What is the Surgeons' Role in Abdominal Aortic Aneurysms Mortality?

A recent study reveals the impact of a surgeons' annual elective aortic volume and other prognostic indicators in early outcomes of ruptured abdominal aortic aneurysm (RAAA) repair.

Researchers at the University of Pittsburgh Medical Center (PA, USA) followed 14 different surgeons who performed consecutive open RAAA repairs on 170 patients between January 2001 and June 2007; mean age of the patients was 74.5 ± 8.1 years. The results showed an operative mortality rate (in-hospital or 30 days post operation, whichever is later) of 38.2%, including 29 intra-operative deaths. Factors that were independent predictors of perioperative deaths included the patient's advanced age as well as postoperative intestinal bowel ischemia; patients with postoperative intestinal bowel ischemia had a lower 30-day survival rate compared with patients who did not (48.1% versus 15.3%), and an increased intraoperative fluid and blood product usage also was associated with this condition. Octogenarians had a lower 30-day survival rate of 49% percent versus 70.5% than their younger counterparts.

However, the most striking variable was the surgeon's annual elective aortic aneurysm volume. The researchers found that patients who were operated on by high-volume surgeons (average annual elective aortic volume of more than 20) had a significantly lower 30-day mortality rate of 21.6%, compared with low-volume surgeons (average elective annual aortic volume less or equal to 20) who had a 30-day mortality rate of 42.1%. Neither the surgeons' experience, determined by number of years in practice nor the annual RAAA volume was found to be predictors of death. The study was published in the July 2008 issue of the Journal of Vascular Surgery.

"The improved early outcomes of surgeons with high-volume AAA have strong implications for training, emergency staffing needs and alternative treatment strategies,” said Jae-Sung Cho, M.D., an associate professor of surgery in the division of vascular surgery. "High-volume surgeons with low mortality rates should be sought out, and a team dedicated to RAAA developed, which may be an effective way of improving surgical outcomes.”

Dr. Cho added that these suggestions would help achieve improved patient survival as well as specialty training in the ‘endovascular era' with rapidly diminishing open as compared to endovascular-aneurysm-repair case experiences. "Using endovascular technology for the treatment of RAAA has not been shown to confer survival benefits over open repair. Even if this were the case, endovascular applicability for RAAA, at present, is limited from the standpoint of both institutional and the surgeons' capabilities as well as patients' anatomic and hemodynamic conditions. It appears that direct open repair is still the mainstay of therapy for RAAA and concerted efforts should be made to improve surgical outcomes in all RAAA repairs.”

RAAA remains a highly lethal problem with death rates ranging from 45-55%, even after surgical repair. If one includes pre-hospital deaths, the overall death rates for all RAAA patients are around 90%. Despite advances in surgical techniques and perioperative care, surgical results after open repairs of RAAA have not improved over the past 50 years.


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University of Pittsburgh Medical Center