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Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm.

IMPROVE trial investigators, ; Powell, JT; Hinchliffe, RJ; Thompson, MM; Sweeting, MJ; Ashleigh, R; Bell, R; Gomes, M; Greenhalgh, RM; Grieve, RJ; et al. IMPROVE trial investigators; Powell, JT; Hinchliffe, RJ; Thompson, MM; Sweeting, MJ; Ashleigh, R; Bell, R; Gomes, M; Greenhalgh, RM; Grieve, RJ; Heatley, F; Thompson, SG; Ulug, P (2014) Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm. British Journal of Surgery, 101 (3). pp. 216-224. ISSN 0007-1323 https://doi.org/10.1002/bjs.9410
SGUL Authors: Hinchliffe, Robert James Thompson, Matthew Merfyn

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Abstract

BACKGROUND: Single-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. METHODS: IMPROVE 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. RESULTS: Some 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). CONCLUSION: These 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.

Item Type: Article
Additional Information: © 2014 The Authors. BJS published by John Wiley & Sons Ltd on behalf of BJS Society Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Keywords: After-Hours Care, Aged, Aged, 80 and over, Aortic Aneurysm, Abdominal, Aortic Rupture, Blood Pressure, Endovascular Procedures, Female, Fluid Therapy, Health Facility Size, Humans, Male, Middle Aged, Patient Transfer, Preoperative Care, Science & Technology, Life Sciences & Biomedicine, Surgery, SURGERY, ENDOVASCULAR REPAIR, METAANALYSIS, MORTALITY, VOLUME, 11 Medical And Health Sciences
SGUL Research Institute / Research Centre: Academic Structure > Molecular and Clinical Sciences Research Institute (MCS) > Vascular & Cardiac Surgery (INCCVC)
Journal or Publication Title: British Journal of Surgery
ISSN: 0007-1323
Language: eng
Dates:
DateEvent
27 January 2014Published
PubMed ID: 24469620
Web of Science ID: WOS:000331175500010
Go to PubMed abstract
URI: http://sgultest.da.ulcc.ac.uk/id/eprint/107245
Publisher's version: https://doi.org/10.1002/bjs.9410

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