37
Sarah Alarabi PGY-2 7/28/2009

Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Embed Size (px)

DESCRIPTION

 

Citation preview

Page 1: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Sarah Alarabi PGY-2

7/28/2009

Page 2: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Cc: low back and right buttock painHPI:

56M brought by ambulance to ED with a two day history of progressive low back pain. Patient has described it as occasionally sharp. He took ibuprofen and tylenol to help alleviate the pain to no avail. On the morning of his presentation, the pain radiated to the right buttock and became very sharp and unbearable enough to come to the ED. He began to feel weak upon his arrival.

PMH: perforated ulcerPSH: ex lap for perforated ulcer with “patch”

repair according to family members

Page 3: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

SH:Smokes 1ppdOccassional ETOHNo admitted hx of illicit drug use

Allergies: NKDAMeds: ibuprofen and tylenol

Page 4: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Initial ED course prior to exam:Pt had arrived with bp 60/40BP rose, without resuscitation, to 90/50Pt underwent CT and surgery was called

secondary to resultsPE:

128/90 92 50 afebrileGenerally fatigued appearanceRapid rhythmTachypniec, CTABLDistended, firm abdomen, +BSAFQ, no pulsatile

mass on palpation

Page 5: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Aneurysm is defined as a permanent and irreversible localised dilation of a blood vessel At least 50% increase compared to normal

M aorta 1.4-2.4 cm infrarenal aorta (AAA 3cm<)F 1.2-2.1 cm infrarenal aorta (AAA 2.6cm<)

Page 6: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

First described in Ebers Papyrus (2000 BC) in peripheral arteries

Antyllus performed first repair of aneurysm in 2nd century by incising it and evacuating its contents

Hunter “fixed” a popliteal artery on a coachman by ligating it after concluding that the patient had developed enough collateral arteries for the limb to survive (1785)

Cooper (one of Hunter’s pts) performed a similar repair for an iliac artery, but the pt did not survive the aortic ligation for more than 2d.

Matas (from New Orleans) buttressed the vessels and ligated the collaterals, 1906

Carrell won Nobel prize 1912 for anastomoses techniques

Debakey, Hopkins, Vorhess (prosthetic graft) added to the developments

Juan Parodi introduced EVAR (endovascular aortic aneurysm repair)

History

Page 7: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

True All 3 layers are involved

False (pseudoaneurysms) not all 3 layers

By morphology Fusiform: symmetrical Saccular: only part of the circumference (higher risk for

rupture)By etiology

Degenerative: by atherosclerotic changes Congenital: rare Other etiologies include mycotic infection, blunt trauma,

iatrogenic (most common site is infrarenal aorta, 65%) (most common site peripherally is the popliteal, 70%)

Page 8: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

No single theory has been accepted What we do know is the following:

90% are associated with athersclerosis Elastin and collagen play a key role with respect to their

degeneration Elastases to memorise: MMP-2, 9, and 12 have increased

expression in aneurysmal tissue (they return to normal levels once repair is made)

Histologically you will find a lot of plasma cells in the media & t cells in the adventitia, leading many to believe that cytokine release has a significant role in aneurysm formation

As many as 50% of aortic aneuryms demonstrate chlamydia pneumoniae

Genetics plays a role in 15-25% of pts Enlargement is governed by Laplace’s Law:

T=PR (t=tangential stress, r=radius, p=transmural pressure) This does not take into account wall thickness (where t=pr/gamma)

Pediatric diseases associated include: Tuberous sclerosis, behcet disease, marfan syndrome, ehlers-danlos

syndrome, infection from umbilical artery catheters

Page 9: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Most common in infrarenal regionClassification:

I – infrarenalII – juxtarenalIII – pararenalIV – suprarenal

Iliacs involved in 40% (90% of which are in common iliacs)

Generally increasing in frequency secondary to increasing aging population and increase in diagnostic imaging

Page 10: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Exact cause is unknownAge

Increases in M over 55 (peak at 6% in 80-85)Increase after 70 in F (peak at 4.5% in 90+)• Gender – 4-5:1 b/n 60-70, then 1:1 after 80

Race - Caucasian (2-3:1::C:B)Tobacco use – 78% assoc with tobacco (8:1)Family hx – 11:1 if first degree relative

Page 11: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Only 50% of ruptures arrive alive at the hospital

7% died before surgery17% died during surgery37% died within 30 days of surgeryOverall mortality post op is 45%

Page 12: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Risk Factor Low Risk Avg Risk High Risk

Diameter <5cm 5-6cm >6cm

Expansion <0.3cm/yr 0.3-0.6cm/yr >0.6cm/yr

Smoke/COPD None, mild Mod Sever/steroids

FMH No relatives One rel Many rel’s

HTN n/l bp Controlled Poorly controlled

Shape Fusiform Saccular Very eccentric

Gender Male female

Page 13: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Good Risk Moderate Risk High Risk

>70 years 70-80 years 80 years

Physically active Active Inactive, poor stamina

No clinically overt cardiac disease

Stable coronary disease; remote MI; EF >35%

Sig. CAD, recent MI, freq. angina; CHF; EF <25%

Creatinine 2.0-3.0

n/l anatomy Adverse anatomy or AAA characteristics

Creatinine >3

No adverse AAA characteristics

Liver disease (albumin <2)

Anticipated operative mortality 1%-3%

Anticipated operative mortality, 3%-7%

Anticipated operative mortality, at least 5%-10%; each comorbid condition adding approximately 3%-5% mortality risk

Page 14: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

In a consecutive series of 180 pts w/ ruptured AAA, the following factors were independently related to the mortality rate: agesystolic BP < 80 mm

Hghistory of

hypertensionAnginamyocardial infarction

(MI)

In pts who survived surg, causes of death were as follows:   Renal /multisystem

failure (32%) Cardiac failure (29%) Resp failure (17%) Coagulopathy (12%) GI hemorrhage (3%) Perf duod ulcer (1.5%) Renal hemorrhage (1.5%) Hemorrhage from graft

anastomosis (1.5%) Stroke (1.5%) Aspiration (1.5%)

Page 15: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

"Blue Toe Syndrome"

Livedo

Reticularis:

Atheroemboli

from small

abdominal

aortic

aneurysms

Page 16: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

In a series of 226 AAAs in Italy, bleeding occurred into the following regions: Retroperitoneal - 85.3% Peritoneal - 7.1% Inferior vena cava (IVC) or iliac vein - 5.8% Enteric - 1.8%ruptures into the retroperitoneum typically

originate from the L posterior aspect of the AAA

ruptures into the intestine tend to occur from the right anterior aspect

Page 17: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Routine PE Pulsatile mass Radiographic study

Sx Compression by bowel may cause early satiety/n/v Chronic, vague abdominal/back pain Severe/sharp/tearing back pain groin pain syncope, paralysis flank mass

Ruptured Triad: Sudden onset midabdominal/flank pain Shock Presence of a pulsatile abdominal mass The diagnosis may be confused with renal calculus,

diverticulitis, incarcerated hernia, or lumbar spine disease.

Page 18: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

PEFirm, pulsatile abdominal mass “eggshell” calcification on plain filmu/sCT with IV contrast is most precise

Screening is encouraged for pts with risk factors due to the fact that 33% will rupture if undiagnosed; screening cuts risk of rupture by 49%

Once found, if AAA is more than 4.5cm, continued monitoring every 6 months is recommended

Page 19: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Abdominal ultrasonography: used as prelim. determination of aneurysm presence,

size, type, & extent. CT scanning: helps define anatomy of aneurysm

& other intra-abdominal pathologies. location of the renal arteries length of the aortic neckcondition of the iliac arteriesanatomic variants (e.g. retroaortic left renal vein or

horseshoe kidney) Enhanced spiral CT of abdomen & pelvis with

multiplanar reconstruction & CT angiography is the test of choice for preop eval for open & endovascular repair

Nonenhanced CT scanning is used to size aneurysms.

Page 20: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Reduce Risk factorsSmoking cessation is of paramount importanceAggressively control HTNInstitute beta-blocker tx, when possible, to

reduce BP & stress on the artery wall.Repair if 5cm or more for men. Female pt

unfortunately do not have a predetermined size for repair, although it is agreed that it is smaller than the size recommended for men.

Page 21: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

AAA diametre (cm)

Rupture risk (%/y)

<4 0

4-5 o.5-5

5-6 3-15

6-7 10-20

7-8 20-40

>8 30-50

Page 22: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Transperitoneal Approach:Midabdominal incision is made, pertinent

anatomy retracted, aneurysm opened, and graft sutured in place

Retroperitoneal Approach:For pt’s with hostile abdomens (e.g. too many

adhesions)Incision in 10th costal interspace, then on to

similar procedure to TP approach

Page 23: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Prepare the skin from the nipples to the mid thigh.

Administer general anesthesia (with or without epidural anesthesia).

Cell Saver use has become popular.

Place nasogastric tube.T & C blood.

Administer prophylactic antibiotics (cefazolin, 1 g IVPB)

Foley catheterLarge-bore IV access Monitor CVP or

establish Swan-Ganz catheterization (if indicated)

Page 24: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Depending pt's anatomy, the aorta can be reconstructed with:tube graftaortic iliac bifurcation graftAortofemoral bypass

Page 25: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

proximal infrarenal control:identify the L renal (patients may have a

retroaortic vein, <5%). Division of L renal vein is usually required to clamp above the renal arteries

inferior mesenteric artery is sacrificedTo prevent colon ischemia, restore at least one

hypogastric (internal iliac) artery perfusionIf hypogastric arteries are sacrificed (associated

aneurysms), reimplant the inferior mesenteric artery

Identification of the ureters is important

Page 26: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Pt is heparinized (5000 U IV) prior to aortic cross-clamping. If significant intraluminal debris, juxtarenal thrombus,

or prior peripheral embolization is present, the distal arteries are clamped first, followed by aortic clamping.

Before restoring lower extremity blood flow, both forward flow (aortic) and back flow (iliac) are allowed to remove debris.

The graft is also irrigated to flush out debris.Before the patient leaves the OR, determine lower

extremity circulation. If a clot was dislodged at the time of aortic clamping,

it can be removed with a Fogarty embolectomy catheter. Heparin reversal is not usually required.

Page 27: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

By CatheterisationIntraoperative angiogram performedVery successfulVery low riskBut has distinct complications…

Page 28: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Requires CVP and vent placementCXR to confirm placement of above24 hrs of beta-blockade to keep HR below 80

bpmPeri-operative Abx should be stopped within

the first 24 hrs

Page 29: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Event Percentage of Patients Affected, %

Case Fatality Rate, %

Respiratroy failure 48 34

Tracheostomy 14 44

Renal Failure 29 76

Sepsis 24 45

MI/CHF 24 66

Bleeding 17 90

Stroke 6 50

Ischemic colitis 5 67

Lower extremity ischemia

3 17

Paraplegia/paraparesis

2 50

Page 30: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Death - 50% if ruptured

Pneumonia - 5% MI - 2-5% Groin infxn - <5% Graft infxn - <1% Colon ischemia - 15-

20% if ruptured Blue toe syndrome

and cholesterol embolization to feet

Renal failure related to preoperative creatinine level, intraoperative cholesterol embolization, & hypotension

Incisional hernia - 10-20%

Bowel obstruction

Page 31: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Amputation from major arterial occlusion Impotence in males - Erectile dysfunction and

retrograde ejaculation (>30%) Paresthesias in thighs from femoral exposure

(rare) Lymphocele in groin - Approximately 2% Late graft enteric fistula

Page 32: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Type Causes Tx options

I Inadequate seal of proximal or distal end of endograft

Balloon dilationPlacement of additional stents or cuffsOpen conversion

II Flow from backbleeding aaPt lumbar, mid sacral, inf mesenteric, hypogastric, accessory renal aa

ObservationCoil embolisation or glueLaparoscopic ligationOpen conversion

III Fabric disruption or tearModule disconnection

Placement of additional stents or cuffsSecondary endograft

IV Flow from fabric porosity

observation

Page 33: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Types of aortic

stent grafts and

their locations

for use

Page 34: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Ali Azizzadeh; Martin A. Villa; Charles C. Miller III; Anthony L. Estrera; Sheila M. Coogan; Hazim J. Safi, 11/2008

Thirty-four publications representing 1,200 patients with RAAA analysed. Of the 1,200 patients531 (44.3%) underwent endovascular aneurysm

repair (EVARaverage age was 74 years13% were femaleAortouni-iliac grafts were used in 49.4% of patients50.6% received bifurcated graftstechnical success rate was 94.9%The mortality rate following EVAR of RAAA is 30%3.8% reduction in mortality was found for each 10%

increase in the percentage of ruptures repaired endovascularly at each center

Page 35: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

Baseline CT obtained at 3 months postThen 6, 12, and 18 monthsIf leak is more than 5mm, then reintervention

should be considered.

Page 36: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic

The long-term prognosis is related to associated comorbidities. Long-term survival is shortened by CHF &

COPD.Rupture of assoc. thoracic aneurysms also

causes late death.

Page 37: Ruptured Abdominal Aortic Aneurysm.ppt - Ruptured Abdominal Aortic