Ruptured Aneurysm Protocol: Lessons From a Busy Aortic Center

Benjamin W. Starnes MD, FACS

The Alexander Whitehill Clowes Endowed Chair of Vascular Surgery

Professor and Chief;

Division of Vascular Surgery

University of Washington

Seattle, WA

Ruptured Aneurysm Protocol:

Lessons From a Busy Aortic Center

Disclosures

• Co-Founder: AORTICA Corporation

1993- 25 years ago

• SOD Walter Reed

• 71 yo male admitted to Neurology service with

four days of low back pain

• Found down in his room- Code Blue

• Suspected MI- transferred to MICU

• Multiple codes- abdomen becoming distended

• Discussed with VS Attending- CT Scan “STAT”

• 45 minutes later in scanner, Arrested and Died

Hughes. Surg. 1954; 36: 65-8

Clamp Before You Cut:Proximal Aortic Control with Balloon Occlusion

CPT Zachary Arthurs MD, CPT Craig See MD,

COL(R) Charles Anderson MD, and LTC Benjamin Starnes MD

Vascular and Endovascular Surgery Service

Madigan Army Medical Center

Tacoma, Washington2002

Harborview Medical Center

Methods

• Data on all rAAA between January 1, 2004

and October 31, 2014

• Six Data Abstractors

• Pre-hospital, Hospital, Op reports, Laboratory

• Over 37,000 variables

• 95,751 images reviewed from 215 evaluable

CT scans

• 30-day and long-term outcome data

16 Lessons Learned

Lesson #1

• Systems and Protocols Make a Difference

• Algorithms serve as surrogates for an

organized approach to rAAA’s and can be an

overall marker for good quality care

July 2007

IRB-approved protocol

2010

0

10

20

30

40

50

60

70

80

2003 2004 2005 2006 2007 2008 2012

Overall

REVAR

REVAR protocol

P<0.001

57.8%

25.3%

16.3%

Mortality 2012

Lesson #2

• Local or No anesthesia makes a difference

• 90 REVARS

– GETA- 30 day mortality= 25.5%

– Local- 30 day mortality= 16.3%} p=0.2

Br J Surg. 2014 Feb;101(3):216-24 Observations from the IMPROVE trial

concerning the clinical care of patients with ruptured abdominal aortic aneurysm.

Lesson #3

• Aortic Occlusion Balloons make a difference

…and Bide Time

– 12 Fr 55cm Sheath

– CODA (Cook, Inc)

– Placed from straightest iliac

Lesson #4

• 73% Qualify for EVAR

– 95,751 images

– 215 rAAA CTs

– Aortic Neck determines candidacy most often

– Iliac Access rarely an exclusion criteria with newer

devices

PMEG Subject 049

Lesson #5

Harborview Risk Score for rAAA

pH < 7.2

Age > 76

Creat > 2.0

Pre-op SBP < 70mmHg

AUC 0.81*

Compared with 0.64 for

Robinson

Glasgow

and Edinburg Scores

* Based on Linear Discriminant Analysis

Lesson #6

• Permissive Hypotension Works!

Lesson #7

• Mean neck Diam is 26.7mm and Length 17.2mm

– 95,751 images

– 215 rAAA CTs

– Standard Grafts

• 28 – 32 mm

• Inventory helps

• Average size is large at 82.4mm (r:37 to 182mm)

Lesson #8

–Pulse Pressure Variation (PPV) is THE BEST

method of resuscitating these patients in OR!

• Goal < 11% PPV

– The REVAR patients are JUST AS SICK as those

undergoing open repair

– Aggressive resuscitation

– Low Index of Suspicion for:

• Abdominal Compartment Syndrome

• Ischemic Colitis

Lesson #9

Lesson #10

• The incidence of Ischemic Colitis has essentially

evaporated for rAAA’s in the Endovascular Era

Results:303 rAAA

23 died in EDor en route

190 Open Repair 90 REVAR

Ischemic ColitisN=40 (21%)

Ischemic ColitisN=6 (6.7%)

P= 0.03

Lesson #11

• Imaging and Image Transfer Technology has

Revolutionized Systems of Care

Lesson #12

• Bifurcated Endografts are more durable than an

AUI/ Fem-Fem Strategy

Lesson #13

• Type 2 Endoleaks don’t matter after REVAR

Lesson #14

• Type 1 Endoleaks after REVAR do matter, are

rapidly fatal and must be ruled out with any

challenging aortic neck anatomy.

Lesson #15

• Patients who are not EVAR candidates and

undergo an attempt at EVAR die.

rAAA who were candidates for EVAR

Procedure Number (%) 30-day mortality

EVAR 85 (54%) 22.4%

Open 71 (46%) 49.2%

156 P=0.0007

rAAA who were NOT candidates for EVAR

Procedure Number (%) 30-day mortality

EVAR 5 (9%) 100%

Open 49 (91%) 46.9%

54 p=0.024

rAAA who were candidates for EVARrAAA who were NOT candidates for EVAR

Lesson #16

• The More You Do, The Better Your Results!

rAAA who were candidates for EVARrAAA who were NOT candidates for EVAR

Acknowledgements

@benstarnesmd