Open Repair of RAAA is always possible -is it always better? No disclosures!! Lazar B. Davidovic MD, PhD, FETCS

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1 Open Repair of RAAA is always possible -is it always better? Lazar B. Davidovic MD, PhD, FETCS Professor of Surgery School of Medicine, University of Belgrade Head of the Clinic for Vascular and Endovascular Surgery Clinical Center of Serbia No disclosures!! President of the ESCVS

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3 2004, 29(1): ; 29 (1): Ann Vasc Surg 2005; 19 (1): Ann Vasc Surg 2016, X: Since 1991: 1035 cases

4 Randomized Controlled Multicenter Trials AJAX, IMPROVE, ECAR 30-day mortality Ann Surg 2013, 258(2): EVAR-21%: OR-25% Br J Surg Feb;101(3): EVAR-35%: OR-37% EVAR-18%: OR-24%

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6 Eur J Vasc Endovasc Surg 2015, 49:

7 Advantages No laparotomy No aortic cross clamping Regional/Local anesthesia Lower blood loss Technical prerequisites MSCT Hybrid theatre Available stent graft Limitations Profound hypovolemic shock Unfavorable anatomy -Aortic neck length < 10 mm -Aortic neck angulation > 60 -Aortic neck diameter < 32 mm -Aortic neck length with reverse taper -Iliac arteries diameters < 6 mm, > 20mm Mid and long-term results Financial limitations

8 Profound Hypovolemic Shock 88% pts with RAAA die >2h after admission Mean time interval onset of symptoms to death 10.5 h Can MDCT be performed? J Vasc Surg 2004, 39:

9 Unfavorable Anatomy Eur J Vasc Endovasc Surg 2014, 47(4):

10 Mid and Long-term Results Br J Surg 2014; 101:

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12 RAAA OR: 30-day-mortality 60,00% 53.7% Ann Vasc Surg 2016, X: ,00% 40,00% 37.4% 30.4% 27.96% 30,00% 20,00% 10,00% 0,00% pts 500 pts 220pts 86pts

13 Br J Surg. 2014, 101(3): Ann Surg 2013, 258(2): Ann Vasc Surg 2016, X: % 35% 30% 25% 20% 15% 10% 5% 25% 37% 24% 28% 0% AJAX IMPROVE ECAR CVEVS CCS

14 Open RAAA Repair Strategy J Vasc Surg 1991; 13: The fast Diagnosis 2. Hypotensive resuscitation 3. Non-selective supraceliac aortic cross clamping 4. Cell saving and autotransfussion 5. Fast and simple procedure

15 1. Fast Diagnosis & Treatment Abdominal/ Low Back Pain Pulsatile Abdominal Tumor Profound Shock (TA < 70 mmhg) Abdominal/ Low Back Pain Pulsatile Abdominal Tumor TA > 100 mmhg Suspected Sprarenal/Thoracoabdominal Aneurysm Duplex ultrasonography Confirmed RAAA MSCT Confirmed RAAA Admission to ICU Additional Analyses Emergency Surgery

16 The mean time from admission to treatment Study/Trial Time (minutes) OR EVAR Markovic M, et al. HERZ 2004, 29 (1): ( ) 128 Mrkovic M, et al. Ann Vasc Sueg 2016, X:1-10 ( ) 43 AJAX trial. Ann Surg 2013, 258: IMPROVE trial. Eur J Vasc Endovasc Surg 2014, 47(4): ECAR. Eur J Vasc Endovasc Surg 2015, 50: Emergency Center

17 2. Permisive Hypotension Aggressive Resuscitation Arterial Pressure Intra-peritoneal rupture Exsanguinations Cardiac Arrest Lethal Outcome

18 3. Supra-celiac ACC

19 4. Cell Salvage & Auto-transfussion VARIBLE Operation duration < 0.01 Postoperative alogenic blood transfusion Postoperative hematologic parametres P < 0.01 < 0.01 Mortality < 0.05 Financial benefit Yes

20 5. Type of aortic repair.need for a bifurcated graft were associated with significantly increased mortality. Eur J Vasc Endovasc Surg 1998; 15: , 29(1): ; 29 (1): Ann Vasc Surg 2005, Ann 19 (1): Vasc Surg 2005; 19 (1): 29-34

21 Conclusions 1 st Operative approach (OR or EVAR) is the only chance for patients with RAAA. J Am Coll Surg 2013, 217 (2):

22 2 nd J Vasc Surg 2008, 48:

23 3 rd All RAAA are not suitable for standard EVAR 4 th Patients with RAAA should be treated in centers that can offer both endovascular and open aortic surgery at all times. Eur J Vasc Endovasc Surg 2014, 47(4): Eur J Vasc Endovasc Surg 2015, 49:

24 5 th The Education in Open Surgery Young vascular surgeons do not want to get too much blood on their hands C. Dzsinich- President of the ESCVS Eur J Vasc Endovasc Surg 2013 (46) 6:

25 th OR of RAAA is not always better It is always possible In some countries-necessity GDP per capita in 2015 (US $ per year)

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