Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm.

BACKGROUND: The aim of this study was to develop a 48-h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. METHODS: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C-statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. RESULTS: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48-h mortality in the IMPROVE data was reasonable (C-statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C-statistic was estimated compared with using age alone. CONCLUSION: The assessed risk scores did not have sufficient accuracy to enable potentially life-saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non-intervention rates, while respecting the wishes of the patient and family.

Predicting risk of rupture and rupture-preventing reinterventions following endovascular abdominal aortic aneurysm repair.

BACKGROUND: Clinical and imaging surveillance practices following endovascular aneurysm repair (EVAR) for intact abdominal aortic aneurysm (AAA) vary considerably and compliance with recommended lifelong surveillance is poor. The aim of this study was to develop a dynamic prognostic model to enable stratification of patients at risk of future secondary aortic rupture or the need for intervention to prevent rupture (rupture-preventing reintervention) to enable the development of personalized surveillance intervals. METHODS: Baseline data and repeat measurements of postoperative aneurysm sac diameter from the EVAR-1 and EVAR-2 trials were used to develop the model, with external validation in a cohort from a single-centre vascular database. Longitudinal mixed-effects models were fitted to trajectories of sac diameter, and model-predicted sac diameter and rate of growth were used in prognostic Cox proportional hazards models. RESULTS: Some 785 patients from the EVAR trials were included, of whom 155 (19·7 per cent) experienced at least one rupture or required a rupture-preventing reintervention during follow-up. An increased risk was associated with preoperative AAA size, rate of sac growth and the number of previously detected complications. A prognostic model using predicted sac growth alone had good discrimination at 2 years (C-index 0·68), 3 years (C-index 0·72) and 5 years (C-index 0·75) after operation and had excellent external validation (C-index 0·76-0·79). More than 5 years after operation, growth rates above 1 mm/year had a sensitivity of over 80 per cent and specificity over 50 per cent in identifying events occurring within 2 years. CONCLUSION: Secondary sac growth is an important predictor of rupture or rupture-preventing reintervention to enable the development of personalized surveillance intervals. A dynamic prognostic model has the potential to tailor surveillance by identifying a large proportion of patients who may require less intensive follow-up.

Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years.

BACKGROUND: The erosion of the early mortality advantage of elective endovascular aneurysm repair (EVAR) compared with open repair of abdominal aortic aneurysm remains without a satisfactory explanation. METHODS: An individual-patient data meta-analysis of four multicentre randomized trials of EVAR versus open repair was conducted to a prespecified analysis plan, reporting on mortality, aneurysm-related mortality and reintervention. RESULTS: The analysis included 2783 patients, with 14 245 person-years of follow-up (median 5·5 years). Early (0-6 months after randomization) mortality was lower in the EVAR groups (46 of 1393 versus 73 of 1390 deaths; pooled hazard ratio 0·61, 95 per cent c.i. 0·42 to 0·89; P = 0·010), primarily because 30-day operative mortality was lower in the EVAR groups (16 deaths versus 40 for open repair; pooled odds ratio 0·40, 95 per cent c.i. 0·22 to 0·74). Later (within 3 years) the survival curves converged, remaining converged to 8 years. Beyond 3 years, aneurysm-related mortality was significantly higher in the EVAR groups (19 deaths versus 3 for open repair; pooled hazard ratio 5·16, 1·49 to 17·89; P = 0·010). Patients with moderate renal dysfunction or previous coronary artery disease had no early survival advantage under EVAR. Those with peripheral artery disease had lower mortality under open repair (39 deaths versus 62 for EVAR; P = 0·022) in the period from 6 months to 4 years after randomization. CONCLUSION: The early survival advantage in the EVAR group, and its subsequent erosion, were confirmed. Over 5 years, patients of marginal fitness had no early survival advantage from EVAR compared with open repair. Aneurysm-related mortality and patients with low ankle : brachial pressure index contributed to the erosion of the early survival advantage for the EVAR group. Trial registration numbers: EVAR-1, ISRCTN55703451; DREAM (Dutch Randomized Endovascular Aneurysm Management), NCT00421330; ACE (Anévrysme de l'aorte abdominale, Chirurgie versus Endoprothèse), NCT00224718; OVER (Open Versus Endovascular Repair Trial for Abdominal Aortic Aneurysms), NCT00094575.

Meta-analysis of the current prevalence of screen-detected abdominal aortic aneurysm in women.

BACKGROUND: Although women represent an increasing proportion of those presenting with abdominal aortic aneurysm (AAA) rupture, the current prevalence of AAA in women is unknown. The contemporary population prevalence of screen-detected AAA in women was investigated by both age and smoking status. METHODS: A systematic review was undertaken of studies screening for AAA, including over 1000 women, aged at least 60 years, done since the year 2000. Studies were identified by searching MEDLINE, Embase and CENTRAL databases until 13 January 2016. Study quality was assessed using the Newcastle-Ottawa scoring system. RESULTS: Eight studies were identified, including only three based on population registers. The largest studies were based on self-purchase of screening. Altogether 1 537 633 women were screened. Overall AAA prevalence rates were very heterogeneous, ranging from 0·37 to 1·53 per cent: pooled prevalence 0·74 (95 per cent c.i. 0·53 to 1·03) per cent. The pooled prevalence increased with both age (more than 1 per cent for women aged over 70 years) and smoking (more than 1 per cent for ever smokers and over 2 per cent in current smokers). CONCLUSION: The current population prevalence of screen-detected AAA in older women is subject to wide demographic variation. However, in ever smokers and those over 70 years of age, the prevalence is over 1 per cent.

Individual-patient meta-analysis of three randomized trials comparing endovascular versus open repair for ruptured abdominal aortic aneurysm.

BACKGROUND: The benefits of endovascular repair of ruptured abdominal aortic aneurysm remain controversial, without any strong evidence about advantages in specific subgroups. METHODS: An individual-patient data meta-analysis of three recent randomized trials of endovascular versus open repair of abdominal aortic aneurysm was conducted according to a prespecified analysis plan, reporting on results to 90 days after the index event. RESULTS: The trials included a total of 836 patients. The mortality rate across the three trials was 31.3 per cent for patients randomized to endovascular repair/strategy and 34.0 per cent for those randomized to open repair at 30 days (pooled odds ratio 0.88, 95 per cent c.i. 0.66 to 1.18), and 34.3 and 38.0 per cent respectively at 90 days (pooled odds ratio 0.85, 0.64 to 1.13). There was no evidence of significant heterogeneity in the odds ratios between trials. Mean(s.d.) aneurysm diameter was 8.2(1.9) cm and the overall in-hospital mortality rate was 34.8 per cent. There was no significant effect modification with age or Hardman index, but there was indication of an early benefit from an endovascular strategy for women. Discharge from the primary hospital was faster after endovascular repair (hazard ratio 1.24, 95 per cent c.i. 1.04 to 1.47). For open repair, 30-day mortality diminished with increasing aneurysm neck length (adjusted odds ratio 0.69 (95 per cent c.i. 0.53 to 0.89) per 15 mm), but aortic diameter was not associated with mortality for either type of repair. CONCLUSION: Survival to 90 days following an endovascular or open repair strategy is similar for all patients and for the restricted population anatomically suitable for endovascular repair. Women may benefit more from an endovascular strategy than men and patients are, on average, discharged sooner after endovascular repair.

Ruptured Aneurysm Trials: The Importance of Longer-term Outcomes and Meta-analysis for 1-year Mortality.

OBJECTIVE: To assess current knowledge for the management of ruptured abdominal aortic aneurysm (AAA), based on the 1-year outcomes of 3 recent randomised trials. METHODS: An individual patient data meta-analysis of three recent randomised trials of endovascular versus open repair, including 817 patients, was conducted according to a pre-specified analysis plan, report all-cause mortality and re-interventions at 1 year after the index event. RESULTS: Mortality across the 3 trials at 1-year was 38.6% for the EVAR or endovascular strategy patient groups and 42.8% for the open repair groups, pooled odds ratio 0.84 (95% CI 0.63-1.11), p = .209. There was no evidence of heterogeneity in the odds ratios between trials. When the patients in the endovascular strategy group of the IMPROVE trial were restricted to those with proven rupture who were anatomically suitable for endovascular repair, the pooled odds ratio reduced slightly to 0.80 (95% CI 0.56-1.16), p = .240. CONCLUSIONS: After 1 year there is a consistent but non-significant trend for lower mortality for EVAR or an endovascular strategy. Taken together with the recent gains in health economic outcomes demonstrated at 1 year in the IMPROVE trial, the evidence suggests that endovascular repair should be used more widely for ruptured aneurysms.

Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm.

BACKGROUND: Single-centre series of the management of patients with ruptured abdominal aortic aneurysm (AAA) are usually too small to identify clinical factors that could improve patient outcomes. METHODS: IMPROVE is a pragmatic, multicentre randomized clinical trial in which eligible patients with a clinical diagnosis of ruptured aneurysm were allocated to a strategy of endovascular aneurysm repair (EVAR) or to open repair. The influences of time and manner of hospital presentation, fluid volume status, type of anaesthesia, type of endovascular repair and time to aneurysm repair on 30-day mortality were investigated according to a prespecified plan, for the subgroup of patients with a proven diagnosis of ruptured or symptomatic AAA. Adjustment was made for potential confounding factors. RESULTS: Some 558 of 613 randomized patients had a symptomatic or ruptured aneurysm: diagnostic accuracy was 91·0 per cent. Patients randomized outside routine working hours had higher operative mortality (adjusted odds ratio (OR) 1·47, 95 per cent confidence interval 1·00 to 2·17). Mortality rates after primary and secondary presentation were similar. Lowest systolic blood pressure was strongly and independently associated with 30-day mortality (51 per cent among those with pressure below 70 mmHg). Patients who received EVAR under local anaesthesia alone had greatly reduced 30-day mortality compared with those who had general anaesthesia (adjusted OR 0·27, 0·10 to 0·70). CONCLUSION: These findings suggest that the outcome of ruptured AAA might be improved by wider use of local anaesthesia for EVAR and that a minimum blood pressure of 70 mmHg is too low a threshold for permissive hypotension.

En-bloc pelvic resection with concomitant rectosigmoid colectomy and immediate anastomosis as part of primary cytoreductive surgery for patients with advanced ovarian cancer.

OBJECTIVE: To assess the authors' experiences in en bloc pelvic resection with concomitant rectosigmoid colectomy and primary anastomosis as a part of primary cytoreductive surgery for patients with advanced ovarian cancer. MATERIALS AND METHODS: Atotal of 22 patients with FIGO Stage IIB-IV epithelial ovarian cancer who underwent en bloc pelvic resection with anastomosis were retrospectively reviewed. Data analyses were carried out using SPSS 10.0 and descriptive statistics, Kaplan-Meier survival curves, and Log Rank (Mantel-Cox) test were used for statistical estimations. RESULTS: Median age was 58.8 years. FIGO stage distribution of the patients was; one (4.5%) IIB, three (13.7%) IIC, three (13.7%) IIIA, six (27.3%) IIIB, and nine (40.9%) IIIC. Median peritoneal cancer index (PCI) was 8 (range 5-22) and optimal cytoreduction was achieved in 18 patients (81.8%) of whom 13 (59.1%) had no macroscopic residual disease (complete cytoreduction). There was no perioperative mortality. A total of nine complications occurred in seven (31.8%) patients. Anastomotic leakage was observed in one (4.5%) patient. There was no re-laparotomy. Mean follow-up time was 60 months. There were 15 (68.2%) recurrences of which 12 (80%) presented in extra-pelvic localizations. Mean disease-free survival (DFS) and overall survival (OVS) were estimated as 43.6 and 50.5 months, respectively. Patients with complete cytoreduction had a better DFS (p = 0.006) and OVS (p = 0.003) than those with incomplete cytoreduction. CONCLUSION: En bloc pelvic resection, as a part of surgical cytoreduction, seems to be a safe and effective procedure in many patients with advanced ovarian cancer if required. Despite relatively high general complication rate, anastomosis-related morbidity of this procedure is low as 0.8%. Nevertheless, surgical plan and perioperative care should be personalized according to medical and surgical conditions of the patient.

The association between inherited thrombophilia and recurrent pregnancy loss in Turkish women.

OBJECTIVE: To investigate the relation between recurrent pregnancy loss (RPL) and factor V Leiden, prothrombin G20210A, and C677T methylenetetrahydrofolate reductase (MTHFR) mutations. MATERIALS AND METHODS: A case-control study was conducted on 95 consecutive cases with RPL, and 40 age-matched controls who had no history of pregnancy loss and had at least one successful pregnancy. After application of exclusion criteria, 60 patients in the study group and 40 control cases were compared for thrombophilic factors. RESULTS: Thirteen out of 60 RPL cases and one out of 40 in the control group were carriers of factor V Leiden mutation. While six patients were carriers of prothrombin G20210A gene mutation, none in the control group carried this mutation. Twenty-nine out of 60 RPL cases and 17 out of 40 control cases had MTHFR mutation. CONCLUSION: The authors found a positive correlation between RPL and FVL and FII gene mutations, but no significant association between RPL and MTHFR gene mutation.

The effect of hysterectomy types on vaginal length, vaginal shortening rate and FSFI scores.

OBJECTIVE: Vaginal length (VL), size and width may show individual differences among women. Hysterectomy causes VL shortening in patients, and this shortening varies according to the type of hysterectomy performed. Some studies in literature have shown that the shortened VL after hysterectomy may cause dyspareunia and have a negative effect on female sexuality. The aim of this study is to compare preoperative and postoperative vaginal lengths, vaginal shortening rate (VSR) not used before in the literature, and postoperative sexual functions according to hysterectomy types. MATERIALS AND METHODS: In the study, which included 136 [55 Total Abdominal Hysterectomy (TAH), 33 Vaginal Hysterectomy (VH), 48 Total Laparoscopic Hysterectomy (TLH)] sexually active patients under the age of 60 who underwent hysterectomy, the patients were divided into three groups according to the type of hysterectomy performed. Groups were compared in terms of demographic variables, preoperative/postop and control VL, vaginal shortening rate and The Female Sexual Function Index (FSFI) scores. RESULTS: Vaginal lengths measured after TLH was longer and vaginal lengths measured after VAH was shorter, the difference was significant (p < 0.01). VSRs were 15.9% in TAH group, 10.9% in VH group and 8.3% in TLH group (p < 0.05). Total FSFI score was higher in TLH group than TAH and VH group (p < 0.01). Group of VSR>15% had statistically significantly lower FSFI scores in lubrication, orgasm, pain and total score than both the VSR<10% group and the VSR 10-15% group (p < 0.05). CONCLUSION: Calculating the VSR after hysterectomy instead of postoperative VL measurement will allow us to obtain more individual and accurate results in predicting postoperative sexual functions. We found that TLH is the best hysterectomy method in terms of preserving sexual functions due to less loss of vaginal tissue in the postoperative period from these three techniques that are frequently.

Should the visceral peritoneum be closed over mesh in abdominal sacrocolpopexy?

INTRODUCTION AND HYPOTHESIS: Peritonisation of mesh during Abdominal sacrocolpopexy is generally advocated to prevent adhesions to the viscera; however, randomized clinical trials are lacking. In this study; we aimed to investigate whether the mesh peritonisation is clinically significant or not. MATERIAL METHOD: Thirty-four patients who were operated for the reason of pelvic organ prolapse were included in the study. Patients were divided into two groups by retrospective scanning from the files and surgical reports. Group 1 patients consisted of those who underwent peritonisation and group 2 patients consisted of those who did not in abdominal sacrocolpopexy. RESULTS: Operative time and the amount of blood lost were statistically less in the group 2. Postoperative pain and analgesic drug requirements were obviously higher in the group 1. Postoperative De novo dyspareunia and urinary urgency were higher in the group 1. There were no statistical differences between the groups in terms of other complications. CONCLUSION: We noticed that there was no difference between the patients who were peritonized and those who were not in terms of postoperative complications.