title: Endovascular repair of ruptured and symptomatic abdominal aortic aneurysms using a structured protocol in a community teaching hospital.
abstract: BACKGROUND
  Open abdominal aortic aneurysm (AAA) repair has gradually been replaced by endovascular aneurysm repair (EVAR). The primary objective of this study is to establish baseline mortality data and compare our institutional mortality rates for ruptured AAA patients with published rates from institutions using similar approaches.
  
  
  METHODS
  This study is a retrospective review of 49 patients treated using a structured ruptured AAA (rAAA) protocol in a community teaching hospital. Variables examined include demographics, repair type, device used, presenting systolic blood pressure, presenting glomerular filtration rate, initial hematocrit, transfusions required, and development of postoperative abdominal compartment syndrome.
  
  
  RESULTS
  Forty-nine patients were treated using the rAAA protocol and 48 underwent repair. The 30-day mortality for rAAA and symptomatic AAA (sAAA) was 36.4% (12/33) and 20.0% (3/15), respectively, with a mean mortality of 31.2% (15/48). Mortality for rAAA treated by EVAR was 32.0% (8/25). Mortality for rAAA in the open repair group was 33% (2/6). Conversion from EVAR to open procedure (3/48) or 6% resulted in 100% mortality (P = 0.266). The development of abdominal compartment syndrome was an absolute predictor of death as mortality was 100% (P < 0.001). Other significant predictors of death include the following: (1) blood transfusion received during operation required in 10/14 deaths (71%) (P = 0.005) and (2) transfusion received anytime during hospitalization required in 12/14 deaths or 86% (P = 0.017).
  
  
  CONCLUSIONS
  The management and endovascular repair of sAAA or rAAA can be improved at the community hospital level by the implementation of standardized protocols. Blood transfusions and development of postoperative abdominal compartment syndrome significantly increase mortality. Individual institutional knowledge of results is critical to effective process improvement and optimal patient outcomes.
authors.affiliation: Department of Graduate Medical Education, General Surgery, Exempla Saint Joseph Hospital, Denver, CO. Electronic address: katrinaoyague@Centura.org.
authors.forename: Katrina S
authors.initials: KS
authors.lastname: Oyague
authors.affiliation: Department of Surgery, Exempla Saint Joseph Hospital, Denver, CO.
authors.forename: Omar A
authors.initials: OA
authors.lastname: Mubarak
authors.affiliation: Department of Surgery, Exempla Saint Joseph Hospital, Denver, CO.
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Nowak
authors.affiliation: Department of Surgery, Exempla Saint Joseph Hospital, Denver, CO.
authors.forename: Jennifer G
authors.initials: JG
authors.lastname: Gainer
authors.affiliation: Department of Vascular Therapy, Colorado Permanente Medical Group, Denver, CO.
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Rehring
authors.affiliation: Department of Biostatistics, University of Colorado, Anschutz Medical Campus, Aurora, CO.
authors.forename: Maureen M
authors.initials: MM
authors.lastname: O'Brien
authors.affiliation: Department of Graduate Medical Education, General Surgery, Exempla Saint Joseph Hospital, Denver, CO.
authors.forename: Harris W
authors.initials: HW
authors.lastname: Hollis
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D002985:Clinical Protocols; D003120:Colorado; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006764:Hospitals, Community; D006784:Hospitals, Teaching; D006801:Humans; D059325:Intra-Abdominal Hypertension / Q000209:etiology / Q000401:mortality; D008297:Male; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D065227:Transfusion Reaction; D016896:Treatment Outcome