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Evar in ruptured aaa + fast track 9.7.61
This document discusses endovascular repair (EVAR) and open surgical repair for ruptured abdominal aortic aneurysms (rAAA). It provides definitions of terminology used and outlines the clinical features, initial management strategies, and operative strategies for rAAA repair. Specifically, it summarizes evidence from studies comparing outcomes of EVAR versus open repair for rAAA, finding that EVAR is associated with lower short-term mortality and fewer complications but long-term outcomes are less certain. It also describes the concept of a "fast-track" approach to rAAA focusing on rapid diagnosis, preparation, and treatment to minimize time to exclusion of the rupture site. Key aspects of this approach include multidisciplinary team coordination, equipment preparation, and
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Evar in ruptured aaa + fast track 9.7.61
- 1. EVAR IN RUPTUREDAAA + FAST-TRACK IN RAAA F2 PARACH SIRISRIRO 9th July 2018
- 2. REFERENCE Rutherford's Vascular Surgeryand Endovascular Therapy, Chapter 74, 3183-3221.e Textbook Journal • Tan, T.-W., et al. (2017). "Outcomes of endovascular and open surgical repair of ruptured abdominal aortic aneurysms in elderly patients." Journal of vascular surgery 66(1): 64-70. • IMPROVE Trial Investigators. Endovascular strategy or open repair for ruptured abdominal aortic aneurysm: oneyear outcomes from the IMPROVE randomized trial. Eur Heart J. 2015;36(31):2061–2069.
- 3. • Reimerink JJ,et al. Systematic review and meta-analysis of population-based mortality from ruptured abdominal aortic aneurysm. Br J Surg. 2013;100(11):1405–1413. • Sarac TP, et al. Comparative predictors of mortality for endovascular and open repair of ruptured infrarenal abdominal aortic aneurysms. Ann Vasc Surg. 2011;25:461–468 • Hoornweg, L., et al. (2007). "The Amsterdam Acute Aneurysm Trial: suitability and application rate for endovascular repair of ruptured abdominal aortic aneurysms." European Journal of Vascular and Endovascular Surgery 33(6): 679-683. REFERENCE
- 4. OUTLINE Terminology Clinical Features Initial ManagementStrategies Fast-track in rAAA Operative Strategies: Endovascular Repair Complications of Ruptured Abdominal Aortic Aneurysm Repair Ramathibodi Fast-track in rAAA
- 5. DEFINITION • RAAA :an abdominal aortic aneurysm (AAA) with extraluminal blood on computed tomography (CT) or noted clinically at the time of surgery • A contained rupture : blood outside the aneurysm sac confined to the retroperitoneal space. • A free rupture : bleeding directly into the peritoneal cavity. Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 6. RUPTURED AAA • 50%die before reaching hospital • 30% who reached hospital die before operation • Mortality rates remain high and unchanged (50%)1 • Mortality from rAAA remains high despite improvements in anesthesia, postoperative intensive care, and surgical techniques2 1 (Cochrane review 2007) 2 (Slater et al. Ann Vasc Surg 2008)
- 7. • The classicpresentation of RAAA includes • The classic triad was present in 34% of the correctly diagnosed group CLINICAL FEATURES - Acute-onset abdominal/back pain - Hypotension, - A pulsatile abdominal mass. (76%) Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 8. DIAGNOSIS EVALUATION • Plain Radiographs: - Enlargement of a calcified aortic wall was seen in 65% - Loss of a psoas shadow from retroperitoneal hemorrhage was identified in 75% Ding-Kuo Chien et al. Circulation. 2010;122:1880-1881
- 9. DIAGNOSIS EVALUATION • Ultrasound :FAST (focused assessment with sonography in trauma) - rapidly identify fluid collections - quickly assess patients for the presence of AAA - It is not sufficiently accurate to exclude rupture Ding-Kuo Chien et al. Circulation. 2010;122:1880-1881
- 10. DIAGNOSIS EVALUATION • CT :“gold standard” it is 77% sensitive and 100% specific - A non–contrastenhanced : identify retroperitoneal haemorrhage and important anatomic information - A contrast enhancement : ideal to plan either open surgical repair (OSR) or EVAR Ding-Kuo Chien et al. Circulation. 2010;122:1880-1881
- 11. INITIAL MANAGEMENT STRATEGIES J Vasc Surg.2010 Jul; 44(1):1-8
- 12. PERIOPERATIVE MANAGEMENT • Airwaymanagement (supplemental oxygen or endotracheal intubation) • Intravenous access (central venous catheter) • Arterial catheter • Notify anesthetic, ICU, and operating teams • Urinary catheter • Blood product (packed red cells, platelets, and fresh frozen plasma) availability and transfusion for resuscitation, severe anemia, and coagulopathy. Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 13. PERMISSIVE HYPOTENSION • Aggressivefluid replacement may cause • Dilutional and hypothermic coagulopathy • Secondary clot disruption from increased blood flow • Increased perfusion pressure • Decreased blood viscosity thereby exacerbating bleeding. Roberts K, Eur J Vasc Endovasc Surg. 2006;31:339-344 Crawford ES. J Vasc Surg. 1991;13:348-350. Hardman DT. J Vasc Surg. 1996;23:123-129. Ohki T. Ann Surg. 2000;232:466-479.
- 14. PERMISSIVE HYPOTENSION • Fluidresuscitation should be sufficient to Maintain consciousness, Minimize organ ischemia Prevent ST depression Maintain a systolic pressures of 70 to 80 mm Hg • The IMPROVE trial demonstrated that those with the lowest BP had the highest mortality and increasing SBP to greater than 70 mm Hg was beneficial Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 15. PERIOPERATIVE MANAGEMENT Imaging • Dependon hemodynamic stability • Stable • High quality CTA abdominal aorta • Aneurysm morphology • Suitability for EVAR : assess neck diameter, angulation, and iliac size is of critical importance. • Unstable • Bedside duplex US • Intraoperative angiogram and intravascular US Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 16. MANAGEMENT • Feasible anatomyfor rEVAR • Neck diameter < 32 mm • Neck length > 10 mm • Neck angulation < 60° (up to < 75° + neck > 15 mm) • Neck shape: non reverse funnel • Neck calcification or thrombus < 40% • Iliac diameter 6 – 20 mm • Distal sealing > 10 mm • No circumferential calcification or thrombus at landing zone • Preserve at least one internal iliac a. Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 17. EVAR OR OPENIN RAAA ?
- 18. Multicentre (29 UKand 1 Canada) trial randomized 613 patients with a clinical diagnosis of ruptured aneurysm; 316 to an endovascular first strategy (if aortic morphology is suitable, open repair if not) and 297 to open repair. Eur Heart J. 2015;36(31):2061–
- 19. EVAR VS OPEN INRAAA Eur Heart J. 2015;36(31):2061–2069.
- 20. Eur Heart J.2015;36(31):2061–2069
- 21. • After 1year, 130 (41.1%) of patients in the endovascular strategy group had died vs. 133 (45.1%) in the open repair group P-value 0.325 Almost half the deaths, in each group, occurred within 24 h and the majority occurred within 30 days • At 1 year, AAA-related mortality (including all deaths within 30 days) in the endovascular strategy and open repair groups, respectively, was 33.9% and 39.3%, P-value 0.161 EVAR VS OPEN IN RAAA
- 22. EVAR VS OPEN INRAAA Eur Heart J. 2015;36(31):2061–2069.
- 23. • Tan, T.-W.,et al. (2017). "Outcomes of endovascular and open surgical repair of ruptured abdominal aortic aneurysms in elderly patients." Journal of vascular surgery 66(1): 64-70. EVAR VS OPEN IN RAAA From 2005-2014 Among 1048 elderly patients who underwent rAAA repair, 450 (43%) and 598 (57%) were treated with EVAR and OAR
- 24. EVAR VS OPEN INRAAA • Tan, T.-W., et al. (2017). "Outcomes of endovascular and open surgical repair of ruptured abdominal aortic aneurysms in elderly patients." Journal of vascular surgery 66(1): 64-70. Use of endovascular repair in the elderly population has increased and is associated with better
- 25. MANAGEMENT • Decision making: Open repair versus endovascular repair • EVAR first if feasible • Aneurysm morphology allow • Available team and equipment • Benefits of EVAR for RAAA • Decrease the early mortality • Fewer complications • bleeding, renal, respiratory, sexual dysfunction • Shorter ICU and hospital stays Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 26. MANAGEMENT • Open repairversus endovascular repair • Disadvantage of EVAR • Take time (graft design) • Uncontrolled type II endoleak • Uncertain long term complication Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 27. EVAR IN RAAA Understandingthe Limitations of EVAR for Rupture • Availability of preoperative computed tomography (CT) in all patients with ruptured AAA. • Availability of dedicated operating room staff equipped to perform emergent EVAR at all times. • Availability of “off-the-shelf” stent grafts. • Inadequate experience in managing unexpected endovascular issues during emergent repair. Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 28. EVAR • Increasing proportionfor RAAA treatment • Prepare for both open and EVAR • Prophylactic antibiotic • Aortic balloon placement can be used • Bilateral groin access Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 29.
- 30. MULTIDISCIPLINARY APPROACH • Emergency roomphysicians • Anesthesiologists • Operating room (OR) nurses, • Technologists • Vascular surgeons. • Blood bank Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 31. Operating room preparation Rutherford'sVascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 32. EQUIPMENT PREPARATION Endograf t Hydrophilic guide wireSheaths Occlusion balloon Diagnostic catheter Stiff wire Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 33. CHOICE OF ANESTHESIAAND APPROACH • Prefer : - local anesthesia with conscious sedation -maintenance of “sympathetic tone” in the hemodynamically compromised • Must be balanced by the potential difficulties with the incoherent and uncooperative patients. • In hemodynamically unstable patients, starting the procedure under local anesthesia, then conversion to general anesthesia after RAAA exclusion, can be required for sheath removal and femoral repair. • Local anesthesia for EVAR in the IMPROVE trial greatly reduced the 30-day mortality compared with general anesthesia Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 34.
- 35. • Placement underlocal anesthetic before induction of general anesthesia ● Minimal disruption to the visceral arteries if inflated at the infrarenal level, ● Rapid improvement in cerebral and coronary artery circulation after inflation ● Reduction in massive hemorrhage when open rAAA repair or EVAR is performed. AORTIC BALLOON Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 36. TREATMENT OF RUPTUREDAOR BF VS AUI ANATOMICAL AND TECHNICAL REQUIREMENTS • Bifurcated stent graft • 1. Two healthy iliac access 2. More measurements 3. Contralateral cannulation 4. Bigger stock 5. Local anesthesia • Aorto-uniliac stent graft 1. One healthy iliac access 2. Less measurements 3. Fem-Fem bypass 4. Smaller Stock 5. General anesthesia Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 37. • Bifurcated stentgraft versus aorto-uniliac stent graft • AUI • Suitable in unstable patient, exclude point of bleeding immediately • Suitable in abnormal contralateral EIA anatomy • Suitable in distal Ao < 15 mm • Less experience • Preserved at least one internal iliac a. EVAR Hoornweg, L., et al. (2007). "The Amsterdam Acute Aneurysm Trial: suitability and application rate for endovascular repair of ruptured abdominal aortic aneurysms." European Journal of Vascular and Endovascular Surgery 33(6): 679-683.
- 38. aorto-uniliac stent graftBifurcatedstent graft
- 39. • Remove deviceand groin wound closure • Post operative monitoring • IAP monitoring, gut function, groin wound • Post EVAR surveillance • Life long follow up • Lower extremity pulse exam or ABI • CTA at 1 and 12 month • CTA yearly Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 40.
- 41. LOCAL COMPLICATIONS :ISCHEMIC COLITIS • Incidence of 38% after OSR and 23% after EVAR • Mortality rate of 55% • Risk factors include - Duration of hypotension - patency of the colonic blood supply and collateral supply • Presentation : Abdominal pain (78%) , lower digestive bleeding (62%) , diarrhea(38%) and Fever higher than 38°C (34%) • If colonic ischemia is suspected: sigmoidoscopy or colonoscopy to visualize the area is diagnostic Huguier, M., et al. (2006). "Ischemic colitis." Am J Surg 192(5): 679-
- 42. LOCAL COMPLICATIONS :ABDOMINALCOMPARTMENT SYNDROME • ACS defined as : Acute and rapid elevation in intraabdominal pressure > 20 mm Hg Cardiovascular, pulmonary, renal, and splanchnic organ dysfunction. • After EVAR of RAAA increases mortality associated with use of an aortic occlusion balloon massive blood transfusions, coagulopathy hemodynamic instability. • A meta-analysis of ACS in RAAA demonstrated an incidence of 21% after EVAR Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 43. Treatment LOCAL COMPLICATIONS :ABDOMINALCOMPARTMENT SYNDROME J Vasc Surg. 2014;59(3):829–842
- 44. • Paraplegia andparaparesis are rare complications after RAAA repair with a risk 0.5% to 11.5% for EVAR. • Factors associated with spinal cord ischemic complications interruption of the pelvic blood supply prolonged aortic balloon occludtion preoperative and intraoperative hypotension embolization Early recognition with CSF drainage and pelvic revascularization are the main therapies LOCAL COMPLICATIONS :SPINAL ISCHEMIA Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 45. SYSTEMIC COMPLICATIONS :CARDIAC COMPLICATIOM • Myocardial infarction develops secondary to the increased demand placed on the heart • Cardiac arrest occurs in up to 20% of patients, with a mortality of 81% to 100%. • Myocardial infarction develops in 15% to 20% of patients, with a mortality rate of 17% to 66%; • Arrhythmias and congestive heart failure develop in nearly 20% of patients, with a mortality approaching 40%. • EVAR for RAAA has not been demonstrated to reduce the number of cardiac complications. Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 46. • Respiratory failure,pneumonia, and pulmonary complications develop in 36% to 41% of patients after OSR of RAAA • Respiratory complications are significantly lower after EVAR compared with OSR (28.5% vs. 35.9%, 4.6% vs. 9.9%, respectively; P < .001 for both) • Lung dysfunction is significantly reduced by EVAR. SYSTEMIC COMPLICATIONS : RESPIRATORY COMPLICATIOM Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 47. • RAAA patientshave an incidence of 26% to 45% • RAAA patients who require dialysis (incidence 11%-40%), the mortality rate is between 76% and 89%. • Renal dysfunction has been found to be increased in those with - suprarenal cross-clamping, - longer duration of cross-clamping - preexisting renal insufficiency, - shock - increased age • Significantly less acute renal failure (ARF) for EVAR(12.1%) compared with 19.6% in OSR. SYSTEMIC COMPLICATIONS : RENAL COMPLICATIOM Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
- 48. IN RAMATHIBODI HOSPITAL •FAST TRACK rAAA referral center tel 02-201-2985 (24.00-7.00) Or Incharge ER Tel 022011182 Notify Chief fellow vascular (0917745683 or 48833) or 2nd yrs Resident Identified : Patient information , Comorbidity , vital sign , patient status and consciousness Blood group Health insurance Ask for telephone number of Referal nurse and physician Anesthesiologists Operating room (OR) nurses Blood bank (1219/1229) And preparing instrument - Chief Fellow : Co-ordinated between transfer physician and transfer team OR team and patient’s relatives Inform consent - OR nurse : ready for operation - 1 st yrs Fellow and Chief resident : transfer patient from ambulance to OR - Others resident : Complete ward post-op Prepare ATB Blood bank coordination Activate team Patient Arrived 1 2 3 4 Record time line Patient arrival Admission time Patient in OR time Incision time Blood component at OR time Finish operation time
- 49. REAL EVENT Diagnosis :rupture AAA from Bangpli hospital 23.40 23.45 Contact Ramathibodi referral center 0.00 2nd yrs Fellow coordinated with Bangpli’s physician Review CT from line contact ask for information of patient comorbidity , vital sign , patient status and consciousness Blood group 0.20 Bangpli start transferred rAAA patient 1.30 Patient arrived Ramathibodi hospital 1.35 Admission time by 2nd Yrs Resident 1.32 Patient reached to OR 2.00 Incision Time 3.50 Finished operation
- 50. CONCLUSIONS • EVAR forRAAA is feasible in selected patients in institution with experience • The mortality after EVAR for RAAA is influenced from operator’s experience and the “suitability of patients” in different centers • The risk of reintervention after EVAR is high and strict follow-up is necessary • Long term data are needed to assist if EVAR is durable treatment in relation to Endoleak and ruptured risk. • The debate for the future would be not which technique is superior, but to define exactly the role of endovascular repair as an additional therapeutic option for RAAAs.
- 51.
Editor's Notes
- #8 Among those subsequently diagnosed with an RAAA, only 23% had a definitive and immediate diagnosis of RAAA made by the first examining physician.56,57 The rate of incorrect diagnosis ranges from 16% to 60%.
- #9 The supine abdominal radiograph showed a large mass of soft tissue density with peripheral calcification (black arrow) over the lower abdomen, which lost its right-side margin (white arrow), with an unvisualized right psoas border, indicating a ruptured abdominal aortic
- #11 Axial view of contrast-enhanced computed tomography of the abdomen shows a large abdominal aortic aneurysm 9 cm in diameter with peripheral calcification and a rupture of the aneurysm over the right side (arrow) with massive right retroperitoneal hemorrhage.
- #15 The IMPROVE trial demonstrated that those with the lowest BP had the highest mortality and increasing SBP to greater than 70 mm Hg was beneficial
- #19 The principal 1-year outcome was mortality; secondary outcomes were re-interventions, hospital discharge, health-related quality-of-life , costs, Quality-Adjusted-Life-Years, and cost-effectiveness
- #22 After 1 year, 130 (41.1%) of patients in the endovascular strategy group had died vs. 133 (45.1%) in the open repair group P-value 0.325 Almost half the deaths, in each group, occurred within 24 h and the majority occurred within 30 days At 1 year, AAA-related mortality (including all deaths within 30 days) in the endovascular strategy and open repair groups, respectively, was 33.9% and 39.3%, P-value 0.161
- #24 The use of endovascular repair is increasing in the elderly population
- #25 Short-term survival. Perioperative morbidities, especially pulmonary complications, were also significantly lower with EVAR.
- #29 BF endografts do not perform better than AUI. AUI endografts in emergency situations can be justified, especially in unstable patients
- #32 Fixed mount imaging suite or hybrid room Mobile C-arm portanle
- #33 Preparation surgical instrument for EVAR and Open repair
- #37 The use of occlusion balloons has usually been reserved for patients who are precipitously hemodynamically unstable. Proximal aortic occlusion can usually be achieved by inflating a large balloon at the level of the descending aorta, which can be placed using transbrachial or transfemoral approaches. The advantages of aortic occlusion balloon catheter insertion are:
- #38 BF endografts do not perform better than AUI. AUI endografts in emergency situations can be justified, especially in unstable patients 30-day mortality was higher in AUI No other significant differences were observed in terms of endoleak rate, graft migration, graft patency, transfemoral and abdominal reinterventions, aneurysm rupture, graft infection and pseudoaneurysm formation.
- #43 Mortality rate of 55% despite aggressive surgical management. inferior mesenteric artery, and collateral supply between the superior mesenteric, inferior mesenteric, and internal iliac arteries.