Ruptured abdominal aortic aneurysms – university center experience
http://www.100md.com
《血管的通路杂志》
a Department of Surgery, University Hospital, Medicine Faculty, Alej svobody 80, 304 60, Plzen, Czech Republic
b Department of Radiology, University Hospital, Medicine Faculty, Plzen, Czech Republic
Presented at the 55th International Congress of the European Society for Cardiovascular Surgery, St Petersburg, Russian Federation, May 11–14, 2006.
Abstract
Objectives: Mortality of ruptured abdominal aortic aneurysm (RAAA) is still very high. Various factors contribute to the patients' mortality. Some of them could be affected. Therefore, we evaluate the main factors of mortality of patients with RAAA who were operated on at our University Vascular Center. Methods: Univariate and multivariate analysis of various factors associated with RAAA was performed in the group of 182 patients operated on for RAAA between 1 January 1992 and 1 September 2005. Results: The 30-day mortality rate was 33.5%. The main factors of mortality were: misdiagnosis, cardiopulmocerebral resuscitation (CPCR) on admission, configuration of RAAA (P<0.001), number of blood transfusions, hypotension on admission (P<0.0001) and duration of operation, type of reconstruction and hypertension in anamnesis (P<0.01). Important factors (P<0.05) of postoperative mortality were also low hemoglobin level on admission, abdominal aortic aneurysm (AAA) diameter and ischemic heart disease in anamnesis. The probability of patient's death is the highest (P<0.003), if factors like CPCR, number of blood transfusions and aneurysm diameter are combined (multivariate analysis, stepwise method). Conclusions: The early detection and elective treatment of AAA, the regular dispensarization of patients with small AAA especially hypertonics, the correct diagnosis of RAAA without time delay are the best tools for patients' survival. The survival of patients with RAAA increases with a highly trained and experienced vascular team in a high volume vascular center.
Key Words: Rupture of abdominal aortic anerurysm; Predictors of mortality
1. Introduction
Since the first successful elective operation of abdominal aortic aneurysm (AAA) was performed by Charles Dubost in Paris in 1951, five decades have passed. While the mortality of elective operations is still improving, the mortality of urgent operations due to rupture is associated with the high mortality rate which has minimally changed during the period mentioned above and recently is approximately between 30–50%. This study follows evaluation of the main factors related to the mortality of patients with RAAA who were operated on at the Department of Surgery, University Hospital in Plzen, Czech Republic and attempts to find some possibilities of reducing the mortality rate of patients.
2. Patients and method
All patients who were admitted and immediately operated on for RAAA at the Department of Surgery, Charles University Hospital in Plzen, Czech Republic were studied. In a retrospective study, a total of 182 patients were evaluated during the 14-year period (1 January 1992–1 September 2005). The male to female ratio was 7:1, and the average age was 72.3±4.8 years. There were 119 (65.3%) hypertonics, 98 (53.8%) smokers, 132 (72.5%) patients with anamnesis of ischemic heart disease and 18 (9.8%) patients with anamnesis of stroke. Twenty-six (14.2%) patients suffered from preoperative renal dysfunction and 38 (20.8%) patients were diabetics. The average diameter of RAAA was 8.1±2.4 cm evaluated by bedside ultrasonography during the emmergency unit patient's admission. The time interval between the first symptoms of RAAA and patient's admission at our hospital was 3.9±4.1 h. The general practitioners had made the correct diagnosis of RAAA in 63.6% of patients. Forty-six (25.2%) patients were cardiopulmocerebrally resuscitated (CPCR), hemoperitoneum was present in 87 (47.8%) cases. One hundred and twelve (61.5%), 64 tube (35.1%) 2 axillobifemoral grafts (1.1%) and 4 (2.2%) endovascular grafts were done. The average operating time was 162±40.1 min (Table 1). The multivariate analysis of various factors – age, gender, history of ischemic heart disease, hypertension, stroke, smoking, chronic obstructive pulmonary disease, chronic renal insufficiency, and diabetes, time passing from the first symptoms to operation, blood pressure, hemoglobin and hematocrit levels on admission, CPCR, hemoperitoneum, diameter and configuration of AAA, type of operation, operating time, number of blood transfusions, length of hospitalization – was done with the end point of the 30-day postoperative patient's mortality. The variables were evaluated by their means, standard deviations, and medians. The analysis of variance, the Wilcoxon test, median and t-test were used for statistical evaluation of significance. Probability values <0.05 were considered as significant.
3. Results
The 30-day mortality rate was 33.5% (n=61). The main causes of patients' death (n=26) were hemorrhagic shock in 56.5% (n=103) and acute myocardial infarction in 25.2% (n=46). The main factors which correlated significantly with mortality were: misdiagnosis (P<0.0001), CPCR on admission (P<0.001), configuration of RAAA (P<0.001), hemorrhagic shock (P<0.02), per- and postoperative complications (P<0.02), artificial ventilation over 24 h (P<0.05) and hypertension (P<0.05) – Table 2.
4. Discussion
The mortality rate of RAAA remains high over five decades despite the improvement in the operative techniques (including the endovascular techniques in the recent years) and perioperative management. The hospital mortality rate is between 30–50%, but the overall mortality of patients with RAAA is even higher [1,2]. The incidence of RAAA is still growing. One third of the patients who suffer from AAA have RAAA during their lives (Table 3). Almost 40% of patients with AAA have as the first symptom of AAA its rupture [3,4]. The classic symptoms of RAAA are back or abdominal pain, hypotension and pulsatory intraabdominal mass. Symptomatology is complete in only half of the patients and is often misleading, which directs doctors to the misdiagnosis as simple back pain or urinary colic, sigmoid diverticulitis etc. [5,6]. In our group of patients there were almost 60% of the patients who were misdiagnosed. The misdiagnosis usually requires more time to determine the proper diagnosis by various radiodiagnostic methods (ultrasonography or computerized tomography). During this time, a patient's chance of survival is gradually decreasing.
Some manifestations of RAAA are difficult to evaluate promptly by simple clinical examination. In patients who are hemodynamically stable we prefer the emergency bedside abdominal ultrasonography as the optimal diagnostic method which takes only a few minutes for establishing the diagnosis of RAAA. Determining the accurate, rapid diagnosis has the utmost significance for the result of the operative treatment of patients with RAAA [7]. The Cleveland Vascular Society (1982) indicates that the operative mortality of patients with accurate initial diagnosis of RAAA was only 35%, whereas misdiagnosis was the cause of 75% mortality. In the present study the misdiagnosis caused the delay of the operative treatment by almost five hours which passed between the beginning of the RAAA first symptoms and patient's arrival at the operating theatre. The time delay was one of the most significant factors of mortality of our patients. Therefore, on the basis of our results we started to organize the educational seminars for general practitioners with the aim to improve the early diagnosis of RAAA.
If hemoperitoneum is present, the chances of patients' survival are very low due to very quickly ongoing hemorrhagic shock. In spite of the total mortality of the whole group of patients being 33.5%, the mortality of patients with the hemoperitoneum was 56.5% and the hemorrhagic shock was a very significant factor for patients' survival.
CPCR at admission is a factor, where the chance for patient's survival in spite of the urgent operation is very low. It is a question whether patients with cardiac arrest, in which there is no hemodynamic answer to CPCR, should be operated on urgently. We believe that especially advanced age patients, unconscious with cardiac arrest without response on the CPCR have no chance for survival. The decision to withhold the aggressive life support in such patients is always a very difficult ethical and also medical problem [8]. It should be performed by an experienced vascular surgeon and anesthesiologist. But each patient, who is resuscitable with the symptomatology of hemorrhagic shock, who is hemodynamically unstable, immediately has to be transported to the operating theatre for urgent laparotomy and clamping of the AAA neck. Spending too much time trying to stabilize the hypotensive patient is the serious error.
The other factors which contribute to the RAAA are aneurysm and patient-related factors. Size, expansion rate and configuration of AAA are the very well known aneurysm-related factors, which have a fundamental influence on the development of RAAA. Size and age have almost no significance for mortality of patients with RAAA. The configuration of AAA has an indirect influence for patient's survival after rupture. If the AAA was localized not only on abdominal aorta, but also on the iliac or femoral arteries, or the aneurysm was juxtarenal or suprarenal, the time of operation was significantly longer in our group of patients. Altogether it was the significant factor of mortality contrary to the patients with AAA localized only to the abdominal aorta, where the tube graft was placed after AAA resection. Although we preferred to use the tube graft also in cases where the terminal aorta was atherosclerotic, but without significant stenoses of iliac arteries, we had to use more often bifurcated grafts due to iliac arteries aneurysms. It was in contrast to the other authors, who could only use the tubegraft mostly in 90% of patients [9]. We started to use the endovascular aneurysm repair in patients with RAAA since June 2005. Although we performed only four procedures in hemodynamically stable patients with RAAA, the mortality rate was 0%. We used aorto-uni-iliac grafts (Zenith, Cook, USA) combined with cross-over bypasses in the whole group of patients. Our results are very encouraging and we will try to continue in this program.
From the factors related to the patient's 30-day postoperative mortality there were statistically significant hypertension and smoking. Hypertension, especially a wrong corrigated is a risk factor for the development of RAAA in general. More than 60% of our patients operated on for RAAA were hypertonics. Hypertension leads to the hypertrophy of the left ventricle with the decreased ability of its relaxation during diastole and an increase of dependence of its function on the filling blood pressures. Severe disturbances of the hemodynamics, tachycardia or other arhythmias can develop during hypotension in hypertonics with RAAA. Hypertension was also a very significant factor of the early (first 30 days) postoperative mortality due to cardiac failure in our group of patients. An acute myocardial infarction was one of the leading factors of the postoperative death of patients in the whole group of RAAA (25.2%) [10].
Smoking was present in almost 66% of patients operated on for RAAA. It is a factor associated with the rapid expansion and danger of abdominal aneurysm (AAA) rupture [19, 20]. Smoking is closely associated with pulmonary dysfunction and has an influence on the operative and late mortality rate of patients after elective operations for AAA. In our study, continued smoking was a very significant factor of early patient mortality after operation for RAAA. If the current smokers have the faster growth of aneurysm, the highest probability of aneurysm rupture and more complicated postoperative course, it is a question, if they should be offered for the earlier elective AAA operation. Because the risk of small aneurysm rupture in smokers is low (<2%), it seems to be more rational to follow the smokers with small AAA. The elective open or endovascular operations are indicated according to general principles of AAA treatment. Prophylactic operation of AAA in smokers will probably have a greater complication rate from the point of view of pulmonary dysfunction after elective operation.
We can conclude that the early detection and surgical or endovascular elective treatment of AAA, the quicker dispensarization of patients with small AAA, especially in hypertonics and smokers, can occur. The correct diagnosis of RAAA without time delay is the best preoperative tool for overall survival of patients with AAA. The patient's chance for survival also increases with highly trained general practitioners and also prehospital resuscitation system. We recommend the immediate transfer of patients with RAAA to the high volume vascular centers with a 24-h vascular service of an experienced vascular team.
References
The UK Small Aneurysm Trial Participants. Mortality results for randomized controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet 1998; 352:1649–1655.
Chen JC, Hildebrand HD, Salvian AJ, Taylor DC, Strandberg S, Myckatyn TM, Hsiang YN. Predictors of death in nonruptured and ruptured abdominal aortic aneurysms. J Vasc Surg 1996; 24:614–623.
Laukantaus SJ, Pattila V, Kantonen I, Salo JA. Utility of surgery for ruptured abdominal aortic aneurysm. Ann Vasc Surg 2006; 20:42–48.
Vaddineni SK, Russo GC, Patterson MA, Taylor SM. Ruptured abdominal aortic aneurysm: a retrospective assessment of open versus endovascular repair. Ann Vasc Surg 2005; 19:782–786.
Haro LH, Krajicek M, Lobl JK. Challenges, controversies, and advances in aortic catastrophes. Emerg Med Clin North Am 2005; 23:1159–1177.
Cota AM, Omer AA, Jaipersad AS, Wilson NV. Elective versus ruptured abdominal aortic aneurysm repair: a 1-year cost-effectivenes analysis. Ann Vasc Surg 2005; 19:858–861.
Harris JR, Forbes TL, Steiner SH, Lawlor DK. Risk-adjusted analysis of early mortality after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2005; 42:387–391.
Chan CY, Tan Ch. Ruptured abdominal aortic aneurysms: a personal experience. Singapore Med J 2001; 42:73–76.
Collin J. Influence of gender on outcome from ruptured abdominal aortic aneurysm. Br J Surg 2000; 87:1249–1250.
Haggart PC, Adam DJ, Ludman PF, Ludman CA, Bradbury AW. Myocardial injury and systemic fibrinolysis in patients undergoing repair of ruptured abdominal aortic aneurysm: a preliminary report. Eur J Vasc Endovasc Surg 2001; 21:529–534(Vladislav Treska, Bohusla)
b Department of Radiology, University Hospital, Medicine Faculty, Plzen, Czech Republic
Presented at the 55th International Congress of the European Society for Cardiovascular Surgery, St Petersburg, Russian Federation, May 11–14, 2006.
Abstract
Objectives: Mortality of ruptured abdominal aortic aneurysm (RAAA) is still very high. Various factors contribute to the patients' mortality. Some of them could be affected. Therefore, we evaluate the main factors of mortality of patients with RAAA who were operated on at our University Vascular Center. Methods: Univariate and multivariate analysis of various factors associated with RAAA was performed in the group of 182 patients operated on for RAAA between 1 January 1992 and 1 September 2005. Results: The 30-day mortality rate was 33.5%. The main factors of mortality were: misdiagnosis, cardiopulmocerebral resuscitation (CPCR) on admission, configuration of RAAA (P<0.001), number of blood transfusions, hypotension on admission (P<0.0001) and duration of operation, type of reconstruction and hypertension in anamnesis (P<0.01). Important factors (P<0.05) of postoperative mortality were also low hemoglobin level on admission, abdominal aortic aneurysm (AAA) diameter and ischemic heart disease in anamnesis. The probability of patient's death is the highest (P<0.003), if factors like CPCR, number of blood transfusions and aneurysm diameter are combined (multivariate analysis, stepwise method). Conclusions: The early detection and elective treatment of AAA, the regular dispensarization of patients with small AAA especially hypertonics, the correct diagnosis of RAAA without time delay are the best tools for patients' survival. The survival of patients with RAAA increases with a highly trained and experienced vascular team in a high volume vascular center.
Key Words: Rupture of abdominal aortic anerurysm; Predictors of mortality
1. Introduction
Since the first successful elective operation of abdominal aortic aneurysm (AAA) was performed by Charles Dubost in Paris in 1951, five decades have passed. While the mortality of elective operations is still improving, the mortality of urgent operations due to rupture is associated with the high mortality rate which has minimally changed during the period mentioned above and recently is approximately between 30–50%. This study follows evaluation of the main factors related to the mortality of patients with RAAA who were operated on at the Department of Surgery, University Hospital in Plzen, Czech Republic and attempts to find some possibilities of reducing the mortality rate of patients.
2. Patients and method
All patients who were admitted and immediately operated on for RAAA at the Department of Surgery, Charles University Hospital in Plzen, Czech Republic were studied. In a retrospective study, a total of 182 patients were evaluated during the 14-year period (1 January 1992–1 September 2005). The male to female ratio was 7:1, and the average age was 72.3±4.8 years. There were 119 (65.3%) hypertonics, 98 (53.8%) smokers, 132 (72.5%) patients with anamnesis of ischemic heart disease and 18 (9.8%) patients with anamnesis of stroke. Twenty-six (14.2%) patients suffered from preoperative renal dysfunction and 38 (20.8%) patients were diabetics. The average diameter of RAAA was 8.1±2.4 cm evaluated by bedside ultrasonography during the emmergency unit patient's admission. The time interval between the first symptoms of RAAA and patient's admission at our hospital was 3.9±4.1 h. The general practitioners had made the correct diagnosis of RAAA in 63.6% of patients. Forty-six (25.2%) patients were cardiopulmocerebrally resuscitated (CPCR), hemoperitoneum was present in 87 (47.8%) cases. One hundred and twelve (61.5%), 64 tube (35.1%) 2 axillobifemoral grafts (1.1%) and 4 (2.2%) endovascular grafts were done. The average operating time was 162±40.1 min (Table 1). The multivariate analysis of various factors – age, gender, history of ischemic heart disease, hypertension, stroke, smoking, chronic obstructive pulmonary disease, chronic renal insufficiency, and diabetes, time passing from the first symptoms to operation, blood pressure, hemoglobin and hematocrit levels on admission, CPCR, hemoperitoneum, diameter and configuration of AAA, type of operation, operating time, number of blood transfusions, length of hospitalization – was done with the end point of the 30-day postoperative patient's mortality. The variables were evaluated by their means, standard deviations, and medians. The analysis of variance, the Wilcoxon test, median and t-test were used for statistical evaluation of significance. Probability values <0.05 were considered as significant.
3. Results
The 30-day mortality rate was 33.5% (n=61). The main causes of patients' death (n=26) were hemorrhagic shock in 56.5% (n=103) and acute myocardial infarction in 25.2% (n=46). The main factors which correlated significantly with mortality were: misdiagnosis (P<0.0001), CPCR on admission (P<0.001), configuration of RAAA (P<0.001), hemorrhagic shock (P<0.02), per- and postoperative complications (P<0.02), artificial ventilation over 24 h (P<0.05) and hypertension (P<0.05) – Table 2.
4. Discussion
The mortality rate of RAAA remains high over five decades despite the improvement in the operative techniques (including the endovascular techniques in the recent years) and perioperative management. The hospital mortality rate is between 30–50%, but the overall mortality of patients with RAAA is even higher [1,2]. The incidence of RAAA is still growing. One third of the patients who suffer from AAA have RAAA during their lives (Table 3). Almost 40% of patients with AAA have as the first symptom of AAA its rupture [3,4]. The classic symptoms of RAAA are back or abdominal pain, hypotension and pulsatory intraabdominal mass. Symptomatology is complete in only half of the patients and is often misleading, which directs doctors to the misdiagnosis as simple back pain or urinary colic, sigmoid diverticulitis etc. [5,6]. In our group of patients there were almost 60% of the patients who were misdiagnosed. The misdiagnosis usually requires more time to determine the proper diagnosis by various radiodiagnostic methods (ultrasonography or computerized tomography). During this time, a patient's chance of survival is gradually decreasing.
Some manifestations of RAAA are difficult to evaluate promptly by simple clinical examination. In patients who are hemodynamically stable we prefer the emergency bedside abdominal ultrasonography as the optimal diagnostic method which takes only a few minutes for establishing the diagnosis of RAAA. Determining the accurate, rapid diagnosis has the utmost significance for the result of the operative treatment of patients with RAAA [7]. The Cleveland Vascular Society (1982) indicates that the operative mortality of patients with accurate initial diagnosis of RAAA was only 35%, whereas misdiagnosis was the cause of 75% mortality. In the present study the misdiagnosis caused the delay of the operative treatment by almost five hours which passed between the beginning of the RAAA first symptoms and patient's arrival at the operating theatre. The time delay was one of the most significant factors of mortality of our patients. Therefore, on the basis of our results we started to organize the educational seminars for general practitioners with the aim to improve the early diagnosis of RAAA.
If hemoperitoneum is present, the chances of patients' survival are very low due to very quickly ongoing hemorrhagic shock. In spite of the total mortality of the whole group of patients being 33.5%, the mortality of patients with the hemoperitoneum was 56.5% and the hemorrhagic shock was a very significant factor for patients' survival.
CPCR at admission is a factor, where the chance for patient's survival in spite of the urgent operation is very low. It is a question whether patients with cardiac arrest, in which there is no hemodynamic answer to CPCR, should be operated on urgently. We believe that especially advanced age patients, unconscious with cardiac arrest without response on the CPCR have no chance for survival. The decision to withhold the aggressive life support in such patients is always a very difficult ethical and also medical problem [8]. It should be performed by an experienced vascular surgeon and anesthesiologist. But each patient, who is resuscitable with the symptomatology of hemorrhagic shock, who is hemodynamically unstable, immediately has to be transported to the operating theatre for urgent laparotomy and clamping of the AAA neck. Spending too much time trying to stabilize the hypotensive patient is the serious error.
The other factors which contribute to the RAAA are aneurysm and patient-related factors. Size, expansion rate and configuration of AAA are the very well known aneurysm-related factors, which have a fundamental influence on the development of RAAA. Size and age have almost no significance for mortality of patients with RAAA. The configuration of AAA has an indirect influence for patient's survival after rupture. If the AAA was localized not only on abdominal aorta, but also on the iliac or femoral arteries, or the aneurysm was juxtarenal or suprarenal, the time of operation was significantly longer in our group of patients. Altogether it was the significant factor of mortality contrary to the patients with AAA localized only to the abdominal aorta, where the tube graft was placed after AAA resection. Although we preferred to use the tube graft also in cases where the terminal aorta was atherosclerotic, but without significant stenoses of iliac arteries, we had to use more often bifurcated grafts due to iliac arteries aneurysms. It was in contrast to the other authors, who could only use the tubegraft mostly in 90% of patients [9]. We started to use the endovascular aneurysm repair in patients with RAAA since June 2005. Although we performed only four procedures in hemodynamically stable patients with RAAA, the mortality rate was 0%. We used aorto-uni-iliac grafts (Zenith, Cook, USA) combined with cross-over bypasses in the whole group of patients. Our results are very encouraging and we will try to continue in this program.
From the factors related to the patient's 30-day postoperative mortality there were statistically significant hypertension and smoking. Hypertension, especially a wrong corrigated is a risk factor for the development of RAAA in general. More than 60% of our patients operated on for RAAA were hypertonics. Hypertension leads to the hypertrophy of the left ventricle with the decreased ability of its relaxation during diastole and an increase of dependence of its function on the filling blood pressures. Severe disturbances of the hemodynamics, tachycardia or other arhythmias can develop during hypotension in hypertonics with RAAA. Hypertension was also a very significant factor of the early (first 30 days) postoperative mortality due to cardiac failure in our group of patients. An acute myocardial infarction was one of the leading factors of the postoperative death of patients in the whole group of RAAA (25.2%) [10].
Smoking was present in almost 66% of patients operated on for RAAA. It is a factor associated with the rapid expansion and danger of abdominal aneurysm (AAA) rupture [19, 20]. Smoking is closely associated with pulmonary dysfunction and has an influence on the operative and late mortality rate of patients after elective operations for AAA. In our study, continued smoking was a very significant factor of early patient mortality after operation for RAAA. If the current smokers have the faster growth of aneurysm, the highest probability of aneurysm rupture and more complicated postoperative course, it is a question, if they should be offered for the earlier elective AAA operation. Because the risk of small aneurysm rupture in smokers is low (<2%), it seems to be more rational to follow the smokers with small AAA. The elective open or endovascular operations are indicated according to general principles of AAA treatment. Prophylactic operation of AAA in smokers will probably have a greater complication rate from the point of view of pulmonary dysfunction after elective operation.
We can conclude that the early detection and surgical or endovascular elective treatment of AAA, the quicker dispensarization of patients with small AAA, especially in hypertonics and smokers, can occur. The correct diagnosis of RAAA without time delay is the best preoperative tool for overall survival of patients with AAA. The patient's chance for survival also increases with highly trained general practitioners and also prehospital resuscitation system. We recommend the immediate transfer of patients with RAAA to the high volume vascular centers with a 24-h vascular service of an experienced vascular team.
References
The UK Small Aneurysm Trial Participants. Mortality results for randomized controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet 1998; 352:1649–1655.
Chen JC, Hildebrand HD, Salvian AJ, Taylor DC, Strandberg S, Myckatyn TM, Hsiang YN. Predictors of death in nonruptured and ruptured abdominal aortic aneurysms. J Vasc Surg 1996; 24:614–623.
Laukantaus SJ, Pattila V, Kantonen I, Salo JA. Utility of surgery for ruptured abdominal aortic aneurysm. Ann Vasc Surg 2006; 20:42–48.
Vaddineni SK, Russo GC, Patterson MA, Taylor SM. Ruptured abdominal aortic aneurysm: a retrospective assessment of open versus endovascular repair. Ann Vasc Surg 2005; 19:782–786.
Haro LH, Krajicek M, Lobl JK. Challenges, controversies, and advances in aortic catastrophes. Emerg Med Clin North Am 2005; 23:1159–1177.
Cota AM, Omer AA, Jaipersad AS, Wilson NV. Elective versus ruptured abdominal aortic aneurysm repair: a 1-year cost-effectivenes analysis. Ann Vasc Surg 2005; 19:858–861.
Harris JR, Forbes TL, Steiner SH, Lawlor DK. Risk-adjusted analysis of early mortality after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2005; 42:387–391.
Chan CY, Tan Ch. Ruptured abdominal aortic aneurysms: a personal experience. Singapore Med J 2001; 42:73–76.
Collin J. Influence of gender on outcome from ruptured abdominal aortic aneurysm. Br J Surg 2000; 87:1249–1250.
Haggart PC, Adam DJ, Ludman PF, Ludman CA, Bradbury AW. Myocardial injury and systemic fibrinolysis in patients undergoing repair of ruptured abdominal aortic aneurysm: a preliminary report. Eur J Vasc Endovasc Surg 2001; 21:529–534(Vladislav Treska, Bohusla)