title: The Rationale for Continuing Open Repair of Ruptured Abdominal Aortic Aneurysm.
abstract: BACKGROUND
  Mortality after open repair of ruptured abdominal aortic aneurysms (RAAAs) remains high. The purpose of this study is to present the results of open RAAA treatment observing 2 different 10-year periods in a single high-volume center and to consider the possibilities of result improvement in the future.
  
  
  METHODS
  Retrospective analysis of 729 RAAA patients who were treated through 1991-2001 (229 patients, Group A) and 2002-2011 (500 patients, Group B) was performed. Variables significantly associated with mortality were defined and analyzed.
  
  
  RESULTS
  Overall 30-day mortality in Group A was 53.7% (123/229 patients) with intraoperative mortality of 13.5% (31/229 patients), while in Group B it was 37.4% (187/500 patients) with intraoperative mortality of 12.4% (62/500 patients). Overall 30-day mortality was significantly lower in Group B (P = 0.012). There was no difference regarding intraoperative mortality (P = 0.797). Preoperative severe hemodynamic instability (P < 0.01, P < 0.001), cardiac arrest (P < 0.01, P < 0.001), consciousness deterioration (P < 0.05, P < 0.001), renal malfunction (P < 0.01, P < 0.001), and significant anemia (P < 0.01, P < 0.001) were associated with increased mortality in both A and B groups, respectively. Aortic cross-clamping level in Group A was predominantly infrarenal (68%) while in Group B it was mostly supraceliac (53%) (P < 0.001). Cross-clamping time, duration of surgery, and type of aortic reconstruction had no influence on survival in Group B (P > 0.05). Intraoperative hemodynamic instability (P < 0.01, P < 0.001), significant bleeding (P < 0.05, P < 0.01), and low urine output (P < 0.05, P < 0.001) remained parameters that favored lethal outcome in both A and B groups, respectively. Cell saving was used only in Group B. The multivariate logistic regression applied on the complete sample of patients presented several significant predictors of lethal outcome: congestive heart failure on admission (odds ratio [OR] 1.954, 95% confidence interval [CI] 1.103-3.460), intraperitoneal rupture (OR 3.009, 95% CI 1.771-5.423), aortofemoral reconstruction (OR 1.928, 95% CI 1.044-3.563), and total operative time (OR 1.005, 95% CI 1.001-1.010). Postoperative multisystem organ failure (P < 0.01, P < 0.001), respiratory (P < 0.01, P < 0.001) and renal (P < 0.05, P < 0.001) failure, postoperative bleeding (P < 0.05), and cerebrovascular incidents (P < 0.05, P < 0.01) significantly increased mortality in both A and B groups.
  
  
  CONCLUSIONS
  Although unselective, aggressive surgical approach in RAAA performed by teams experienced in open repair can improve patient's survival. Short admission/surgery time, supraceliac aortic cross-clamping, and the use of intraoperative cell saving are recommended.
authors.affiliation: Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia. Electronic address: drmiroslav@gmail.com.
authors.forename: Miroslav
authors.initials: M
authors.lastname: Marković
authors.affiliation: Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia.
authors.forename: Ivan
authors.initials: I
authors.lastname: Tomić
authors.affiliation: Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia.
authors.forename: Nikola
authors.initials: N
authors.lastname: Ilić
authors.affiliation: Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia.
authors.forename: Marko
authors.initials: M
authors.lastname: Dragaš
authors.affiliation: Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia.
authors.forename: Igor
authors.initials: I
authors.lastname: Končar
authors.affiliation: Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Institute for Medical Statistics and Informatics, Faculty of Medicine, Belgrade, Serbia.
authors.forename: Zoran
authors.initials: Z
authors.lastname: Bukumirić
authors.affiliation: Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia.
authors.forename: Miloš
authors.initials: M
authors.lastname: Sladojević
authors.affiliation: Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia.
authors.forename: Lazar
authors.initials: L
authors.lastname: Davidović
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D003250:Constriction; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D061847:Hospitals, High-Volume; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D057725:Operative Blood Salvage; D061646:Operative Time; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D055771:Serbia; D013997:Time Factors; D016896:Treatment Outcome