Sakalihasan Natzi MD,PhDDepartment of Cardiovascular and Thoracic Surgery

University hospital of Liège,

Experimental Research Center of the Cardiovascular Surgery Department, GIGA-Cardiovascular Science Unit, University of Liège,

Liège, BELGIUM

Factors influencing the mortality rate in AAA rupture. Preliminary results of Liege AAA

(single center) rupture Study

Factors promoting the aortic rupture

INFLAMMATION

GENETICS & FAMILIAL

SMOKING

GENDER

Aneurysm rupture occurs when the mechanical stress acting on the wall exceeds the strength of the wall

Abdominal Aortic AneurysmRupture

• Mortality rate for patients with ruptured AAA is 65%−85%

• Approximately half of deaths attributed to rupture occur before the patient reaches the surgical room

Lederle FA, et al. N Engl J Med. 2002;346:1437-1444 ;Sakalihasan N, et al. Lancet. 2005;365:1577-1589

Material

105 concecutive patientsadmitted between 2004 and 2013 for ruptured AAA.

1.Demography 5 Year of admissionSeason of admissionAge of the patient at amission (years)Sex (Male , female)Body mass index (BMI, kg/m²)

2. Medical background 24Known AAA (<1 an, 1-5 ans, >5 ans, inconnu)familial history of AAA (yes,no )Tabac use (current ,never, past smokers )Cholesterol (yes,no)Anti-cholesterol treatment (yes , no)Artérial hypertension (AHT) (yes, no)anti-AHT (yes , no)Diabetes (yes, no)Anti-diabetic treatment (yes, no)Problème cardiac problems (yes, no)Type of cardiac problem ( type of pathology :ischemia, valvular, rythmic, dilated myocardiopathy,multiples cardiopathy)

Antiagregant or anticoagulant treatment (yes, no)Maladie coronarr artery diseases (yes, no)CABG (yes, no)Coronary angioplasty (yes, no)Peripheral arterielle diseases (yes , no)Type of vasular pathology (occlisive, other anevrysm, )Varices (yes , no)COPD (yes , no)Renal Insuffisancy (yes, no)Dialyse (yes , no)CVA /TIA (yes , no)Hernie inguinal hernia (yes , no)Cancer (yes , no)

Methods IRetrospective analysis of 101 parameters

3. Diagnostic – first signs 7Diagnostic

Pulsatil mass (yes , no)Pain (yes , no)

First signsAbdominal pain (yes , no)Hypovolémic choc (yes , no)

Confirmation of diagnostic by :Clinical exam (yes , no)US (yes , no)CT-scan (yes , no)

4. Biology at admission 19 Hématocrite (%)Hémoglobine (g/dL)RBC (106/mm³)Plattles (10³/mm³)WBC (10³/mm³)Neutrophiles (10³/mm³)CPK (UI/L)Urea (g/L)Creatinine (mg/L)NA (mmol/L)K (mmol/L)HCO3 (mmol/L)GFR (mL/min)CRP (mg/L)LDH (UI/L)Fybrinogen (g/L)pHLactate (mg/L)INR

5. Parameters at admission 8Systolic blood pressure (mmHg)Heart rate ( bpm)Saturation oxygen saturation (%) (<90, 90-95, 95-100%)EKG Ischémia signes (yes , no)Cardiac arrest (yes , no)Cardio-pulmonary reanimation (yes , no)Loss of consciousness (yes , no)Intubation (yes , no)

6. Surgical treatment 2Laparotomy (yes , no)Type of prosthesis (tube, aortobiiliaque, aortobifémorale,aortoiliaque/fémorale, any)

7. Surgical complications 11Insuffisance cardiac Insuffisciency (yes, no)Acute kydney Insuffisciency (yes i, no)Mesentéric ischemia (yes , no)Redo –laparotomy (yes , no)Non fatal redo surgery (yes , no)Atrial fibrillation (yes, no)Pneumonia (yes,no)Pleural effusion (yes, no)Respiratory distress (yes, no)Sepsis (yes , no)Deep wound (yes , no)

8. Time limit 4Service mobile d’urgence et de réanimation SMUR, hospital)Delay first sign and diagnosis (h)Delay diagnostic – surgical management (min)Delay admission CHU – Intervention (min)

Methods IIRetrospective analysis of 101 parameters

9. Anatomic and procedural parameters 13Diamètre aortique maximal (mm)Clampage infra-rénal (yes, no)Clampage supra-rénal (yes, no)Mésentérique inférieure (ligaturée, réimplantée, occluse, aucun)Héparine (U) (0, 2500, 3500, 4000, 5000, >5000)Pack de globules rouges (GR) (U) (0, 1-3, >3)Autotransfusion (mL) (0, 0-500, 500-1000, 1000-2000, >2000)Plasma (mL) (0, 0-500, 500-1000, >1000)Unités de plaquettes (U) (0, 1, >1)Cristalloïdes (mL) (0, 0-1000, 1000-3000, >3000)Durée de la procédure (h) (<2h, 2-4h, 4-6h, >6h)Inotropes (mL) (0, 0-10, 10-20, 20-30, >30)Durée clampage aortique (0 min, <30 min, 30min-1h, 1-2h, >2h)

10. Issue 8Died (yes, no)Preoperative Death (yes , no) Peroperative death (yes, no)Postoperative death (tes, no)Postoperative death < 30 days (yes, no)Postoperative death >30 jdays (yes, no)Causes of death (MOF , hypovolemic shock or respiratoiry distress , arrêt cardias arrest , , sepsis, other)Raisons to not operated (alteration of general satatus, deep hypovolelic shock , cardiac arrest , refus, death before surgery)

• Death at admssion,

• Death during surgery

• Death at 30days (patients underwent surgeryand alive)

• Global mortality (admission-30 days )

Methods III

Results:

Demography: 88 male (83.8%), 17 Female (16.2%)Mean age 75.5 ± 10 years (51 – 99)47.7% of the patients presented ponderal excess

40 Patients65 Patients

SMUR (Service Mobile d’Urgence et de Réanimation)

Anatomic and procedural parameters(N=105)

Comparison of parameters between patients operated alive and deceased at 30 days by logistic regression (N = 69)

*Régression logistique ordinale (p=0.027)

Fisher exact test

Significant Predictors of mortality in the patients (n:86)

Elderly patients, in particular octogenariansBMI - categories <18 kg / m² and ≥ 40 kg / m² Known aneurysm for more than 5 yearsAnti-aggregating / anticoagulant drugsHigh creatinine valuesLow HCO3 valuesLow GFR valuesRenal failureMesenteric ischemiaRespiratory distress…..

Summary

Equation I:At the multivariate level

If stepwise regression is used, including only significant variables at P <0.05

For example, if the patient has the 3 factors,

Complication "mesenteric ischemia" (p = 0.030)Anticoagulant drugs (p = 0.027)

Complication "renal failure" (p = 0.045)

Risk score (Y) = -3.11 + 1.65 x (mesenteric ischemia)* + 1.51 x (anticoagulants)* + 1.39 x (renal insufficiency)*

Probability of 30 days mortality = exp (Y) / [1 + exp (Y)]

Y = -3.11 + 1.65 + 1.51+ 1.39 = 1.44

the probability of death at 30 days is 0.808 or 81%

* Coefficient of variation

Equation II:

• Mesenteric ischemia (p = 0.030), anticoagulants (p = 0.029), pulsatile mass (p = 0.027) and creatinine (p = 0.040).

The equation is :

Probability of 30 days mortality = 4.41 + 1.81 x (mesenteric ischemia) + 1.59 x (anticoagulants) + 1.85 x (pulsating mass) + 0.108 x (creatinine) = 81%

If no factor is present, the probability of death is 4.3%

total familial sporadic

incidence of rupture 14,6% 32% 8.7% p < 0.0001*(313 probands,1995)

incidence of rupture 5,9% 8% 2.4% p < 0.0001**( 618 probands,2014)

* Verloes P, Sakalihasan N, Koulischer L, Limet R. J Vasc Surg 1995** Sakalihasan N et al; Annals of Vascular Surgery (2014), doi: 10.1016/j.avsg.2013.11.005.

Factors promoting the aortic rupture(Single center (CHU) experiences)

Asymptomatic Abdominal Aortic Aneurysm

2.5 – 2.9cm 4.5 - 5.0 cm 5.0 - 5.5 cm >5.5 cm

Follow-upUS every5 years

Follow-upUS every 3months for women, 6months formen

MenFollow-upUS every 3- 6 months

Women *SurgeryOpen or EVAR

Surgery*Open or EVAR

3.0 - 3.9 cm 4.0 - 4.5 cm

Follow-upUS every 24-36 months

Follow-upUS every 6-12 months

*if surgically fitEarlier intervention may be considered

for patients with:

•rapidly growing AAA (10 mm/year)

•AAA with increased PET signals

•Saccular AAA

•mycotic AAA

•inflammatory AAA

•family history of AAA rupture

Abdominal Aortic Aneurysm*Natzi Sakalihasan, Jean-Olivier Defraigne, Athanasios Katsargyris, Helena Kuivaniemi, Jean-Baptiste MichelAlain Nchimi Longang, Janet Powell, Koichi Yoshimura, Rebecka Hultgren

Submitted to publication, Nature Reviews Disease Primers

Modified from Sakalihasan et al, Lancet 365, 1577-1589 (2005)

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