Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm
Male
Patient Transfer
SURGERY
Aortic Rupture
610
Blood Pressure
03 medical and health sciences
0302 clinical medicine
After-Hours Care
616
Preoperative Care
80 and over
Humans
Abdominal
METAANALYSIS
Aged
Aged, 80 and over
Health Facility Size
Science & Technology
MORTALITY
Endovascular Procedures
ENDOVASCULAR REPAIR
IMPROVE trial investigators
11 Medical And Health Sciences
Original Articles
Middle Aged
Aortic Aneurysm
3. Good health
VOLUME
Fluid Therapy
Surgery
Female
Life Sciences & Biomedicine
Aortic Aneurysm, Abdominal
DOI:
10.1002/bjs.9410
Publication Date:
2014-01-27T12:09:10Z
AUTHORS (13)
ABSTRACT
AbstractBackgroundSingle-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.MethodsIMPROVE 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.ResultsSome 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).ConclusionThese 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.
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