Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA.
Ann Vasc Surg. 2022 Aug;84:47-54. doi: 10.1016/j.avsg.2022.03.014. Epub 2022 Mar 23.
Abdominal compartment syndrome (ACoS) is a devastating complication after endovascular aneurysm repair for ruptured abdominal aortic aneurysms (rEVAR). This study sought to develop a risk score for ACoS to identify patients who would benefit from early decompressive laparotomy.
Model derivation was performed with Vascular Quality Initiative data for rEVAR from 2013 to 2020. The primary outcome was evacuation of abdominal hematoma. A multivariable logistic regression was used to create and validate a scoring system to predict ACoS. The model was validated using institutional data for rEVAR from 1998 to 2019.
The derivation cohort included 2,310 patients with rEVAR. Abdominal hematoma evacuation occurred in 265 patients (11.5%). Factors associated with abdominal hematoma evacuation on a multivariable analysis included transfer from an outside hospital, preoperative creatinine ≥1.4 mg/dL, preoperative systolic blood pressure ≤85 mmHg, preoperative altered mental status, ≥3.0 liters intraoperative crystalloid, and ≥4 units of red blood cells transfused intraoperatively. The validation cohort consisted of 67 rEVAR; ACoS occurred in 8 patients (11.9%). The c-statistic was 0.84 in the derivation and 0.87 in the validation cohort, whereas Hosmer-Lemeshow was P = 0.15 in the derivation and 0.84 in the validation cohorts, suggesting good model discrimination and calibration. Points were applied based on β-coefficients to produce a risk score ranging from -1 to 13. A cutoff of risk score ≥8 resulted in a sensitivity and specificity of 87.5% and 83.1% for detecting patients with ACoS, respectively. ACoS conveyed a significantly higher mortality in both the derivation (ACoS: 49.8% vs. No ACoS: 17.8%; P < 0.001) and validation cohorts (ACoS: 75.0% vs. No ACoS: 15.2%; P < 0.001).
In patients with equivocal signs/symptoms of ACoS, this scoring system can be used to guide surgeons on when to perform decompressive laparotomy prior to leaving the operating room for rEVAR. Patients with a risk score ≥8 would benefit from decompressive laparotomy at index rEVAR.
腹部间隔室综合征（ACoS）是腹主动脉瘤破裂血管内修复术（rEVAR）后一种毁灭性的并发症。本研究旨在建立一种 ACoS 风险评分系统，以识别需要早期减压剖腹术的患者。
利用 2013 年至 2020 年血管质量倡议（Vascular Quality Initiative）的数据进行模型推导。主要结局为腹部血肿清除。使用多变量逻辑回归创建和验证预测 ACoS 的评分系统。该模型使用 1998 年至 2019 年 rEVAR 的机构数据进行验证。
推导队列包括 2310 例 rEVAR 患者。265 例（11.5%）患者行腹部血肿清除术。多变量分析中与腹部血肿清除相关的因素包括来自外院的转院、术前血肌酐≥1.4mg/dL、术前收缩压≤85mmHg、术前意识改变、术中晶体液≥3.0L 和术中输血量≥4 个单位的红细胞。验证队列包括 67 例 rEVAR；8 例（11.9%）发生 ACoS。推导队列的 C 统计量为 0.84，验证队列为 0.87，而推导和验证队列的 Hosmer-Lemeshow 分别为 P=0.15 和 0.84，提示模型具有良好的区分度和校准度。根据β系数给分以产生风险评分，范围为-1 至 13。风险评分≥8 的截断值分别对应检测 ACoS 患者的灵敏度和特异性为 87.5%和 83.1%。在推导和验证队列中，ACoS 患者的死亡率显著高于无 ACoS 患者（ACoS：49.8%比无 ACoS：17.8%，P<0.001；ACoS：75.0%比无 ACoS：15.2%，P<0.001）。
对于有可疑 ACoS 体征/症状的患者，该评分系统可用于指导外科医生何时在离开手术室进行 rEVAR 之前进行减压剖腹术。风险评分≥8 的患者将从指数 rEVAR 时的减压剖腹术中获益。
