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Perioperative Mortality of Elective Abdominal Aortic Aneurysm Surgery: A Clinical Prediction Rule Based on Literature and Individual Patient Data

Perioperative Mortality of Elective Abdominal Aortic Aneurysm Surgery: A Clinical Prediction Rule... Abstract Background: Abdominal aortic aneurysm surgery is a major vascular procedure with a considerable risk of (mainly cardiac) mortality. Objective: To estimate elective perioperative mortality, we developed a clinical prediction rule based on several well-established risk factors: age, gender, a history of myocardial infarction, congestive heart failure, ischemia on the electrocardiogram, pulmonary impairment, and renal impairment. Methods: Two sources of data were used: (1) individual patient data from 246 patients operated on at the University Hospital Leiden (the Netherlands) and (2) studies published in the literature between 1980 and 1994. The Leiden data were analyzed with univariate and multivariate logistic regression. Literature data were pooled with meta-analysis techniques. The clinical prediction rule was based on the pooled odds ratios from the literature, which were adapted by the regression results of the Leiden data. Results: The strongest adverse risk factors in the literature were congestive heart failure and cardiac ischemia on the electrocardiogram, followed by renal impairment, history of myocardial infarction, pulmonary impairment, and female gender. The literature data further showed that a 10-year increase in age more than doubled surgical risk. In the Leiden data, most multivariate effects were smaller than the univariate effects, which is explained by the positive correlation between the risk factors. In the clinical prediction rule, cardiac, renal, and pulmonary comorbidity are the most important risk factors, while age per se has a moderate effect on mortality. Conclusions: A readily applicable clinical prediction rule can be based on the combination of literature data and individual patient data. The risk estimates may be useful for clinical decision making in individual patients.(Arch Intern Med. 1995;155:1998-2004) References 1. Fielding JWL, Black J, Ashton F, Slaney G, Campbell DJ. Diagnosis and management of 528 abdominal aortic aneurysms. BMJ . 1981;283:355-359.Crossref 2. Crawford ES. Ruptured abdominal aortic aneurysm: an editorial. J Vasc Surg . 1991;13:348-350.Crossref 3. Katz DA, Littenberg B, Cronenwett JL. Management of small abdominal aneurysms: early surgery vs watchful waiting. JAMA . 1992;268:2678-2686.Crossref 4. Michaels JA. The management of small abdominal aortic aneurysms: a computer simulation using Monte Carlo methods. Eur J Vasc Surg . 1992;6:551-557.Crossref 5. Geroulakos G, Nicolaides A. Infrarenal abdominal aortic aneurysms less than five centimeters in diameter: the surgeon's dilemma. Eur J Vasc Surg . 1992; 6:616-622.Crossref 6. Morris DM, Colquitt J. Concomitant abdominal aortic aneurysm and malignant disease: a difficult management problem. J Surg Oncol . 1988;39:122-125.Crossref 7. Lierz MF, Davis BE, Noble MJ, Wattenhofer SP, Thomas JH. Management of abdominal aortic aneurysm and invasive transitional cell carcinoma of bladder. J Urol . 1993;149:476-479. 8. Lundell L. Norbäck B. Abdominal aortic aneurysm: results of treatment in nonspecialized units. Acta Chir Scand . 1983;149:695-702. 9. Noppeney T, Raithel D. Age as a high-risk factor in the treatment of abdominal aortic aneurysm. Vasc Surg . 1990;24:271-276.Crossref 10. Morishita Y, Toyohira H, Yuda T, et al. Surgical treatment of abdominal aortic aneurysm in the high-risk patient. Jpn J Surg . 1991;21:595-599.Crossref 11. Diehl JT, Cali RF, Hertzer NR, Beven EG. Complications of abdominal aortic reconstruction: an analysis of perioperative risk factors in 557 patients. Ann Surg . 1983;197:49-56. 12. McCabe CJ, Coleman WS, Brewster DC. The advantage of early operation for abdominal aortic aneurysm. Arch Surg . 1981;116:1025-1029.Crossref 13. D'Angelo F, Vaghi M, Zorzoli C, Gatti S, Tacconi A. Is age an important risk factor for the outcome of elective abdominal aneurysm surgery? J Cardiovasc Surg . 1993;34:153-155. 14. Paty PSK, Lloyd WE, Chang BB, et al. Aortic replacement for abdominal aortic aneurysm in elderly patients. Am J Surg . 1993;166:191-193.Crossref 15. Akkersdijk GJM, Van der Graaf Y, van Bockel JH, De Vries AC, Eikelboom BC. Mortality rates associated with operative treatment of infrarenal abdominal aortic aneurysm in the Netherlands. Br J Surg . 1994;81:706-709.Crossref 16. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm, part II: variables predicting morbidity and mortality. J Vasc Surg . 1989;9:437-447.Crossref 17. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med . 1977;297:845-850.Crossref 18. Detsky AS, Abrams HB, Forbath N, et al. Cardiac assessment for patients undergoing noncardiac surgery: a multifactorial clinical risk index. Arch Intern Med . 1986;146:2131-2134.Crossref 19. Spiegelhalter DJ. Probabilistic prediction in patient management and clinical trials. Stat Med . 1986;5:421-433.Crossref 20. Harrell FE, Lee KL, Califf RM, Pryor DB, Rosatie RA. Regression modelling strategies for improved prognostic prediction. Stat Med . 1984;3:143-152.Crossref 21. de Mol Van Otterloo JCA. Risk Analysis of Aortic Reconstruction. Pasman, Yugoslavia: Den Haag; 1995. Thesis. 22. Hosmer DW, Lemeshow S. Applied Logistic Regression . New York, NY: John Wiley & Sons Inc; 1989. 23. Hilden J, Habbema JDF, Bjerregaard B. The measurement of performance in probabilistic diagnosis, II: trustworthiness of the exact values of the diagnostic probabilities. Methods Inform Med . 1978;17:227-237. 24. Brown MB, chief ed. Los Angeles, Calif: BMDP Statistical Software Inc; 1990. 25. Cox DR. The Analysis of Binary Data . London, England: Methuen; 1970. 26. StatXact Statistical Software for Exact Nonparametric Inference . Cambridge, Mass: CYTEL Software Corp; 1991. 27. Zelen M. The analysis of several 2×2 contingency tables. Biometrika . 1971; 58:129-137. 28. Simel DL, Samsa GP, Matchar DB. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol . 1991;44:763-770.Crossref 29. Greenland S. Quantitative methods in the review of epidemiologic literature. Epidemiol Rev . 1987;9:1-30. 30. Hannan EL, Kilburn H, O'Donnell et al. A longitudinal analysis of the relationship between in-hospital mortality in New York State and the volume of abdominal aortic aneurysm surgeries performed. Health Serv Res . 1992;27:517-542. 31. Katz DJ, Stanley JC, Zelenock GB. Operative mortality rates for intact and ruptured abdominal aortic aneurysms in Michigan: an eleven-year statewide experience. J Vasc Surg . 1994;19:804-817.Crossref 32. Chang FC, Smith JL, Rahbar A, Farha GJ. Abdominal aneurysms: a comparative analysis of surgical treatment of symptomatic and asymptomatic patients. Am J Surg . 1978;136:705-708.Crossref 33. AbuRahma AF, Robinson PA, Boland JP, et al. Elective resection of 332 abdominal aortic aneurysms in a southern West Virginia community during a recent five-year period. Surgery . 1991;109:244-251. 34. Bosman CHR. Report on 20 Years of Experience With Atherosclerotic Aneurysms of the Abdominal Aorta. Leiden, the Netherlands: Jongbloed en zoon; 1983. Thesis. 35. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm, I: population and operative management. J Vasc Surg . 1988;7:69-81.Crossref 36. Crawford ES, Saleh SA, Babb JW, Glaeser DH, Vaccaro PS, Silvers A. Infrarenal abdominal aortic aneurysms: factors influencing survival after operations performed over a 25 year period. Ann Surg . 1981;193:699-709.Crossref 37. Guy AJ, Lambert D, Jones NAG, Chamberlain J. After the confidential enquiry into perioperative deaths—aortic aneurysm surgery in the northern region. Br J Surg . 1990;77:A344-A345. Abstract. 38. Campbell WB. Mortality statistics for elective aortic aneurysms. Eur J Vasc Surg . 1991;5:111-113.Crossref 39. Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in peripheral vascular patients: a classification of 1000 coronary angiograms and results of surgical management. Ann Surg . 1984;199:223-233.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Perioperative Mortality of Elective Abdominal Aortic Aneurysm Surgery: A Clinical Prediction Rule Based on Literature and Individual Patient Data

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References (37)

Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430180108012
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Abstract

Abstract Background: Abdominal aortic aneurysm surgery is a major vascular procedure with a considerable risk of (mainly cardiac) mortality. Objective: To estimate elective perioperative mortality, we developed a clinical prediction rule based on several well-established risk factors: age, gender, a history of myocardial infarction, congestive heart failure, ischemia on the electrocardiogram, pulmonary impairment, and renal impairment. Methods: Two sources of data were used: (1) individual patient data from 246 patients operated on at the University Hospital Leiden (the Netherlands) and (2) studies published in the literature between 1980 and 1994. The Leiden data were analyzed with univariate and multivariate logistic regression. Literature data were pooled with meta-analysis techniques. The clinical prediction rule was based on the pooled odds ratios from the literature, which were adapted by the regression results of the Leiden data. Results: The strongest adverse risk factors in the literature were congestive heart failure and cardiac ischemia on the electrocardiogram, followed by renal impairment, history of myocardial infarction, pulmonary impairment, and female gender. The literature data further showed that a 10-year increase in age more than doubled surgical risk. In the Leiden data, most multivariate effects were smaller than the univariate effects, which is explained by the positive correlation between the risk factors. In the clinical prediction rule, cardiac, renal, and pulmonary comorbidity are the most important risk factors, while age per se has a moderate effect on mortality. Conclusions: A readily applicable clinical prediction rule can be based on the combination of literature data and individual patient data. The risk estimates may be useful for clinical decision making in individual patients.(Arch Intern Med. 1995;155:1998-2004) References 1. Fielding JWL, Black J, Ashton F, Slaney G, Campbell DJ. Diagnosis and management of 528 abdominal aortic aneurysms. BMJ . 1981;283:355-359.Crossref 2. Crawford ES. Ruptured abdominal aortic aneurysm: an editorial. J Vasc Surg . 1991;13:348-350.Crossref 3. Katz DA, Littenberg B, Cronenwett JL. Management of small abdominal aneurysms: early surgery vs watchful waiting. JAMA . 1992;268:2678-2686.Crossref 4. Michaels JA. The management of small abdominal aortic aneurysms: a computer simulation using Monte Carlo methods. Eur J Vasc Surg . 1992;6:551-557.Crossref 5. Geroulakos G, Nicolaides A. Infrarenal abdominal aortic aneurysms less than five centimeters in diameter: the surgeon's dilemma. Eur J Vasc Surg . 1992; 6:616-622.Crossref 6. Morris DM, Colquitt J. Concomitant abdominal aortic aneurysm and malignant disease: a difficult management problem. J Surg Oncol . 1988;39:122-125.Crossref 7. Lierz MF, Davis BE, Noble MJ, Wattenhofer SP, Thomas JH. Management of abdominal aortic aneurysm and invasive transitional cell carcinoma of bladder. J Urol . 1993;149:476-479. 8. Lundell L. Norbäck B. Abdominal aortic aneurysm: results of treatment in nonspecialized units. Acta Chir Scand . 1983;149:695-702. 9. Noppeney T, Raithel D. Age as a high-risk factor in the treatment of abdominal aortic aneurysm. Vasc Surg . 1990;24:271-276.Crossref 10. Morishita Y, Toyohira H, Yuda T, et al. Surgical treatment of abdominal aortic aneurysm in the high-risk patient. Jpn J Surg . 1991;21:595-599.Crossref 11. Diehl JT, Cali RF, Hertzer NR, Beven EG. Complications of abdominal aortic reconstruction: an analysis of perioperative risk factors in 557 patients. Ann Surg . 1983;197:49-56. 12. McCabe CJ, Coleman WS, Brewster DC. The advantage of early operation for abdominal aortic aneurysm. Arch Surg . 1981;116:1025-1029.Crossref 13. D'Angelo F, Vaghi M, Zorzoli C, Gatti S, Tacconi A. Is age an important risk factor for the outcome of elective abdominal aneurysm surgery? J Cardiovasc Surg . 1993;34:153-155. 14. Paty PSK, Lloyd WE, Chang BB, et al. Aortic replacement for abdominal aortic aneurysm in elderly patients. Am J Surg . 1993;166:191-193.Crossref 15. Akkersdijk GJM, Van der Graaf Y, van Bockel JH, De Vries AC, Eikelboom BC. Mortality rates associated with operative treatment of infrarenal abdominal aortic aneurysm in the Netherlands. Br J Surg . 1994;81:706-709.Crossref 16. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm, part II: variables predicting morbidity and mortality. J Vasc Surg . 1989;9:437-447.Crossref 17. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med . 1977;297:845-850.Crossref 18. Detsky AS, Abrams HB, Forbath N, et al. Cardiac assessment for patients undergoing noncardiac surgery: a multifactorial clinical risk index. Arch Intern Med . 1986;146:2131-2134.Crossref 19. Spiegelhalter DJ. Probabilistic prediction in patient management and clinical trials. Stat Med . 1986;5:421-433.Crossref 20. Harrell FE, Lee KL, Califf RM, Pryor DB, Rosatie RA. Regression modelling strategies for improved prognostic prediction. Stat Med . 1984;3:143-152.Crossref 21. de Mol Van Otterloo JCA. Risk Analysis of Aortic Reconstruction. Pasman, Yugoslavia: Den Haag; 1995. Thesis. 22. Hosmer DW, Lemeshow S. Applied Logistic Regression . New York, NY: John Wiley & Sons Inc; 1989. 23. Hilden J, Habbema JDF, Bjerregaard B. The measurement of performance in probabilistic diagnosis, II: trustworthiness of the exact values of the diagnostic probabilities. Methods Inform Med . 1978;17:227-237. 24. Brown MB, chief ed. Los Angeles, Calif: BMDP Statistical Software Inc; 1990. 25. Cox DR. The Analysis of Binary Data . London, England: Methuen; 1970. 26. StatXact Statistical Software for Exact Nonparametric Inference . Cambridge, Mass: CYTEL Software Corp; 1991. 27. Zelen M. The analysis of several 2×2 contingency tables. Biometrika . 1971; 58:129-137. 28. Simel DL, Samsa GP, Matchar DB. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol . 1991;44:763-770.Crossref 29. Greenland S. Quantitative methods in the review of epidemiologic literature. Epidemiol Rev . 1987;9:1-30. 30. Hannan EL, Kilburn H, O'Donnell et al. A longitudinal analysis of the relationship between in-hospital mortality in New York State and the volume of abdominal aortic aneurysm surgeries performed. Health Serv Res . 1992;27:517-542. 31. Katz DJ, Stanley JC, Zelenock GB. Operative mortality rates for intact and ruptured abdominal aortic aneurysms in Michigan: an eleven-year statewide experience. J Vasc Surg . 1994;19:804-817.Crossref 32. Chang FC, Smith JL, Rahbar A, Farha GJ. Abdominal aneurysms: a comparative analysis of surgical treatment of symptomatic and asymptomatic patients. Am J Surg . 1978;136:705-708.Crossref 33. AbuRahma AF, Robinson PA, Boland JP, et al. Elective resection of 332 abdominal aortic aneurysms in a southern West Virginia community during a recent five-year period. Surgery . 1991;109:244-251. 34. Bosman CHR. Report on 20 Years of Experience With Atherosclerotic Aneurysms of the Abdominal Aorta. Leiden, the Netherlands: Jongbloed en zoon; 1983. Thesis. 35. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm, I: population and operative management. J Vasc Surg . 1988;7:69-81.Crossref 36. Crawford ES, Saleh SA, Babb JW, Glaeser DH, Vaccaro PS, Silvers A. Infrarenal abdominal aortic aneurysms: factors influencing survival after operations performed over a 25 year period. Ann Surg . 1981;193:699-709.Crossref 37. Guy AJ, Lambert D, Jones NAG, Chamberlain J. After the confidential enquiry into perioperative deaths—aortic aneurysm surgery in the northern region. Br J Surg . 1990;77:A344-A345. Abstract. 38. Campbell WB. Mortality statistics for elective aortic aneurysms. Eur J Vasc Surg . 1991;5:111-113.Crossref 39. Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in peripheral vascular patients: a classification of 1000 coronary angiograms and results of surgical management. Ann Surg . 1984;199:223-233.Crossref

Journal

Archives of Internal Medicine – American Medical Association

Published: Oct 9, 1995

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