Who Should We Operate On and How Do We Decide: Predicting Rupture and Survival in Patients with Aortic Aneurysm
Section snippets
Rupture Risk
For the past five decades, the primary determinant of rupture risk has been maximum aneurysm diameter, based on the work of Szilagyi et al in the 1960s.1 These authors compared the outcomes of small-diameter and large-diameter aneurysms, and found that patients with larger aneurysms (>6 cm) were much more likely to die of a ruptured aneurysm. In that era, the diameter had to be determined by physical exam and abdominal x-ray, which are both now known to overestimate the actual diameter, such
Operative Risk
Operative mortality is the most widely reported of all aneurysm-related variables. A literature review by Blankensteijn et al21 found that population-based studies reported mortality rates as high as 8% (prospective), and as a whole are significantly higher than single-center reports averaging 3.8%. A review by Hallin et al22 found a weighted operative mortality for elective open AAA repair of 5%, which is consistent with the UK SAT of 5.6%,23 US hospital discharge data (5.6% for a review of
Life Expectancy
Of the three factors determining who should have an aneurysm repair, life expectancy is perhaps the most difficult to have a “feel” for, but nonetheless critical to determining whether the patient will benefit from repair. One of the difficulties of determining life expectancy is that it is not a simple linear function. A typical 60-year-old surviving AAA repair has a 13-year life expectancy, but a 70-year-old surviving a AAA repair has a 10-year life expectancy, and an 80-year-old has a 6-year
Putting the Factors Together: Simple, Right?
So how do we “operationalize” the concept that intervention for an AAA is appropriate when the cumulative risk of rupture exceeds the risk of repair, within the context of patient life expectancy? Of course, this is often not a simple matter, but it is not always difficult, either. For a young, healthy patient with a large aneurysm, the recommendation for intervention is a relatively easy decision. In healthy patients with aneurysms <5.5 cm in diameter, and in high surgical risk patients with
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