Topical oxygen therapy promotes the healing of chronic diabetic foot ulcers: a pilot study.

OBJECTIVE: Interventions that can heal or reduce diabetic foot ulcer (DFU) size may reduce the incidence of infection and amputation, and reduce associated social and economic costs. Many chronic wounds exhibit a degree of hypoxia and this leads to a reduction in healing processes including cell division and differentiation, angiogenesis, infection prevention, and collagen production. The aim of this pilot study was to assess the effects of a device supplying continuous oxygen ambulatory therapy on healing in chronic DFUs. METHOD: Patients with chronic DFUs from two tertiary referral hospitals in the UK received treatment with the device. Data were prospectively obtained on wound size using standardised digital images measured by a clinician blinded to the study. Data on device satisfaction and pain were also obtained. RESULTS: We recruited 10 patients, with a mean ulcer duration of 43 weeks (median: 43 weeks) before treatment. By week eight, mean ulcer size had decreased by 51% (median: 53%). Seven of the 10 ulcers were in a healing trajectory, one ulcer present for 56 weeks healed completely, a two-year old ulcer was reduced by more than 50%, and a third, present for 88 weeks, was down to 10% of its original size by the end of the eight-week study. There was also a non-significant trend towards reduction in pain and the device was extremely well tolerated. CONCLUSION: The ambulatory topical oxygen delivery device showed a significant beneficial effect on wound size. This poses practical advantages over currently existing oxygen-based wound therapies such as hyperbaric oxygen therapy due to its continuous oxygen delivery, ease of use, safety and lower cost. The results of this study warrant further review of the device in comparison to standard wound therapies.

Incidence and Outcomes of Severe Renal Impairment Following Ruptured Abdominal Aortic Aneurysm Repair.

INTRODUCTION: Acute kidney injury (AKI) following ruptured abdominal aortic aneurysm (rAAA) repair is common and multifactorial. A standard definition of AKI after endovascular repair (EVAR), the Aneurysm Renal Injury Score (ARISe), has been proposed to facilitate standardised reporting and thus improve understanding of this issue. METHODS: Data were collected retrospectively on AKI in a prospectively maintained database of all patients treated for rAAA in a single tertiary referral centre since the availability of routine out of hours emergency EVAR. The ARISe score was used to describe the degree of AKI and factors which correlated with poor renal outcomes were assessed. RESULTS: Two-hundred and five patients were treated between January 2006 and April 2014. Of these, 125 were treated with open repair (OSR) and 80 were treated with EVAR. Severe AKI (defined as ARISe score ≥3) occurred in 36% of patients. After correction for confounders, patients treated with OSR were significantly more likely to develop severe AKI (43% vs. 26%, p = .02). There was no significant difference in preoperative serum creatinine between groups, but increased preoperative serum creatinine was strongly associated with severe AKI postoperatively (p < .001). Age, sex, endograft type, and preoperative CT scanning were not associated with differences in renal outcomes. Clamp position above renal arteries was predictive of severe AKI in patients treated with OSR (p < .01). Patients suffering severe AKI had significantly higher mortality at 30 days and 12 months (28% vs. 5% and 44% vs. 13%, p < .001 for both comparisons). CONCLUSION: Severe AKI is common following successful repair of rAAA. In this large case series of high-risk patients, OSR was associated with significantly higher rates of severe AKI compared with EVAR, despite the increased dose of contrast involved in EVAR and the older age of these patients. In turn, severe AKI was associated with higher mortality rates.

Effect of frailty on short- and mid-term outcomes in vascular surgical patients.

BACKGROUND: Frailty is a multidimensional vulnerability resulting from age-associated decline. The impact of frailty on outcomes was assessed in a cohort of vascular surgical patients. METHODS: The study included patients aged over 65 years with length of hospital stay (LOS) greater than 2 days, who were admitted to a tertiary vascular unit over a single calendar year. Demographics, mode of admission, diagnosis, mortality, LOS and discharge destination were recorded, as well as a variety of frailty-specific characteristics. The impact of frailty on LOS, discharge destination, survival and readmission rate was assessed using multivariable regression techniques. The ability of the models to predict these outcomes was also assessed. RESULTS: In total, 413 patients of median age 77 years were followed for a median of 18 (range 12-24) months. The in-hospital, 3- and 12-month mortality rates were 3·6, 8·5 and 13·8 per cent respectively. Receiver operating characteristic (ROC) curve analysis revealed that frailty-based regression models were excellent predictors of 12-month mortality (area under the ROC curve (AUC) = 0·81), prolonged LOS (AUC = 0·79) and discharge to a care institution (AUC = 0·84). A simple additive frailty score using six key features retained strong predictive power for 12-month mortality (AUC = 0·83), discharge to a care institution (AUC = 0·78) and prolonged LOS (AUC = 0·74). This frailty score was also strongly associated with readmission rates (P < 0·001). CONCLUSION: Frailty in vascular surgery patients predicts a multiplicity of poorer outcomes. Optimal management should include identification of at-risk patients and treatment of modifiable risk factors.

Survival following ruptured abdominal aortic aneurysm before and during the IMPROVE Trial: a single-centre series.

OBJECTIVES: The first large-scale randomised trial (Immediate Management of the Patient with Rupture: Open Versus Endovascular repair [IMPROVE]) for endovascular repair of ruptured abdominal aortic aneurysm (rEVAR) has recently finished recruiting patients. The aim of this study was to examine the impact on survival after rEVAR when the IMPROVE protocol was initiated in a high volume abdominal aortic aneurysm (AAA) centre previously performing rEVAR. METHODS: One hundred and sixty-nine patients requiring emergency infrarenal AAA repair from January 2006 to April 2013 were included. Eighty-four patients were treated before (38 rEVAR, 46 open) and 85 (31 rEVAR, 54 open) were treated during the trial period. A retrospective analysis was performed. RESULTS: Before the trial, there was a significant survival benefit for rEVAR over open repair (90-day mortality 13% vs. 30%, p = .04, difference remained significant up to 2 years postoperatively). This survival benefit was lost after starting randomisation (90-day mortality 35% vs. 33%, p = .93). There was an increase in overall 30-day mortality from 15% to 31% (p = .02), while there was no change for open repair (p = .438). There was a significant decrease in general anaesthetic use (p = .002) for patients treated during the trial. Randomised patients had shorter hospital and intensive treatment unit stays (p = .006 and p = .03 respectively). CONCLUSIONS: The change in survival seen during the IMROVE trial highlights the need for randomised rather than cohort data to eliminate selection bias. These results from a single centre reinforce those recently reported in IMPROVE.

Mid-term cost-effectiveness analysis of open and endovascular repair for ruptured abdominal aortic aneurysm.

BACKGROUND: Emergency endovascular repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) may have lower operative mortality rates than open surgical repair. Concerns remain that the early survival benefit after EVAR for rAAA may be offset by late reinterventions. The aim of this study was to compare reintervention rates and cost-effectiveness of EVAR and open repair for rAAA. METHODS: A retrospective analysis was undertaken of patients with rAAA undergoing EVAR or open repair over 6 years. A health economic model developed for the cost-effectiveness of elective EVAR was used in the emergency setting. RESULTS: Sixty-two patients (mean age 77·9 years) underwent EVAR and 85 (mean age 75·9 years) had open repair of rAAA. Median follow-up was 42 and 39 months respectively. There was no significant difference in 30-day mortality rates after EVAR and open repair (18 and 26 per cent respectively; P = 0·243). Reintervention rates were also similar (32 and 31 per cent; P = 0·701). The mean cost per patient was €26,725 for EVAR and €30,297 for open repair, and the cost per life-year gained was €7906 and €9933 respectively (P = 0·561). Open repair had greater initial costs: longer procedural times (217 versus 178·5 min; P < 0·001) and intensive care stay (5·0 versus 1·0 days; P = 0·015). Conversely, EVAR had greater reintervention (€156,939 versus €35,335; P = 0·001) and surveillance (P < 0·001) costs. CONCLUSION: There was no significant difference in reintervention rates after EVAR or open repair for rAAA. EVAR was as cost-effective at mid-term follow-up. The increased procedural costs of open repair are not outweighed by greater surveillance and reintervention costs after EVAR.

Early results from the ENGAGE registry: real-world performance of the Endurant Stent Graft for endovascular AAA repair in 1262 patients.

OBJECTIVE: The ENGAGE registry was undertaken to examine the real-world outcome after endovascular abdominal aortic aneurysm (AAA) repair (EVAR) with the Endurant Stent Graft in a large, contemporary, global series of patients. METHODS: From March 2009 to April 2011, 1262 AAA patients (89.6% men; mean age 73.1 years, range 43-93 years) were enrolled from 79 sites in 30 countries and treated with Endurant. Results are described following the reporting standards for EVAR. Follow-up data were tabulated for all 1262 patients at a 30-day follow-up and for the first 500 patients at a 1-year follow-up. RESULTS: Intra-operative technical success was achieved in 99.0% of cases. Within 30 days, adverse events were reported in 3.9% of patients, including a 1.3% mortality rate. Type-I or -III endoleaks were identified in 1.5% of cases. Estimated overall survival, aneurysm-related survival and freedom from secondary interventions at 1 year were 91.6%, 98.6% and 95.1%, respectively. At 1 year, aneurysm size increased ≥ 5 mm in 2.8% and decreased ≥ 5 mm in 41.3% of cases. CONCLUSION: Early results from this real world, global experience are promising and indicate that endovascular AAA repair with the Endurant Stent Graft is safe and effective across different geographies and standards of practice. Longer-term follow-up is necessary to assess durability of these results.

Mid-term outcomes following emergency endovascular aortic aneurysm repair for ruptured abdominal aortic aneurysms.

OBJECTIVE: Emergency Endovascular Aortic Aneurysm Repair (eEVAR) is a rapidly evolving approach to ruptured Abdominal Aortic Aneurysms (rAAA). Yet longer-term outcomes following eEVAR remain unclear. This study compares mid-term outcomes of eEVAR and open rAAA. METHODS: A prospective database for all patients undergoing eEVAR and open rAAA from January 2006 to April 2010 was analysed. Patients were offered eEVAR if anatomically suitable. RESULTS: 52 patients (45 male, median age 78 years (62-92 years), underwent eEVAR, 50 patients (44 male, median age = 71 (62-95 years) underwent open rAAA repair. In-hospital mortalities were 12% (6/52) for eEVAR, 32% (16/50) for open repair. There were five re-interventions (10%) in the eEVAR group. The peri-operative survival benefits of eEVAR over open rAAA repair were maintained at 1 and 2 years post-operatively with open repair demonstrating a two-fold increased risk of mortality (Hazard ratio 2.2, Fisher Exact test, 95% Confidence Interval (CI) 1.108-4.62, p = 0.0122). Overall survival was 81% at 1 year, 73% at 2 years for eEVAR, and 62% at 1 year and 52% at 2 years for open rAAA repair. CONCLUSION: EEVAR is associated with excellent mid-term survival in this cohort. We would recommend eEVAR as the management of choice for rAAA in anatomically suitable patients where local facilities and expertise exist.

Duplex ultrasound and contrast-enhanced ultrasound versus computed tomography for the detection of endoleak after EVAR: systematic review and bivariate meta-analysis.

INTRODUCTION: Contrast-enhanced computed tomography (CT) has become the 'gold-standard' imaging modality for surveillance following EVAR. However repeated CT causes cumulative contrast related renal injury. Duplex ultrasound (USS) and contrast-enhanced (non-nephrotoxic) duplex scanning (CEUS) are less invasive but considered less accurate than CT. The aim of this study was to determine the diagnostic accuracy of imaging modalities used to detect endoleak. Accordingly, we undertook a systematic review and meta-analysis of the evidence base for USS and CEUS compared to CT following EVAR. METHODS: Medline, Embase, trial registries, conference proceedings and article reference lists were searched to identify trials comparing USS or CEUS with CT following EVAR. Contrast-enhanced computed tomography was taken as the 'gold-standard' investigation. USS and CEUS were compared to CT in separate meta-analyses. RESULTS: Twenty-one studies in 2601 patients compared USS with CT. The sensitivity of USS at detecting endoleak was 0.77 (95% CI 0.64-0.86; I(2)=0.82) and pooled specificity 0.94 (95% CI 0.88-0.97; I(2)=0.90). Seven studies (288 patients) compared CEUS vs CT. The pooled sensitivity was 0.98 (95% CI 0.90-0.99; I(2)=0.32) and specificity 0.88 (95% CI 0.78-0.94; I(2)=0.67). CONCLUSION: This study confirms that unenhanced USS has poor sensitivity for endoleak detection; however CEUS is a highly sensitive modality. These results should be interpreted with some caution due to heterogeneity in analysed trials and further research is needed to evaluate the efficacy of CEUS before it can be utilised as the primary imaging modality for EVAR surveillance.

Novel uses for statins in surgical patients.

BACKGROUND: Aside from their cholesterol-lowering effects statins are known to have a range of other 'pleiotropic' effects. We present an overview of the basic science behind these effects and then review clinical trials and the current role of statins relevant to modern surgical practice. METHODS: A systematic review of the literature was performed using the keywords surgery and the MeSH term for statins. All clinical studies relating to statin use in surgical patients were evaluated. An overview of the literature on statin use and cardiac outcomes was performed. CONCLUSIONS: Statins are safe and have a wide range of pleiotropic effects relevant to surgical practice. Strongest evidence for their clinical use comes in primary cardiac risk reduction in many types of vascular surgery. There is a large body of evidence showing their benefit perioperatively in high-risk vascular and cardiac surgery but the picture is less clear for low-risk patients. Further studies are needed to evaluate exact dosage regimes and timing of administration. Novel uses of their anti-inflammatory properties in sepsis and vasomotor properties in subarachnoid haemorrhage are being further investigated by randomised trials.

Low molecular weight heparin significantly reduces embolisation after carotid endarterectomy--a randomised controlled trial.

OBJECTIVES: The administration of unfractionated heparin (UFH) prior to carotid clamping during carotid endarterectomy (CEA) transiently increases the platelet aggregation response to arachidonic acid (AA) despite the use of aspirin. We hypothesized that this phenomenon might be reduced by using low molecular weight heparin (LMWH) resulting in fewer emboli in the early post-operative period. METHODS: 183 aspirinated patients undergoing CEA were randomised to 5000 IU UFH (n=91) or 2500 IU LMWH (dalteparin, n=92) prior to carotid clamping. End-points were: transcranial Doppler (TCD) measurement of embolisation, effect on bleeding and platelet aggregation to AA and adenosine 5'-diphosphate (ADP). RESULTS: Patients randomised to UFH had twice the odds of experiencing a higher number of emboli in the first 3h after CEA, than those randomised to LMWH (p=0.04). This was not associated with increased bleeding (mean time from flow restoration to operation end: 23 min (UFH) vs. 24 min (LMWH), p=0.18). Platelet aggregation to AA increased significantly following heparinisation, but was unaffected by heparin type (p=0.90). The platelets of patients randomised to LMWH exhibited significantly lower aggregation to ADP compared to UFH (p<0.0001). CONCLUSIONS: Intravenous LMWH is associated with a significant reduction in post-operative embolisation without increased bleeding. The higher rate of embolisation seen with UFH may be mediated by increased platelet aggregation to ADP, rather than to AA.

An emergency EVAR service reduces mortality in ruptured abdominal aortic aneurysms.

OBJECTIVES: The aim of this study was to compare all in-hospital mortality for ruptured abdominal aortic aneurysms (rAAAs) before and after the establishment of an emergency EVAR (eEVAR) service. DESIGN AND METHODS: An eEVAR service was established in January 2006, since when all patients presenting with rAAAs have been considered for endovascular repair. Data for all rAAAs presenting between January 2006 and December 2007 was prospectively collected (Group 1). This patient group was compared to those presenting with rAAA between January 2003 and December 2005 when eEVAR was not offered at our institution (Group 2). These records had also been collected prospectively and submitted to the National Vascular Database (NVD). RESULTS: A total of 50 rAAAs (17 eEVAR, 29 open repairs, 4 palliated) presented after the introduction of eEVAR (Group 1) and 71 in the historical Group 2 of which 54 underwent open repair and 17 were palliated. The total in-hospital mortality was significantly lower in Group 1 20% (eEVAR (n=1), 6%: Open (n=5), 17%: palliated (n=4), 100%) when compared to Group 2 54% (Open (n=21), 39%: palliated (n=17), 100%) (p=0.000001). Furthermore similar significant differences were seen in 30-day operative mortalities between the two groups 13% in Group 1 versus 39% in Group 2 (p=0.0003). In addition the proportion of patients who were palliated has significantly decreased (8% Group 1 versus 24% Group 2, p=0.01). CONCLUSIONS: The establishment of an eEVAR service has significantly reduced in-hospital mortality for patients presenting with ruptured abdominal aortic aneurysms.

The pink pulseless hand: a review of the literature regarding management of vascular complications of supracondylar humeral fractures in children.

Supracondylar fractures of the humerus are the commonest upper limb fractures in children, accounting for up to 70% of all paediatric elbow fractures [Wilson MJ, Hunter JB. Supracondylar fractures of the humerus in children--wire removal in the outpatient setting. Injury Extra 2006 Aug;37(8):313-315] and are often complicated by neurovascular injury. Much confusion surrounds the management of the child with a "pink pulseless hand" post-fracture reduction and several treatment options have been proposed including observation, immediate exploration and angiography. The literature contains a number of case series with variable follow-up. Both angiography and colour duplex ultrasound provide little benefit in the management of these patients. A child with a pink pulseless hand post-fracture reduction can be managed expectantly unless additional signs of vascular compromise develop, in which case exploration should be undertaken.

Gene therapy as a novel therapeutic option in the treatment of peripheral vascular disease: systematic review and meta-analysis.

BACKGROUND: Stimulation of therapeutic angiogenesis using gene therapy is a novel intervention for peripheral vascular disease (PVD). Despite encouraging outcomes from animal studies and phase 1 trials, results from larger trials in this area have been conflicting. We undertook a systematic review and meta-analysis of randomised controlled trials in this field, to clarify the current situation. METHODS: Medline, Embase, trial registries, the American Heart Association (AHA) abstract database and article reference lists were searched to identify randomised controlled trials of gene therapy for treatment of PVD. The outcomes were change in peak walking time and claudication onset time at 90 and 180 days post-treatment, and change in ankle-brachial pressure index (ABPI) at 90 days. Weighted mean differences (WMD) were calculated for these outcomes. RESULTS: Five eligible randomised clinical trials were identified, containing 508 patients. There were no significant differences between control and intervention groups for any outcomes, irrespective of whether low-dose or high-dose gene therapy was tried. CONCLUSION: The available data suggests that gene therapy confers no benefit on patients with PVD. Closer examination of the individual trials shows that several have an excessive placebo response, which may go some way to explaining our result. Further research in this area in needed.

Comparison of the inflammatory burden of truly asymptomatic carotid atheroma with atherosclerotic plaques in patients with asymptomatic carotid stenosis undergoing coronary artery bypass grafting: an ultrasmall superparamagnetic iron oxide enhanced magnetic resonance study.

INTRODUCTION: Inflammation is a recognized risk factor for the vulnerable atherosclerotic plaque. The aim of this study was to explore whether there is a difference in the degree of Magnetic Resonance (MR) defined inflammation using Ultra Small Super-Paramagnetic Iron Oxide (USPIO) particles, within carotid atheroma in completely asymptomatic individuals and the asymptomatic carotid stenosis in a cohort of patients undergoing coronary artery bypass grafting (CABG). METHODS: 10 patients awaiting CABG with asymptomatic carotid disease and 10 completely asymptomatic individuals with no documented coronary artery disease underwent multi-sequence MR imaging before and 36 hours post USPIO infusion. Images were manually segmented into quadrants and signal change in each quadrant, normalised to adjacent muscle signal, was calculated following USPIO administration. RESULTS: The mean percentage of quadrants showing signal loss was 94% in the CABG group, compared to 24% in the completely asymptomatic individuals (p<0.001). The carotid plaques from the CABG patients showed a significant mean signal intensity decrease of 16.4% after USPIO infusion (95% CI 10.6% to 22.2%; p<0.001). The truly asymptomatic plaques showed a mean signal intensity increase (i.e. enhancement) after USPIO infusion of 8.4% (95% CI 2.6% to 14.2%; p=0.007). The mean signal difference between the two groups was 24.9% (95% CI 16.7% to 33.0%; p<0.001). CONCLUSIONS: These findings are consistent with the hypothesis that inflammatory atheroma is a systemic disease. The carotid territory is more likely to take up USPIO if another vascular territory is symptomatic.

Assessment of pre-operative delays in the management of elective abdominal aortic aneurysms.

INTRODUCTION: Successful endovascular aneurysm repair (EVAR) requires detailed pre-operative imaging to allow device planning. This process may delay surgery and some aneurysms may rupture prior to intervention. The aim of this study was to quantify these delays. PATIENTS AND METHODS: Data were collected prospectively on all patients presenting with non-ruptured abdominal aortic aneurysms (AAAs) between January 2003 and October 2005. The delay between referral, the first out-patient visit, CT-scan, follow-up appointment and surgery were quantified in all patients and compared between two groups undergoing open repair and EVAR. RESULTS: A total of 146 patients underwent AAA repair during the study (48 EVAR versus 98 open repair). There was no significant differences in the wait for CT scans between the groups (median 42 days for EVAR versus 47 days for open repairs [P = 0.48]) or the median interval between decision to operate and surgery (56 days versus 42 days [P = 0.075]). However, the median delay between referral and surgery was significantly longer in those patients undergoing EVAR at 129 days versus 77 days for open repair (P = 0.02). CONCLUSIONS: Patients presenting electively with AAAs experienced significant delay from referral to surgery. This delay was significantly greater in those patients undergoing endovascular repair. Inevitably, some patients will rupture whilst waiting and strategies aimed at reducing delay should be pursued.

Efficacy of TNP on lower limb wounds: a meta-analysis.

This meta-analysis of the three RCTs that have compared topical negative pressure with conventional treatment in patients with lower limb ulcers found that it significantly reduced healing times and increased the number of healed wounds.

Internal iliac artery branch graft for common iliac artery aneurysm following previous open abdominal aortic aneurysm repair.

To demonstrate the use of a commercially available branch stent graft system, designed to preserve the internal iliac artery (IIA) in common iliac artery (CIA) aneurysms (CIAA) in two patients, who had undergone previous abdominal aortic aneurysm (AAA) surgery.

Five day antibiotic prophylaxis for major lower limb amputation reduces wound infection rates and the length of in-hospital stay.

OBJECTIVE: To compare wound infection, revision rates and hospital stay after major lower limb amputation between patients receiving 24 hours versus 5 days of prophylactic antibiotics. METHODS: The outcomes of a consecutive series of 40 major lower limb amputations in patients receiving a short 24-hour course of combined prophylactic antibiotics (flucloxacillin/vancomycin + gentamicin/ciproxin + metronidazole) were retrospectively analysed. Following this a further consecutive group of 40 major lower limb amputations were studied prospectively following the institution of a 5-day combined regime using the same antibiotics. RESULTS: The 2 groups of patients were similar in terms of demographics, vascular risk factors and level of amputation. The 5-day antibiotic regime led to a significant reduction in wound infection rates (5% vs. 22.5%, P=0.023) and a reduced length of hospital stay (22 vs. 34 days, P=0.001). Revision rates were lower (2.5% vs. 10%) but did not reach statistical significance (P=0.36). More patients in the prospective 5-day antibiotic series were operated on by the vascular trainee. (77.5% vs. 55% P=0.033). CONCLUSIONS: This data supports the use of a prolonged 5-day course of combined antibiotics after major lower limb amputation. This appears to reduce stump infection rates leading to shorter in-hospital stay.

Comparison of risk-scoring methods in predicting the immediate outcome after elective open abdominal aortic aneurysm surgery.

BACKGROUND & OBJECTIVES: The aim of this study was to apply three simple risk - scoring systems to prospectively collected data on all elective open Abdominal Aortic Aneurysm (AAA) operations in the Cambridge Academic Vascular Unit over a 6 - year period (January 1998 to January 2004), to compare their predictive values and to evaluate their validity with respect to prediction of mortality and post-operative complications. METHODS: 204 patients underwent elective open infra-renal AAA repair. Data were prospectively collected and risk assessment scores were calculated for mortality and morbidity according to the Glasgow Aneurysm Score (GAS), VBHOM (Vascular Biochemistry and Haematology Outcome Models) and Estimation of Physiologic Ability and Surgical Stress (E-PASS). RESULTS: The mortality rate was 6.3% (13/204) and 59% (121/204) experienced a post-operative complication (30-day outcome). For GAS, VBHOM and E-PASS the receiver operating characteristics (ROC) curve analysis for prediction of in-hospital mortality showed area under the curve (AUC) of 0.84 (95% confidence interval [CI], 0.76 to 0.92; p<0.0001), 0.82 (95% CI, 0.68 to 0.95; p=0.0001) and 0.92 (95% CI, 0.87 to 0.97; p<0.0001) respectively. There were also significant correlations between post-operative complications and length of hospital stay and each of the three scores, but the correlation was substantially higher in the case of E-PASS. CONCLUSIONS: All three scoring systems accurately predicted the risk of mortality and morbidity in patients undergoing elective open AAA repair. Among these, E-PASS seemed to be the most accurate predictor in this patient population.