000601:surgery*; D001019:Aortic Rupture / Q000401:mortality* / Q000601:surgery*; D002983:Clinical Competence; D006801:Humans; D008297:Male; D017063:Outcome Assessment, Health Care; D010414:Pennsylvania; D011379:Prognosis; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000401:mortality / Q000706:statistics & numerical data*