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Purpose: There has been much discussion in the literature of factors that affect the mortality rate of patients who undergo repair of ruptured abdominal aortic aneurysms. Some studies have suggested restricting patient selection for repair on the basis of certain preoperative factors including age, increased creatinine level, low hemoglobin level, loss of consciousness, electrocardiographic changes, and preoperative cormorbid medical conditions. A retrospective review of 96 patients who underwent repair of a ruptured abdominal aortic aneurysm was performed to determine whether these factors would necessarily be applicable to all populations., Methods: A retrospective chart review of all patients who underwent repair of a ruptured abdominal aortic aneurysm was performed over a study period of 20 years. Data was analyzed by both univariate and multivariate analysis., Results: The mean age of the patients was 73 years. The intraoperative mortality rate was 23%. The in-hospital mortality rate was 60.4%, with a 30-day mortality rate of 56.3%. By univariate analysis of various factors associated with the mortality rate, hemoglobin level, creatinine level, lowest preoperative and average intraoperative systolic blood pressure, packed red blood cells transfused, estimated blood loss, intraoperative urine output, and temperature were statistically significant. A history of loss of consciousness was also statistically significant. No preoperative comorbid medical conditions were significant, nor was age. On a multivariate analysis, preoperative factors of loss of consciousness, a lowest preoperative systolic blood pressure less than 90 mm Hg, a hemoglobin level less than 10 g/dl, and a creatinine level greater than 1.5 mg/dl were predictive of death. The effects of the hemoglobin level, creatinine level, and loss of consciousness on the mortality rate were strongest in patients who had a lowest preoperative systolic blood pressure greater than 90 mm Hg. In patients who had the sets of preoperative factors that were associated with a 100% mortality rate, there were intraoprative factors that influenced their death., Conclusions: These findings suggest that the factors (loss of consciousness, creatinine level, hemoglobin level) that are predictive of death may be a reflection of shock in this patient population. Further studies should be directed to optimizing preoperative resuscitation. Patients who have a ruptured abdominal aortic aneurysm should not be denied therapy on the basis of any specific set of preoperative factors.

Seventy cases of ruptured abdominal aortic aneurysms (RAAAs) repaired over a 14-year period from 1975 to 1989 were analyzed. Age, heart disease, chronic obstructive pulmonary disease (COPD), hypertension, diabetes, or specific postoperative complications did not correlate with mortality. If the time interval from arrival at the hospital to skin incision (emergency room (ER) or operating room (OR] was less than six hours, there was no correlation with survival. Mortality correlated significantly with admitting systolic blood pressure, blood pressure at the time of skin incision, a comparison of ER to OR time of less than or more than six hours, blood loss of less than compared to more than ten units, and time in the operating room of less than five hours compared to more than five hours. Both time in the operating room and blood loss correlated with technical problems. Prior to 1985, 11 general and vascular surgeons had repaired RAAAs with a mortality of 76%. Since 1985, six vascular surgeons repaired RAAAs with a significant decrease in mortality (54%). Our data indicate that patients profoundly hypotensive on admission or at the time of incision are unlikely to survive regardless of other factors; patients with a systolic blood pressure greater than 100 mm Hg have the best chance of survival; a delay of up to six hours prior to surgery in patients with a systolic blood pressure greater than 100 mm Hg does not increase mortality; and a smaller number of surgeons operating on RAAAs increases survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic elastase, antiprotease (a-1-antitrypsin) and total protein were assayed in 37 patients who underwent an operation on the abdominal aorta for ruptured abdominal aortic aneurysms (AAA), an elective procedure for AAA or aortofemoral bypass for occlusive disease. Aortic elastase modified by local antiprotease activity (elastase/a-1-antitrypsin) was significantly higher in patients with a ruptured AAA compared with patients with an elective AAA or occlusive aortic disease: 241 nanograms per milligram of tissue in AAA-rupture versus 57 nanograms per milligram of tissue in AAA-elective versus 32 nanograms per milligram of tissue for occlusive (p less than 0.003). Patients with a ruptured AAA had the highest elastase activity (354 nanograms per milligram of tissue) and the lowest a-1-antitrypsin (1.07 nanograms per milligram of tissue) compared with patients with an elective AAA and occlusion (p less than 0.05). These data suggest that the homeostatic balance between elastase and antiprotease may be significantly altered in the aortic wall at the time of aneurysm rupture. Increased elastase unchecked by low antiprotease results in increased elastin breakdown which may be the inciting event for rupture of a compromised, thin aortic aneurysm wall.

One hundred and sixty-eight ruptured aortic aneurysms presenting at the Princess Alexandra Hospital in an 11-year period have been reviewed. Surgical treatment still carries a high mortality and a very high postoperative morbidity. The survival rate in the Vascular Unit of this hospital has improved during the period studied and in the last five years has risen to 61%. The operative technique is described in detail, and the operative problems and complications are discussed. It is felt that prompt surgical treatment, and accurate assessment of blood loss with adequate replacement during surgery, combined with attention to early postoperative problems, particularly those of a respiratory nature, are the most important factors in survival.