rAAA and role of EVAR

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

4. OUTLINE
Terminology
Clinical Features
Initial Management Strategies
Fast-track in rAAA
Operative Strategies: Endovascular Repair
Complications of Ruptured Abdominal Aortic Aneurysm
Repair
Ramathibodi Fast-track in rAAA

5. DEFINITION
• RAAA : an abdominal aortic aneurysm (AAA) with extraluminal
blood on computed tomography (CT) or noted clinically at the time of
surgery
• A contained rupture : blood outside the aneurysm sac confined to the
retroperitoneal space.
• A free rupture : bleeding directly into the peritoneal cavity.
Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e

6. RUPTURED AAA
• 50% die before reaching hospital
• 30% who reached hospital die before operation
• Mortality rates remain high and unchanged (50%)1
• Mortality from rAAA remains high despite improvements in
anesthesia, postoperative intensive care, and surgical
techniques2
1 (Cochrane review 2007)
2 (Slater et al. Ann Vasc Surg 2008)

7. • The 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

11. INITIAL
MANAGEMENT
STRATEGIES
J Vasc Surg. 2010 Jul; 44(1):1-8

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

17. EVAR OR OPEN IN RAAA ?

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–

19. EVAR VS OPEN
IN RAAA
Eur Heart J. 2015;36(31):2061–2069.

20. Eur Heart J. 2015;36(31):2061–2069

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

22. EVAR VS OPEN
IN RAAA
Eur Heart J. 2015;36(31):2061–2069.

23. • Tan, T.-W., et al. (2017). "Outcomes of endovascular and open surgical repair of ruptured abdominal
aortic aneurysms in elderly patients." Journal of vascular surgery 66(1): 64-70.
EVAR VS OPEN
IN RAAA
From 2005-2014
Among 1048 elderly
patients who underwent
rAAA repair, 450 (43%) and
598 (57%) were treated with
EVAR and OAR

24. EVAR VS OPEN
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

29. FAST-TRACT IN RAAA

30. MULTIDISCIPLINARY
APPROACH
• Emergency room physicians
• Anesthesiologists
• Operating room (OR) nurses,
• Technologists
• Vascular surgeons.
• Blood bank
Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e

31. Operating room preparation
Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e

32. EQUIPMENT PREPARATION
Endograf
t
Hydrophilic
guide wire Sheaths
Occlusion balloon
Diagnostic
catheter
Stiff wire
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

34. AORTIC
BALLOON

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.

38. aorto-uniliac stent graftBifurcated stent graft

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

40. POST-OPERATIVE
COMPLICATION

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

43. Treatment
LOCAL COMPLICATIONS :ABDOMINAL COMPARTMENT SYNDROME
J Vasc Surg. 2014;59(3):829–842

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.

51. THANK YOU