RUPTURE OF KNOWN ABDOMINAL AORTIC-ANEURYSMS - AN ETHICAL DILEMMA

Elderly patients with abdominal aortic aneurysms (AAA) may be deemed i noperable due to the presence of comorbid conditions. Presentation of these patients with acute rupture can then result in difficult ethical decisions regarding surgical treatment. Over six years, 80 patients w ere treated emergently for ruptured AAA. Of these patients, 26 (32.5%) had known aneurysms. This study was performed to determine outcome an d factors affecting mortality in patients with known AAAs. There were no significant differences between known and unknown AAA groups with r egard to operative risk. In the overall group (n = 80), patient delay in seeking treatment averaged 20.4 hours with a trend towards shorter times in those with known AAAs (13.8 hours) compared with the unknown group (23.6 hours; p = 0.09). Medical transport delay, however, was si gnificantly shorter for patients with known AAA (124 minutes versus 23 0 minutes; p = 0.04). Overall mortality was 56 per cent (n = 45). Thos e patients with known AAAs had a higher mortality (69%; n = 18) than t hose with unknown AAAs (50%, n = 27) but this was not statistically si gnificant (P = 0.10). In patients with known AAAs, operative death was related to patient delay, with an average delay in seeking medical ad vice of 21.3 hours in nonsurvivors compared with 8.6 hours in survivor s (P = 0.04). No other risk or demographic factors correlated with mor tality. Despite a known AAA, significant delay in seeking medical advi ce occurred, and this delay resulted in decreased survival. Patient ed ucation is imperative if nonoperative treatment is chosen. Although pa tients with rupture of known AAAs had a higher mortality, three of ten left the hospital, justifying an aggressive surgical approach.