Annual Academic Conference SLSVS 23 Joel Arudchelvam MBBS, MD ( SUR ), MRCS (ENG), FCSSL Consultant Vascular and Transplant Surgeon Aortic aneurysms Abnormal focal dilatation of a vessel of more than 50 % of its normal diameter Abdominal aorta more than 3 cms (normal diameter - 2 cms) Open AAA repair Endo Vascular Aneurysm Repair (EVAR) Arch de-branching Sri Lankan Experience 15 Vascular and transplant units Emergency AAA repair Open TAA repair Future directions

1. Joel Arudchelvam
MBBS, MD ( SUR ), MRCS (ENG), FCSSL
Consultant Vascular and Transplant Surgeon
Aneurysm repair
(Open / EVAR)
Sri Lankan perspective
Annual Academic Conference
SLSVS 23

2. Aortic aneurysms
▪ Abnormal focal dilatation of a vessel of more
than 50 % of its normal diameter
▪ Abdominal aorta more than 3 cms (normal
diameter - 2 cms)
Arudchelvam, J. (2023). Abdominal aortic dimensions in Sri Lankan patients: a computed tomography
imaging based preliminary study. Sri Lanka Journal of Surgery, 41(1).

3. Aortic aneurysms
▪ Total - 141
▪ Male - 80%
▪ Mean age – 68 years (35–86)
▪ Abdominal – 72.1%
• Gunawansa N, Goonerathne T, Cassim R, Wijeyaratne M. Open repair of infra renal abdominal aortic aneurysms: a single center
experience from the developing world. Ann Vasc Dis. 2011;4(4):313-8.
• NHSL – unpublished data

4. Open AAA repair

5. Aneurysm sac

6. Open AAA repair - inlay graft

7. Closure of sac

8. Endo Vascular Aneurysm Repair
(EVAR)

9. Endo Vascular Aneurysm Repair
(EVAR)

10. Endo Vascular Aneurysm Repair
(EVAR)

11. Endo Vascular Aneurysm Repair
(EVAR)

12. Arch de-branching
Outcome of endovascular aneurysm repair (EVAR) in state sector hospitals. N Gowcikan, Joel Arudchelvam, MWijeyaratne, M
M N AMarasinghe, B M P Bandaranayake, N L Mohotti, N Harivallavan, Rezni Cassim, SYatheeskar. Issue Supplement S1 ISSN
1391-491X, 2022,The Sri Lanka Journal of Surgery,Vol. 40, p. 29

15. Sri Lankan Experience
National Hospital of Sri Lanka, Colombo (NHSL)

16. Sri Lankan Experience
(NHSL) - 2022
Aneurysm repairs
▪ Open
▪ 24 (2 – TAA)
▪ T/ EVAR
▪ 4 (3- TEVAR)

17. Sri Lanka -
V & T units
15 Vascular and transplant
units
▪ 70 -80 AA repairs / year
▪ Only 4 EVARs

18. Open AAA repair
NHSL - 2004 - 2010
▪ 141 referrals
▪ Emergency referral – 33 (23.4%)
▪ Repaired – 51.1%
▪ Elective – 45
▪ Emergency – 27
Gunawansa N, Goonerathne T, Cassim R, Wijeyaratne M. Open repair of infra renal abdominal aortic aneurysms: a single center
experience from the developing world. Ann Vasc Dis. 2011;4(4):313-8.

19. Open AAA repair
Reasons for not intervening (69/141)
▪ Aneurysm diameter < 5.5cm – 32/141 (22.7%)
▪ Refused surgery – 12 (8.5%)
▪ Not fit for surgery – 19 (13.5%)
Gunawansa N, Goonerathne T, Cassim R, Wijeyaratne M. Open repair of infra renal
abdominal aortic aneurysms: a single center experience from the developing world. Ann
Vasc Dis. 2011;4(4):313-8.

20. Open AAA repair
NHSL - 2004 - 2010
▪ Mortality
▪ Elective - 07.6%
▪ Emergency repair - 37.0%
▪ Causes of death
▪ Myocardial ischaemia
▪ Multi organ dysfunction
▪ ICH
Gunawansa N, Goonerathne T, Cassim R, Wijeyaratne M. Open repair of infra renal abdominal aortic aneurysms: a single center
experience from the developing world. Ann Vasc Dis. 2011;4(4):313-8. /;’?

21. Emergency AAA repair (Open)
NHSL
▪ Total - 36
▪ Mean age - 63.7 years (42-73)
▪ Males. - 88.9%
.
Long-term outcome of ruptured Abdominal Aortic Aneurysm:Acase series by single vascular surgical unit. Sanjaya Iddamalgoda, Gurusamy Kapilan, Joel
Arudchelvam : s.n., 2021. 50 Annual Academic Sessions - 2021 of The College Of Surgeons of Sri Lanka. p.64.
* Gurusamy Kapilan, Sanjaya Iddamalgoda, Joel Arudchelvam. Ruptured mycotic abdominal aortic aneurysm presenting with spinal cord ischaemia: A
very rare presentation. Int J Case Rep Surg 2020;2(1):09-11

22. Emergency AAA repair (Open)
Presentation
▪ Abdominal pain and backache - 88.8%
▪ Hypotension / Dizziness -14(38.9% )
▪ Paraplegia * - 1 (02.8%)
.
Long-term outcome of ruptured Abdominal Aortic Aneurysm:Acase series by single vascular surgical unit. Sanjaya Iddamalgoda, Gurusamy Kapilan, Joel
Arudchelvam : s.n., 2021. 50 Annual Academic Sessions - 2021 of The College Of Surgeons of Sri Lanka. p.64.
* Gurusamy Kapilan, Sanjaya Iddamalgoda, Joel Arudchelvam. Ruptured mycotic abdominal aortic aneurysm presenting with spinal cord ischaemia: A
very rare presentation. Int J Case Rep Surg 2020;2(1):09-11

23. Emergency AAA repair (Open)
Intraoperative findings
9 patients (documented)
▪ Retroperitoneal leak - 6 (66.7%)
▪ Aorto-enteric fistula (AEF) - 2 (22.2%)
▪ Intra-peritoneal rupture - 1 (11.1%)
Long-term outcome of ruptured Abdominal Aortic Aneurysm:Acase series by single vascular surgical unit. Sanjaya Iddamalgoda,
Gurusamy Kapilan, Joel Arudchelvam : s.n., 2021. 50 Annual Academic Sessions - 2021 of The College Of Surgeons of Sri Lanka. p.64.
.

24. Emergency AAA repair (Open)
Outcome
▪ 13 (36.1 %) perioperativel deaths.
Causes of mortality
▪ Massive blood loss – 6
▪ Multiorgan failure - 4
▪ Myocardial ischaemia - 2
▪ Pneumonia – 1
Long-term outcome of ruptured Abdominal Aortic Aneurysm:Acase series by single vascular surgical unit. Sanjaya Iddamalgoda,
Gurusamy Kapilan, Joel Arudchelvam : s.n., 2021. 50 Annual Academic Sessions - 2021 of The College Of Surgeons of Sri Lanka. p.64.

25. Open TAA repair
NHSL (2004 – 2023)
▪ 17 Patients
▪ Male : Female – 6 : 1
▪ 64.1 years (21 - 77)
NHSL – Unpublished data

26. Open TAA repair
NHSL (2004 – 2023)
Mode of repair
▪ Elective – 14
▪ Emergency – 3
Outcome
▪ 5 deaths - 29.4%
▪ Elective - 3/14 (21.4%)
▪ Emergency - 2/3 (66.7%)
NHSL – Unpublished data

27. Endo Vascular Aneurysm Repair
(T/EVAR)
NHSL + Private sector (2012 – 2022)
▪ Total - 26 patients
▪ EVAR - 21
▪ TEVAR - 05
▪ Mean age - 57.8 years (38 - 71)
▪ Arch de-branching prior to EVAR – 02
R. Cassim, et.al. unpublished data.

28. Arch de-branching
Outcome of endovascular aneurysm repair (EVAR) in state sector hospitals. N Gowcikan, Joel Arudchelvam, MWijeyaratne, M
M N AMarasinghe, B M P Bandaranayake, N L Mohotti, N Harivallavan, Rezni Cassim, SYatheeskar. Issue Supplement S1 ISSN
1391-491X, 2022,The Sri Lanka Journal of Surgery,Vol. 40, p. 29

29. Endo Vascular Aneurysm Repair
(T/EVAR)
▪ Mean follow-up - 20.2 months
▪ Outcome
▪ Type 1 endoleak - 3 (11.5%)
▪ Graft infection - 1
▪ AEF - 1
▪ Deaths - 4 (15.4%)
▪ ( TEVAR vs Open – 0.0 % % vs 21.4%)
Outcome of endovascular aneurysm repair (EVAR) in state sector hospitals. N Gowcikan, Joel Arudchelvam, M Wijeyaratne, M M N
AMarasinghe, B M P Bandaranayake, N L Mohotti, N Harivallavan, Rezni Cassim, S Yatheeskar. Issue Supplement S1 ISSN 1391-491X,
2022, The Sri Lanka Journal of Surgery, Vol. 40, p. 29
R. Cassim, et.al. unpublished data

30. Future directions
▪ National database
▪ Establishment of EVAR
▪ Size definitions - 19.3 mm vs 16.4 mm (P< 0.05)

31. Thank You