Das rupturierte abdominale Aortenaneurysma – Ergebnisse und prognostische Faktoren an einem gefäßchirurgischen Zentrum

 

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Zusammenfassung

Einleitung: Trotz des optimierten perioperativen Managements über die letzten Jahrzehnte hat sich die Prognose der Patienten mit rupturiertem abdominalem Aortenaneurysma (rAAA) nicht wesentlich verbessert. Ziel dieser retrospektiven Studie war, prä-, intra- und postoperative Faktoren zu identifizieren, die das perioperative und das langfristige Outcome der Patienten beeinflussen und die iatrogen beeinflussbar wären.

Methoden: Es erfolgte die retrospektive Datenanalyse von 49 Patienten, welche zwischen Anfang 2006 und Ende 2012 an einem gefäßchirurgischen Zentrum wegen eines rAAA operiert worden sind. Der Mindest-Follow-up betrug 30 Monate. Die statistischen Analysen erfolgten univariat mit der Kaplan-Meier-Methode und dem Log-Rank-Test, multivariat mit dem Cox-Modell.

Ergebnisse: Die intrahospitale Mortalität lag bei 40,8 %. Die 30-Tage-Letalität lag bei 28,9 %, die 1-Jahres-Überlebensrate bei 52,4 % und die 5-Jahres-Überlebensrate bei 45,3 %. In der univariaten Analyse bestanden signifikante Unterschiede bei der frühpostoperativen Überlebenswahrscheinlichkeit in Abhängigkeit von dem präoperativen systolischen RR-Wert, dem präoperativen Hb-Wert (< 10 vs. ≥ 10 g/dl), dem intraoperativen Transfusionsbedarf, der Rupturform, der Aneurysmalokalisation, der Notwendigkeit chirurgischer Folgeeingriffe, von postoperativem Multiorganversagen (MOV) und akutem Nierenversagen (ANV) sowie der postoperativen Sepsis. Bei den vollständig erfassten entlassenen Patienten (n = 27) hatten nur die Rupturform, die Aneurysmalokalisation, die präexistente KHK oder Diabetes mellitus einen signifikanten Einfluss auf die Langzeitüberlebenswahrscheinlichkeit. In der multivariaten Analyse nach dem Cox-Modell hatten Patienten mit einer vorbestehenden KHK ein 3,9-fach und mit einer freien Perforation ein 10-fach erhöhtes relatives Risiko, nach der Operation des rAAA zu versterben.

Schlussfolgerung: Die hohe Sterblichkeit des rAAA wird durch den hämorrhagischen Schock mit vorrangig nicht chirurgischen Komplikationen verursacht. Die therapeutischen Anstrengungen sollten sich auf die perioperativen Einflussfaktoren konzentrieren, welche sich optimieren lassen. Neben der Zentralisierung der rAAA-Versorgung in gefäßchirurgischen „high-volume“-Einrichtungen spielt das systematische Ultraschall-Screening der Bevölkerung über 65 Jahre eine bedeutende Rolle. Ein möglicher Vorteil der endovaskulären Aneurysmaausschaltung (EVAR) beim rAAA muss durch laufende Studien, z. B. IMPROVE, RCAR, AJAX, noch bewiesen werden.

Abstract

Introduction: Although the perioperative management has been optimised over the past few decades, there has not been a remarkable improvement in the mortality rates of patients with a ruptured abdominal aortic aneurysm (rAAA). The aim of this retrospective trial was to define pre-, intra- and postoperative parameters which influence the perioperative and long-term outcome of patients and which can be modified by the operating team.

Methods: A retrospective database analysis was performed in 49 patients who had undergone an operation of rAAA in our certified centre of vascular surgery between the beginning of 2006 and the end of 2012. The minimal follow-up period was 30 months. The statistical analysis was done univariately using the Kaplan-Meier method and a log-rank-test, and multivariately with the Cox model.

Results: Intrahospital mortality was 40.8 %, perioperative mortality (30 postoperative days) was 28.9 %. The survival rate for 1 year was 52.4 %; the survival rate for 5 years was 45.3 %. In the univariate analysis, significant differences in the early postoperative survival rates were found depending on preoperative systolic blood pressure, preoperative haemoglobin (< 10 vs. ≥ 10 g/dl), the intraoperative need of blood and frozen plasma transfusions, type of perforation, type of AAA, the need for further surgical interventions, postoperative MOF, acute kidney failure and postoperative septicaemia. The late survival rates were significantly influenced by the type of perforation and AAA, pre-existing coronary disease and diabetes mellitus in fully identified patients discharged from hospital (n = 27). In the multivariate analysis pursuant to the Cox model, patients with pre-existing coronary disease had a 3.9-fold higher relative risk to die after the operation of rAAA, while patients with a free perforation of the rAA had a 10-fold higher relative risk.

Conclusion: The high mortality of rAAA is caused by haemorrhagic shock and its complications, which are mostly non-surgical. Therapeutic efforts should focus on those perioperative parameters which can be modified by the treating teams. Alongside the centralisation of rAAA in high-volume-departments of vascular surgery, the systematic sonographic screening for asymptomatic AAA in the population older than 65 years should be enforced. A possible advantage of EVAR in rAAA has yet to be shown by trials in progress such as IMPROVE, AJAX and RCAR.

• Literatur

• 1 Forsdahl SH, Singh K, Solberg S et al. Risk factors for abdominal aortic aneurysms: a 7-year prospective study: the Tromso Study, 1994–2001. Circulation 2009; 119: 2202-2208
  CrossrefPubMedGoogle Scholar
• 2 Moll FL, Powell JT, Fraedrich G et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011; 41 (Suppl. 01) S1-S58
  CrossrefPubMedGoogle Scholar
• 3 Dillavou ED, Muluk SC, Makaroun MS. A decade of change in abdominal aortic aneurysm repair in the United States: have we improved outcomes equally between men and women?. J Vasc Surg 2006; 43: 230-238
  CrossrefPubMedGoogle Scholar
• 4 Bown MJ, Cooper NJ, Sutton AJ et al. The post-operative mortality of ruptured abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2004; 27: 65-74
  CrossrefPubMedGoogle Scholar
• 5 Hoornweg LL, Storm-Versloot MN, Ubbink DT et al. Meta analysis on mortality of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2008; 35: 558-570
  CrossrefPubMedGoogle Scholar
• 6 Antonello M, Frigatti P, Maturi C et al. Open repair for ruptured abdominal aortic aneurysm: is it possible to predict survival?. Ann Vasc Surg 2009; 23: 159-166
  CrossrefPubMedGoogle Scholar
• 7 Gawenda M, Block A, Majd PM et al. [Is there a role for risk-scoring methods in ruptured abdominal aortic aneurysm (rAAA)?]. Zentralbl Chir 2012; 137: 453-459
  Article in Thieme ConnectPubMedGoogle Scholar
• 8 van Beek SC, Reimerink JJ, Vahl AC et al. Editorʼs choice – external validation of models predicting survival after ruptured abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2015; 49: 10-16
  CrossrefPubMedGoogle Scholar
• 9 Gawenda M, Brunkwall J. Ruptured abdominal aortic aneurysm: the state of play. Dtsch Arztebl Int 2012; 109: 727-732
  PubMedGoogle Scholar
• 10 IMPROVE trial investigators. Powell JT, Hinchliffe RJ et al. Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm. Br J Surg 2014; 101: 216-224
  CrossrefPubMedGoogle Scholar
• 11 van Beek SC, Reimerink JJ, Vahl AC et al. Effect of regional cooperation on outcomes from ruptured abdominal aortic aneurysm. Br J Surg 2014; 101: 794-801
  CrossrefPubMedGoogle Scholar
• 12 Antoniou GA, Ahmed N, Georgiadis GS et al. Is endovascular repair of ruptured abdominal aortic aneurysms associated with improved in-hospital mortality compared with surgical repair?. Interact Cardiovasc Thorac Surg 2015; 20: 135-139
  CrossrefPubMedGoogle Scholar
• 13 Reimerink JJ, Hoornweg LL, Vahl AC et al. Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial. Ann Surg 2013; 258: 248-256
  CrossrefPubMedGoogle Scholar
• 14 Luebke T, Brunkwall J. Risk-adjusted meta-analysis of 30-day mortality of endovascular versus open repair for ruptured abdominal aortic aneurysms. Ann Vasc Surg 2015; 29: 845-863
  CrossrefPubMedGoogle Scholar
• 15 Trenner M, Haller B, Söllner H et al. 12 Jahre Qualitätssicherung zum rupturierten und nicht rupturierten abdominalen Aortenaneurysma der Deutschen Gesellschaft für Gefäßchirurgie und Gefäßmedizin (DGG). Teil 3: Prädiktoren für das perioperative Ergebnis unter besonderer Berücksichtigung der Fallzahl/Jahr. Gefässchirurgie 2014; 19: 573-585
  CrossrefPubMedGoogle Scholar
• 16 Sweeting MJ, Ulug P, Powell JT et al. Ruptured aneurysm trials: the importance of longer-term outcomes and meta-analysis for 1-year mortality. Eur J Vasc Endovasc Surg 2015; 50: 297-302
  CrossrefPubMedGoogle Scholar
• 17 Dubois L. Part one: for the motion. EVAR offers no survival benefit over open repair for the treatment of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2015; 49: 116-119
  PubMedGoogle Scholar
• 18 Mayer D, Rancic Z, Veith FJ et al. Part two: against the motion. EVAR offers no survival benefit over open repair for the treatment of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2015; 49: 119-127
  PubMedGoogle Scholar
• 19 Schlösser FJ, Vaartjes I, van der Heijden GJ et al. Mortality after hospital admission for ruptured abdominal aortic aneurysm. Ann Vasc Surg 2010; 24: 1125-1132
  CrossrefPubMedGoogle Scholar
• 20 Johnston KW. Ruptured abdominal aortic aneurysm: six-year follow-up results of a multicenter prospective study. Canadian Society for Vascular Surgery Aneurysm Study Group. J Vasc Surg 1994; 19: 888-900
  CrossrefPubMedGoogle Scholar
• 21 Dardik A, Burleyson GP, Bowman H et al. Surgical repair of ruptured abdominal aortic aneurysms in the state of Maryland: factors influencing outcome among 527 recent cases. J Vasc Surg 1998; 28: 413-420
  CrossrefPubMedGoogle Scholar
• 22 Chen JC, Hildebrand HD, Salvian AJ et al. Predictors of death in nonruptured and ruptured abdominal aortic aneurysms. J Vasc Surg 1996; 24: 614-620
  CrossrefPubMedGoogle Scholar
• 23 Olsen PS, Schroeder T, Agerskov K et al. Surgery for abdominal aortic aneurysms. A survey of 656 patients. J Cardiovasc Surg (Torino) 1991; 32: 636-642
  PubMedGoogle Scholar
• 24 Ambler GK, Coughlin PA, Hayes PD et al. Incidence and outcomes of severe renal impairment following ruptured abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2015; 50: 443-449
  CrossrefPubMedGoogle Scholar
• 25 Piper G, Patel NA, Chandela S et al. Short-term predictors and long-term outcome after ruptured abdominal aortic aneurysm repair. Am Surg 2003; 69: 703-709
  PubMedGoogle Scholar
• 26 Karthikesalingam A, Hinchliffe RJ, Loftus IM et al. Volume-outcome relationships in vascular surgery: the current status. J Endovasc Ther 2010; 17: 356-365
  CrossrefPubMedGoogle Scholar
• 27 Laukontaus SJ, Aho PS, Pettila V et al. Decrease of mortality of ruptured abdominal aortic aneurysm after centralization and in-hospital quality improvement of vascular service. Ann Vasc Surg 2007; 21: 580-585
  CrossrefPubMedGoogle Scholar
• 28 Marković M, Davidović L, Maksimović Z et al. Ruptured abdominal aortic aneurysm. Predictors of survival in 229 consecutive surgical patients. Herz 2004; 29: 123-129
  CrossrefPubMedGoogle Scholar
• 29 Mell MW, Wang NE, Morrison DE et al. Interfacility transfer and mortality for patients with ruptured abdominal aortic aneurysm. J Vasc Surg 2014; 60: 553-557
  CrossrefPubMedGoogle Scholar
• 30 Cho JS, Kim JY, Rhee RY et al. Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality. J Vasc Surg 2008; 48: 10-17
  CrossrefPubMedGoogle Scholar
• 31 Mell MW, OʼNeil AS, Callcut RA et al. Effect of early plasma transfusion on mortality in patients with ruptured abdominal aortic aneurysm. Surgery 2010; 148: 955-962
  CrossrefPubMedGoogle Scholar
• 32 Halpern VJ, Kline RG, DʼAngelo AJ et al. Factors that affect the survival rate of patients with ruptured abdominal aortic aneurysms. J Vasc Surg 1997; 26: 939-945
  CrossrefPubMedGoogle Scholar
• 33 Davidović L, Marković M, Kostić D et al. Ruptured abdominal aortic aneurysms: factors influencing early survival. Ann Vasc Surg 2005; 19: 29-34
  CrossrefPubMedGoogle Scholar
• 34 Hardman DT, Fisher CM, Patel MI et al. Ruptured abdominal aortic aneurysms: who should be offered surgery?. J Vasc Surg 1996; 23: 123-129
  CrossrefPubMedGoogle Scholar
• 35 AbuRahma AF, Woodruff BA, Lucente FC et al. Factors affecting survival of patients with ruptured abdominal aortic aneurysm in a West Virginia community. Surg Gynecol Obstet 1991; 172: 377-382
  PubMedGoogle Scholar
• 36 Johansson PI, Stensballe J. Hemostatic resuscitation for massive bleeding: the paradigm of plasma and platelets–a review of the current literature. Transfusion 2010; 50: 701-710
  PubMedGoogle Scholar
• 37 Laukontaus SJ, Lepäntalo M, Hynninen M et al. Prediction of survival after 48-h of intensive care following open surgical repair of ruptured abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2005; 30: 509-515
  CrossrefPubMedGoogle Scholar
• 38 Hatori N, Yoshizu H, Shimizu M et al. Prognostic factors in the surgical treatment of ruptured abdominal aortic aneurysms. Surg Today 2000; 30: 785-790
  CrossrefPubMedGoogle Scholar
• 39 Sasaki S, Yasuda K, Yamauchi H et al. Determinants of postoperative and long-term survival of patients with ruptured abdominal aortic aneurysms. Surg Today 1998; 28: 30-35
  CrossrefPubMedGoogle Scholar
• 40 Lederle FA, Johnson GR, Wilson SE et al. Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Ann Intern Med 1997; 126: 441-449
  CrossrefPubMedGoogle Scholar
• 41 IMPROVE Trial Investigators. The effect of aortic morphology on peri-operative mortality of ruptured abdominal aortic aneurysm. Eur Heart J 2015; 36: 1328-1334
  CrossrefPubMedGoogle Scholar
• 42 Sweeting MJ, Balm R, Desgranges P et al. Individual-patient meta-analysis of three randomized trials comparing endovascular versus open repair for ruptured abdominal aortic aneurysm. Br J Surg 2015; 102: 1229-1239
  CrossrefPubMedGoogle Scholar
• 43 Lachat M, Steuer J. Outcome of ruptured abdominal aortic aneurysm repair: impact of aortic morphology. Eur Heart J 2015; 36: 1288-1289
  CrossrefPubMedGoogle Scholar
• 44 Cambria RP, Brewster DC, Abbott WM et al. Transperitoneal versus retroperitoneal approach for aortic reconstruction: a randomized prospective study. J Vasc Surg 1990; 11: 314-324
  CrossrefPubMedGoogle Scholar
• 45 Arthurs Z, Starnes B, See C et al. Clamp before you cut: Proximal control of ruptured abdominal aortic aneurysms using endovascular balloon occlusion–Case reports. Vasc Endovascular Surg 2006; 40: 149-155
  CrossrefPubMedGoogle Scholar
• 46 Greiner A, Grommes J, Jacobs MJ. The place of endovascular treatment in abdominal aortic aneurysm. Dtsch Arztebl Int 2013; 110: 119-125
  PubMedGoogle Scholar
• 47 Ullery BW, Tran K, Chandra V et al. Association of an endovascular-first protocol for ruptured abdominal aortic aneurysms with survival and discharge disposition. JAMA Surg 2015; 150: 1058-1065
  CrossrefPubMedGoogle Scholar
• 48 Livesay JJ, Talledo OG. Endovascular aneurysm repair is not the treatment of choice in most patients with ruptured abdominal aortic aneurysm. Tex Heart Inst J 2013; 40: 556-559
  PubMedGoogle Scholar
• 49 Greenhalgh RM, Brown LC, Powell JT et al. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010; 362: 1863-1871
  CrossrefPubMedGoogle Scholar
• 50 Knapp J, Bernhard M, Rauch H et al. [Anesthesiologic procedure for elective aortic surgery]. Anaesthesist 2009; 58: 1161-1182
  CrossrefPubMedGoogle Scholar
• 51 Eckstein HH, Böckler D, Flessenkämper I et al. Ultrasonographic screening for the detection of abdominal aortic aneurysms. Dtsch Arztebl Int 2009; 106: 657-663
  PubMedGoogle Scholar