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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