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Original article

The impact of perioperative factors on the outcome in patients with ruptured abdominal aortic aneurysm

Dajana Čović1, Miloš Stjepanović2, Milan Majkić3, Dušan Tucaković4, Nebojša Budakov5,6, Vladimir Manojlović5,6
  • General Hospital Subotica, Subotica, Serbia
  • JZU Hospital “St. Luke the Apostle”, Doboj, Bosnia and Herzegovina
  • Clinical Center of Vojvodina, Clinic for Orthopedic Surgery and Traumatology, Novi Sad, Serbia
  • Clinical Center of Vojvodina, Clinic for Eye Diseases Novi Sad, Serbia
  • Clinical Center of Vojvodina, Clinic for Vascular and Transplantation Surgery, Novi Sad, Serbia
  • University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia

ABSTRACT

Introduction: An aneurysm is a permanent, localized extension of an artery diameter by at least 50% relative to its physiological diameter. Its most common localization is on the abdominal aorta. Rupture, the most common complication of an aneurysm, is clinically significant because of the high mortality rate. Patients with ruptured aneurysm of the abdominal aorta undergo urgent surgical treatment, where despite the efforts of surgeons and expansive progress in both medicine and technology, intraoperative and postoperative mortality is still present in a high percentage.

Aim: To examine how different perioperative factors affect the outcome in patients with ruptured aneurysms of the abdominal aorta.

Material and methods: A retrospective study based on medical records for a two-year period, in which descriptive statistical methods processed and analyzed perioperative clinical parameters and their impact on outcome in 57 patients operated on for rupture of abdominal aortic aneurysm.

Results: Preoperative values of hemoglobin and components of the hemostasis system, intraoperative blood replenishment and intraoperative pH, and postoperative values of potassium, lactate, and the amount of diuresis in the first 24 hours after surgery showed a statistically significant effect on the outcome in patients operated at the Clinical Center of Vojvodina due to rupture of abdominal aortic aneurysm.

Conclusion: The operative outcome in rAAA is still unpredictable despite many years of research into perioperative factors and attempts to find an ideal scoring system.


INTRODUCTION

An aneurysm is a permanent localized dilation of an artery diameter of at least 50% compared to the normal diameter for a given localization [1]. It can be formed on any arterial blood vessel, but the most common localization is the abdominal aorta, namely its infrarenal segment. Aneurysms can be complicated by rupture, thrombosis, and distal embolization, and the most clinically important and potentially fatal complication is rupture [2]. At infrarenal localization, the most significant complication is rupture. In even 50% of cases, rupture is the first manifestation of an aneurysm [3]. The risk of rupture is related to the size of the aneurysm, gender (it occurs more often in women), the form of the aneurysm, and the presence of parietal thrombotic masses. Smoking and chronic obstructive pulmonary disease are also independent predictors of abdominal aortic aneurysm rupture [2]. Rupture of abdominal aortic aneurysm (hereinafter referred to as rAAA) can manifest itself in the form of retroperitoneal bleeding, intraperitoneal hemorrhage, chronic rupture, aorto-enteric fistula, and aorto-caval fistula. The most common are ruptures into the retroperitoneal and intraperitoneal space. Diagnosis of rAAA is made clinically, with ultrasound or CT angiography [1]. This condition requires urgent surgical treatment to save lives. Treatment can be open surgical or endovascular. The open surgical approach consists of xenophobic laparotomy, intestinal evisceration, proximal and distal vascular control, and reconstruction of the aneurysmatically altered aorta, with or without evacuation of the hematoma.

Aneurysm rupture is responsible for approximately 1.5% of deaths in men over the age of 55 and is the thirteenth leading cause of death in the Western world. Autopsy studies indicate a total mortality rate of 90% if patients who do not make it to the hospital alive are taken into account. Intrahospital survival of the remaining patients, according to data published in the literature, ranges from 25 to 70% [2].

The survival of these patients depends on the type of rupture, the time that elapsed from the initial symptoms to the first medical treatment, as well as, the arrival at the appropriate surgical institution dealing with aortic surgery. Death in the first 30 days after surgery is mainly due to dysfunction of a vital organ, an isolated organ system, or very often, due to multiorgan systemic dysfunction [2].

Decades of analyzing a large number of perioperative factors and associated comorbidities, and studying their individual and interdependent relationships with the outcome of operational treatment of patients with rAAA, standardized scoring systems for perioperative risk assessment have been established. Several scoring systems are in use, the most commonly cited in the literature are the Vascular-Physiological and Operative Severity score for emUmeration of Mortality and Morbidity (V)-POSSUM, Ruptured Abdominal Aortic Aneurysm RAAA-POSSUM [4], Hardman index [4], Glasgow Aneurysm score [5], Dutch aneurysm score [6], and more recently – Edinburgh Ruptured Aneurysm score [7] and Vancouver Scoring System [7]. Each of these scoring systems is used by a different combination of hemodynamic, biochemical, and clinical variables. The goal of these scoring systems is to try to quantify the risk for each patient with rAAA.

THE AIM OF THE WORK

This study aims to examine whether certain perioperative (preoperative, intraoperative, and postoperative) clinical parameters affected the outcome of surgical treatment of patients with ruptured abdominal aortic aneurysm.

MATERIAL AND METHODS

A retrospective study was conducted based on the collected medical records from the archives of the Clinic for Vascular and Transplant Surgery and the archives of the Emergency Center of the Clinical Center of Vojvodina. The study included a two-year period (01.01.2016.- 31.12.2017). We analyzed the data for all patients who were due to rAAA operated in the operational block of the Emergency Center of the Clinical Center of Vojvodina. The inclusion criteria in the study involved the following: localization of aneurysms on the abdominal aorta and intraoperative survival of the patient, and the criteria for exclusion from the study were the localization of the aneurysm on the thoracoabdominal aorta and intraoperative mortality. During the study, a total of 82 patients with rAAA were operated on. Of these, for 21 patients, adequate clinical parameters corresponding to the study were not found by examining their medical records, and these patients were omitted from the research. Of the remaining 61 patients, 4 died intraoperatively, which, by examining the inclusion and exclusion criteria, and consequently excluding these patients from further study, reduced the sample to 57.

Based on the monitoring of the outcome of surgery in the first 30 postoperative days, we divided all patients into two groups:
1. Patients who survived 30 days of surgery
2. Patients who died within 30 days of surgery.

In patients, we monitored a total of 22 perioperative parameters: 9 preoperative, 4 intraoperative, and 9 postoperative parameters (Table 1).

Table 1. Classification of observed parameters with defined reference values and variables that are individually dependent

p417 1

Each patient diagnosed with rAAA, based on anamnestic and/or heteroanamnestic data and clinical examination, and possible additional diagnostic procedures (ultrasound, CT angiography) within the reception department of the Emergency Center of the Clinical Center of Vojvodina, rAAA was diagnosed, had laboratory findings urgently carried out, and urgent surgical procedure was indicated by the on-call vascular surgeon. These findings necessarily implied the following clinical parameters that we included in our study: hemoglobin (Hgb), hematocrit (Hct), platelet count (Tr), serum urea (Ur), serum creatinine (Kr), activated partial thromboplastin time (APTT), prothrombin time (PT), potassium (K), and erythrocyte count (Er). At the same time, the opening of the medical history, provision of the airway as needed, provision of blood and blood derivatives, placement of peripheral and central venous lines, arterial line, urinary catheter, and rapid transport to the operating room were performed.

The indicated emergency aneurysmectomy was performed by vascular surgeons of the Clinic for Vascular and Transplant Surgery of the Clinical Center of Vojvodina, with the cooperation and assistance of appropriate medical staff. During this operational procedure, various intraoperative clinical variables were monitored, which are cumulatively contained and recorded in the anesthesia protocol. Some of them were used for the study, namely: measured intraoperative blood loss, blood compensation (resuspended erythrocytes, fresh frozen plasma, and autologously restored blood from Cell saver), diuresis, and intraoperative pH. Postoperatively, patients were placed in intensive care units of the Emergency Center of the Clinical Center of Vojvodina, where postoperative parameters were measured daily and on several occasions whose values we used for research: twenty-four-hour diuresis, twenty-fourhour fluid intake, serum urea (Ur), serum creatinine (Kr), as well as the following variables of gas analysis: pH, potassium (K), lactates, partial oxygen pressure (pO2), and oxygen saturation (sO2). Parameters with defined reference values as well as clinically changeable variables are tabularly presented (Table 1). The reference values applied in the study were taken from the laboratory of the Emergency Center of the Clinical Center of Vojvodina, where they are used in everyday clinical practice as official reference values. We used data that covered the first 24 hours after surgery. The surviving patients were transferred to the Department of the Clinic for Vascular and Transplant Surgery of the Clinical Centre of Vojvodina. After the discharge of patients from the department, the court on further survival was made on the basis of the mandatory first outpatient control at the specialist polyclinic of the Clinic for Vascular and Transplant Surgery of the Clinical Center of Vojvodina.

As part of the statistical data processing, we used descriptive statistics for both groups together and for each separately, and finally comparative statistics of one group with the other. The analysis of the data was based on the results of statistical significance tests (t-test and ANOVA), correlations and χ2 tests, and measures of central tendency (arithmetic mean, median, and range of minimum and maximum values). Descriptive and comparative statistics were done in Microsoft Office Excel 2007.

The research was approved by the Ethics Committee of the Clinical Centre of Vojvodina.

RESULTS

In a total sample of 57, the number of men was 50 (87.72%), while the number of women was 7 (12.28%). Within the age structure where the average age was 69.9 years, the youngest person was 54 years old, while the oldest person was 85. The group of survivors counted 30 patients – 4 women and 26 men, while in the second group, there were 27 patients – 3 women and 24 men (Table 2). By group, the median age was 68.6 for survivors (range 55-85) and deceased 71.3 (range 54- 85). The descriptive statistics for both of these groups are presented in a tabular manner (Table 3).

Table 2. Demographic data of the sample examined

p417 2

Table 3. Descriptive statistics for all patients

p418 1

Based on the data, it follows that in most patients with rAAA (regardless of their subsequent outcome), just before surgery, hemoglobin, hematocrit, and erythrocyte counts were reduced, while serum urea and creatinine were elevated. It was also found that in patients prothrombin time was prolonged. During the operation, most of the patients were in acidosis. In the first 24 hours after surgery, regardless of the subsequent outcome, urea and creatinine, as well as preoperatively were elevated in most cases. Lactate values were also postoperatively elevated in patients of both study groups. In the conducted research within the preoperative parameters, we obtained the following results (Table 4).

Table 4. Preoperative parameters for both groups

p418 2

The mean hemoglobin and hematocrit values in both groups were lower than the reference values, but in the group of deceased, these deviations were more pronounced. Platelet counts in both study groups ranged at reference intervals. The APTT in both groups was in the range of reference values, while the PT in the group of deceased was extended. Serum urea was higher than the reference values in both groups, but in the group of survivors, it had a slight deviation from the group of deceased. Serum creatinine was significantly elevated in the group of deceased than in surviving patients. Preoperatively measured potassium in both study groups proved to be a parameter that did not deviate from physiological values. The number of erythrocytes in both groups was lowered, but in the group of patients with better outcomes, it was closer to the benchmark limit compared to the group with lethal outcomes. In sum, all preoperative parameters that deviated from the reference range had a more pronounced deviation in the group with a subsequent lethal outcome.

The collected intraoperative variables for the given patient groups are presented in a tabular manner (Table 5).

Table 5. Intraoperative values of different pairs of amateurs and variables for both groups

p419

Intraoperative blood loss was higher in patients with lethal outcomes, as was blood compensation. Diuresis during the operation had slightly more value in the survivors than in the deceased but without any major differences in these two groups. The intraoperatively measured pH proved to be a parameter that was lowered in both groups, with a greater deviation in later deceased patients.

The collected and statistically processed data for postoperative parameters and variables for both study groups are presented in a tabular manner (Table 6).

Table 6. Postoperative values of clinical parameters and variables for both groups

p420

The values of diuresis measured in the first 24 hours after surgery in both groups were within physiological values, but with values lower in patients who subsequently died. Fluid intake in both study groups was without any major differences in quantity. Serum urea, as well as serum creatinine in both groups, were above the upper limits of their reference values, with a slightly higher deviation in the group of deceased. The mean postoperatively measured potassium in both groups showed no deviation from the reference values. Lactates were elevated in both groups, with higher values predominant in the group of deceased. Mean pO2 levels were elevated in both groups, while saturation was lowered in both groups.

Based on the applied statistical methods, it was concluded that the following parameters were shown as statistically significant for the outcome in patients with rAAA: hemoglobin, APTT, PT before surgery; the volume of intraoperatively compensated blood and the pH value during surgery; and the values of potassium, lactate, and the amount of diuresis after surgery.

DISCUSSION

Treatment of patients with rupture aneurysm is still one of the greatest challenges for both vascular surgeons and anesthesiologists because it is a life-threatening condition, where most of them are elderly patients, with one or more associated comorbidities associate (which, in our region, are often inadequately treated or even before rupture of the aneurysm and admission to a health institution unknown to the patient himself) [2].

The median age of all patients in our study was 69.9, which is slightly lower than in other studies that analyzed age as an outcome prediction factor in patients with rAAA, while male predominance in our study followed the representation of men in other studies of this type. In the study from the Netherlands, the average age was 76 for Amsterdam, and 73 years for Gröningen and Rotterdam, with male predominance by more than 80% for all three cities observed [8]. The average age closer to ours was recorded in Padua, where in a seventeen-year study it was 71.1 years [9]. In a 2004 paper published by Markovic and co-authors, which covered a ten-year period, the average age was 67 years, and the male representation was 83% [10], which is relatively close to our percentage of 87.7% for male patients. In our country, the average age of survivors was 68.6, and in the group of deceased, it was 71.3. Scientists from Finland have presented data that also do not deviate much from ours; the age of 70 was the mean of the years in survivors, and 74 in the deceased [11]. In our study, age did not prove to be statistically significant for the outcome.

Neilson and co-authors, for the purpose of their study on The Rapid Ruptured Abdominal Aortic Aneurysm score, tracked mortality for 30 days after surgery. This percentage was 32.9% [12]. In the Dutch study, mortality in the first 30 days after surgery ranged from 26-36%, depending on the city observed [8]. Both of these studies took into account both patients operated on for classical aneurysmurectomy, as well as patients operated on endovascular treatment.

On the other hand, in a study conducted in Switzerland, which looked exclusively at patients with open-label surgical treatment, mortality in the first 30 days was 30% [13]. In a nine-year study conducted by Healey and co-authors mortality in the first 30 days of surgery was 33.4%, also for open aneurysmatomy [14]. Unlike studies conducted in Western countries, a study of a similar character was conducted in Belgrade (in which, as in our study, patients were operated on with an open surgical technique) had a mortality rate similar to ours [15]. In their case, this number was 48.3% while in our study it was 47.3%. Since scientists in countries with higher standards of living have proven that it is not impossible to reduce mortality to below 40% unrelated to the method of surgical approach, and the outcome in our patients is similar to that of the Belgrade study, we can conclude that the quality of health care and health services has a major impact on outcomes in patients with rAAA. More modern technology and a more modern operational approach contribute to a better outcome.

Hemoglobin, which is shown as statistically significant in our study, is a parameter most commonly used in studies of a similar character to assess its correlation with the outcome after surgery. The mean hemoglobin values in our study were 115.5 for survivors, and 94.5 for deceased patients. Davidović and his co-authors proved it as statistically significant for the outcome, in whose work the values in survivors were 111.4, and in the deceased 99.4 [15]. The study was conducted in Switzerland, which had the same number of subjects as ours, for the mean hemoglobin values in survivors were 122.7, and 91.8 in the group of deceased, and was also proven to be statistically significant [13].

The components of the hemostasis system in the preoperative period (APTT, PT) in our study proved to be statistically significant for the outcome. Kawatani and co-authors in their study studied the effect of the same parameters on patients operated on endovascular methods, where these parameters were not proven to be statistically significant for the outcome [16].

The amount of intraoperatively compensated blood in most papers is described through units, or the minimum number of units of transfused blood. In our study, a small methodological difference was made. Intraoperative blood compensation, which proved to be significant in our study, was expressed in milliliters, implying both the volume of a unit of resuspended erythrocytes and fresh frozen plasma, as well as the volume of autologously returned blood by Cell saver.

Intraoperatively measured pH values in both of our study groups were largely around 7.29 in survivors, and 7.13 in the deceased. Postoperatively, we were able to observe a similar situation – the pH of most survivors was closer to the reference values compared to the pH of deceased patients.

Several papers deal more with the values of urea and creatinine postoperatively, than they are based on postoperative diuresis. Certainly, based on the collected data within our study, which showed diuresis after surgery as statistically significant for the outcome, we can say that in our work patients with a better outcome postoperatively had higher values of diuresis compared to those with a later lethal outcome. The difference in mean values for both observed groups was over 900ml. The maximum values were also higher in the group of survivors, while in the group of deceased, there was even anuria.

Postoperatively measured lactates in our study proved to be statistically significant for the outcome. In a study conducted by Singhal and associates [17], lactates were also statistically significant, with mean values of 1.9 for survivors, and 7 for the deceased. In our country, these values were 1.62 for survivors, and 6.55 in the group of deceased patients. However, they used the first lactate values measured after surgery for the study, while we used values obtained between 20 and 24 hours after surgery. Lieberg and colleagues pointed out that perioperatively elevated lactate values proved to be determinants of mortality after surgery in patients with rAAA [18].

Combining different clinical, biochemical, and laboratory parameters, numerous studies have been carried out around the world for decades to find the ideal scoring system for assessing outcomes in patients with rAAA. Some of the scores that have previously been applied extensively are POSSUM, Hardman index, and Glasgow Aneurysm score, with the Glasgow Aneurysm score proven to be reliable in predicting outcomes but in elective operations rAAA [19]. The POSSUM score consists of two components; physiological variables (age, presence of cardiomyopathy and/or respiratory diseases, blood pressure, pulse, Glasgow coma score, hemoglobin amount, leukocyte count, urea, sodium, potassium, ECG), and 6 operating parameters. The Hardman index contains five parameters – years, hemoglobin value, serum creatinine concentration, ischemic changes in ECG, and the presence of loss of consciousness [20].

In recent times, an attempt has been made to obtain a score that would have a minimum number of variables, which are quickly and easily accessible. The scoring system of this type is the Vancouver score, which is calculated based on only three data – the average age of the patient, whether there is a loss of consciousness, and whether there was a cardiac arrest. Similar is the Edinburgh Ruptured Aneurysm score, whose value is obtained from the assessment of the state of consciousness, and the values of systolic pressure and hemoglobin preoperatively [7]. In scoring systems of the new generation, with a reduced number of parameters, the Dutch Aneurysm score is added, for which it is important to consider the patient’s age, systolic blood pressure, hemoglobin concentrations, and whether cardiopulmonary resuscitation was required in this patient [6].

In recent years, studies have been done on the topic of comparing different scoring systems, in order to find the best. Although these scoring systems are applied in clinical practice, none of them can be used independently as the only criterion for decisions about whether or not to operate on a patient, as well as what the subsequent outcome will be. Certainly, it would not be ethical to treat patients solely based on a scoring system. Our study does not contain data that would fully correspond to any of the above scoring systems (state of consciousness, systolic blood pressure, comorbidities, leukocyte count, sodium concentration, and cardiological parameters – cardiac arrest, ECG record, and cardiopulmonary resuscitation data), because we could not find data relevant to each of the above parameters in the medical records. The only one of the observed parameters contained in both the scoring systems and our study, that had statistical significance in our study, was hemoglobin. Serum creatinine concentration preoperatively used in the Hardman index is not statistically significant. Also, the study did not prove a significant impact of preoperative values of potassium and urea, which are used in calculating the value of the POSSUM score.

CONCLUSION

Based on the applied statistical methods, it was concluded that the following parameters were shown as statistically significant for the outcome in patients with rAAA: hemoglobin, APTT, PT before surgery; the volume of intraoperatively compensated blood and the pH value during surgery; and the values of potassium, lactate, and the amount of diuresis after surgery.

  • Conflict of interest:
    None declared.

Informations

Volume 4 No 4

December 2023

Pages 415-427
  • Keywords:
    aneurysm, rupture, abdominal aorta
  • Received:
    24 October 2023
  • Revised:
    31 October 2023
  • Accepted:
    22 December 2023
  • Online first:
    25 December 2023
  • DOI:
  • Cite this article:
    Čović D, Stjepanović M, Majkić M, Tucaković D, Budakov N, Manojlović V. The impact of perioperative factors on the outcome in patients with ruptured abdominal aortic aneurysm. Serbian Journal of the Medical Chamber. 2023;4(4):413-25. doi: 10.5937/smclk4-47314
Corresponding author

Dajana Čović
General Hospital Subotica
3 Izvorska Street, 24111 Subotica, Serbia
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


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REFERENCES

1. Cronenwett JL, Johnston KW. Rutherford’s vascular surgery. 8th ed. Philadelphia: Elsevier Health Sciences; 2014.

2. Davidović L. Hirurgija aorte. Beograd: Zavod za udžbenike; 2015.

3. Jang HN, Park HO, Yang JH, Yang TW, Byun JH, Moon SH, et al. Evaluation of preoperative predictors of 30-day mortality in patients with ruptured abdominal aortic aneurysm. Vasc Specialist Int. 2017 Sep;33(3):93-8. doi: 10.5758/ vsi.2017.33.3.93. [CROSSREF]

4. Neary WD, Crow P, Foy C, Prytherch D, Heather BP, Earnshaw JJ. Comparison of POSSUM scoring and the Hardman Index in selection of patients for repair of ruptured abdominal aortic aneurysm. Br J Surg. 2003 Apr;90(4):421-5. doi: 10.1002/bjs.4061. [CROSSREF]

5. Patterson BO, Holt PJ, Hinchliffe R, Loftus IM, Thompson MM. Predicting risk in elective abdominal aortic aneurysm repair: a systematic review of current evidence. Eur J Vasc Endovasc Surg. 2008 Dec;36(6):637-45. doi: 10.1016/j. ejvs.2008.08.016. [CROSSREF]

6. Vos CG, de Vries JP, Werson DA, van Dongen EP, Schreve MA, Ünlü Ç. Evaluation of five different aneurysm scoring systems to predict mortality in ruptured abdominal aortic aneurysm patients. J Vasc Surg. 2016 Dec;64(6):1609- 16. doi: 10.1016/j.jvs.2016.05.099. [CROSSREF]

7. van Beek SC, Reimerink JJ, Vahl AC, Wisselink W, Peters RJ, Legemate DA, et al. Amsterdam Acute Aneurysm Trial Collaborators. Editor’s choice--External validation of models predicting survival after ruptured abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2015 Jan;49(1):10-6. doi: 10.1016/j.ejvs.2014.10.012. [CROSSREF]

8. von Meijenfeldt GC, van Beek SC, Bastos Gonçalves F, Verhagen HJ, Zeebregts CJ, Vahl AC, et al. Development and external validation of a model predicting death after surgery in patients with a ruptured abdominal aortic aneurysm: the Dutch Aneurysm Score. Eur J Vasc Endovasc Surg. 2017 Feb;53(2):168-74. doi: 10.1016/j.ejvs.2016.10.024. [CROSSREF]

9. Antonello M, Lepidi S, Kechagias A, Frigatti P, Tripepi A, Biancari F, et al. Glasgow Aneurysm Score predicts the outcome after emergency open repair of symptomatic, unruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2007 Mar;33(3):272-6. doi: 10.1016/j.ejvs.2006.09.006. [CROSSREF]

10. Marković M, Davidović L, Maksimović Ž, Kostić D, Pejkić S, Kuzmanović I, et al. Uticaj intraoperacionih parametara na preživljavanje bolesnika sa rupturom aneurizme abdominalne aorte. Srp Arh Celok Lek. 2004 Jan-Feb;132(1-2):5-9. Serbian. doi: 10.2298/sarh0402005m. [CROSSREF]

11. Laukontaus SJ, Lepäntalo M, Hynninen M, Kantonen I, Pettilä V. Prediction of survival after 48-h of intensive care following open surgical repair of ruptured abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 2005 Nov;30(5):509-15. doi: 10.1016/j.ejvs.2005.06.013. [CROSSREF]

12. Neilson M, Healey C, Clark D, Nolan B. External validation of a rapid ruptured abdominal aortic aneurysm score. Ann Vasc Surg. 2018 Jan;46:162-67. doi: 10.1016/j.avsg.2017.08.016. [CROSSREF]

13. Kniemeyer HW, Kessler T, Reber PU, Ris HB, Hakki H, Widmer MK. Treatment of ruptured abdominal aortic aneurysm, a permanent challenge or a waste of resources? Prediction of outcome using a multi-organ-dysfunction score. Eur J Vasc Endovasc Surg. 2000 Feb;19(2):190-6. doi: 10.1053/ejvs.1999.0980. [CROSSREF]

14. Healey CT, Neilson M, Clark D, Schanzer A, Robinson W; Vascular Study Group of New England None. Predicting mortality of ruptured abdominal aortic aneurysms in the era of endovascular repair. Ann Vasc Surg. 2017 Jan;38:59- 63. doi: 10.1016/j.avsg.2016.09.006. [CROSSREF]

15. Davidović L, Marković M, Kostić D, Činara I, Marković D, Maksimović Ž, et al. Ruptured abdominal aortic aneurysms: factors influencing early survival. Ann Vasc Surg. 2005 Jan;19(1):29-34. doi: 10.1007/s10016-004-0148-9. [CROSSREF]

16. Kawatani Y, Nakamura Y, Kurobe H, Suda Y, Hori T. Correlations of perioperative coagulopathy, fluid infusion and blood transfusions with survival prognosis in endovascular aortic repair for ruptured abdominal aortic aneurysm. World J Emerg Surg. 2016 Jun 17;11:29. doi: 10.1186/s13017-016-0087-0. [CROSSREF]

17. Singhal R, Coghill JE, Guy A, Bradbury AW, Adam DJ, Scriven JM. Serum lactate and base deficit as predictors of mortality after ruptured abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2005 Sep;30(3):263-6. doi: 10.1016/j.ejvs.2005.04.003. [CROSSREF]

18. Lieberg J, Pruks L-L., Kals M, Paapstel K, Aavik A, Kals J. Mortality after elective and ruptured abdominal aortic aneurysm surgical repair: 12-year single-center experience of Estonia. Scan J Surg. 2018 Jun;107(2):152-7. doi: 10.1177/1457496917738923. [CROSSREF]

19. Biancari F, Leo E, Ylönen K, Vaarala MH, Rainio P, Juvonen T. Value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of infrarenal abdominal aortic aneurysm. Br J Surg. 2003 Jul;90(7):838-44. doi: 10.1002/bjs.4130. [CROSSREF]

20. Tambyraja AL, Murie JA, Chalmers RT. Prediction of outcome after abdominal aortic aneurysm rupture. J Vasc Surg. 2008 Jan;47(1):222-30. doi: 10.1016/j. jvs.2007.07.035. [CROSSREF]

1. Cronenwett JL, Johnston KW. Rutherford’s vascular surgery. 8th ed. Philadelphia: Elsevier Health Sciences; 2014.

2. Davidović L. Hirurgija aorte. Beograd: Zavod za udžbenike; 2015.

3. Jang HN, Park HO, Yang JH, Yang TW, Byun JH, Moon SH, et al. Evaluation of preoperative predictors of 30-day mortality in patients with ruptured abdominal aortic aneurysm. Vasc Specialist Int. 2017 Sep;33(3):93-8. doi: 10.5758/ vsi.2017.33.3.93. [CROSSREF]

4. Neary WD, Crow P, Foy C, Prytherch D, Heather BP, Earnshaw JJ. Comparison of POSSUM scoring and the Hardman Index in selection of patients for repair of ruptured abdominal aortic aneurysm. Br J Surg. 2003 Apr;90(4):421-5. doi: 10.1002/bjs.4061. [CROSSREF]

5. Patterson BO, Holt PJ, Hinchliffe R, Loftus IM, Thompson MM. Predicting risk in elective abdominal aortic aneurysm repair: a systematic review of current evidence. Eur J Vasc Endovasc Surg. 2008 Dec;36(6):637-45. doi: 10.1016/j. ejvs.2008.08.016. [CROSSREF]

6. Vos CG, de Vries JP, Werson DA, van Dongen EP, Schreve MA, Ünlü Ç. Evaluation of five different aneurysm scoring systems to predict mortality in ruptured abdominal aortic aneurysm patients. J Vasc Surg. 2016 Dec;64(6):1609- 16. doi: 10.1016/j.jvs.2016.05.099. [CROSSREF]

7. van Beek SC, Reimerink JJ, Vahl AC, Wisselink W, Peters RJ, Legemate DA, et al. Amsterdam Acute Aneurysm Trial Collaborators. Editor’s choice--External validation of models predicting survival after ruptured abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2015 Jan;49(1):10-6. doi: 10.1016/j.ejvs.2014.10.012. [CROSSREF]

8. von Meijenfeldt GC, van Beek SC, Bastos Gonçalves F, Verhagen HJ, Zeebregts CJ, Vahl AC, et al. Development and external validation of a model predicting death after surgery in patients with a ruptured abdominal aortic aneurysm: the Dutch Aneurysm Score. Eur J Vasc Endovasc Surg. 2017 Feb;53(2):168-74. doi: 10.1016/j.ejvs.2016.10.024. [CROSSREF]

9. Antonello M, Lepidi S, Kechagias A, Frigatti P, Tripepi A, Biancari F, et al. Glasgow Aneurysm Score predicts the outcome after emergency open repair of symptomatic, unruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2007 Mar;33(3):272-6. doi: 10.1016/j.ejvs.2006.09.006. [CROSSREF]

10. Marković M, Davidović L, Maksimović Ž, Kostić D, Pejkić S, Kuzmanović I, et al. Uticaj intraoperacionih parametara na preživljavanje bolesnika sa rupturom aneurizme abdominalne aorte. Srp Arh Celok Lek. 2004 Jan-Feb;132(1-2):5-9. Serbian. doi: 10.2298/sarh0402005m. [CROSSREF]

11. Laukontaus SJ, Lepäntalo M, Hynninen M, Kantonen I, Pettilä V. Prediction of survival after 48-h of intensive care following open surgical repair of ruptured abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 2005 Nov;30(5):509-15. doi: 10.1016/j.ejvs.2005.06.013. [CROSSREF]

12. Neilson M, Healey C, Clark D, Nolan B. External validation of a rapid ruptured abdominal aortic aneurysm score. Ann Vasc Surg. 2018 Jan;46:162-67. doi: 10.1016/j.avsg.2017.08.016. [CROSSREF]

13. Kniemeyer HW, Kessler T, Reber PU, Ris HB, Hakki H, Widmer MK. Treatment of ruptured abdominal aortic aneurysm, a permanent challenge or a waste of resources? Prediction of outcome using a multi-organ-dysfunction score. Eur J Vasc Endovasc Surg. 2000 Feb;19(2):190-6. doi: 10.1053/ejvs.1999.0980. [CROSSREF]

14. Healey CT, Neilson M, Clark D, Schanzer A, Robinson W; Vascular Study Group of New England None. Predicting mortality of ruptured abdominal aortic aneurysms in the era of endovascular repair. Ann Vasc Surg. 2017 Jan;38:59- 63. doi: 10.1016/j.avsg.2016.09.006. [CROSSREF]

15. Davidović L, Marković M, Kostić D, Činara I, Marković D, Maksimović Ž, et al. Ruptured abdominal aortic aneurysms: factors influencing early survival. Ann Vasc Surg. 2005 Jan;19(1):29-34. doi: 10.1007/s10016-004-0148-9. [CROSSREF]

16. Kawatani Y, Nakamura Y, Kurobe H, Suda Y, Hori T. Correlations of perioperative coagulopathy, fluid infusion and blood transfusions with survival prognosis in endovascular aortic repair for ruptured abdominal aortic aneurysm. World J Emerg Surg. 2016 Jun 17;11:29. doi: 10.1186/s13017-016-0087-0. [CROSSREF]

17. Singhal R, Coghill JE, Guy A, Bradbury AW, Adam DJ, Scriven JM. Serum lactate and base deficit as predictors of mortality after ruptured abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2005 Sep;30(3):263-6. doi: 10.1016/j.ejvs.2005.04.003. [CROSSREF]

18. Lieberg J, Pruks L-L., Kals M, Paapstel K, Aavik A, Kals J. Mortality after elective and ruptured abdominal aortic aneurysm surgical repair: 12-year single-center experience of Estonia. Scan J Surg. 2018 Jun;107(2):152-7. doi: 10.1177/1457496917738923. [CROSSREF]

19. Biancari F, Leo E, Ylönen K, Vaarala MH, Rainio P, Juvonen T. Value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of infrarenal abdominal aortic aneurysm. Br J Surg. 2003 Jul;90(7):838-44. doi: 10.1002/bjs.4130. [CROSSREF]

20. Tambyraja AL, Murie JA, Chalmers RT. Prediction of outcome after abdominal aortic aneurysm rupture. J Vasc Surg. 2008 Jan;47(1):222-30. doi: 10.1016/j. jvs.2007.07.035. [CROSSREF]


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