Regarding “Prediction of 30-day mortality after endovascular repair or open surgery in patients with ruptured abdominal aortic aneurysms”
Article Outline
We read with interest the article by Dr Visser and colleagues.1
The Glasgow Aneurysm Score (GAS) was described in 1994 as a tool for prognostic scoring in patients undergoing open repair of either intact or ruptured abdominal aortic aneurysm (AAA). A retrospective, multicentred, nonconsecutive sample of 500 patients undergoing aneurysm repair at general surgical units in Glasgow between 1980 and 1990 was examined for risk factors associated with death.2 Recently, this risk-scoring instrument has been the subject of external validation. When applied to our own series' of both retrospective and prospective data on patients undergoing attempted repair of ruptured AAA, the instrument performed with moderate accuracy at best, and lacked discriminative ability in patients at high risk.3, 4 Furthermore, when the instrument is applied to endovascular repair of intact aneurysms, the tool is found wanting too. Suboptimal performance was found in a retrospective series from London, and the prospective data of the DREAM trial noted poor validity in high risk patients.5, 6
The poor performance of the GAS in contemporary series of patients undergoing AAA repair is unsurprising given the origins of the dataset with which it was modeled – patients treated with open surgery in low-volume, nonspecialist, general surgical units more than 20 years ago. To expect this risk-scoring instrument to demonstrate validity, despite the existing reports questioning its precision, on a series of patients undergoing open and endovascular repair of ruptured AAA is hopeful to say the least. However, to attempt to refine the performance of the tool, so that it better fits the reported data, seems intrinsically flawed.
The GAS was never intended for application in patients undergoing endovascular aneurysm repair and lacks validity in high-risk patients. Fifteen years from its conception, perhaps it is time to acknowledge these deficiencies and accept that it is no longer fit for purpose. Valuable data, such as those of the 4-A group, may be better utilized to develop novel, original risk scoring instruments.
References
- . Prediction of 30-day mortality after endovascular repair or open surgery in patients with ruptured abdominal aortic aneurysms. J Vasc Surg. 2009;49:1093–1099
- . Glasgow aneurysm score. Cardiovasc Surg. 1994;2:41–44
- . Validity of the Glasgow Aneurysm Score and Hardman Index in predicting outcome after ruptured abdominal aortic aneurysm repair. Br J Surg. 2005;92:570–573
- . Prediction of outcome after abdominal aortic aneurysm rupture - a prospective evaluation. J Vasc Surg. 2008;47:282–286
- . Objective risk-scoring systems for repair of abdominal aortic aneurysms: applicability in endovascular repair?. Eur J Vasc Endovasc Surg. 2008;36:172–177
- . The Glasgow Aneurysm Score as a tool to predict 30-day and 2-year mortality in the patients from the Dutch Randomized Endovascular Aneurysm Management trial. J Vasc Surg. 2008;47:277–281
PII: S0741-5214(09)01449-9
doi:10.1016/j.jvs.2009.06.062
© 2009 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Prediction of 30-day mortality after endovascular repair or open surgery in patients with ruptured abdominal aortic aneurysms
