title: Derivation and validation of a practical risk score for prediction of mortality after open repair of ruptured abdominal aortic aneurysms in a US regional cohort and comparison to existing scoring systems.
abstract: OBJECTIVE
  Scoring systems for predicting mortality after repair of ruptured abdominal aortic aneurysms (RAAAs) have not been developed or tested in a United States population and may not be accurate in the endovascular era. Using prospectively collected data from the Vascular Study Group of New England (VSGNE), we developed a practical risk score for in-hospital mortality after open repair of RAAAs and compared its performance to that of the Glasgow aneurysm score, Hardman index, Vancouver score, and Edinburg ruptured aneurysm score.
  
  
  METHODS
  Univariate analysis followed by multivariable analysis of patient, prehospital, anatomic, and procedural characteristics identified significant predictors of in-hospital mortality. Integer points were derived from the odds ratio (OR) for mortality based on each independent predictor in order to generate a VSGNE RAAA risk score, which was internally validated using bootstrapping methodology. Discrimination and calibration of all models were assessed by calculating the area under the receiver-operating characteristic curve (C-statistic) and applying the Hosmer-Lemeshow test.
  
  
  RESULTS
  From 2003 to 2009, 242 patients underwent open repair of RAAAs at 10 centers. In-hospital mortality was 38% (n = 91). Independent predictors of mortality included age >76 years (OR, 5.3; 95% confidence interval [CI], 2.8-10.1), preoperative cardiac arrest (OR, 4.3; 95% CI, 1.6-12), loss of consciousness (OR, 2.6; 95% CI, 1.2-6), and suprarenal aortic clamp (OR, 2.4; 95% CI, 1.3-4.6). Patient stratification according to the VSGNE RAAA risk score (range, 0-6) accurately predicted mortality and identified those at low and high risk for death (8%, 25%, 37%, 60%, 80%, and 87% for scores of 0, 1, 2, 3, 4, and ≥5, respectively). Discrimination (C = .79) and calibration (χ(2) = 1.96; P = .85) were excellent in the derivation and bootstrap samples and superior to that of existing scoring systems. The Glasgow aneurysm score, Hardman index, Vancouver score, and Edinburg ruptured aneurysm score correlated with mortality in the VSGNE cohort but failed to identify accurately patients with a risk of mortality >65%.
  
  
  CONCLUSIONS
  Existing scoring systems predict mortality after RAAA repair in this cohort but do not identify patients at highest risk. This parsimonious VSGNE RAAA risk score based on four variables readily assessed at the time of presentation allows accurate prediction of in-hospital mortality after open repair of RAAAs, including identification of those patients at highest risk for postoperative mortality.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester, MA 01655, USA. William.Robinson@umassmemorial.org
authors.forename: William P
authors.initials: WP
authors.lastname: Robinson
authors.forename: Andres
authors.initials: A
authors.lastname: Schanzer
authors.forename: Youfu
authors.initials: Y
authors.lastname: Li
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
authors.forename: Brian W
authors.initials: BW
authors.lastname: Nolan
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Eslami
authors.forename: Jack L
authors.initials: JL
authors.lastname: Cronenwett
authors.forename: Louis M
authors.initials: LM
authors.lastname: Messina
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D016002:Discriminant Analysis; D005260:Female; D006305:Health Status Indicators; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009511:New England / Q000453:epidemiology; D016017:Odds Ratio; D018579:Patient Selection; D012372:ROC Curve; D012042:Registries; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality*