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Meta Analysis on Mortality of Ruptured Abdominal Aortic Aneurysms

Open ArchivePublished:January 21, 2008DOI:https://doi.org/10.1016/j.ejvs.2007.11.019

      Objectives

      To assess the mortality of patients with ruptured abdominal aortic aneurysms undergoing open surgery and examine changes in mortality over time.

      Methods

      Literature databases were searched for relevant articles published between 1991 and 2006. Two reviewers independently performed study inclusion and data extraction. Primary outcome measure was 30 day or in-hospital mortality. Subgroup analyses were performed examining the effect of population- and hospital-based studies, hospital volume and type of surgeon.

      Results

      From a total of 1419 identified studies, 145 observational studies met the inclusion criteria of which 116 were included in the systematic review comprising 60,822 patients. Overall mortality was 48.5% (95% CI: 48.1–48.9%) and did not change significantly over the years. Age increased over the years. For overall mortality a trend was seen in favour of high-volume hospitals.

      Conclusions

      This meta-analysis suggests that mortality of patients with RAAA treated by open surgery has not changed over the past 15 years. This could be explained by increased age of patients undergoing RAAA repair.

      Keywords

      Introduction

      The incidence of ruptured abdominal aortic aneurysms (RAAA) is 5.6–17.5 per 100,000 person-years in Western countries
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      • Bergqvist D.
      Ruptured abdominal aortic aneurysm: a population-based study.
      • Johansson G.
      • Swedenborg J.
      Ruptured abdominal aortic aneurysms: a study of incidence and mortality.
      • Mealy K.
      • Salman A.
      The true incidence of ruptured abdominal aortic aneurysms.
      and the overall mortality rate of patients with a RAAA is approximately 80–90%.
      • Bengtsson H.
      • Bergqvist D.
      Ruptured abdominal aortic aneurysm: a population-based study.
      • Kantonen I.
      • Lepantalo M.
      • Brommels M.
      • Luther M.
      • Salenius J.P.
      • Ylonen K.
      Mortality in ruptured abdominal aortic aneurysms. The Finnvasc Study Group.
      • Semmens J.B.
      • Norman P.E.
      • Lawrence-Brown M.M.
      • Holman C.D.
      Influence of gender on outcome from ruptured abdominal aortic aneurysm.
      Hence RAAA signifies an important cause of death, which may further increase as the population ages. The only therapeutic option for patients with RAAA is emergency open or endovascular surgery.
      Despite considerable improvements in emergency care, diagnostic facilities, anaesthesiology and intensive care, mortality rates of RAAA repair have stayed more or less the same over time, and are still reported to be as high as 40% to 50%.
      • Akkersdijk G.J.M.
      • van der G.Y.
      • van Bockel J.H.
      • de Vries A.C.
      • Eikelboom B.C.
      Mortality rates associated with operative treatment of infrarenal abdominal aortic aneurysm in The Netherlands.
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      • et al.
      Surgical repair of ruptured abdominal aortic aneurysms in the state of Maryland: factors influencing outcome among 527 recent cases.
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      Outcomes after abdominal aortic aneurysm repair in those > or =80 years of age: recent Veterans Affairs experience.
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      Hospital volume, calendar age, and short term outcomes in patients undergoing repair of abdominal aortic aneurysms: the Ontario experience, 1988–92.
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      However, in a meta-analysis Bown et al. suggested a slight decrease in operative mortality from 1954 to 1997.
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      A review reporting on more recent studies is lacking.
      Several studies have shown a discrepancy in outcome of RAAA between national and hospital registries, with better outcome in the latter.
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      The importance of complete follow-up for results after femoro-infrapopliteal vascular surgery.
      Hospital volume also might influence outcome of RAAA, but reports on mortality in patients with RAAA in high and low volume centers remain contradicting.
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      • Luther M.
      • Ylonen K.
      Mortality in abdominal aortic aneurysm surgery–the effect of hospital volume, patient mix and surgeon's case load.
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      • Zelenock G.B.
      Operative mortality rates for intact and ruptured abdominal aortic aneurysms in Michigan: an eleven-year statewide experience.
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      • Parker M.A.
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      Hospital vascular surgery volume and procedure mortality rates in California, 1982–1994.
      The aim of the present study was to perform a systematic review of recent literature on mortality in patients with RAAA treated with open surgery and examine changes in mortality over time. In addition we evaluated the concordance of national registries with hospital registries, and explored the effect of age, hospital-volume and type of surgeon on mortality rates.

      Methods

       Search strategy

      Electronic literature searches were performed by two independent investigators using Pubmed, Medline, Embase, Sumsearch, Cinahl, The Cochrane Central Register of Controlled Trials and Excerpta Medica. While aiming to obtain the most recent articles and bearing in mind a previous meta-analysis which included studies up to 2000,
      • Bown M.J.
      • Sutton A.J.
      • Bell P.R.F.
      • Sayers R.D.
      A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair.
      we restricted our search to the studies published after 1991. The search strategy used for each database is described in the Appendix. In addition, we manually searched the reference lists of relevant articles to identify articles missed by electronic searches. Language was restricted to English, German, French, Spanish and Dutch. We did not systematically search abstract books of conference proceedings, did not hand search leading journals, and did not contact leading authors in the field to retrieve potential extra papers.

       Inclusion and exclusion criteria

       Types of studies

      Any prospective or retrospective studies evaluating mortality of conventional surgical treatment in patients with RAAA were considered. Studies had to describe an original patient series. In case series reported on more than one occasion the report with the most complete information on outcomes was included. Studies had to comprise a minimal number of forty patients and to describe a consecutive patient series to be eligible for inclusion.

       Types of participants

      Studies were eligible if they defined a RAAA as the presence of blood outside the aortic wall diagnosed by ultrasound or computed tomography (CT), or confirmed during surgery, and we included articles if investigators clearly distinguished RAAA from symptomatic abdominal aortic aneurysms. Studies reporting on thoracic, inflammatory or mycotic aneurysms were excluded. Also studies reporting solely on subgroups, such as octogenarians, were excluded to prevent confounding on mortality rates by age.

       Types of intervention

      Treatment of patients with surgery had to be described in the studies. No restrictions were made with respect to the operative technique, which was either trans- or retroperitoneal.

       Types of outcome measures

      At least one of the following primary outcome measures had to be reported: intra-operative (during operation), or overall mortality rates (30 day or in-hospital, i.e. procedure related). Secondary outcome measures were: hospital volume (mean number of RAAA operations yearly per hospital), type of surgeon (general or vascular) and hospital-based studies or population-based (data from national or regional registries).

       Study selection

      After identifying relevant titles, the corresponding abstracts were judged independently by two reviewers (LH and MNSV). If disagreement occurred, the final decision regarding inclusion was based on the full article. Any discrepancies on article selection were resolved by discussion or a third reviewer (MK).

       Methods of the meta-analysis

       Study quality and data extraction

      Two reviewers (LH and MSV) extracted the data independently. The data collected from each study included (1) the mid-time point of the study (the date half way through the inclusion period), (2) country of origin, (3) patient characteristics (total number of patients operated on, mean or median age, sex) and (4) intra-operative and overall mortality rates. If possible, we noted the number of patients who died before a surgical intervention.
      We applied the guidelines for meta-analysis of observational studies in epidemiology (MOOSE).
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      • Berlin J.A.
      • Morton S.C.
      • Olkin I.
      • Williamson G.D.
      • Rennie D.
      • et al.
      Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.

       Statistical analysis

      Meta-regression analysis was performed for intra-operative as well as overall mortality rates. Both outcomes were used in a regression model plotted against time and weighted by study size. Funnel plots were made to explore potential publication bias for mortality rates. Data were analyzed using SPSS Version 12.0.2 (SPSS Inc., Chicago, Illinois, USA).

      Results

      The search identified 1419 potentially eligible studies of which 1119 were excluded based on title and abstract. From the remaining 300 studies full articles were collected and re-evaluated. One hundred forty-five articles satisfied our inclusion criteria. Study flow and reasons for exclusion are presented in Fig. 1. Twenty-nine articles reported on similar databases, resulting in 116 articles to be included in the systematic review. Agreement on inclusion of these full articles resulted in a good kappa value of 0.78.
      • Landis J.R.
      • Koch G.G.
      The measurement of observer agreement for categorical data.

       Study descriptions

      Characteristics of the included articles are shown in Table 1. These articles represented 60,822 patients undergoing surgery for RAAA over a period of 33 years (mid time point of studies between 1970 and 2003). One hundred fifteen articles reported in-hospital or 30-day mortality rates, one article exclusively reported on intra-operative mortality. A total of 37 articles reported intra-operative mortality rates. The number of patients that died before surgery was reported in 24 articles. Mean age was described in 58 articles and distinction between gender was made in 67 articles. Sixty nine articles allowed for calculation of the number of operated patients per year per hospital. Type of surgeon was specified in 4 articles and 20 articles reported data originating from a national registry. Only 17 studies were prospective, 52 studies were retrospective and 47 articles failed to describe the study design.
      Table 1Study characteristics
      AuthorMidpoint of studyYear of publicationCountry of originMean age (yrs)Women N (%)Patients operated NDiseased before operation NOverall mortality N (%)Peroperative mortality N (%)RAAA per yearRegistryType of surgeonStudy design
      Drott C
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      Age-standardized incidence of ruptured aortic aneurysm in a defined Swedish population between 1952 and 1988: mortality rate and operative results.
      19701992Sweden71nr184nr96(52,2)nrnrYesgen/vasnr
      Chen JC
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      Progress in abdominal aortic aneurysm surgery: four decades of experience at a teaching center.
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      Thevenet A
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      Progress in the surgery of abdominal aortic aneurysm.
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      Ghilardi G
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      Rupture of abdominal aortic aneurysms into the major abdominal veins.
      19781993Italynrnr373nr130(34,9)nrnrNonrnr
      Trotter MC
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      Ruptured abdominal aortic aneurysms: a retrospective look at a ten-year interval.
      19781992USAnrnr45321(46,7)nr11Novascretro
      Poulias GE
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      Abdominal aneurysmectomy and determinants of improved results and late survival. Surgical considerations in 672 operations and 1–15 year follow-up.
      19801994Greecenrnr80nr33(41,3)nrnrNovascnr
      Jaakkola P
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      Infrarenal aortofemoral bypass surgery: risk factors and mortality in 330 patients with abdominal aortic aneurysm or aortoiliac occlusive disease.
      19801996Finland674(8)48nr31(64,6)nr5Nonrnr
      Bonamigo TP
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      • Silva J.H.
      • Siliprandi L.R.
      Ruptured abdominal aortic aneurysm. Analysis of 50 procedures.
      19811991Brasilia703(6)50nr27(54,0)4(8,0)3Nonrnr
      Soisalon-Soininen S
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      Emergency surgery of non-ruptured abdominal aortic aneurysm.
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      Cohen JR
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      Experience in managing 70 patients with ruptured abdominal aortic aneurysms.
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      Cheng SWK
      • Cheng S.W.K.
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      Abdominal aortic aneurysms in Hong Kong.
      19821994Chinanrnr61728(45,9)2(3,3)4Nonrretro
      Albes JM
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      • Laas J.
      Ruptured abdominal aortic aneurysms: risk factors of early mortality.
      19821991Germany6911(8)142265(45,8)nr12Novascretro
      Reitsma JB
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      Prager M
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      Abdominal vascular surgery emergencies: abdominal aortic aneurysm, acute mesenteric ischemia–indications, technique, results.
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      Surgery of aortic aneurysms in patients older than 70: survival expectancy and quality of life.
      19831995Francenrnr45nr18(40,0)nrnrNovascretro
      Stonebridge PA
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      • Jenkins A.M.
      • Ruckley C.V.
      Comparison of long-term survival after successful repair of ruptured and non-ruptured abdominal aortic aneurysm.
      19841993UK7145(20)227nr61(26,9)nr20Novascretro
      McCready RA
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      Ruptured abdominal aortic aneurysms in a private hospital: a decade's experience (1980–1989).
      19841993USA7032(16)2062101(49,0)39(18,9)20Novascretro
      Ruberti U
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      Surgical treatment of abdominal aortic aneurysm. A ten-year experience (1980–1989) referred to 1725 patients operated on.
      19841991Italynrnr314nr113(36,0)nrnrNovascnr
      Johansen K
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      • Kohler T.R.
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      • Kazmers A.
      Ruptured abdominal aortic aneurysm: the Harborview experience.
      19841991USA75nr1806124(68,9)25(13,9)20Novascretro
      Giorgetti PL
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      Abdominal aortic aneurysms surgery in over 75 years old patients. Experience in 142 cases treated between 1980–1989.
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       Meta analysis

       Mortality

      The weighted mean overall mortality was 48.5% (95% CI: 48.1–48.9%). Fig. 2 shows crude overall mortality rates per year from 1991 onwards. For 37 studies reporting intra-operative mortality, the weighted mean was 13.3% (95% CI: 12.3–14.3%).
      Figure thumbnail gr2
      Fig. 2Overall mortality estimates per midpoint of study.

       Metaregression analysis

      For overall mortality metaregression analysis showed a reduction of 1.6% over 33 years which was not significant (p=0.84, Fig. 3). For intra-operative mortality rates the metaregression is shown in Fig. 4. The regression suggested an increase of 1.2% in 29 years, which was not significant over time (p=0.69).
      Figure thumbnail gr3
      Fig. 3Meta regression of 115 studies reporting on % overall mortality (Y axis) against midpoint of the study (X axis) weighted for study size (dot size) with 95% CI.
      Figure thumbnail gr4
      Fig. 4Meta regression of 37 studies reporting on % per-operative mortality (Y axis) against midpoint of the study (X axis) weighted for study size (dot size) with 95% CI.
      Metaregression analysis on the 58 articles reporting on age demonstrated a significant change of age over time (p=0.03, Fig. 5). Metaregression analysis for the subgroup of 58 studies describing the number of RAAA repairs carried out per year (Fig. 6) demonstrated a positive association between hospital volume and overall mortality rates (p=0.04). Although the mortality rates decrease as the hospital volume increases, we have to consider the wide 95% confidence interval. Very few centers performed more than 30 RAAA repairs per year.
      Figure thumbnail gr5
      Fig. 5Meta regression of 58 studies reporting on age of the patients (Y axis) against midpoint of the studies (X axis) with 95% CI.
      Figure thumbnail gr6
      Fig. 6Meta regression of 69 studies reporting on % overall mortality (Y axis) against hospital volume (X axis) with 95% CI.
      There was no significant difference in overall mortality presented in articles retrieving data from national registries and articles retrieving data from hospital records (mean difference 2.1%; 95% CI −6.9 to 2.8%; p=0.4, Wilcoxon test).
      Only 4 articles discerned precisely the subspecialty of the operating surgeon, making any analysis meaningless.
      • Basnyat P.S.
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      • Lewis M.H.
      Mortality from ruptured abdominal aortic aneurysm in Wales.
      • Choksy S.A.
      • Quick C.R.
      • Wilmink A.B.M.
      Ruptured abdominal aortic aneurysm in the Huntingdon district: a 10-year experience.
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      Age-standardized incidence of ruptured aortic aneurysm in a defined Swedish population between 1952 and 1988: mortality rate and operative results.
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      Ruptured abdominal aortic aneurysms: repair should not be denied.
      A considerable difference was observed for studies of different design. The pooled overall mortality for prospective studies was 46.7% (95% CI: 36.7–56.7%) versus 41.1% (95% CI: 32.5–49.7%) for retrospective studies (P=0.03). However the subgroup of prospective studies was relatively small which makes interpretation difficult.

       Assessment of publication bias

      A funnel plot was performed for all 115 studies reporting on overall mortality to detect publication bias (Fig. 7). Asymmetry in a funnel plot often indicates publication bias. Since data were symmetrically spread around the vertical axis (representing mean % overall mortality), no publication bias was apparent. We also performed a funnel plot for 37 studies reporting on intra-operative mortality (Fig. 8). This demonstrated publication bias as the plot was asymmetrical.
      Figure thumbnail gr7
      Fig. 7Funnel plot to assess publication bias for articles reporting on overall mortality. The % overall mortality of each study on X axis against the size of the study on Y axis presented on log scale. Vertical axis presents mean overall mortality.
      Figure thumbnail gr8
      Fig. 8Funnel plot to assess publication bias for articles reporting on per-operative mortality. The % per-operative mortality of each study on X axis against the size of the study on Y axis presented on log scale. Vertical axis presents mean per-operative mortality.

      Discussion

      The aim of this study was to evaluate mortality in patients with RAAA undergoing open surgery and examine changes over time. In articles published over the last 15 years an overall mortality of 49% was reported. No significant change over time could be demonstrated. In contrast, Bown et al.
      • Bown M.J.
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      • Bell P.R.F.
      • Sayers R.D.
      A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair.
      reported a decrease in mortality rate estimates of 55% in 1960 to 41% in 2000. This can be explained by the inclusion of relatively old studies. Their review reports on studies in which the inclusion times ranging from 1954 to1997, comprising 21,523 patients. Our review includes articles published from 1991 onwards, with mid-time points of studies ranging from 1970 to 2003, and comprises a considerably higher number of patients (60,822), resulting in additional statistical power.
      We found an association between increasing age and mid-time point of the studies, which may explain why our findings are different from Bown et al. Aging of the population and a more liberal trend towards surgical interventions in the elderly might eliminate improvements in emergency care, diagnostic facilities, anaesthesiology and intensive care. Intra-operative mortality showed a small increase from 6.3% in 1974 to 7.4% in 2003, which supports this idea.
      Some limitations of our study should be mentioned. First, it is possible that besides the increasing age of the operated patients, complications of postoperative multi-organ failure are responsible for the persistence of high mortality rates in patients with RAAA. Important aspects of postoperative and operative care such as level of intensive care unit, experience of anaesthesiologists and intensivists could not be analysed in this study. Second, the publication bias found for studies reporting on intra-operative mortality limits conclusions from this outcome. Third, despite our efforts we may have missed eligible articles in our electronic or manual search. The literature search resulted in a large number of case series often containing small numbers of patients. We excluded series with fewer than forty patients, and as a result some data may have been lost from the meta-analysis. We included population based studies generated from national databases. In some of these reports clear confirmation of the ruptured nature of the aortic aneurysm is lacking. This may have confounded our analysis by the inadvertent inclusion of symptomatic abdominal aortic aneurysms. Furthermore, due to the absence of randomised controlled trials on this subject, only observational studies were retrieved which results in a number of biases. For example, retrospective studies often fail to describe important factors such as time between diagnoses and treatment, haemodynamic status or patients' medical history. These factors influence mortality rates significantly, but were unavailable for analyses. There was a significant difference in outcomes between prospective and retrospective studies. However, the number of prospective studies was relatively low, which makes interpretation of these results difficult. We tried to reduce the large degree of clinical heterogeneity by defining strict inclusion and exclusion criteria.
      We found a trend in favour of high-volume hospitals in terms of mortality, but it was not possible to establish a cut-off point for the number of RAAA repairs a hospital should perform to reduce mortality rates from these data. A recent meta-analysis
      • Holt P.J.
      • Poloniecki J.D.
      • Gerrard D.
      • Loftus I.M.
      • Thompson M.M.
      Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery.
      investigated the volume-outcome relationship for RAAA repair and showed a significant reduction in mortality rate in high-volume centers. They included 11 original studies of which 5 were published before 1991. Our search was restricted to articles published from 1991 onwards to evaluate recent data on mortality rates and this could explain the lack of a significant association in our meta-analysis. It has been postulated that patients with RAAA treated at trauma centers have decreased mortality compared with non designated hospitals of equal volume size because of the wide range of immediately available resources in trauma centers.
      • Utter G.H.
      • Maier R.V.
      • Rivara F.P.
      • Nathens A.B.
      Outcomes after ruptured abdominal aortic aneurysms: the “halo effect” of trauma center designation.
      Readily available supplies of blood and coagulation products, rapid mobilisation of operating resources and experienced vascular surgeons also might play a role. Availability of a trained vascular surgeon and an intensive care unit staffed appropriately have been linked to better results of AAA repair.
      • Birkmeyer J.D.
      • Stukel T.A.
      • Siewers A.E.
      • Goodney P.P.
      • Wennberg D.E.
      • Lucas F.L.
      Surgeon volume and operative mortality in the United States.
      • Pronovost P.J.
      • Angus D.C.
      • Dorman T.
      • Robinson K.A.
      • Dremsizov T.T.
      • Young T.L.
      Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review.
      • Dueck AD.
      • Kucey DS.
      • Johnston KW.
      • Alter D.
      Survival after ruptured abdominal aortic aneurysm: effect of patient, surgeon, and hospital factors.
      We were unable to examine these in the present study.
      Despite improvements in emergency care, diagnostic facilities, anaesthesiology and intensive care overall mortality of patients undergoing open repair for RAAA has not changed. Increased age of patients selected for operation may explain this finding.

      Acknowledgment

      The authors thank Ingrid Riphagen, VuMC medical library Amsterdam, for her assistance with the search strategy.

       Funding

      This study was supported by the Dutch heart foundation (2002B197).

      Appendix. Search strategy

       Embase

      ‘Abdominal aorta aneurysm’/exp/dm_su,dm_th OR (‘abdominal aorta aneurysm’/exp AND (mortality/de OR ‘surgical mortality’de)) OR ('aorta aneurysm’/de/dm_su,dm_th OR ‘aorta rupture’/de/dm_su,dm_th OR ‘aorta dissecting aneurysm’/de/dm_su,dm_th) AND (abdomen/de OR abdom* OR thoracoabdom*) OR (‘aneurysm rupture’/de/dm_su,dm_th OR ‘dissecting aneurysm’/de/dm_su,dm_th) AND (abdomen/de OR abdom* OR thoracoabdom*) AND (aorta/de OR ‘abdominal aorta’/de OR aorta OR aortic) AND rupture* OR emergen* OR acute OR spontaneous* AND Survival/exp OR Prognosis/de OR Prediction/de OR Forecasting/de OR ‘Treatment outcome’/exp OR Mortality/de OR ‘Surgical mortality’/de OR ‘Clinical trial’/exp OR Comorbidity/de OR Morbidity/de OR ‘Cohort analysis’/de OR ‘Postoperative complication’/exp OR ‘Postoperative period’/de OR Complication/de OR Evaluation/de OR ‘Comparative study’/de OR survival:ti OR mortality:ti OR outcome*:ti OR comorbidity:ti OR morbidity:ti OR fatality or complicat*.
      NOT Review:it OR Note:it OR Letter:it OR Editorial:it OR ‘case control study’/de OR ‘Case report’/de OR ‘Retrospective study’/de OR ‘Practice guideline’/de OR ‘Mass screening’/exp AND/limit English:la OR german:la OR french:la OR spanish:la OR dutch:la AND/limit from1991.

       Pubmed

      (“Aortic Aneurysm, Abdominal/therapy”[MeSH] OR “Aortic Aneurysm, Abdominal/mortality”[MeSH] OR (“Aortic Aneurysm/therapy”[MeSH:noexp] OR “Aortic Aneurysm/mortality”[MeSH:noexp] OR “Aortic Rupture/therapy”[MeSH:noexp] OR “Aortic Rupture/mortality”[MeSH:noexp] OR ((“Aneurysm, ruptured/therapy”[MeSH:noexp] OR “Aneurysm, ruptured/mortality”[MeSH:noexp]) AND (aorta[tw] OR aortic[tw])) AND (“Abdomen”[MeSH] OR abdom*[ti] OR thoracoabdom*[tw]))) AND (rupture*[tw] OR emergen* [tw] OR acute[tw] OR spontaneous*[tw]) AND (“Disease-Free Survival”[MeSH] OR Prognosis[MeSH:NoExp] OR “Medical Futility”[MeSH] OR “Treatment Outcome”[MeSH] OR “Mortality”[MeSH] OR “mortality”[Subheading] OR clinical trial[pt] OR “Comorbidity”[MeSH] OR morbidity[mesh] OR “Survival”[MeSH] OR “Cohort Studies”[MeSH] OR survival[ti] OR mortality[ti] OR outcome*[ti] OR comorbidity[ti] OR morbidity[ti] OR fatality or “Postoperative Complications”[MeSH] OR postoperative period[mesh] OR complicat*[tw] OR complications[sh] OR evaluation studies[pt] OR evaluation studies[mesh] OR comparative study[pt]) NOT (review[pt] OR case-control studies[mh] OR retrospective studies[mh] OR case reports[pt] OR practice guideline [publication type] OR comment [publication type] OR Editorial [Publication Type] OR Letter [Publication Type] OR mass screening [mesh]) AND (English[la] OR german[la] OR french[la] OR spanish[la] OR dutch[la]).

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