The Management and Treatment of Ruptured Abdominal ......Mortality of EVAR (22.8%) patients In...

The Management and Treatment of

Ruptured Abdominal Aortic Aneurysm(RAAA)

Disclosure

Speaker name: Ren Wei, Li Zhui, Li Fenghe, Zhao Yu

Department of Vascular Surgery, The First Affiliated Hospital of

Chongqing Medical University

1# Youyi Road, Yuzhong Dist, Chongqing, 400016 China

We do not have any potential conflict of interest to report

.................................................................................Background

➢ The prompt recognition and effective management of RAAA still

have significant challenges in case of emergency

➢ Either delay in recognition of or failure to adequately manage

RAAA remains very common in a few centers

➢ Mortality associated with RAAA is still remarkably high

.................................................................................

➢ A latest review shows more than 190,000 patients with RAAA

died from hemorrhage annually worldwide#

➢ RAAA is the second cause of hemorrhage-related death after

trauma

# Cannon JW. hemorrhagic shock. N Engl J Med. 2018.

...................................................................................................Data and experience from our center

➢ Between 2007 and 2017, 121 patients with RAAA admitted to

our center, 38 (31.4%) patients were died before treatment.

➢ Among 83 treated patients: 57 cases underwent EVAR, 26

cases with open surgical repair (OSR).

➢ Age ranged from 64 to 81, average age: 72.9 ± 8.1 years

➢ 97 male and 24 female, the ratio of male/female: 5:1

➢ The mean aneurysm diameter : 73.1 ±30.5mm (CT scan)

...................................................................................................

Table 1. Comorbidities of patients with RAAA

Characteristics N=121

Coronary artery disease 58(47.9%)

Chronic renal insufficiency 4(3.3%)

Hypertension 62(51.2%)

Chronic obstructive pulmonary disease 41(33.8%)

Diabetes 35(28.9%)

Hyperlipidemia 78(64.5%)

➢ Most of RAAA patients combined with other diseases: e.g.

coronary artery disease, hypertension, diabetes, and so on

..................................................................................................

➢ Sonography was used to rapidly confirm aneurysm presence

in the clinical sign of a patient suspected rupture, then a multi-

sliced computed tomography angiography (CTA) of the entire

aorta from neck to groins is performed immediately

..................................................................................................

➢ RAAA patients with shock were resuscitated using a permissive

hypotensive regimen

➢ Patients with unstabe haemodynamics were treated with

laparotomy operation

..................................................................................................

➢ Aortic balloon occlusion employed occasionally ,but not routinely for

control of bleeding before OSR or EVAR

➢ Swift, definite and complete bleeding control by finger pressure or

clamping during OSR absolutely essential

..................................................................................................

➢ Indications of EVAR for RAAA includes:

Relatively stable haemodynamics.

Good anatomical morphology:Aneurysmal neck diameter < 32 mm,

Enough anchor area for stent: Infrarenal segment length >10 mm,

Access assessment: Iliofemoral diameter >6 mm,

Aortic neck angulation of aneursym< 60°

...................................................................................................

➢ Coil embolization was frequently used to promote thrombosis in

sac during EVAR, and to prevent the stent migration as well as

to avoid the development of type II endoleak

...................................................................................................

➢ Stent graft ( such as Endrant II Medtronic® ) with characteristics of

smooth delivery and precise positioning were considered as preferred

selection for the patients with hostile and difficult anatomical

morphology

...................................................................................................Results

➢ A total of 54 patients died among 121 cases

➢ Mortality of EVAR (22.8%) patients In 24-hours after operation was

greater than that ( 15.4% ) of OSR

➢ No significant difference of 30 days mortality between these two

groups (3.5% in EAVR V.S. 3.8% in OSR)

...................................................................................................

Group EVAR (n=57) OSR (n=26) P value

24 hours mortality % 22.8 (9/57) 15.4 (4/26) 0.025

30 days mortality % 3.5 (2/57) 3.8 (1/26) 0.094

Operation time, min 274±17 151±12 0.041

Blood transfusion, mL 1810±201 330±20 0.001

ICU stay, days 7.5±4.1 3.2±1.4 0.033

ACS % 12.3 (7/57) 7.7 (2/26) 0.022

Table 2. Postoperative outcomes for patients undergoing EVAR

and OSR for RAAA

...................................................................................................

➢ Independent risk factors for death related to operation (both EVAR and

OSR) include Hemoglobin, Blood loss, Rutherford classification

#Rutherford classification of Hemodynamic status: level 3: incomplete response to resuscitation, with persistent or

recurrent hypotension and/or no restoration of urine output; and level 4: negligible response to resuscitation.

Risk factors HR P value 95% CI

Age ≥ 70 years 0.97 0.091 0.421-7.224

Gender, male 0.81 0.070 0.776-10.021

Hemoglobin<9.0 g/dL 2.23 0.011 2.323-7.612

AAA size ≥ 7cm 1.02 0.072 0.238-3.671

Blood loss >2000ml 1.89 0.044 2.299–12.821

Bowel ischemia 2.02 0.035 1.539–7.692

Rutherford classification (level 3, 4)* 4.45 0.012 1.914–11.257

……. … … …

Table 3. High risk factors of death related to operation

Discussion.................................................................................

➢ The 1st 50 years of RAAA

publications noted that the

mortality rate for ruptured repair

has fallen only 3.5% per decade

since the initial successful

repairs were reported.

Bown MJ, et al: Br J Surg 89:714–730, 2002.

.................................................................................

➢ A meta-analysis of publications between

1991 and 2006 suggested no signicant

overall change in mortality with OSR

during this period.

Hoornweg L Eur J Vasc Endovasc

Surg 35:558–570, 2008.

*Mehta M et al. J Vasc Surg. 2013

.................................................................................

➢ The proportion of RAAA treated by EVAR had increased to 31% during

2002 to 2012.

➢ Whereas open survivors require few graft-related interventions, up to

23% of EVAR patients will require reintervention for endoleaks or graft

migration.

..................................................................................................................................................................

study cases mortality complications

EVAR/OSR EVAR OSR EVAR OSR

Giles KA, et al. 2009 121/446 24% 36% 47% 62%

Mandawat A, et al. 2012 64/207 18% 36% 66% 78%

Nedeau AE, et al. 2012 19/55 15.7% 49%

Gupta PK, et al. 2014 499/948 35.6% 52.8%

Von Meijenfeldt GC, 2014 83/138 24% 40% 58% 76%

Giles KA, et al. J Endovasc Ther. 2009 Jun.

Nedeau AE, et al. J Vasc Surg. 2012 Jul.

Mandawat A, et al. J Endovasc Ther. 2012 Feb.

Gupta PK, et al. J Vasc Surg. 2014 Aug.

Von Meijenfeldt GC, et al. Eur J Vasc Endovasc Surg. 2014 May.

➢ Observational studies demonstrated the EVAR patients had a

significantly lower all-cause mortality in than that of the OSR patients

.................................................................................

➢ The widespread preference for endovascular techniques for

elective vascular surgery coupled with fewer and fewer open

vascular surgery cases

➢ However, the coveted benefits of EVAR for RAAA in operative

mortality have not been supported by randomized controlled

trial (RCT)

.................................................................................

➢ Nottingham, Amsterdam and IMPROVE randomized trial revealed

that there are no significant difference in mortality and complication

rate between EVAR and OSR group

.................................................................................

➢ Compared with RCT, potential biases are likely to be greater for

observational studies

➢ In fact, the choice of treatment options more depends on

hemodynamic status of patients, expertise of surgeon and

commercially available products.

.................................................................................

➢ The implementation of a ultrasonography screening program

has been suggested to decrease the incidence of ruptured

aneurysms

➢ The use of ultrasound scanning for people older than 50 years

could reduce the incidence rate of rupture by 49%

.................................................................................

➢ Although the progression of AAA is lentitude, its development is

irreversible. When high risk factors such as hypertension or

arteriosclerosis are combined, rupture may soon occur

➢ In addition, there are some RAAA with a diameter of less than

5cm

➢ Whether the interventions, such as the EVAR, a minimally

invasive treatment, should be performed to the AAA patients who

with the high risk factors of rupture, despite the diameter is less

than 5 cm?

.................................................................................Summary and Conclusion

➢ Effective management of RAAA requires team members with both

skill and experience in open vascular surgery and the capability to

perform timely endovascular techniques

➢ Every effort to maintain preoperative hemodynamic stability, to

reduce volumes of blood loss in operation, and to minimize

postoperative deterioration of organ functions would be essential to

improve patient survival

➢ Continued recognition of patients of non-ruptured aneurysm and

repair in the elective setting with low mortality rate remains the ideal

treatment, either with open or endovascular management

Thanks for your attention!

The Management and Treatment of

Ruptured Abdominal Aortic Aneurysm(RAAA)

Disclosure

Speaker name: Ren Wei, Li Zhui, Li Fenghe, Zhao Yu

Department of Vascular Surgery, The First Affiliated Hospital of

Chongqing Medical University

1# Youyi Road, Yuzhong Dist, Chongqing, 400016 China

We do not have any potential conflict of interest to report