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A ruptured abdominal aortic aneurysm that requires preoperative cardiopulmonary resuscitation is not necessarily lethal

Open ArchivePublished:September 29, 2015DOI:https://doi.org/10.1016/j.jvs.2015.08.061

      Objective

      A ruptured abdominal aortic aneurysm (RAAA) is associated with a high mortality rate. If cardiopulmonary resuscitation (CPR) is required before surgical repair, mortality rates are said to approach 100%. The aim of this multicenter, retrospective study was to study outcome in RAAA patients who required CPR before a surgical (endovascular or open) repair (CPR group). RAAA patients who did not need CPR served as controls (non-CPR group).

      Methods

      Over a 5-year time period, demographic and clinical characteristics and specifics of preoperative CPR if necessary were studied in all patients who were treated for a RAAA in three large, nonacademic hospitals.

      Results

      A total of 199 consecutive RAAA patients were available for analysis; 176 patients were surgically treated. Thirteen of these 176 patients (7.4%) needed CPR, and 163 (92.6%) did not. A 38.5% (5 of 13) survival rate was observed in the CPR group. Thirty-day mortality was almost three times greater in the CPR group compared with the non-CPR group (61.5% vs 22.7%; P = .005). Both CPR patients who received endovascular aortic repair survived. In contrast, survival in 11 CPR patients who underwent open RAAA repair was 27% (3 of 11; P = .128). A trend for higher Hardman index was found in patients who received CPR compared with patients who did not receive CPR (P = .052). The 30-day mortality in patients with a 0, 1, 2, or 3 Hardman index was 16.1%, 31.0%, 37.9%, and 33.3%, respectively (P = .093).

      Conclusions

      An RAAA that requires preoperative CPR is not necessarily a lethal combination. Patient selection must be tailored before surgery is denied.
      Although there has been substantial improvement in health care over the past decades, mortality rates in populations with a ruptured abdominal aortic aneurysm (RAAA) remain invariably high. For instance, the estimated total mortality rate of a recent series of patients who suffered from RAAAs was 81%.
      • Reimerink J.J.
      • van der Laan M.J.
      • Koelemay M.J.
      • Balm R.
      • Legemate D.A.
      Systematic review and meta-analysis of population-based mortality from ruptured abdominal aortic aneurysm.
      In case patients arrive alive in the hospital and undergo emergent surgery, up to half will subsequently die in the perioperative period.
      • Hardman D.T.
      • Fisher C.M.
      • Patel M.I.
      • Neale M.
      • Chambers J.
      • Lane R.
      • et al.
      Ruptured abdominal aortic aneurysms: who should be offered surgery?.
      • Powell J.T.
      • Sweeting M.J.
      • Thompson M.M.
      • Ashleigh R.
      • Bell R.
      • Gomes M.
      • et al.
      IMPROVE Trial Investigators
      Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial.
      • Reimerink J.J.
      • Hoornweg L.L.
      • Vahl A.C.
      • Wisselink W.
      • van den Broek T.A.
      • Legemate D.A.
      • et al.
      Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial.
      Surgical outcome of RAAA might possibly improve if selection criteria for intervention are optimized. Scoring systems that combine clinical findings and biochemical results were introduced for RAAA patients as a means to predict survival. One of these tools is the Hardman index, which uses a set of five parameters. Although easily applicable, additional factors might also determine outcome.
      • Hardman D.T.
      • Fisher C.M.
      • Patel M.I.
      • Neale M.
      • Chambers J.
      • Lane R.
      • et al.
      Ruptured abdominal aortic aneurysms: who should be offered surgery?.
      To date, not a single scoring system allows for a proper preoperative selection of candidates who might optimally benefit from vascular surgery for RAAA.
      The necessity of preoperative cardiopulmonary resuscitation (CPR) reflects the dismal condition of a RAAA before an invasive procedure. Therefore, it is highly questionable whether RAAA patients who require preoperative CPR should be offered surgical treatment at all. Previous publications on the matter show that after cardiac arrest there is a possibility of survival.
      • Cho J.S.
      • Kim J.Y.
      • Rhee R.Y.
      • Gupta N.
      • Marone L.K.
      • Dillavou E.D.
      • et al.
      Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality.
      • Gloviczki P.
      • Pairolero P.C.
      • Mucha Jr., P.
      • Farnell M.B.
      • Hallett Jr., J.W.
      • Ilstrup D.M.
      • et al.
      Ruptured abdominal aortic aneurysms: repair should not be denied.
      However, a slim body of low-level literature are adamant that these patients are unlikely to survive.
      • Greeven A.P.
      • Bouwman L.H.
      • Smeets H.J.
      • van Baalen J.M.
      • Hamming J.F.
      Outcome of patients with ruptured abdominal aortic aneurysm after cardiopulmonary resuscitation.
      • Urwin S.C.
      • Ridley S.A.
      Prognostic indicators following emergency aortic aneurysm repair.
      • Johansen K.
      • Kohler T.R.
      • Nicholls S.C.
      • Zierler R.E.
      • Clowes A.W.
      • Kazmers A.
      Ruptured abdominal aortic aneurysm: the Harborview experience.
      Senior authors of the present study have experienced that some patients might survive after the unfortunate combination of CPR before RAAA treatment.
      The aim of the study was to evaluate clinical outcome in RAAA patients who received CPR before surgery (CPR). RAAA patients who did not need CPR served as controls (non-CPR). We also studied whether the Hardman index was of prognostic value in these resuscitated RAAA patients.

      Methods

       Patient population

      Consecutive patients registered with an RAAA (Dutch administrative code: DBC 406) between February 2009 and January 2014 were identified from hospital records of three large, nonacademic teaching hospitals in the Netherlands. Inclusion criteria were RAAA and treatment with either endovascular aortic repair (EVAR) or open repair (OR). An RAAA was defined as a typical event of sudden severe abdominal pain in a patient with an aneurysm of the abdominal aorta and the presence of blood outside the adventitia of an aneurysmal abdominal aortic wall determined using ultrasound. A contrast-enhanced computed tomography angiography scan was performed, if possible, to confirm the diagnosis and to allow for a precise treatment plan. Patients were excluded if evidence of a rupture was lacking during OR. This retrospective study was conducted according to the Declaration of Helsinki and approved by the local medical ethics committees. Patient informed consent was not required because this retrospective study did not involve medical treatment. Patient data were stored anonymously.
      Patient data were collected through hospital, emergency department (ED), and surgical records. All patients were treated by or under the supervision of a consultant vascular surgeon. Type of surgery (OR or EVAR) was left to the discretion of the surgeon. If the prognosis was deemed exceedingly poor because of comorbidity or if treatment options were limited, patients were managed conservatively after consultation in the presence of the patient and family.

       Definitions and outcomes

      Two patient populations were compared, a CPR and a non-CPR group. CPR was defined as the combination of artificial respiration and heart massage by the exertion of pressure on the chest for at least a 5-minute period before the decision to institute invasive vascular surgery in an RAAA patient. A 5-minute minimum was used to preclude the chance that an inadequate bystander reaction on loss of consciousness was registered as CPR. Whether the indication to initiate CPR was correct (type of cardiac arrest [eg, ventricular fibrillation] was not the aim of our study, because we studied outcome after CPR [performed by bystander, paramedic, or in-hospital]). We strived to answer the question whether CPR in itself was conditional for a surgeon to abstain from further action. The primary end point was 30-day or in-hospital mortality.
      The Hardman index was chosen for risk assessment. This tool was selected because it is easy to use in an emergency room setting as opposed to other scoring systems. It converts the presence or absence of five factors including age (>76 years), serum creatinine (>190 μmol/L), hemoglobin (<5.6 mmol/L), loss of consciousness after arrival at the ED, and electrocardiographic signs of ischemia into a 0- to 5-point score.
      • Hardman D.T.
      • Fisher C.M.
      • Patel M.I.
      • Neale M.
      • Chambers J.
      • Lane R.
      • et al.
      Ruptured abdominal aortic aneurysms: who should be offered surgery?.
      We calculated the Hardman index only in treated RAAA patients with available information regarding all five factors to avoid underscoring.

       Statistical analysis

      Statistical analyses were performed using SPSS version 21 for MAC (IBM Corp, Armonk, NY). Categorical variables are presented as frequencies with percentages. Continuous variables are presented as mean ± standard deviation or as median and interquartile range (IQR) in case of skewed data. The χ2 or Fisher exact test were used for categorical variables according to sample size. Incidence rates with 95% confidence intervals were determined. A P value < .05 was considered statistically significant.

      Results

      A total of 199 consecutive RAAA patients were identified during the 5-year period of interest. No surgical treatment was offered to 23 patients (11.6%). Seven of these received prolonged CPR (>30 minutes) during transportation and/or during their stay in the ED. However, these efforts were in vain and they did not regain cardiac output. Sixteen additional patients received palliation; a vascular intervention, as considered by the attending vascular surgeon, was no option. Subjective reasons to deny invasive treatment in these patients were severe comorbidity and unfavorable vascular anatomy in patients who were physically not suitable to undergo OR.
      In the remaining 176 patients (88.4%), a treatment strategy consisting of controlled hypotension, medication, and intravenous fluids followed by surgery was initiated. Temporary CPR before surgery was required in 13 patients (CPR group, 7.4%) and 163 patients did not (non-CPR group, 92.6%). There were no significant age or sex differences between these two groups (Table I). One hundred three open procedures (58.5%) and 73 endovascular procedures (41.5%) were performed (Table II).
      Table IBaseline characteristics, Hardman index, 30-day mortality
      VariableCPR (n = 13)
      Values are reported as mean ± standard deviation, median [IQR], or as frequencies (%) (n/N). Denominator differs when there are missing values.
      Non-CPR (n = 163)
      Values are reported as mean ± standard deviation, median [IQR], or as frequencies (%) (n/N). Denominator differs when there are missing values.
      P
      Mean age, years75.3 ± 8.074.2 ± 8.0.623
      Male sex84.6 (11/13)85.3 (139/163)1.000
      Fisher exact test.
      Hemoglobin, mmol/L7.0 ± 1.47.5 ± 1.3.199
      Creatinine, μmol/L102 [95-153]107 [90-133].604
      Hardman index.052
      Fisher exact test.
       00 (0/9)30.4 (31/102)
       133.3 (3/9)38.2 (39/102)
       244.4 (4/9)24.5 (25/102)
       322.2 (2/9)6.9 (7/102)
      Treatment.047
       Open aneurysm repair84.6 (11/13)57.1 (92/163)
       Endovascular aneurysm repair15.4 (2/13)42.9 (71/163)
      30-Day mortality61.5 (8/13)22.7 (37/163).005
      Fisher exact test.
      CPR, Cardiopulmonary resuscitation; IQR, interquartile range.
      a Values are reported as mean ± standard deviation, median [IQR], or as frequencies (%) (n/N). Denominator differs when there are missing values.
      b Fisher exact test.
      Table IIOutcome based on type of treatment
      VariableOR (n = 103)EVAR (n = 73)P
      Age, years73.9 ± 8.074.9 ± 8.0.430
      Male sex85.4 (88/103)84.9 (62/73).926
      CPR10.7 (11/103)4.1 (2/73).047
      Hardman index.503
      Fisher exact test.
       026.6 (17/64)29.8 (14/47)
       135.9 (23/64)40.4 (19/47)
       231.3 (20/64)19.1 (9/47)
       36.3 (4/64)10.6 (5/47)
      Thirty-day mortality32.0 (33/103)16.4 (12/73).019
      CPR, Cardiopulmonary resuscitation; EVAR, endovascular aneurysm repair; OR, open aneurysm repair.
      Values are reported as mean ± standard deviation, or as frequencies (%) (n/N).
      a Fisher exact test.
      There were more open procedures in the CPR group (11 of 13; 84.6%) compared with the non-CPR group (92 of 163; 56.4%; P = .047). Table III shows patient demographic and CPR characteristics including duration and adrenalin and atropine administration. Most patients were resuscitated in the hospital (10 of 13; 76.9%). Median CPR duration was 20 minutes (IQR, 12.5-30 minutes). Table III also shows the lowest pH, highest lactate levels, and intraoperative-required blood products.
      Table IIIOverview of patient characteristics, perioperative status, and follow-up of patients in the cardiopulmonary resuscitation (CPR) group
      PatientSexAge, yearsCPR locationCPR duration, minutesAdrenalin,
      Administration during CPR and intraoperative support.
      mg
      DefibrillationPerformed byNarrativeSurgerySurvival, daysStatus
      1F76ED/OT30NRNRDoctorRR not measurable; regained blood pressure after aortic clamping.OR20Dead
      2M66Ward/OT201NRDoctorCPR from ward to OT. Output in OT, RR 68/45.

      8 Times ECC, 900 cc CellSaver, 6 times FFP, pH 6.98, lactate 9.9 mmol/L.
      OR2092Alive
      3M69ED/OT5 + 2516.3TwiceDoctorRegained output in ED after 5 minutes. In OT again arrhythmia. CPR ceased after 25 minutes. 15 times ECC, 4 times FFP, 3.3 mg adrenaline, pH 6.8.OR0Dead
      4M79Home5NoneNRBystanderRegained output when ambulance arrived with RR 50/30.

      6 Times ECC, twice FFP, 4 times colloid, pH 7.32, lactate 2.2 mmol/L.
      OR1939Alive
      5M78Ward5NoneNRNurseCPR started by nurse. RR 90/40.

      12 Times ECC, twice thrombocytes, 4 times FFP, pH 6.89, lactate 11.5 mmol/L.
      OR1Dead
      6M85AmbulanceNRNoneOnceParamedicVentricular tachycardia for which defibrillation was used. Regained output with RR 70/60.

      4 Times ECC, pH 7.07, lactate 11.5 mmol/L.
      EVAR1631Alive
      7M76ED5NRNRNRRegained output in ED, remained perioperative hemodynamically unstable, RR 86/50. pH 7.21, lactate 10.8 mmol/L.OR21Dead
      8M78ED/OT20 + 103NRDoctor20 minutes CPR in ED. In OT after aortic clamping 10 minutes CPR, unsuccessful.

      5 Times ECC.
      OR0Dead
      9M83ED30NRNRDoctorCardiac arrest after CTA.

      11 Times ECC, 4 times FFP, pH 7.18, lactate 6.6 mmol/L.
      OR9Dead
      10M82Home/ambulance15NoneNRBystanderRib fractures with tension pneumothorax. Regained output in ambulance.

      10 Times ECC, 4 time FFP, once thrombocytes, pH 7.12, lactate 7.4 mmol/L.
      OR1038Alive
      11F84Home/OT5 + 153NRParamedicRegained consciousness in ambulance. RR 80/64. In again OT 15 minutes CPR, however, treatment stopped because of a DNR code.OR0Dead
      12M61ED305NRDoctorAfter CTA cardiac arrest.

      Adrenaline, ECC and FFPs administered, amounts unknown.
      OR0Dead
      13M63ED205.5Three timesDoctorCPR in CT room, patient regained consciousness in OT.

      3 Times ECC, pH 6.90, lactate 13 mmol/L.
      EVAR432Alive
      CT, Computed tomography; CTA, computed tomography angiography; DNR, do not resuscitate; ECC, erythrocyte concentrate; ED, emergency department; EVAR, endovascular aortic repair; F, female; FFP, fresh frozen plasma; M, male; NR, not reported; OR, open repair; OT, operating theater; RR, lowest reported blood pressure.
      Lactate, normal level <1.3 mmol/L; pH normal range, 7.35-7.45.
      a Administration during CPR and intraoperative support.

       Hardman index

      A full set of five variables was obtained and analyzed in 111 of 176 patients (63.1%) who received surgery. Values of serum creatinine, loss of consciousness, and electrocardiographic information was missing in 3 (1.7%), 7 (4.0%), and 63 (35.8%) of the patients, respectively. No risk factor was present in 31 patients whereas 42 patients had 1, 29 patients had 2, and 9 patients had 3; no patient possessed more than three risk factors. Hardman index values were comparable between EVAR and OR patients (P = .503). As expected, the CPR group showed a trend toward a higher Hardman index compared with non-CPR patients (P = .052).

       Mortality

      CPR patients had an almost three times higher 30-day mortality rate compared with non-CPR patients (CPR, 8 of 13; 61.5% vs non-CPR, 37 of 163; 22.7%; P = .005). The five surviving CPR patients were still alive, and lived independently, at the time of the writing of this report (March 2015) with a median of 1631 days (IQR, 735-2015 days; Table III). Notably, 30-day mortality was significantly lower for EVAR compared with OR across the entire population (EVAR 16.4% vs OR 32.0%; P = .019). Thirty-day mortality in the CPR group was zero in patients who received EVAR (n = 2) compared with 73% for patients who received OR (8 of 11; P = .128). The overall mortality rates in groups with a 0, 1, 2, or 3 Hardman Index were 16.1%, 31.0%, 37.9%, and 33.3%, respectively (Table IV). There was a tendency (P = .093) toward the presence of a higher Hardman index and mortality.
      Table IVThirty-day mortality in relation to the Hardman index
      VariableMortality, % (n/N)P
      Risk factors, No..093
       016.1 (5/31)
       131.0 (13/42)
       237.9 (11/29)
       333.3 (3/9)

      Discussion

      The ominous effect of CPR on survival in RAAA patients has been scarcely studied. Two studies that reported a 100% mortality rate in preoperatively resuscitated patients advocate that invasive treatment should be denied.
      • Greeven A.P.
      • Bouwman L.H.
      • Smeets H.J.
      • van Baalen J.M.
      • Hamming J.F.
      Outcome of patients with ruptured abdominal aortic aneurysm after cardiopulmonary resuscitation.
      • Johansen K.
      • Kohler T.R.
      • Nicholls S.C.
      • Zierler R.E.
      • Clowes A.W.
      • Kazmers A.
      Ruptured abdominal aortic aneurysm: the Harborview experience.
      In contrast, 67% and 72.8% 30-day mortality rates have been observed in patients with an RAAA that required CPR.
      • Gloviczki P.
      • Pairolero P.C.
      • Mucha Jr., P.
      • Farnell M.B.
      • Hallett Jr., J.W.
      • Ilstrup D.M.
      • et al.
      Ruptured abdominal aortic aneurysms: repair should not be denied.
      • Crawford E.S.
      Ruptured abdominal aortic aneurysm.
      To our knowledge, this is the first multicenter study to describe survivors after resuscitation before RAAA surgery. As expected, the present study shows a substantially higher mortality rate in resuscitated RAAA patients (CPR 61.5% vs non-CPR, 22.7%; P = .005). Conversely, the 38.5% survival rate in our CPR patients is not far removed from the 33% survival rate reported by Crawford.
      • Crawford E.S.
      Ruptured abdominal aortic aneurysm.
      The identification of people who require out-of-hospital CPR is difficult if not impossible. As a consequence, timing and duration of CPR might not always be optimal.
      • White L.
      • Rogers J.
      • Bloomingdale M.
      • Fahrenbruch C.
      • Culley L.
      • Subido C.
      • et al.
      Dispatcher-assisted cardiopulmonary resuscitation: risks for patients not in cardiac arrest.
      Although CPR might possibly be deemed unnecessary in retrospect by experts, a CPR before ED presentation might lead to a less objective and a less aggressive patient assessment, on the basis of the premise that the combination of CPR and RAAA is always lethal. A recent report on palliated RAAA patients created a subgroup on the basis of CPR, and indicated this as the main reason for palliation.
      • van Beek S.C.
      • Vahl A.C.
      • Wisselink W.
      • Balm R.
      Amsterdam Acute Aneurysm Trial Collaborators
      Fate of patients unwilling or unsuitable to undergo surgical intervention for a ruptured abdominal aortic aneurysm.
      In contrast, the current study demonstrated that 38.5% of RAAA patients survived a period of CPR before surgery and should therefore be given a fair assessment.
      Several explanations for increased survival rates after preoperative CPR in an RAAA population might be proposed. Overall, improvements in preoperative management have reduced RAAA mortality rates in the past 2 decades.
      • Reimerink J.J.
      • van der Laan M.J.
      • Koelemay M.J.
      • Balm R.
      • Legemate D.A.
      Systematic review and meta-analysis of population-based mortality from ruptured abdominal aortic aneurysm.
      A previous adage of aggressive fluid administration in an RAAA patient was replaced by the concept of permissive hypotension. In 1991, Crawford suggested that extensive volume resuscitation in RAAA promoted loss of whole blood and coagulation factors. In contrast, ‘permissive’ hypotension would reduce these losses and thus increase survival possibilities.
      • Crawford E.S.
      Ruptured abdominal aortic aneurysm.
      This concept is widely accepted and integrated in contemporary guidelines.
      • Moll F.L.
      • Powell J.T.
      • Fraedrich G.
      • Verzini F.
      • Haulon S.
      • Waltham M.
      • et al.
      Management of abdominal aortic aneurysms clinical practice guidelines of the European Society for Vascular Surgery.
      Systolic blood pressures between 50 and 100 mm Hg are considered optimal if tolerated.
      • Moll F.L.
      • Powell J.T.
      • Fraedrich G.
      • Verzini F.
      • Haulon S.
      • Waltham M.
      • et al.
      Management of abdominal aortic aneurysms clinical practice guidelines of the European Society for Vascular Surgery.
      Survival is in part also determined by the experience of dedicated professionals. In the Netherlands, well-trained paramedics provide prehospital care. The application of permissive hypotension by Dutch ambulance staff in a retrospective study demonstrated an 81% adherence rate.
      • Reimerink J.J.
      • Hoornweg L.L.
      • Vahl A.C.
      • Wisselink W.
      • Balm R.
      Controlled hypotension in patients suspected of a ruptured abdominal aortic aneurysm: feasibility during transport by ambulance services and possible harm.
      These modifications in preoperative patient management possibly have led to a better outcome.
      The second major paradigm shift to influence outcome in RAAA is related to the vascular technique. Most modern vascular surgeons would contend that EVAR is the treatment of choice in elective RAAA surgery.
      • Paravastu S.C.
      • Jayarajasingam R.
      • Cottam R.
      • Palfreyman S.J.
      • Michaels J.A.
      • Thomas S.M.
      Endovascular repair of abdominal aortic aneurysm.
      With increased endovascular possibilities, experienced vascular centers have also adopted an ‘EVAR first approach’ for the treatment of RAAAs. In our study, not all three centers used an EVAR first approach at any time. However, an increase of endovascular repair over time was observed. Large efforts such as in the Immediate Management of the Patient with Rupture: Open Versus Endovascular strategies (IMPROVE) trial and the Amsterdam Acute Aneurysm trial that compared EVAR with OR and failed to demonstrate a beneficial effect of either technique on mortality rates.
      • Powell J.T.
      • Sweeting M.J.
      • Thompson M.M.
      • Ashleigh R.
      • Bell R.
      • Gomes M.
      • et al.
      IMPROVE Trial Investigators
      Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial.
      • Reimerink J.J.
      • Hoornweg L.L.
      • Vahl A.C.
      • Wisselink W.
      • van den Broek T.A.
      • Legemate D.A.
      • et al.
      Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial.
      However, centers that introduced an EVAR-first approach for RAAA did report improved overall mortality rates.
      • Moore R.
      • Nutley M.
      • Cina C.S.
      • Motamedi M.
      • Faris P.
      • Abuznadah W.
      Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms.
      • Arya N.
      • Makar R.R.
      • Lau L.L.
      • Loan W.
      • Lee B.
      • Hannon R.J.
      • et al.
      An intention-to-treat by endovascular repair policy may reduce overall mortality in ruptured abdominal aortic aneurysm.
      The reduction in mortality is presumably related to reduced blood loss and shorter procedural time.
      • Reimerink J.J.
      • Hoornweg L.L.
      • Vahl A.C.
      • Wisselink W.
      • van den Broek T.A.
      • Legemate D.A.
      • et al.
      Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial.
      • Peppelenbosch N.
      • Geelkerken R.H.
      • Soong C.
      • Cao P.
      • Steinmetz O.K.
      • Teijink J.A.
      • et al.
      Endograft treatment of ruptured abdominal aortic aneurysms using the Talent aortouniiliac system: an international multicenter study.
      Moreover, emergency EVAR can be safely performed with local anesthesia in cooperative patients and avoid systemic cardiovascular depression associated with general anesthesia.
      • Lachat M.L.
      • Pfammatter T.
      • Witzke H.J.
      • Bettex D.
      • Kunzli A.
      • Wolfensberger U.
      • et al.
      Reprinted article “Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms”.
      • Ellard L.
      • Djaiani G.
      Anaesthesia for vascular emergencies.
      In our total population the 30-day mortality on the basis of treatment alone was significantly lower for EVAR compared with OR, respectively 16.4% vs 32.0% (P = .019). Of the treated patients, EVAR was performed in two patients who required CPR (14.5%) and in 71 (42.9%) patients who did not. It is noteworthy that both CPR patients who underwent EVAR survived even though their parameters such as pH, lactate, and lowest blood pressure were poor (Table III). Therefore, endovascular repair is a feasible therapy, also in highly unstable patients. A recent study supports the contention that hemodynamically unstable RAAA patients possibly benefit from EVAR compared with OR, reflected by 30-day mortality rates.
      • Gupta P.K.
      • Ramanan B.
      • Engelbert T.L.
      • Tefera G.
      • Hoch J.R.
      • Kent K.C.
      A comparison of open surgery versus endovascular repair of unstable ruptured abdominal aortic aneurysms.
      There are roughly two options in the management of hemodynamic unstable RAAA patients. Patients can be directly transported to the operating theater to initiate OR, or they can undergo a computed tomography scan to allowing for a decision on EVAR or OR. When considering that aneurysm morphology is a predictor of mortality in EVAR and OR, a computed tomography angiography scan is of the utmost importance in treatment selection.
      IMPROVE Trial Investigators
      The effect of aortic morphology on peri-operative mortality of ruptured abdominal aortic aneurysm.
      In specialized vascular centers, there is sufficient time to perform imaging and to assess EVAR suitability.
      • Boyle J.R.
      • Gibbs P.J.
      • Kruger A.
      • Shearman C.P.
      • Raptis S.
      • Phillips M.J.
      Existing delays following the presentation of ruptured abdominal aortic aneurysm allow sufficient time to assess patients for endovascular repair.
      Despite all of these considerations, RAAA mortality rates are exceedingly high. It is therefore important to study tools that allow for an improved selection of patients, and prevent fruitless attempts and high costs. In the present study, 23 RAAA patients (11.6%) did not receive invasive treatment (CPR, n = 7; non-CPR, n = 16). These patients were deemed inoperable or were deceased before surgery could be initiated. A turndown rate of 11.6% is low compared with previously reported rates of up to 40%.
      • Karthikesalingam A.
      • Holt P.J.
      • Vidal-Diez A.
      • Ozdemir B.A.
      • Poloniecki J.D.
      • Hinchliffe R.J.
      • et al.
      Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA.
      Comparisons in RAAA care between the United States and the United Kingdom show a very different palliation rate although treatment mortality rates are comparable.
      • Karthikesalingam A.
      • Holt P.J.
      • Vidal-Diez A.
      • Ozdemir B.A.
      • Poloniecki J.D.
      • Hinchliffe R.J.
      • et al.
      Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA.
      Although there is no obvious explanation for this difference, the results do underline the difficulty in selecting patients who benefit from surgical repair.
      Various scoring systems to objectively identify high-risk patients have been forwarded including the Glasgow Aneurysm Score, the Vascular-Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity, Vancouver scorings system, and the Hardman index.
      • Hardman D.T.
      • Fisher C.M.
      • Patel M.I.
      • Neale M.
      • Chambers J.
      • Lane R.
      • et al.
      Ruptured abdominal aortic aneurysms: who should be offered surgery?.
      • Samy A.K.
      • Murray G.
      • MacBain G.
      Glasgow aneurysm score.
      • Prytherch D.R.
      • Ridler B.M.
      • Beard J.D.
      • Earnshaw J.J.
      Audit and Research Committee, The Vascular Surgical Society of Great Britian and Ireland. A model for national outcome audit in vascular surgery.
      • Chen J.C.
      • Hildebrand H.D.
      • Salvian A.J.
      • Taylor D.C.
      • Strandberg S.
      • Myckatyn T.M.
      • et al.
      Predictors of death in nonruptured and ruptured abdominal aortic aneurysms.
      The Hardman index is a five-parameter tool that does not require calculations or knowledge of the patient's medical history and is therefore highly suitable in an emergency setting. It was previously found that mortality rates were 16%, 37%, 72%, and 100% in populations with a score of 0, 1, 2, or 3, respectively.
      • Hardman D.T.
      • Fisher C.M.
      • Patel M.I.
      • Neale M.
      • Chambers J.
      • Lane R.
      • et al.
      Ruptured abdominal aortic aneurysms: who should be offered surgery?.
      Because the Hardman index is reasonably blunt, it provides a method less capable in identification of individual high-risk patients.
      • Tambyraja A.L.
      • Murie J.A.
      • Chalmers R.T.
      Prediction of outcome after abdominal aortic aneurysm rupture.
      • Acosta S.
      • Ogren M.
      • Bergqvist D.
      • Lindblad B.
      • Dencker M.
      • Zdanowski Z.
      The Hardman index in patients operated on for ruptured abdominal aortic aneurysm: a systematic review.
      In the present study, the Hardman index was not a priori determined as a tool to preoperatively identify high-risk patients. After selection by the attending surgeon, the 30-day mortality rates of the entire population were 16.1%, 31.0%, 37.9%, and 33.3% for a Hardman index of respectively 0, 1, 2, and 3. These percentages indicate that experienced vascular surgeons are capable of selecting patients, even from a group regarded as high-risk patients. Therefore, a surgeon's experience and judgment should always outweigh a tool like the Hardman index. In addition, Cho et al showed that CPR is not associated with an increased mortality rate.
      • Cho J.S.
      • Kim J.Y.
      • Rhee R.Y.
      • Gupta N.
      • Marone L.K.
      • Dillavou E.D.
      • et al.
      Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality.
      This underlines that tools like the Hardman index and the notion of CPR should not be referred to as a reason for palliation; individual assessment is vital.

       Study limitations

      The present study is a retrospective analysis with a limited sample size and therefore has its shortcomings. An unknown number of RAAA patients might have died before being correctly diagnosed so registration was possibly incomplete. Because of the urgent nature of an RAAA, documentation is sometimes limited. As a consequence, a substantial percentage of Hardman parameters were missing (36.9%). The conclusions should be interpreted with caution because of the limited sample size. Nevertheless, these limitations do not affect the finding of the present study in which a group of patients survived the combination of CPR and treatment for a RAAA as opposed to previous beliefs.

      Conclusions

      Patients with RAAAs who respond to CPR before emergency repair do have a chance of survival. Although CPR and a high Hardman index are associated with a poor outcome, both parameters should not be used as an absolute criterion to deny surgical intervention in a patient with an RAAA.

      Author contributions

      Conception and design: PB, YM, ML, MRS, LB, PC, MvS, JT
      Analysis and interpretation: PB, YM, ML, MRS, JT
      Data collection: PB, YM, ML, LB
      Writing the article: PB, YM, ML, MRS, LB, PC, MvS, JT
      Critical revision of the article: PB, YM, ML, MRS, LB, PC, MvS, JT
      Final approval of the article: PB, YM, ML, MRS, LB, PC, MvS, JT
      Statistical analysis: PB, YM
      Obtained funding: Not applicable
      Overall responsibility: JT

      References

        • Reimerink J.J.
        • van der Laan M.J.
        • Koelemay M.J.
        • Balm R.
        • Legemate D.A.
        Systematic review and meta-analysis of population-based mortality from ruptured abdominal aortic aneurysm.
        Br J Surg. 2013; 100: 1405-1413
        • Hardman D.T.
        • Fisher C.M.
        • Patel M.I.
        • Neale M.
        • Chambers J.
        • Lane R.
        • et al.
        Ruptured abdominal aortic aneurysms: who should be offered surgery?.
        J Vasc Surg. 1996; 23: 123-129
        • Powell J.T.
        • Sweeting M.J.
        • Thompson M.M.
        • Ashleigh R.
        • Bell R.
        • Gomes M.
        • et al.
        • IMPROVE Trial Investigators
        Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial.
        BMJ. 2014; 348: f7661
        • Reimerink J.J.
        • Hoornweg L.L.
        • Vahl A.C.
        • Wisselink W.
        • van den Broek T.A.
        • Legemate D.A.
        • et al.
        Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial.
        Ann Surg. 2013; 258: 248-256
        • Cho J.S.
        • Kim J.Y.
        • Rhee R.Y.
        • Gupta N.
        • Marone L.K.
        • Dillavou E.D.
        • et al.
        Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality.
        J Vasc Surg. 2008; 48 (discussion: 17-8): 10-17
        • Gloviczki P.
        • Pairolero P.C.
        • Mucha Jr., P.
        • Farnell M.B.
        • Hallett Jr., J.W.
        • Ilstrup D.M.
        • et al.
        Ruptured abdominal aortic aneurysms: repair should not be denied.
        J Vasc Surg. 1992; 15 (discussion: 857-9): 851-857
        • Greeven A.P.
        • Bouwman L.H.
        • Smeets H.J.
        • van Baalen J.M.
        • Hamming J.F.
        Outcome of patients with ruptured abdominal aortic aneurysm after cardiopulmonary resuscitation.
        Acta Chir Belg. 2011; 111: 78-82
        • Urwin S.C.
        • Ridley S.A.
        Prognostic indicators following emergency aortic aneurysm repair.
        Anaesthesia. 1999; 54: 739-744
        • Johansen K.
        • Kohler T.R.
        • Nicholls S.C.
        • Zierler R.E.
        • Clowes A.W.
        • Kazmers A.
        Ruptured abdominal aortic aneurysm: the Harborview experience.
        J Vasc Surg. 1991; 13 (discussion: 245-7): 240-245
        • Crawford E.S.
        Ruptured abdominal aortic aneurysm.
        J Vasc Surg. 1991; 13: 348-350
        • White L.
        • Rogers J.
        • Bloomingdale M.
        • Fahrenbruch C.
        • Culley L.
        • Subido C.
        • et al.
        Dispatcher-assisted cardiopulmonary resuscitation: risks for patients not in cardiac arrest.
        Circulation. 2010; 121: 91-97
        • van Beek S.C.
        • Vahl A.C.
        • Wisselink W.
        • Balm R.
        • Amsterdam Acute Aneurysm Trial Collaborators
        Fate of patients unwilling or unsuitable to undergo surgical intervention for a ruptured abdominal aortic aneurysm.
        Eur J Vasc Endovasc Surg. 2015; 49: 163-165
        • Moll F.L.
        • Powell J.T.
        • Fraedrich G.
        • Verzini F.
        • Haulon S.
        • Waltham M.
        • et al.
        Management of abdominal aortic aneurysms clinical practice guidelines of the European Society for Vascular Surgery.
        Eur J Vasc Endovasc Surg. 2011; 41: S1-S58
        • Reimerink J.J.
        • Hoornweg L.L.
        • Vahl A.C.
        • Wisselink W.
        • Balm R.
        Controlled hypotension in patients suspected of a ruptured abdominal aortic aneurysm: feasibility during transport by ambulance services and possible harm.
        Eur J Vasc Endovasc Surg. 2010; 40: 54-59
        • Paravastu S.C.
        • Jayarajasingam R.
        • Cottam R.
        • Palfreyman S.J.
        • Michaels J.A.
        • Thomas S.M.
        Endovascular repair of abdominal aortic aneurysm.
        Cochrane Database Syst Rev. 2014; 1: CD004178
        • Moore R.
        • Nutley M.
        • Cina C.S.
        • Motamedi M.
        • Faris P.
        • Abuznadah W.
        Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms.
        J Vasc Surg. 2007; 45: 443-450
        • Arya N.
        • Makar R.R.
        • Lau L.L.
        • Loan W.
        • Lee B.
        • Hannon R.J.
        • et al.
        An intention-to-treat by endovascular repair policy may reduce overall mortality in ruptured abdominal aortic aneurysm.
        J Vasc Surg. 2006; 44: 467-471
        • Peppelenbosch N.
        • Geelkerken R.H.
        • Soong C.
        • Cao P.
        • Steinmetz O.K.
        • Teijink J.A.
        • et al.
        Endograft treatment of ruptured abdominal aortic aneurysms using the Talent aortouniiliac system: an international multicenter study.
        J Vasc Surg. 2006; 43 (discussion: 1123): 1111-1123
        • Lachat M.L.
        • Pfammatter T.
        • Witzke H.J.
        • Bettex D.
        • Kunzli A.
        • Wolfensberger U.
        • et al.
        Reprinted article “Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms”.
        Eur J Vasc Endovasc Surg. 2011; 42: S86-S93
        • Ellard L.
        • Djaiani G.
        Anaesthesia for vascular emergencies.
        Anaesthesia. 2013; 68: 72-83
        • Gupta P.K.
        • Ramanan B.
        • Engelbert T.L.
        • Tefera G.
        • Hoch J.R.
        • Kent K.C.
        A comparison of open surgery versus endovascular repair of unstable ruptured abdominal aortic aneurysms.
        J Vasc Surg. 2014; 60: 1439-1445
        • IMPROVE Trial Investigators
        The effect of aortic morphology on peri-operative mortality of ruptured abdominal aortic aneurysm.
        Eur Heart J. 2015; 36: 1328-1334
        • Boyle J.R.
        • Gibbs P.J.
        • Kruger A.
        • Shearman C.P.
        • Raptis S.
        • Phillips M.J.
        Existing delays following the presentation of ruptured abdominal aortic aneurysm allow sufficient time to assess patients for endovascular repair.
        Eur J Vasc Endovasc Surg. 2005; 29: 505-509
        • Karthikesalingam A.
        • Holt P.J.
        • Vidal-Diez A.
        • Ozdemir B.A.
        • Poloniecki J.D.
        • Hinchliffe R.J.
        • et al.
        Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA.
        Lancet. 2014; 383: 963-969
        • Samy A.K.
        • Murray G.
        • MacBain G.
        Glasgow aneurysm score.
        Cardiovasc Surg. 1994; 2: 41-44
        • Prytherch D.R.
        • Ridler B.M.
        • Beard J.D.
        • Earnshaw J.J.
        Audit and Research Committee, The Vascular Surgical Society of Great Britian and Ireland. A model for national outcome audit in vascular surgery.
        Eur J Vasc Endovasc Surg. 2001; 21: 477-483
        • Chen J.C.
        • Hildebrand H.D.
        • Salvian A.J.
        • Taylor D.C.
        • Strandberg S.
        • Myckatyn T.M.
        • et al.
        Predictors of death in nonruptured and ruptured abdominal aortic aneurysms.
        J Vasc Surg. 1996; 24 (discussion: 621-3): 614-620
        • Tambyraja A.L.
        • Murie J.A.
        • Chalmers R.T.
        Prediction of outcome after abdominal aortic aneurysm rupture.
        J Vasc Surg. 2008; 47: 222-230
        • Acosta S.
        • Ogren M.
        • Bergqvist D.
        • Lindblad B.
        • Dencker M.
        • Zdanowski Z.
        The Hardman index in patients operated on for ruptured abdominal aortic aneurysm: a systematic review.
        J Vasc Surg. 2006; 44: 949-954