1) The authors established a protocol for endovascular repair of ruptured abdominal aortic aneurysms (r-AAAs) to address limitations in coordinating patient care between the emergency department and operating room.
2) As part of the protocol, 5 patients underwent simulated emergencies to test the protocol, which involved alerting vascular surgery and preparing an endovascular-capable operating room.
3) Since implementing the protocol, 40 of 42 actual r-AAA patients underwent successful endovascular repair, with a mortality rate of 18% once the protocol was established to streamline patient care.
Mitral stenosis surgery is recommended for adolescent or young adult patients with congenital mitral stenosis who have symptoms and a mean mitral valve gradient greater than 10 mm Hg. Mitral valve surgery is also reasonable for asymptomatic patients with mild symptoms and a mean gradient over 10 mm Hg, or asymptomatic patients with pulmonary artery systolic pressure over 50 mm Hg and a mean gradient over 10 mm Hg. The effectiveness of surgery is uncertain for asymptomatic patients with new onset atrial fibrillation or embolisms while on anticoagulation.
This letter reports on a novel technique for transcatheter aortic valve replacement (TAVR) called transcaval retrograde TAVR. The technique involves using a guidewire to create an arteriovenous fistula between the inferior vena cava and the aorta, allowing access from the femoral vein. It was successfully performed in 4 inoperable patients with severe aortic stenosis who were not suitable candidates for standard approaches. All procedures were completed safely without complications. This new caval-aortic approach avoids femoral arterial complications and may expand treatment options for patients without other access routes.
The document discusses the use of additional morphological and functional techniques with transradial approaches, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT) to assess coronary artery lesions. Functionally, fractional flow reserve (FFR) can be measured using a pressure wire. The document argues that combining anatomical data from IVUS/OCT with functional data from FFR provides more accurate diagnosis and guidance for percutaneous coronary intervention compared to angiography alone. Studies demonstrate the benefits of IVUS-guided stenting over angiography for long term mortality outcomes.
This document provides guidelines for using multimodality imaging to evaluate patients with repaired tetralogy of Fallot (TOF). It describes the role of echocardiography, cardiovascular magnetic resonance (CMR), computed tomography (CT), nuclear scintigraphy, and angiography. Echocardiography and CMR are well-suited for longitudinal follow-up due to lack of radiation. CMR is considered the reference standard for assessing right ventricular size and function and pulmonary regurgitation. A multimodality approach is recommended to comprehensively evaluate the complex anatomy and physiology while considering each patient's needs and institutional resources.
Management of aaa clinical practice guidelines of the esvsuvcd
This document provides guidelines for the management of abdominal aortic aneurysms (AAA). It includes 130 recommendations across 7 chapters covering topics such as screening, decision-making for repair, pre- and post-operative imaging, management of ruptured and non-ruptured AAAs, and follow-up after repair. The guidelines are based on a systematic review of the literature and aim to standardize care and improve outcomes for AAA patients across Europe.
The document summarizes the NAUSICA trial which compared outcomes of percutaneous coronary interventions (PCI) using 4 French versus 6 French guide catheters. The trial found that 4 French PCI resulted in significantly lower access site complications and hemostasis times compared to 6 French PCI, with comparable procedural success. 4 French PCI also showed a numerically lower risk of radial artery occlusion. The 4 French coronary accessor was also found to be useful for the mother-child guiding catheter technique, providing backup support comparable to larger catheters.
Mitral stenosis surgery is recommended for adolescent or young adult patients with congenital mitral stenosis who have symptoms and a mean mitral valve gradient greater than 10 mm Hg. Mitral valve surgery is also reasonable for asymptomatic patients with mild symptoms and a mean gradient over 10 mm Hg, or asymptomatic patients with pulmonary artery systolic pressure over 50 mm Hg and a mean gradient over 10 mm Hg. The effectiveness of surgery is uncertain for asymptomatic patients with new onset atrial fibrillation or embolisms while on anticoagulation.
This letter reports on a novel technique for transcatheter aortic valve replacement (TAVR) called transcaval retrograde TAVR. The technique involves using a guidewire to create an arteriovenous fistula between the inferior vena cava and the aorta, allowing access from the femoral vein. It was successfully performed in 4 inoperable patients with severe aortic stenosis who were not suitable candidates for standard approaches. All procedures were completed safely without complications. This new caval-aortic approach avoids femoral arterial complications and may expand treatment options for patients without other access routes.
The document discusses the use of additional morphological and functional techniques with transradial approaches, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT) to assess coronary artery lesions. Functionally, fractional flow reserve (FFR) can be measured using a pressure wire. The document argues that combining anatomical data from IVUS/OCT with functional data from FFR provides more accurate diagnosis and guidance for percutaneous coronary intervention compared to angiography alone. Studies demonstrate the benefits of IVUS-guided stenting over angiography for long term mortality outcomes.
This document provides guidelines for using multimodality imaging to evaluate patients with repaired tetralogy of Fallot (TOF). It describes the role of echocardiography, cardiovascular magnetic resonance (CMR), computed tomography (CT), nuclear scintigraphy, and angiography. Echocardiography and CMR are well-suited for longitudinal follow-up due to lack of radiation. CMR is considered the reference standard for assessing right ventricular size and function and pulmonary regurgitation. A multimodality approach is recommended to comprehensively evaluate the complex anatomy and physiology while considering each patient's needs and institutional resources.
Management of aaa clinical practice guidelines of the esvsuvcd
This document provides guidelines for the management of abdominal aortic aneurysms (AAA). It includes 130 recommendations across 7 chapters covering topics such as screening, decision-making for repair, pre- and post-operative imaging, management of ruptured and non-ruptured AAAs, and follow-up after repair. The guidelines are based on a systematic review of the literature and aim to standardize care and improve outcomes for AAA patients across Europe.
The document summarizes the NAUSICA trial which compared outcomes of percutaneous coronary interventions (PCI) using 4 French versus 6 French guide catheters. The trial found that 4 French PCI resulted in significantly lower access site complications and hemostasis times compared to 6 French PCI, with comparable procedural success. 4 French PCI also showed a numerically lower risk of radial artery occlusion. The 4 French coronary accessor was also found to be useful for the mother-child guiding catheter technique, providing backup support comparable to larger catheters.
The field of transcatheter mitral valve repair (TMVr) for
mitral regurgitation (MR) is rapidly evolving. Besides the
well-established transcatheter mitral edge-to-edge repair
approach, there is also growing evidence for therapeutic
strategies targeting the mitral annulus and mitral valve
chordae. A patient-tailored approach, careful patient
selection and an experienced interventional team is crucial
in order to optimise procedural and clinical outcomes. With
further data from ongoing clinical trials to be expected,
consensus in the Heart Team is needed to address these
complexities and determine the most appropriate TMVr
therapy, either single or combined, for patients with severe
MR
This document summarizes the diagnosis and management of local complications associated with transradial access for coronary procedures. It discusses radial artery occlusion, hand ischemia, radial artery spasm, forearm hematoma, compartment syndrome, catheter entrapment, pseudoaneurysm, and arteriovenous fistula. Predictors and treatments for various complications are provided. The incidence of radial artery occlusion can range from 0.8-30% depending on the time and method of assessment. Hand ischemia due to radial artery occlusion is rare but can occur in systemically unwell patients with prolonged radial cannulation. Radial artery spasm is common and treatments include antispasmodic medications and adequate analgesia/sedation.
This document discusses techniques for transradial access and intervention. It begins by outlining three levels of competency for operators and discusses when radial access may not be appropriate. It then provides a step-by-step guide for radial access procedures, covering patient positioning, arterial puncture, navigating vascular anatomy, catheter selection, and hemostasis. Predictors of procedural failure are presented. The document concludes by providing tips for implementing a successful radial program.
TransUlnar approach - our experience in nhf . Dr. Ashok DuttaAshok Dutta
1) The study compares the transulnar approach (TUA) to coronary angiography and angioplasty with the traditional transradial approach (TRA) in Bangladeshi patients, with the goal of assessing safety, efficacy, and procedural factors of both approaches.
2) Over 12 months, 225 patients underwent TUA while 229 underwent TRA. Successful cannulation was higher with TRA (92.14% vs 81.72% for TUA), but complications were lower for TUA.
3) Procedural times, radiation exposure, and findings during coronary angiography were generally similar between the two groups. Loss of arterial pulse was lower for TUA both during hospitalization and follow-up.
The document discusses optimizing transradial interventions and managing complications. It begins by emphasizing the importance of patient selection based on anatomy, using proper techniques to avoid failure, and anticipating common and rare complications. Several key points are covered, including assessing hand collateral arteries using tests like the modified Allen's test before proceeding. Anatomical variations that could impact access are reviewed. Causes of access failure like radial artery loops and spasm are described. Technical tips for successful cannulation include using a small needle and guidewire, followed by a vasodilator "cocktail" to prevent spasm. Severe spasm is identified as a rare but preventable complication.
This document discusses the learning curve associated with trans-radial procedures. It notes that the trans-radial approach is more challenging due to the small artery size, risk of spasm, and anatomical variation. Several studies characterized the learning curve, finding that operators improved with experience. The right radial approach has a steeper learning curve than the left. Operators were more successful with trans-radial PCI after 50-100 cases. Proper patient selection, technique, and experience were noted to help overcome challenges associated with the trans-radial learning curve.
1) Percutaneous angioplasty is a feasible treatment for critical hand ischemia, with a technical success rate of 88-96% and clinical success rate of 85-100% based on a study of 75 patients.
2) Complications occurred in 6-16% of patients and included perforation, distal embolization, dissection, and access site issues.
3) Long term follow up showed a high rate of major adverse events (22.6% at 1 year) and target lesion revascularization (16%).
This study evaluated outcomes of 44 neonates who underwent staged biventricular repair for left ventricular outflow tract obstruction, ventricular septal defect, and aortic arch obstruction. The first stage was a Norwood procedure. Stage one mortality was 9%. Interstage survival was 100% for nonsyndromic patients and 46% for syndromic patients. Twenty-four patients later underwent successful biventricular completion repair. The study found that genetic syndromes and prematurity significantly increased the risk of mortality. The staged approach allowed for repair using a larger conduit and delayed need for reintervention compared to previous studies.
This document discusses hepatocellular carcinoma and its treatment options. It then summarizes a study comparing transradial versus transfemoral access for transarterial chemoembolization. 201 radial cases were performed with few complications. Nurses surveyed preferred radial access as patients had less pain, could ambulate sooner, and required fewer nursing hours. Radial access also resulted in cost savings of $100 per case. The conclusion is that radial access improves patient safety, comfort, and privacy while reducing costs.
Medium and long term results following evar success or disappointmentuvcd
1. EVAR was found to have a 3% reduced 30-day mortality but increased long-term reintervention rates compared to open repair in trials. However, the rate of reintervention continues to increase over time for both methods.
2. While EVAR provides an initial survival benefit for ruptured AAA, the results are inconclusive due to heterogeneity and many patients still require open repair due to anatomical limitations.
3. Open repair remains the gold standard treatment for AAA due to the increasing long-term reintervention rates with EVAR and concerns about the overuse and liberal guidelines for device usage not aligning with patient risk factors and life expectancy.
The document provides guidance on patient setup and arterial access for right and left radial cardiac catheterization. It recommends using a board to position the patient comfortably, accessing from the right or left radial artery, using hydrophilic sheaths to prevent spasm, anticoagulating patients, and administering a spasmolytic cocktail. It emphasizes that training staff is important for successful radial procedures.
This document discusses infrainguinal arterial procedures, focusing on femoropopliteal bypass surgery. It begins with an overview of preoperative testing and imaging, including duplex scanning, MRI angiography, CT angiography, and conventional angiography. The key steps of an above-the-knee femoropopliteal bypass are then described in detail, including harvesting the great saphenous vein, exposing the femoral artery, and exposing the popliteal artery distally. The bypass is performed by anastomosing the vein graft proximally to the femoral artery and distally to the popliteal artery above the knee. Precise surgical technique is important for successful bypass outcomes.
new technologies for Mitral regurgitationdrmaisano
This document discusses potential treatments for mitral regurgitation beyond the MitraClip procedure. It notes that while the MitraClip is effective for selected patients, other options are needed to treat a wider range of patients. These include open heart surgery, combining approaches synergistically, and new technologies such as annuloplasty, neochordae implantation, and mitral valve replacement. Several new transcatheter techniques are discussed such as devices to implant neochordae or reshape the coronary sinus. The document emphasizes tailoring the treatment approach to each individual patient based on their anatomy, comorbidities, and goals of care.
Safety and efficacy of using a single transradial MAC guiding catheter for coronary angiography and intervention in patients with ST-elevation myocardial infarction (RAPID)
Ultrasound imaging of the arm arteries prior to cardiac catheterization can help anticipate procedural failure and enhance success. In a study of over 2,000 patients, pre-procedure ultrasound identified anatomical anomalies in 9.8% of patients and helped select the largest accessible artery. This led to a procedural success rate of 98.7% and a low 1.3% crossover rate. Pre-procedure ultrasound takes on average 6 minutes and can help reduce radiation time and procedural complications by avoiding difficult arterial access.
Push and Puff Technique for Mechanical ThrombectomyDr Vipul Gupta
This document describes the push and puff technique for mechanical thrombectomy and one physician's experience using this technique with the Solitaire stent retriever. It summarizes a case study of a 65-year-old female patient who presented with left-sided weakness and was found to have a right terminal ICA occlusion that was successfully treated with mechanical thrombectomy using the push and puff technique. The physician's early experience using this technique with the Solitaire device in 7 patients demonstrated a 100% first pass reperfusion rate and modified TICI 3 reperfusion in 85% of patients. Commonly encountered challenges after stent retrieval included vessel spasm and residual thrombus. The conclusion is that the push and puff technique appears very promising for improving outcomes
percutaneous therapies for mitral regurgitationRavi Kanth
This document discusses mitral regurgitation (MR) and percutaneous approaches to mitral valve repair. It provides background on the anatomy of the mitral valve and the types of MR. Surgical repair or replacement is the standard treatment for MR but percutaneous options are being developed to provide less invasive alternatives for high-risk patients. The MitraClip procedure has been used successfully in humans and involves deploying a clip to grasp and oppose the mitral valve leaflets, reducing regurgitation. Indications, outcomes, limitations, and components of the MitraClip system are described.
This document discusses the transpedal approach for peripheral interventions. The transpedal approach involves accessing the pedal or tibial arteries in the foot retrogradely to perform endovascular interventions for conditions like chronic total occlusions in the leg arteries. Some key advantages of the transpedal approach are that it allows dual access for complex interventions, avoids complications associated with femoral access, and can be used when recanalizing total occlusions from above has failed. The document reviews various studies demonstrating the safety, feasibility and clinical outcomes of the transpedal approach.
How to learn the catheter skill techniquesdrmaisano
The document discusses the need for cross-training of surgeons and interventional cardiologists in percutaneous heart valve treatment. It states that the procedure requires skills independent of one's base discipline, and that specific training is required. Those undergoing the procedural training should be experienced interventionalists or surgeons. The document then outlines various pathways for acquiring the necessary skills through simulation, proctoring, visiting other centers, and industry-supported opportunities.
perioperative management Pacemaker Insertion In Congenital HeartAhmed Shalabi
This document describes the perioperative management of a 6-month-old boy undergoing permanent pacemaker implantation for congenital complete heart block. Key aspects of management included premedication with atropine and promethazine to prevent vagal stimulation, induction with ketamine to avoid negative chronotropic effects, and maintenance with non-depressant anesthetics like isoflurane. Intraoperative monitoring and defibrillator equipment were readily available due to the risk of arrhythmias. The pacemaker implantation procedure and postoperative course were uncomplicated with this careful anesthetic approach.
The field of transcatheter mitral valve repair (TMVr) for
mitral regurgitation (MR) is rapidly evolving. Besides the
well-established transcatheter mitral edge-to-edge repair
approach, there is also growing evidence for therapeutic
strategies targeting the mitral annulus and mitral valve
chordae. A patient-tailored approach, careful patient
selection and an experienced interventional team is crucial
in order to optimise procedural and clinical outcomes. With
further data from ongoing clinical trials to be expected,
consensus in the Heart Team is needed to address these
complexities and determine the most appropriate TMVr
therapy, either single or combined, for patients with severe
MR
This document summarizes the diagnosis and management of local complications associated with transradial access for coronary procedures. It discusses radial artery occlusion, hand ischemia, radial artery spasm, forearm hematoma, compartment syndrome, catheter entrapment, pseudoaneurysm, and arteriovenous fistula. Predictors and treatments for various complications are provided. The incidence of radial artery occlusion can range from 0.8-30% depending on the time and method of assessment. Hand ischemia due to radial artery occlusion is rare but can occur in systemically unwell patients with prolonged radial cannulation. Radial artery spasm is common and treatments include antispasmodic medications and adequate analgesia/sedation.
This document discusses techniques for transradial access and intervention. It begins by outlining three levels of competency for operators and discusses when radial access may not be appropriate. It then provides a step-by-step guide for radial access procedures, covering patient positioning, arterial puncture, navigating vascular anatomy, catheter selection, and hemostasis. Predictors of procedural failure are presented. The document concludes by providing tips for implementing a successful radial program.
TransUlnar approach - our experience in nhf . Dr. Ashok DuttaAshok Dutta
1) The study compares the transulnar approach (TUA) to coronary angiography and angioplasty with the traditional transradial approach (TRA) in Bangladeshi patients, with the goal of assessing safety, efficacy, and procedural factors of both approaches.
2) Over 12 months, 225 patients underwent TUA while 229 underwent TRA. Successful cannulation was higher with TRA (92.14% vs 81.72% for TUA), but complications were lower for TUA.
3) Procedural times, radiation exposure, and findings during coronary angiography were generally similar between the two groups. Loss of arterial pulse was lower for TUA both during hospitalization and follow-up.
The document discusses optimizing transradial interventions and managing complications. It begins by emphasizing the importance of patient selection based on anatomy, using proper techniques to avoid failure, and anticipating common and rare complications. Several key points are covered, including assessing hand collateral arteries using tests like the modified Allen's test before proceeding. Anatomical variations that could impact access are reviewed. Causes of access failure like radial artery loops and spasm are described. Technical tips for successful cannulation include using a small needle and guidewire, followed by a vasodilator "cocktail" to prevent spasm. Severe spasm is identified as a rare but preventable complication.
This document discusses the learning curve associated with trans-radial procedures. It notes that the trans-radial approach is more challenging due to the small artery size, risk of spasm, and anatomical variation. Several studies characterized the learning curve, finding that operators improved with experience. The right radial approach has a steeper learning curve than the left. Operators were more successful with trans-radial PCI after 50-100 cases. Proper patient selection, technique, and experience were noted to help overcome challenges associated with the trans-radial learning curve.
1) Percutaneous angioplasty is a feasible treatment for critical hand ischemia, with a technical success rate of 88-96% and clinical success rate of 85-100% based on a study of 75 patients.
2) Complications occurred in 6-16% of patients and included perforation, distal embolization, dissection, and access site issues.
3) Long term follow up showed a high rate of major adverse events (22.6% at 1 year) and target lesion revascularization (16%).
This study evaluated outcomes of 44 neonates who underwent staged biventricular repair for left ventricular outflow tract obstruction, ventricular septal defect, and aortic arch obstruction. The first stage was a Norwood procedure. Stage one mortality was 9%. Interstage survival was 100% for nonsyndromic patients and 46% for syndromic patients. Twenty-four patients later underwent successful biventricular completion repair. The study found that genetic syndromes and prematurity significantly increased the risk of mortality. The staged approach allowed for repair using a larger conduit and delayed need for reintervention compared to previous studies.
This document discusses hepatocellular carcinoma and its treatment options. It then summarizes a study comparing transradial versus transfemoral access for transarterial chemoembolization. 201 radial cases were performed with few complications. Nurses surveyed preferred radial access as patients had less pain, could ambulate sooner, and required fewer nursing hours. Radial access also resulted in cost savings of $100 per case. The conclusion is that radial access improves patient safety, comfort, and privacy while reducing costs.
Medium and long term results following evar success or disappointmentuvcd
1. EVAR was found to have a 3% reduced 30-day mortality but increased long-term reintervention rates compared to open repair in trials. However, the rate of reintervention continues to increase over time for both methods.
2. While EVAR provides an initial survival benefit for ruptured AAA, the results are inconclusive due to heterogeneity and many patients still require open repair due to anatomical limitations.
3. Open repair remains the gold standard treatment for AAA due to the increasing long-term reintervention rates with EVAR and concerns about the overuse and liberal guidelines for device usage not aligning with patient risk factors and life expectancy.
The document provides guidance on patient setup and arterial access for right and left radial cardiac catheterization. It recommends using a board to position the patient comfortably, accessing from the right or left radial artery, using hydrophilic sheaths to prevent spasm, anticoagulating patients, and administering a spasmolytic cocktail. It emphasizes that training staff is important for successful radial procedures.
This document discusses infrainguinal arterial procedures, focusing on femoropopliteal bypass surgery. It begins with an overview of preoperative testing and imaging, including duplex scanning, MRI angiography, CT angiography, and conventional angiography. The key steps of an above-the-knee femoropopliteal bypass are then described in detail, including harvesting the great saphenous vein, exposing the femoral artery, and exposing the popliteal artery distally. The bypass is performed by anastomosing the vein graft proximally to the femoral artery and distally to the popliteal artery above the knee. Precise surgical technique is important for successful bypass outcomes.
new technologies for Mitral regurgitationdrmaisano
This document discusses potential treatments for mitral regurgitation beyond the MitraClip procedure. It notes that while the MitraClip is effective for selected patients, other options are needed to treat a wider range of patients. These include open heart surgery, combining approaches synergistically, and new technologies such as annuloplasty, neochordae implantation, and mitral valve replacement. Several new transcatheter techniques are discussed such as devices to implant neochordae or reshape the coronary sinus. The document emphasizes tailoring the treatment approach to each individual patient based on their anatomy, comorbidities, and goals of care.
Safety and efficacy of using a single transradial MAC guiding catheter for coronary angiography and intervention in patients with ST-elevation myocardial infarction (RAPID)
Ultrasound imaging of the arm arteries prior to cardiac catheterization can help anticipate procedural failure and enhance success. In a study of over 2,000 patients, pre-procedure ultrasound identified anatomical anomalies in 9.8% of patients and helped select the largest accessible artery. This led to a procedural success rate of 98.7% and a low 1.3% crossover rate. Pre-procedure ultrasound takes on average 6 minutes and can help reduce radiation time and procedural complications by avoiding difficult arterial access.
Push and Puff Technique for Mechanical ThrombectomyDr Vipul Gupta
This document describes the push and puff technique for mechanical thrombectomy and one physician's experience using this technique with the Solitaire stent retriever. It summarizes a case study of a 65-year-old female patient who presented with left-sided weakness and was found to have a right terminal ICA occlusion that was successfully treated with mechanical thrombectomy using the push and puff technique. The physician's early experience using this technique with the Solitaire device in 7 patients demonstrated a 100% first pass reperfusion rate and modified TICI 3 reperfusion in 85% of patients. Commonly encountered challenges after stent retrieval included vessel spasm and residual thrombus. The conclusion is that the push and puff technique appears very promising for improving outcomes
percutaneous therapies for mitral regurgitationRavi Kanth
This document discusses mitral regurgitation (MR) and percutaneous approaches to mitral valve repair. It provides background on the anatomy of the mitral valve and the types of MR. Surgical repair or replacement is the standard treatment for MR but percutaneous options are being developed to provide less invasive alternatives for high-risk patients. The MitraClip procedure has been used successfully in humans and involves deploying a clip to grasp and oppose the mitral valve leaflets, reducing regurgitation. Indications, outcomes, limitations, and components of the MitraClip system are described.
This document discusses the transpedal approach for peripheral interventions. The transpedal approach involves accessing the pedal or tibial arteries in the foot retrogradely to perform endovascular interventions for conditions like chronic total occlusions in the leg arteries. Some key advantages of the transpedal approach are that it allows dual access for complex interventions, avoids complications associated with femoral access, and can be used when recanalizing total occlusions from above has failed. The document reviews various studies demonstrating the safety, feasibility and clinical outcomes of the transpedal approach.
How to learn the catheter skill techniquesdrmaisano
The document discusses the need for cross-training of surgeons and interventional cardiologists in percutaneous heart valve treatment. It states that the procedure requires skills independent of one's base discipline, and that specific training is required. Those undergoing the procedural training should be experienced interventionalists or surgeons. The document then outlines various pathways for acquiring the necessary skills through simulation, proctoring, visiting other centers, and industry-supported opportunities.
perioperative management Pacemaker Insertion In Congenital HeartAhmed Shalabi
This document describes the perioperative management of a 6-month-old boy undergoing permanent pacemaker implantation for congenital complete heart block. Key aspects of management included premedication with atropine and promethazine to prevent vagal stimulation, induction with ketamine to avoid negative chronotropic effects, and maintenance with non-depressant anesthetics like isoflurane. Intraoperative monitoring and defibrillator equipment were readily available due to the risk of arrhythmias. The pacemaker implantation procedure and postoperative course were uncomplicated with this careful anesthetic approach.
This document reviews the management of hypertensive emergencies associated with aortic dissection and thoracic aortic aneurysms. It discusses that immediate control of blood pressure is critical for these conditions to prevent further damage. For aortic dissections, surgery is usually recommended for Type A dissections while medical therapy is preferred for Type B dissections. The goals of treatment are to relieve symptoms, reduce complications, and prevent rupture. Several antihypertensive drugs are discussed for rapidly lowering blood pressure in hypertensive emergencies associated with these aortic conditions. Outcomes have improved but morbidity and mortality remain high, posing a significant treatment challenge.
This study optimized prebiotic mixtures in soybean milk using mixture experiments. Thirteen soybean milk formulations with varying proportions of inulin, galacto-oligosaccharides, and isomalto-oligosaccharides were evaluated based on sensory properties and growth of probiotic bacteria. The growth of Bifidobacterium bifidum, Lactobacillus plantarum, and Lactobacillus acidophilus were used to determine the best prebiotic mixture. The optimized formulation containing 0.11 inulin, 0.62 galacto-oligosaccharides, and 0.27 isomalto-oligosaccharides stimulated the highest growth of all three probiotic strains without affecting sensory attributes.
This review article discusses the use of ketamine as an induction agent for rapid sequence induction (RSI) of anesthesia in emergency patients who are hemodynamically compromised. The authors argue that ketamine represents a rational choice for RSI in such patients due to its favorable pharmacological properties that confer hemodynamic stability compared to other induction agents. Specifically, ketamine has a short time to reach effective brain concentrations, does not significantly lower blood pressure, and maintains cerebral perfusion pressure and intracranial pressure within normal limits when used for induction and maintained with general anesthesia. While ketamine has traditionally been contraindicated when brain injury is present, the authors claim any adverse effects on intracranial pressure or cerebral blood flow are mit
This document summarizes key concepts regarding drug chirality and stereoisomers in anesthesia. It defines terms like enantiomers, stereoisomers, and the R/S naming system. It discusses how stereoisomers can have different receptor affinities and pharmacokinetic profiles. As an example, it examines the local anesthetics bupivacaine, levobupivacaine (S-bupivacaine), and ropivacaine. It describes how these drugs act on sodium channels and reviews clinical studies comparing their sensory/motor blocking effects.
Anesthetic Effects On The Fetus And NewbornAhmed Shalabi
Anesthetics are generally not teratogenic, though some animal studies found increased abnormalities with nitrous oxide exposure. Epidemiological studies in humans found no association between anesthetic exposure and birth defects. While anesthetics are not structural teratogens, some may cause behavioral changes in developing brains by interfering with receptor development. Epidural analgesia is associated with increased maternal fever during labor, which epidemiological evidence links to higher risks of cerebral palsy and other neurological injuries in infants. However, the mechanisms linking epidurals, fever, and injury remain unclear.
Anesthesia For Children With Congenital Heart Disease1Ahmed Shalabi
This document discusses children with congenital heart disease and provides information on:
1. The incidence of congenital heart disease is 7 to 10 per 1000 live births, with certain populations having higher rates.
2. Congenital heart disease can range from simple defects like atrial septal defects to complex conditions like hypoplastic left heart syndrome.
3. Proper preoperative evaluation is important for anesthetic planning and involves understanding the child's specific cardiac anatomy and physiology.
El documento describe varios parámetros y métodos para monitorear la oxigenación tisular y la adecuada entrega de oxígeno en pacientes críticos, incluyendo lactato, déficit de base, saturación venosa de oxígeno, tonometría gástrica y sublingual. Se explica cómo cada uno refleja diferentes aspectos de la oxigenación a nivel sistémico y tisular, y su utilidad pronóstica.
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results.
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results.
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results
The document provides an overview of transcatheter aortic valve implantation (TAVI), including a brief history of its development, descriptions of the Edwards Sapien valve and delivery systems, approaches for TAVI, and complications. It also discusses patient screening and risk stratification, as well as newer valve devices that are being developed.
This document summarizes some of the challenges and complexities involved in endovascular abdominal aortic aneurysm (AAA) repair (EVAR) and hybrid procedures. It describes various patient and anatomical factors that can make AAA intervention difficult, such as short and angulated neck anatomy, iliac artery tortuosity and stenosis, accessory renal arteries, and aneurysms involving the common iliac arteries. It also discusses the risks of pelvic ischemia when occluding internal iliac arteries and highlights mortality and morbidity rates reported in studies of hybrid AAA procedures.
Ann Vasc Surg 2012; 26: 141-148-Selected technique- Funnel Technique for EVAR: ‘‘A Way Out’’ for Abdominal Aortic Aneurisms With Ectatic Proximal Necks
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
This meta-analysis examined short-term and long-term mortality rates following elective open abdominal aortic aneurysm (AAA) repair versus endovascular aneurysm repair (EVAR) based on data from four randomized controlled trials with a total of 2783 patients. The analysis found that 30-day all-cause mortality was significantly higher for open repair compared to EVAR (3.2% vs 1.2%). However, there was no significant difference in long-term all-cause mortality between the two groups. Reintervention rates were higher following EVAR compared to open repair (18.9% vs 9.3%), but this finding was considered doubtful due to large heterogeneity. No significant differences were found between the
Trans-radial access (TRad) is commonly used for coronary interventions due to lower complication rates compared to femoral access. This study evaluated the safety and feasibility of TRad for non-coronary and peripheral vascular interventions in 24 cases over 3 years. TRad was successful in all cases with no access complications. Indications included absent femoral pulses, morbid obesity, femoral bypass, and groin infections. Procedures included diagnostic angiograms and interventions like iliac angioplasty/stenting and femoral anastomosis angioplasty. 31% had asymptomatic radial artery occlusion. Larger sheath sizes were associated with higher occlusion rates. TRad is a safe alternative to femoral access for select peripheral cases
A technical modification of carotid endarterectomy experience with 400 pati...uvcd
This document discusses techniques for carotid endarterectomy based on the experience of 400 patients. It finds that eversion carotid endarterectomy had a lower restenosis rate of 1.7% compared to 9.3% for primary closure and 6.5% for patch angioplasty. Additionally, eversion carotid endarterectomy had a faster mean operative time of 31 minutes compared to 39 minutes for primary closure and 46 minutes for patch angioplasty. Finally, a study of over 1,900 carotid endarterectomies found primary closure was associated with significantly higher risks of perioperative stroke at 5.6% and stroke or death at 6.0% compared to 2.2-2.5% for
This document summarizes the results of a study on the long-term outcomes of balloon angioplasty for discrete native coarctation of the aorta in adolescents and adults. The study followed 58 patients for up to 22 years after undergoing balloon angioplasty. Immediate results showed a reduction in peak gradient across the coarctation from 60 mm Hg to 8.5 mm Hg. At 12-month follow-up, the residual gradient was 5 mm Hg. Long-term follow-up with MRI, echocardiography and catheterization found excellent long-term results, with only a small number developing restenosis or aneurysms. The results support balloon angioplasty as a good first option for treating
Mitral stenosis surgery is recommended for adolescent or young adult patients with congenital mitral stenosis who have symptoms such as shortness of breath (NYHA class III or IV) and a mean mitral valve gradient over 10 mm Hg on echocardiography. Mitral valve surgery is also reasonable for asymptomatic patients with mild symptoms (NYHA class II) and a mean gradient over 10 mm Hg, or asymptomatic patients with pulmonary artery systolic pressure over 50 mm Hg and a mean gradient over 10 mm Hg. The effectiveness of surgery is uncertain for asymptomatic patients with new onset atrial fibrillation or embolisms while on anticoagulation.
This document discusses novel techniques for recanalizing the radial artery after late occlusion. In 95 cases of radial artery occlusion out of over 2000 repeat transradial interventions, recanalization was successful in 82 cases using techniques similar to those used for coronary chronic total occlusions or tibial arteries, including wire strategies, penetration techniques, and balloon angioplasty. A new distal entry point via the deep palmar arch was used successfully in 13 of 14 cases. Hydrodynamic recanalization, where liquid is injected under high pressure, also helped in 4 cases. A new study is proposed to compare the traditional entry point to the new distal puncture technique to assess radial artery occlusion rates and safety.
The document summarizes a study comparing outcomes of patients who underwent aortic arch surgery using antegrade cerebral perfusion (ACP) versus without ACP. The study found significantly lower rates of postoperative stroke (2% vs 13%) and better 3-year survival (93% vs 78%) in the ACP group. Multivariate analysis confirmed ACP was associated with reduced stroke risk and improved long-term survival. The results suggest ACP provides neuroprotective and survival advantages over surgery without ACP for aortic arch pathology requiring prolonged repair periods.
Endovascular repair of traumatic aortic transection six years of experienceGeorge Trellopoulos
This document discusses endovascular repair as an alternative treatment for ruptured abdominal aortic aneurysms compared to open repair. Endovascular repair has the benefits of avoiding general anesthesia, clamping, and blood loss. Several studies show endovascular repair results in lower mortality and morbidity rates compared to open repair. However, patient hemodynamic status and anatomy must meet certain criteria for endovascular repair to be feasible. Key considerations for successful endovascular repair include the patient's clinical condition, CT imaging of anatomy, type of anesthesia used, stent graft configuration, and potential use of an occlusion balloon. Long-term data is still needed but endovascular repair shows promise as an additional treatment option for ruptured abdominal aortic aneurys
This review article discusses aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI). It notes that AR is more common after TAVI than surgical aortic valve replacement, with mild AR observed in about 70% of TAVI patients. Even mild AR has been linked to decreased survival up to two years after the procedure. The review aims to provide an overview of the three types of AR that can occur after TAVI - transvalvular, paravalvular, and supraskirtal - focusing on their different pathophysiological mechanisms. Accurate evaluation and classification of AR is important for understanding its implications, but challenging due to limitations of echocardiography for assessing transcatheter
Successful Valve in Ring Abolishing the Stenosis and Regurgitation with Robus...Premier Publishers
Transcatheter mitral valve-in ring implantation (TMViRI), is a novel alternative treatment strategy and promising technique for patients at high risk of repeat open-heart surgery. In this report we demonstrate a case of 61 years old male with multiple co morbidities who underwent mitral valve repair long time ago who successfully treated and dramatically improved through trans-septal approach, under trans oesophageal echocardiography and fluoroscopic guidance in Hybrid catheterization laboratory.
This document provides guidelines for the diagnosis and management of aortic disease from the 2022 ACC/AHA writing committee. Some of the key points discussed include:
- Multidisciplinary aortic team care is recommended to optimize outcomes for patients with aortic disease.
- Imaging of the aorta should follow standardized approaches and measurements.
- Thresholds for surgical intervention in thoracic aortic aneurysms have been lowered to 5.0 cm at experienced centers.
- Endovascular techniques are increasingly used for thoracic aortic aneurysms and dissections when anatomy allows.
- Screening of relatives is recommended for patients with thoracic aortic aneurysms or dissections.
This study evaluated the effect of heparin on the patency of arteriovenous fistulas in 198 patients undergoing surgery for hemodialysis access. Patients were randomly assigned to receive either intraoperative intravenous heparin (n=96) or no heparin (n=102). Early patency rates were similar between groups, but at 2 weeks follow up, the patency rate was higher in the heparin group (85%) compared to the control group (74%), a statistically significant difference. The study concludes that intraoperative heparin administration improves short-term arteriovenous fistula patency.
Assessment of Intermediate Coronary Artery Lesion with Fractional Flow Reserv...Premier Publishers
Fraction flow reserve (FFR) is considered the gold standard for assessing intermediate coronary lesions. Retrospective data analyses showed variable relationship between intravascular ultrasound (IVUS) parameters and FFR results. This study aimed to determine the optimal minimum lumen area (MLA) by IVUS that correlates with FFR and to assess the correlation between two modalities in assessing intermediate coronary lesions. Methods: Fifty eight intermediate coronary lesions mainly located in proximal and mid segments of large main coronary vessels with RVD (3-4mm) were analyzed using both IVUS and FFR to assess the significance of coronary stenting and to determine the optimal IVUS-MLA that correlates with FFR value < 0.8. Results: IVUS-MLA ranged from 2.5 to 4.2 mm2 had a highly significant positive correlation with FFR value < 0.8 (p < 0.0001). Using the ROC curve analysis, IVUS-MLA < 3.9 mm2 (84.2% sensitivity, 80% specificity, area under curve (AUC) = 0.68) was the best threshold value for identifying FFR <0.8>< 0.8 in coronary vessels with RVD (3-4mm). Different MLA cutoffs should be used for different vessel diameters.
This document describes a study that aimed to identify reliable predictors of radial artery size to help minimize the risk of radial artery occlusion from cardiac catheterization procedures. The study found that wrist circumference, male sex, and non-South Asian ancestry are independent predictors of larger radial artery size. Based on these factors, the study developed the "GRASP radial artery size prediction score" to predict radial artery diameter with reasonable accuracy and help operators choose the best arterial access approach or sheath size for a patient.
Similar to Protocol For Endovasc Repair Of Rupture A A (20)
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
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Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
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2. JOURNAL OF VASCULAR SURGERY
2 Mehta et al July 2006
ruptured AAA (r-AAA), although it is associated with a patient evaluation by the emergency department physician
high morbidity and mortality ranging from 35% to 80%.5–7 who alerted the on-call vascular surgeon and the operating
Recently, several centers have reported on the feasibility room (Fig). While in the emergency department, each
and efficacy of EVAR for treating r-AAAs; however, ambi- simulation patient had an expeditious CT scan and was then
guity remains among the vascular surgeons about the wide transported to the operating room equipped with fluoro-
acceptance of an endovascular approach for treating r- scopic equipment. The operating room staff was set up for
AAAs. endovascular and open surgical AAA repair. The proce-
There are several reasons for our failure to adopt the dures were well rehearsed with the anesthesiologists, the
endovascular means for treating r-AAAs: unavailability of operating room staff, and the radiology technicians that
preoperative computed tomography (CT) in patients with were knowledgeable of the sequence of steps involved.
r-AAAs, unavailability of a dedicated operating room and All procedures were performed in the operating room
ancillary staff equipped to perform emergent EVAR at all with general anesthesia via bilateral femoral cutdown. The
times, unavailability of off-the-shelf stent-grafts, and the stent-grafts used were currently approved by United States
lack of data from multicenter randomized trials. We too Food and Drug Administration (FDA) and available off the
recognized the limitations of this technology in treating shelf. Although initially only the AneuRx (Medtronic AVE,
patients with r-AAAs in that it was not necessarily the Santa Rosa, Calif) was available as off the shelf for emergent
stent-graft design, but rather our inability to coordinate a use, two other stent-grafts, the Excluder (W. L. Gore &
seamless transition for these patients from the emergency Associates, Flagstaff, Ariz) and Zenith (Cook, Inc, Bloom-
department to the operating room to undergo endovascu- ington, Ind), later gained FDA approval and were available
lar repair. After our first successful attempt of endovascular for treating patients with r-AAAs. The selection of particu-
r-AAA repair, it was all too obvious that a strict protocol lar stent-grafts was up to the discretion of the surgeon and
was needed to streamline the patient through-put from the determined primarily by the anatomic limitations of pa-
emergency department to an operating room that was fully tient’s aortoiliac morphology.
equipped with trained interventional surgeons, anesthesi- After a femoral artery cutdown, ipsilateral access was
ologists, and staff (nurses and interventional radiology obtained into the descending thoracic aorta using a floppy
technicians) to expeditiously perform EVAR in emergent guidewire and a guiding catheter. The floppy guidewire was
settings. exchanged for a super-stiff wire that was used to place a
We therefore established a protocol that trained these large sheath (12F to 22F) in the ipsilateral femoral artery. A
health care providers who would be involved in treating 33-mm or 40-mm compliant Equalizer occlusion balloon
patients with r-AAAs by simulating these emergent circum- catheter (Boston Scientific/Medi-Tech, Natick, Mass) was
stances on patients with symptomatic AAAs. Once a stan- advanced over the super-stiff wire up to the supraceliac
dardized protocol was established for treating r-AAAs, we abdominal aorta under fluoroscopic guidance and was not
used endovascular means as our primary modality for treat- inflated. Access was then obtained from the contralateral
ing patients with aneurysm rupture. femoral cutdown, and an arteriogram was done to better
define the aortoiliac morphology. Unless anatomically pro-
MATERIAL AND METHODS hibitive, the femoral artery contralateral to the site of aortic
In 2002, we established a multidisciplinary approach occlusion balloon was used for the stent-graft main body.
for treating patients with r-AAAs. This included vascular The patients received intravenous heparin (50 U/kg), the
surgeons, emergency department physicians, anesthesiolo- aortic occlusion balloon was exchanged for a marker flush
gists, operating room staff, radiology technicians, the avail- catheter, and an aortogram was done to better define the
ability of a variety of stent-graft sizes and types, and an aortic neck morphology. The remainder of the EVAR was
operating room that was adequately equipped to perform conducted in routine fashion.
endovascular procedures with an OEC-9800 (GE OEC It was only after five patients with symptomatic AAAs
Medical Systems, Salt Lake City, Utah) mobile fluoroscopic underwent simulation of patients presenting with r-AAAs
unit. Initially, we established treatment algorithms for r- that we routinely adopted the endovascular approach for
AAAs and rehearsed modus operandi with all the emer- treating r-AAAs at our institution. There were a few differ-
gency department physicians, designated operating room ences in the treatment algorithm of nonsimulation patients
staff that would participate in EVAR, anesthesiologists, and that presented with r-AAAs. The only exclusion criterion
the radiology technicians. In doing so, we accomplished was a preoperative CT scan indicating an aneurysm clearly
getting them interested in understanding the implications unsuitable for endovascular repair. We accepted an aortic
of emergent diagnosis and treatment in this setting. Be- neck length 5 mm, and inability to gain access from the
cause a patient with a r-AAA can present at any time, we femoral arteries was never a limiting factor. The stent-grafts
rehearsed the procedure with staff who worked through the were oversized 15% to 20% based on the maximum aortic
morning, evening, and night shifts. neck diameters.
Five patients with symptomatic but not r-AAAs who When the infrarenal aortic neck for endovascular repair
were deemed suitable for endovascular repair underwent a was sized, the location of measurements varied depending
simulation of patients presenting to the emergency depart- on the type of stent-graft used. Aortic neck sizing for the
ment with r-AAAs. The simulation included an expeditious Excluder stent-graft was done from inner wall to inner wall,
3. JOURNAL OF VASCULAR SURGERY
Volume 44, Number 1 Mehta et al 3
Figure. A uniform triage protocol was established for endovascular repair of ruptured abdominal aortic aneurysms
(r-AAA). ER, Emergency room; CTA, computed tomographic angiography; BP, blood pressure; EVAR, endovascular
aneurysm repair.
as recommended by the guidelines of the pivotal phase II anticoagulate patients during these procedures. We found
trials. For the AneuRx and Zenith, the aortic neck measure- an increased activated partial thromboplastin time to be a
ments were done from outer wall to outer wall. significant risk factor for the development of abdominal
Other limitations were that of the on-call surgeon’s bias compartment syndrome in these patients.10
and unease in performing EVAR in emergent settings and In patients with hemodynamic instability or anatomic
the lack of available endovascularly trained staff at hospitals limitations that precluded expeditious exclusion of the
other than Albany Medical Center where this study was r-AAA, modular bifurcated stent grafts were converted to
conducted. A preoperative CT scan, when unavailable from aortouniiliac (AUI) devices by deploying aortic cuffs (An-
referring institutions, was only obtained in hemodynami- euRx, Excluder, or Zenith AUI converter) across the stent-
cally stable patients. Unstable patients with systolic blood graft flow-divider. The contralateral iliac artery was inter-
pressures 80 mm Hg who could not safely undergo a rupted by open ligation, endoluminal occlusion, or
preoperative CT scan were taken directly to the operating placement of a covered stent from the internal iliac artery
room. We routinely used the technique of hypotensive into the external iliac artery, and femorofemoral bypass was
hemostasis in all patients with r-AAAs by limiting resusci- performed.
tation and maintaining a detectable blood pressure to limit Perioperative data were prospectively collected in a
the potential for ongoing hemorrhage.8 –9 vascular surgery registry to analyze the outcomes of pa-
We used brachial artery access for placement the su- tients undergoing endovascular repair for r-AAAs
praceliac aortic occlusion balloon catheter in the initial two
cases; subsequently, we have routinely used the femoral RESULTS
approach for placement of aortic occlusion balloon, as In all five patients with symptomatic AAAs who under-
needed. went simulation of r-AAA, endovascular repair was un-
Earlier in our experience, patients received systemic eventful. The mean procedure time was 80 minutes (range,
heparinization during EVAR for r-AAAs, but we no longer 35 to 125 minutes), the mean blood loss was 260 mL
4. JOURNAL OF VASCULAR SURGERY
4 Mehta et al July 2006
Table I. Demographics of patients presenting with a Table II. Procedural characteristics of patients with a
ruptured abdominal aortic aneurysm ruptured abdominal aortic aneurysm
Characteristic N 40 (%)* Characteristic N 40 (%)*
Male 29 (73) Patient hemodynamically stable 30 (75)
Mean age, years (range) 74 (54–88) Patient hemodynamically unstable 10 (25)
Coronary artery disease 26 (65) Preoperative CT available 30 (75)
Hypertension 23 (58) Need for aortic occlusion balloon 7 (18)
COPD 7 (18) Stent-graft conversion to AUI device 6 (15)
Renal insufficiency 2 (5) Mean operative time, minutes (range) 80 (35–125)
Diabetes 9 (23) Mean blood loss in mL (range) 455 (150–1100)
COPD, Chronic obstructive pulmonary disease. CT, Computed tomography; AUI, aortouniiliac.
*Data presented are numbers (%) or means (ranges). *Data presented are numbers (%) or means (ranges).
(range, 150 to 400 mL), and the average length of hospital Table III. Morbidity and mortality after endovascular
stay was 1.4 days (range, 1 to 2 days). None of the patients ruptured abdominal aortic aneurysm
had complications of myocardial infarction, renal insuffi-
ciency, respiratory failure, wound infections, stent-graft Event N 40 (%)*
migration, or limb thrombosis. One patient with persistent
Myocardial infarction 2 (5)
type II endoleak 6 months after EVAR underwent success- Respiratory failure 2 (5)
ful translumbar coil embolization of the aneurysm sac. Renal failure, dialysis 2 (5)
Since 2002, 85 patients presented to our institution Ischemic colitis 2 (5)
with r-AAAs and underwent endovascular (n 40, 47%) or ACS 7 (18)
Mean hospital LOS (days)
open surgical repair (n 45, 53%). Overall, EVAR was Without ACS (range) 9 (2–26)
attempted in 42 patients, and two patients (4.8%) in our With ACS (range) 34 (8–83)
earlier experience were converted to open surgical repair Mortality
because of technical difficulties encountered during the Without ACS 3/33 (9)
With ACS 4/7 (57)
procedure that precluded expeditious r-AAA exclusion.
Overall mortality 7 (18)
During the emergent open surgical conversion, a com-
pliant aortic occlusion balloon catheter was left at the level ACS, Abdominal compartment syndrome; LOS, length of stay.
*Data presented are numbers (%) or means (ranges).
of the supraceliac aorta and was ready for aortic occlusion,
if needed. Forty patients with r-AAAs underwent EVAR
with the AneuRx (n 9, 23%), Excluder (n 27, 68%), or nulate the contralateral gate. The mean external blood loss
the Zenith (n 4, 10%) stent-grafts. The mean age was 73 was 455 mL (range, 150 to 1100 mL) (Table II).
years (range, 54 to 88 years), and pre-existing comorbidi- The overall mortality rate was 18% (7 of 40). One
ties included coronary artery disease in 26 (65%), hyperten- patient died 1 hour of the procedure due to myocardial
sion in 23 (58%), chronic obstructive pulmonary disease in infarction, and the rest of the deaths were secondary to
seven (18%), renal insufficiency not on dialysis in two (5%), multisystem organ dysfunction. In two patients (5%) each,
and diabetes in nine (23%) (Table I). morbidities included myocardial infarction, renal failure
Fourteen patients (38%) were diagnosed with r-AAAs requiring dialysis, respiratory failure requiring tracheot-
at another hospital and were transferred to us, and 26 (62%) omy, and ischemic colitis requiring colon resection and
presented directly to the emergency department at our colostomy; and seven patients (18%) had abdominal com-
institution. At the initial presentation, 30 patients (75%) partment syndrome (ACS) (Table III). Although the over-
were hemodynamically stable and either had a CT scan at an all mean hospital length of stay was 15 days, it was much
outside hospital or in our emergency department, and 10 higher for patients who developed ACS (mean, 34 days;
(25%) hemodynamically unstable patients were rushed to range, 8 to 83 days) than for patients who did not develop
the operating room for EVAR without a preoperative CT ACS (mean, 9 days; range, 2 to 26 days) (Table III).
scan. The mean time from the presumptive diagnosis of a Over a mean follow-up of 17 months, three patients
r-AAA in the emergency department to the operating room with endovascular r-AAA repair required four secondary
for EVAR was 20 minutes (range, 10 to 35 minutes), and procedures. One patient with an angulated aortic neck
the mean operative time from skin incision to closure was presented with stent-graft migration from the proximal
80 minutes (range, 35 to 125 minutes). fixation site at the 6-month follow-up and underwent suc-
During the procedure, supraceliac aortic occlusion bal- cessful placement of an aortic cuff. The second patient
loon was required in seven patients (18%): one from the refused to attend follow-up after the initial endovascular
brachial approach, and the remainder from the femoral r-AAA repair, but presented at 16 months with a recurrent
approach. In six patients (15%), modular bifurcated stent- r-AAA secondary to stent-graft migration from the proxi-
grafts were converted to AUI devices due to ongoing mal fixation site. He underwent a successful endovascular
hemodynamic instability and inability to expeditiously can- repair of the recurrent r-AAA with placement of an aortic
5. JOURNAL OF VASCULAR SURGERY
Volume 44, Number 1 Mehta et al 5
cuff at the proximal infrarenal aortic neck. The third patient the patient survived, there was a lack of coordinated effort
presented at 6 months with a type II endoleak and an among the emergency department staff, operating room
increase in AAA sac diameter and underwent translumbar staff, anesthesiologists, radiology technicians, and the vas-
aneurysm sac coil embolization. He presented at 9 months cular surgeon.
with stent-graft migration from the proximal fixation site at We therefore established a standardized approach to
the aortic neck that required placement of a proximal aortic the endovascular procedure and obtained an adequate in-
cuff. At the 12-month follow-up, he had a persistent type II ventory of commercially available stent-grafts, catheters,
endoleak and a further increase in the maximum aneurysm wires, balloons, sheaths, and fluoroscopic equipment in the
sac diameter from 8.5 cm to 11 cm. He subsequently had a operating room. Although we were able to acquire a sub-
successful elective conversion to open surgical repair and stantial inventory of stent-grafts in that we have had the
stent-graft explant. availability of all sizes that the Excluder, AneuRx, and
Since 2002, we have also treated 45 patients with Zenith offered, we do not think a large inventory is neces-
r-AAAs via open surgical approach, with a mortality of 51%. sary for treating patients with r-AAAs. We recommend that
These patients did have a selection bias in that they either surgeons and interventionists should be comfortable per-
presented at an outside hospital that was not adequately forming endovascular aneurysm repair under elective cir-
equipped for endovascular procedures due to lack of equip- cumstances and have an inventory of standard equipment
ment and endovascularly trained staff, or the on-call sur- (wires, catheters, sheaths, balloons, particularly large, com-
geon was reluctant to pursue endovascular treatment for pliant aortic occlusion balloons, and fluoroscopic equip-
r-AAAs. Only three (6.7%) of the 45 patients with pararenal ment) before attempting endovascular repair of r-AAAs.
aortic aneurysms had aortoiliac morphology that was pro- Surgeons and interventionalists who are involved in estab-
hibitive for endovascular r-AAA repair. Since 2002, the lishing an endovascular program for treating r-AAAs
overall mortality of patients undergoing open surgical and should choose the stent-grafts they are most comfortable
endovascular r-AAA repair was 35% (30 of 85). using and should get the sizes to match the largest aortic
neck diameter and the shortest aneurysm length, and a
DISCUSSION variety of iliac extensions. We recommend the following
The mortality rate of open surgical repair for r-AAAs stent-graft inventory: for the Excluder, a 28.5 mm 140
remains notably high, from 32% to 70%.5–7 Although en- mm and a 24 mm 140 mm; for the AneuRx, a 28 mm
dovascular r-AAA repair remains experimental, it is evolv- 135 mm and a 24 mm 135 mm; and for the Zenith, a 32
ing and offers the potential for improved outcomes in mm 77 mm, and a 28 mm 77 mm.
patients that otherwise have a high morbidity and mortal- Once adequate equipment was acquired, we rehearsed
ity. In our experience, a multidisciplinary approach that the procedure with all health care providers who would be
involves the vascular surgeon, emergency department phy- involved in treating patients with r-AAAs, and established a
sicians, anesthesiologists, operating room staff, radiology uniform triage protocol (Fig). The emergency department
technicians, the availability of a variety of available off-the- physician would alert the vascular surgery team, the oper-
shelf stent-grafts, and an operating room that is adequately ating room staff, and the radiology technician, and obtain a
equipped to perform endovascular procedures is crucial in CT in hemodynamically stable patients with systolic blood
obtaining better outcomes. After establishing a protocol for pressure 80 mm Hg. All other patients were directly
endovascular treatment of r-AAAs, we were able to expe- transferred to the operating room that was ready and
dite the recognition and treatment of patients with r-AAAs, equipped to perform both endovascular and open surgical
resulting in a survival rate of 82% when patients were procedures. As long as the patients maintained a measur-
treated by endovascular means, which is markedly im- able blood pressure, the technique of hypotensive hemo-
proved compared with the historical data of open surgical stasis was used in all patients, limiting resuscitation to
repair for AAA rupture. maintain a detectable blood pressure to help minimize
This study is unique in that 25% of the patients with ongoing hemorrhage.8,11 These standardizations led to an
r-AAAs were hemodynamically unstable and did not have a acceptable transfer time (mean, 20 minutes) of patients
preoperative CT scan to evaluate their aortoiliac morphol- from the emergency department to the operating room.
ogy before endovascular repair, and all patients were Lloyd et al12 recently published their data on a time-
treated with commercially available off-the-shelf stent- to-death study in patients with r-AAAs who did not un-
grafts with a standardized endovascular approach. dergo any treatment.12 Their findings indicate that 88% (49
Despite the technique, treatment of r-AAAs can be of 56) died 2 hours after admission with the diagnosis of
arduous and requires a synchrony of events for optimum a r-AAA. The median time interval from the onset of
patient outcomes. With the changing paradigm and the symptoms to admission to the hospital was 2.5 hours, and
evolution of EVAR for treating r-AAAs, a coordinated the interval between hospital admission with the diagnosis
multidisciplinary approach is increasingly crucial. Although of r-AAA and death was 10.5 hours. Their data also suggest
we have had a substantial experience with elective endovas- that most patients with r-AAAs have time to undergo an
cular AAA repair, our first attempt of endovascular r-AAA expeditious CT scan before repair.
repair was disheartening as we realized our deficiencies in The decision to use a particular stent-graft type and size
treating patients under emergent circumstances. Although was determined by the patient’s aortoiliac morphology. In
6. JOURNAL OF VASCULAR SURGERY
6 Mehta et al July 2006
25% of patients that were hemodynamically unstable and juxtarenal aorta when the stent-graft fails to accommodate
did not have a preoperative CT scan, the device selection the angulated aortic neck.
was based on intraoperative angiographic findings; we have In the setting of hemodynamic instability or anatomic
routinely oversized the stent-graft generously when sizing limitations that precluded expeditious exclusion of the
is based solely on intraoperative arteriographic findings. We r-AAA, temporary use of aortic occlusion balloon was re-
recognize that stent-graft sizing based only on arterio- quired in seven patients (18%). Like others, we also have
graphic findings can sometimes be misleading. Our goal in used the brachial approach for placement of the aortic
endovascular r-AAA repair has been to exclude the aneu- occlusion balloon; however, we prefer to use the femoral
rysm at presentation and get the patient though the initial approach and have found this to have several advantages:
high-risk period, even at the cost of an elective secondary
1. It allows the anesthesia team to have access to both
procedure or conversion to open surgical repair once the
upper extremities for arterial and venous access.
patient is hemodynamically stable.
2. Patients who require the aortic occlusion balloon are
Although we did not use intravascular ultrasound guid-
often hypotensive, and percutaneous brachial access can
ance, one can speculate on its usefulness in identifying
be difficult in these patients and more time consuming
proximal and distal stent graft landing sites in patients
than femoral cutdown.
without a preoperative CT scan.
3. The currently available aortic occlusion balloons require
In patients with a difficult anatomy, hybrid stent-grafts
at least a 12F sheath, which requires a brachial artery
were used by combining pieces from different manufactur-
cutdown and repair, and stiff wires and catheters across
ers (Excluder, AneuRx, and Zenith). In a recent analysis
the aortic arch without prior imaging under emergent
comparing morphologic features of intact and ruptured
circumstances might lead to other arterial injuries, or
aortic aneurysms, our findings after evaluating 39 CT scans
embolization causing a stroke, or both.
of patients with a r-AAA indicate that most (85%) were
suitable for endovascular repair if the inclusion criteria were Although distal migration of the aortic occlusion bal-
modified to include aortic neck length of 10 mm and loon by the blood flow can occur when the femoral ap-
neck diameter of 30 mm. Hinchliffe et al13 have also proach is used, this can be easily overcome by placing the
analyzed morphologic features of r-AAA. Their findings balloon through a long 12F sheath ( 55-cm length). Once
suggest that only 43% of patients are amenable to endovas- the tip of the sheath is placed in the distal thoracic aorta,
cular ruptured aneurysm repair. Their inclusion criteria just below the level of aortic occlusion balloon, it can be
were strict, however, and similar to that of pivotal EVAR used to support the occlusion balloon and prevent distal
trials: aortic neck length 15 mm, neck diameter 30 mm, migration. Once the stent-graft is adequately positioned at
and iliac artery diameter 22 mm.13 the aortic neck, the occlusion balloon is deflated and with-
Since the primary objective of treating r-AAAs is to drawn with the sheath into the aortic aneurysm sac (while
increase patient survival, we believe that the use of a mod- maintaining wire access), and the stent-graft is deployed.
ified anatomic inclusion criteria for EVAR in these patients The modular bifurcated stent-grafts were converted to
is justified as long as the patients undergo vigilant follow-up AUI devices in six patients (15%), and all patients with the
and evaluations for the possible complications of stent-graft AUI devices also had a femorofemoral bypass and contralat-
failure. With this approach, we have been successful in 95% eral common iliac artery interruption via ligation and coil
of patients (40 of 42) who underwent an attempted EVAR embolization in four, or endovascular external-to-internal iliac
for rupture. At a mean follow-up of 17 months, the inci- bypass with a covered stent in two. In our experience, there
dence of secondary interventions in 33 survivors was only was a selection bias in that most patients who underwent
12% (4 procedures in 3 patients), and elective open surgical conversion of bifurcated stent-grafts into AUI devices were
conversion was 3% (1 patient). hemodynamically unstable and required aggressive resuscita-
None of the three patients who required secondary tion. One can speculate that perhaps ongoing retroperitoneal
procedures had any significant morbidity or mortality. All hemorrhage in these patients could have contributed to ACS
had undergone EVAR with the AneuRx stent-graft, and in 67% of patients (4 of 6) with AUI devices.
migration from the proximal fixation at the infrarenal aortic One can also speculate whether the primary use of AUI
neck was the primary cause of stent-graft failure. A detailed devices for these patients might lead to less blood loss and
evaluation of the infrarenal aortic neck anatomy in this decreased morbidity and mortality. The use of AUI stent-
cohort indicated that the aortic neck angulation (infrarenal grafts was first reported by the Montefiore group with the use
aortic neck of the AAA) was approximately 60° in two of a surgeon-made Montefiore Endovascular Grafting System
patients and 45° in the third patient. None of these patients (MEGS), which included a large balloon-expandable stent
had an aortic neck diameter 26 mm or an aortic neck (Palmaz 4910) sutured to a thin-wall expandable polytetra-
length 15 mm. As one might expect, migration from the fluoroethylene graft, in conjunction with contralateral com-
proximal fixation sites in two of these patients could have mon iliac artery interruption and a femorofemoral bypass.8,11
been attributed to the significant aortic neck angulation. In their experience of 30 patients with r-AAAs who under-
The number of patients is too small to make any drastic went endovascular repair, preferably with the MEGS since it
changes on our approach to patients with angulated aortic was readily available and off the shelf, the incidence of ACS
necks; however, we often place a Palmaz (5010) stent at the was 3% (1 of 30), and the overall mortality was 11%.
7. JOURNAL OF VASCULAR SURGERY
Volume 44, Number 1 Mehta et al 7
In our experience of endovascular r-AAA repair, the inci- Critical revision of the article: MM, RCD, PBK, KJO,
dence of ACS was much higher at 18% (7 of 40) than previous PSKP, BBC, SPR, DMS, YS
reports. One might expect a higher incidence of ACS, because Final approval of the article: MM, JBT, RCD, PBK, KJO,
our protocol did not exclude hemodynamically unstable pa- PSKP, BBC, SPR, DMS, YS
tients with r-AAAs from undergoing EVAR. The resulting Statistical analysis: Not applicable
overall mortality was 18% (7 of 40); however, patients without Obtained funding: Not applicable
ACS experienced far less mortality at 9% (3 of 33) compared Overall responsibility: MM
with 57% (4 of 7) in those with ACS.
Our findings are supported by several other recent articles
on the endovascular treatment of r-AAAs.14 –22 Although REFERENCES
these studies have smaller numbers and do not include estab- 1. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, Van Sambeek MR,
lishment of a standardized protocol based on a simulation of Balm R, et al. A randomized trial comparing conventional and endovas-
patients presenting to the emergency department with r- cular repair of abdominal aortic aneurysms. N Engl J Med 2004;351:
1607-18.
AAAs, they support our findings of a limited morbidity and
2. Blankensteijn JK, De Jong SECA, Prinssen M, van der Ham AC, Buth
mortality in patients undergoing endovascular r-AAA repair. J, van Sterkenburg SM, et al. Two-year results of a randomized trial
This study is a prospective analysis of outcomes based on a comparing conventional and endovascular repair of abdominal aortic
protocol for endovascular treatment of r-AAAs; however, it aneurysms. N Engl J Med 2005;352:2398-405.
has several limitations: patients were not randomized to en- 3. The EVAR Trial Participants. Comparison of endovascular aneurysm repair
dovascular vs open surgical repair, preoperative CT scans were with open repair in patents with abdominal aortic aneurysms (EVAR trial
1): randomized controlled trial. Lancet 2005;365:2179-86.
not available in all patients to establish suitability for endovas-
4. The EVAR Trial Participants. Does endovascular aneurysm repair im-
cular repair, and the on-call surgeon’s bias and unease in prove outcome in patients unfit for open repair with abdominal aortic
performing EVAR in emergent settings. aneurysms (EVAR trial 2): randomized controlled trial. Lancet 2005;
365:2187-92.
CONCLUSION 5. Noel AA, Gloviczki P, Cherry KJ, Bower TC, Panneton JM, Mozes GI,
Endovascular repair of r-AAAs is evolving and offers the et al. Ruptured abdominal aortic aneurysms: the excessive mortality rate
of conventional repair. J Vasc Surg 2001;34:41-6.
potential for improved outcomes, particularly in patients who
6. Perez MA, Segura RJ, Sanchez J, Sicard G, Barreiro A, Garcia M, et al.
otherwise have a high mortality of open surgical repair. Most Factors increasing the mortality rate for patients with ruptured abdom-
patients with a r-AAA can be treated with currently available inal aortic aneurysms. Ann Surg 2001;15:601-7.
bifurcated modular stent-grafts, and AUI devices are required 7. Harris LM, Faggioli GL, Fiedler R, Curl GR, Ricotta JJ. Ruptured
in only 15%. We recommend that a standardized protocol for abdominal aortic aneurysms: Factors affecting mortality rates. J Vasc
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8. Veith FJ, Ohki T, Lipsitz EC, Suggs WD, Cynamon J. Endovascular grafts
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the vascular surgeons, and the availability of adequate equip- 9. Crawford ES. Ruptured abdominal aortic aneurysms. J Vasc Surg
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ment algorithm can minimize delays and even lead to treat- 10. Mehta M, Darling RC 3rd, Roddy SP, Fecteau S, Ozsvath KJ, Kreien-
berg PB, et al. Factors associated with abdominal compartment syn-
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Furthermore, the anatomic inclusion criteria for EVAR aneurysms. J Vasc Surg 2005;42;1047-51.
should be modified to accept patients who would under 11. Ohki T, Veith FJ. Endovascular grafts and other image-guided catheter-
elective circumstances be considered to have an unfavorable based adjuncts to improve the treatment of ruptured aortoiliac aneu-
anatomy. Preoperative CT is not an absolute necessity. As rysms. Ann Surg 2000;232:466-79.
long as adequate proximal and distal sealing can be obtained 12. Lloyd GM, Brown MJ, Norwood MGA, Deb R, Fishwick G, Bell PRF,
et al. Feasibility of preoperative computed tomography in patients with
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promising and warrant further randomized controlled inves- Comparison of morphological features of intact and ruptured aneu-
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AUTHOR CONTRIBUTIONS 15. Gerassimidis TS, Papazaglou KO, Kamparoudis AG, Konstantindis K,
Karkos CD, Karamanos D, et al. Endovascular management of ruptured
Conception and design: MM, RCD, PBK, KJO, PSKP, abdominal aortic aneurysms: 6 year experience from a Greek center. J
BBC, SPR, DMS Vasc Surg 2005;42:615-23.
Analysis and interpretation: MM, JBT, RCD, PBK, KJO, 16. Lee WA, Hirneise CM, Tayyarah M, Huber TS, Seeger JM. Impact of
endovascular repair on early outcomes of ruptured abdominal aortic
PSKP, BBC, SPR, DMS, YS
aneurysms. J Vasc Surg 2004;40:211-5.
Data collection: MM, JBT, RCD, PBK, KJO, PSKP, BBC, 17. Peppelenbosch N, Yilmaz N, van Marrewijk C, Buth J, Cuypers P,
SPR, DMS, YS Duijm L, et al. Emergency treatment of acute symptomatic and rup-
Writing the article: MM, JBT, RCD tured abdominal aortic aneurysms. Outcome of a prospective-
8. JOURNAL OF VASCULAR SURGERY
8 Mehta et al July 2006
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2004;27:450-1. berger U, et al. Endovascular repair with bifurcated stentgrafts under
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abdominal aortic aneurysms: a shift of paradigm? J Endovascular Ther- Eur J Vasc Endovasc Surg 2002;23:528-36.
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19. Scharrer-Pamler R, Kotsis T, Kapfer X, Gorich J, Sunder-Plassmann L. based adjunct to improve the treatment of ruptured aortoiliac aneu-
Endovascular stent-graft repair of ruptured aortic aneurysms. J Endo- rysms. Ann Surg 2000;232:4-79.
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20. Resch T, Malina M, Lindbald B, Dias NV, Sonesson B, Ivancev K.
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INVITED COMMENTARY
Takao Ohki, MD, New York, NY
At Montefiore, we performed our first endovascular aneurysm was achieved after developing a hospital-wide protocol, rehearsing
repair (EVAR) for ruptured abdominal aortic aneurysm (r-AAA) in it, and building a multidisciplinary team. They have ironed out the
1994, and since then, we have pushed this technology in an details, which are of paramount importance under this urgent
attempt to apply it to as many patients as possible.1 Use of aortic setting. I recommend all the physicians who currently treat r-AAA
occlusion balloons, permissive hypotension, preferential use of to read this practical paper. It may be beneficial to post the
percutaneous delivery, and local anesthesia led to the increased algorithm (Fig 1) in the emergency department and the operating
penetration of this technology. Such efforts led to improved out- room.
come at Montefiore, but this could not be reproduced readily I agree with Dr Mehta that EVAR is the treatment of choice in
elsewhere. One reason is that the early pioneers, including our- most cases of r-AAA; however, we should not forget that a poorly
selves, failed to publish and describe the logistic details and its prepared and ill-executed EVAR for r-AAA is worse than a well-
importance for performing EVAR for r-AAA. executed open repair. The fact that the mortality rate after open
What good is a gifted endovascular surgeon who doesn’t have repair is 70% to 80% does not give one a blank check to do
the appropriate catheters and stents? What good is a high quality
anything, including EVAR.
C-arm, if the patient is lying on a table that is not compatible with
fluoroscopy? What good is a well-executed EVAR accomplished in
60 minutes if the intensivist/anesthesiologist has already infused REFERENCE
10,000 mL of crystalloid? (Ruptured AAA reflex). Indeed, “the
devils are in the details.” 1. Ohki T, Veith FJ. Endovascular grafts and other image-guided catheter
Dr Mehta and the group are congratulated for this fine study based adjuncts to improve the treatment of ruptured aortoiliac aneu-
in which improved survival after EVAR and open repair for r-AAA rysms. Ann Surg 2000;232:466-79.