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
in endo era. aortic is one of the industrial driven medical proedure & one of the most expensive. Its morbidity are quoet acceptable, but......... surgeon if the best deal behind this awsome techno
Principles of angioplasty -Endovascular Management of Peripheral Vascular Dis...Saurabh Joshi
This presentation covers the principles of peripheral angioplasty with and explanation of the TASC stratification and selection of appropriate management according to current guidelines. Endovascular management of peripheral vascular disease.
in endo era. aortic is one of the industrial driven medical proedure & one of the most expensive. Its morbidity are quoet acceptable, but......... surgeon if the best deal behind this awsome techno
Principles of angioplasty -Endovascular Management of Peripheral Vascular Dis...Saurabh Joshi
This presentation covers the principles of peripheral angioplasty with and explanation of the TASC stratification and selection of appropriate management according to current guidelines. Endovascular management of peripheral vascular disease.
Peripheral Angioplasty / Endovascular Management of PVD - PrinciplesSaurabh Joshi
This presentation covers the principles of peripheral angioplasty with and explanation of the TASC stratification and selection of appropriate management according to current guidelines. Endovascular management of peripheral vascular disease.
my aortic surgery presentation in Solo as an introduction for general practitioner and cardiology resident
Cover the basic diagram of surgical procedures of aorta.
definitely not for surgeon.
Intravascular lithotripsy (ivl) for peripheral arterial diseaseRamachandra Barik
There are a number of observations that suggest IVL produces
compliance changes in the vessel wall:Effacement of calcified stenoses with lithotripsy at low pressure with no change in angioplasty balloon pressure •Changes in echotexture on Duplex Ultrasound•Changes in appearances on Optical Coherence Tomography
Surgical Management of Lower Limb Occlusive Arterial Diseaserajendra meena
This slide explains briefly touches upon Occlusive Arterial Disease (Peripheral Arterial Disease (PAD)) in the lower limbs along with the types, classification, diagnostic evaluation and various management protocols.
Transcatheter Aortic Valve Replacement (TAVR): Established and Emerging Indic...Allina Health
By Paul Sorajja, MD. The efficacy and safety of transcatheter valve replacement in high-risk, non-operable patients is leading to new valve therapy options for a broader pateint population. "The options we have today to fix problems without opening the chest would have been unimaginable 10 years ago."
Peripheral Angioplasty / Endovascular Management of PVD - PrinciplesSaurabh Joshi
This presentation covers the principles of peripheral angioplasty with and explanation of the TASC stratification and selection of appropriate management according to current guidelines. Endovascular management of peripheral vascular disease.
my aortic surgery presentation in Solo as an introduction for general practitioner and cardiology resident
Cover the basic diagram of surgical procedures of aorta.
definitely not for surgeon.
Intravascular lithotripsy (ivl) for peripheral arterial diseaseRamachandra Barik
There are a number of observations that suggest IVL produces
compliance changes in the vessel wall:Effacement of calcified stenoses with lithotripsy at low pressure with no change in angioplasty balloon pressure •Changes in echotexture on Duplex Ultrasound•Changes in appearances on Optical Coherence Tomography
Surgical Management of Lower Limb Occlusive Arterial Diseaserajendra meena
This slide explains briefly touches upon Occlusive Arterial Disease (Peripheral Arterial Disease (PAD)) in the lower limbs along with the types, classification, diagnostic evaluation and various management protocols.
Transcatheter Aortic Valve Replacement (TAVR): Established and Emerging Indic...Allina Health
By Paul Sorajja, MD. The efficacy and safety of transcatheter valve replacement in high-risk, non-operable patients is leading to new valve therapy options for a broader pateint population. "The options we have today to fix problems without opening the chest would have been unimaginable 10 years ago."
Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low...Shadab Ahmad
The role of transcatheter aortic valve replacement (TAVR) in the treatment of patients with severe, symptomatic aortic stenosis has evolved on the basis of evidence from clinical trials.
Previous randomized trials of TAVR with both balloon-expandable valves and self-expanding valves showed that, in patients who were at intermediate or high risk for death with surgery, TAVR was either superior or noninferior to standard therapies, including surgical aortic-valve replacement.
However, most patients with severe aortic stenosis are at low surgical risk, and there is insufficient evidence regarding the comparison of TAVR with surgery in such patients.
DETAILS OF EVIDENCE TAVI FROM ITS EXISTENCE IN INTERVENTIONAL CARDIOLOGY TO THE SURTAVI REGISTRY ..AS AN OPTION FROM HIGH RISK UNOPERABLE PATIENTS TO INTERMEDIATE AND LOW RISK PATIENTS
atherosclerosis is one of most common cause of aortic ds,screening of abdominal aorta in vulnerable population is very useful for prevention and early detection of future omplication.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
1. EVAR IN RUPTURED AAA +
FAST-TRACK IN RAAA
F2 PARACH SIRISRIRO
9th July 2018
2. REFERENCE
Rutherford's Vascular Surgery and 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
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 classic presentation 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
12. PERIOPERATIVE MANAGEMENT
• Airway management (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
• Aggressive fluid 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
• Fluid resuscitation 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
• Depend on 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 anatomy for 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
18. Multicentre (29 UK and 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–
21. • 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
EVAR VS OPEN
IN RAAA
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
IN RAAA
• 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 repair versus 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
Understanding the 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 proportion for 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
33. CHOICE OF ANESTHESIA AND 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
35. • Placement under local 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 RUPTURED AOR 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 stent graft 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.
39. • Remove device and 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
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 :ABDOMINAL COMPARTMENT 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
44. • Paraplegia and paraparesis 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 patients have 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 for RAAA 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.
Among those subsequently diagnosed with an RAAA, only 23% had a definitive and immediate diagnosis of RAAA made by thefirst examining physician.56,57 The rate of incorrect diagnosis ranges from 16% to 60%.
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
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.
The IMPROVE trial demonstrated that those with the lowest BP had the highest mortality and increasing SBP to greater than 70 mmHg was beneficial
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
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
The use of endovascular repair is increasing in the elderly population
Short-term survival. Perioperative morbidities, especially pulmonary complications,were also significantly lower with EVAR.
BF endografts do not perform better than AUI.
AUI endografts in emergency situations can be justified, especially in unstable patients
Fixed mount imaging suite or hybrid room
Mobile C-arm portanle
Preparation surgical instrument for EVAR and Open repair
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 transbrachialor transfemoral approaches.
The advantages of aortic occlusion balloon catheter insertion are:
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.
Mortality rate of 55% despite aggressive surgical management.
inferior mesenteric artery, and collateral supply between the superior mesenteric, inferior mesenteric, and internal iliac arteries.