How to select ruptured AAA for EVAR or open repair?

Transcription

1 How to select ruptured AAA for EVAR or open repair? Dr. Skyi Pang Associate Consultant Division of Vascular Surgery Department of Surgery Pamela Youde Nethersole Eastern Hospital Hong Kong SAR, China

2 Disclosure Speaker name:... I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest

3 How to select treatment for rupture AAA Clinical Evidence Lower peri-operative mortality Lower morbidity Feasibility Technical expertise & facilities Patient s clinical situation Aneurysmal anatomy Cost

4 Clinical evidence Randomized Trial AJAX Trial ECAR Trial IMPROVE Trial

5 Ajax Trial > 100 patients Randomized after CT Only patient fit for both EVAR and OR were included 30d mortality 21% assigned EVAR 25% assigned OR p = 0.66 Ann Surg 2013;258:

6 French ECAR trial > 100 patients Randomized after CT 30d mortality 18% EVAR 24% OR p= Eur J Vasc Endovasc Surg (2015) 50, 303e310

7 IMPROVE Trial ~300 patients on each arm Randomize before CT scan 30-day mortality on intention to treat Endovascular strategy 35% Open strategy 37%

8 IMPROVE Trial In the subgroups Endovascular strategy (n=316) 47% EVAR - 30d mortality 25% 35% OAR - 30d mortality 38% 5% no repair - 30d mortality 94% 1.5% EVAR open - 30d mortality 100% Open repair (n=297) 74% OAR - 30d mortality 37% 12% EVAR - 30d mortality 22% 6% no repair 30d mortality 100%

9 Longer-term outcome Included patients in the three RCTs 1 year mortality EVAR: 38.6% OR: 42.8% p = Eur J Vasc Endovasc Surg (2015) 50, 297e302

10 Systemic Review/Meta-Analysis Involved/based on cohort studies All favor endovascular approach in terms of peri-operative mortality Publication and selection bias PLOS ONE Jan2014 Vol 9 Issue 1 e87465 EJVES June 2014 Volume 47, Issue 6,

11 Do we still need evidence? Lots of variation in the critical situation Different health care system Wide spread use of EVAR EVAR open Data from SOMIP reports, Hospital Authority Hong Kong

12 Pros of revar Benefit of aortic balloon occlusion under local anaesthesia Benefit for patients who were deemed unfit for open repair Shorter hospital stay

13 Cons of revar Required specific hardware Involving lots of logistic arrangement The need for pre-operative imaging Specific problems of stenting Unfavourable anatomy Endoleak ACS

14 Feasibility Technical expertise & facilities Facilities Hybrid OR is ideal Expertise in EVAR Centralization Team work Multidisciplinary approach Patient s clinical situation Aneurysmal anatomy

15 Multi-disciplinary approach A&E Physicians In-house Surgeons Anaesthetists Interventionist/Vascular Surgeon Operating room Nurses and other staff Radiology department ICU Physician and Nurses

16 Rupture protocol To standardize the management algorithm is the key to success EVAR first approach aortic balloon tamponade aortography Proceed EVAR if feasible

17 Our workflow AED suspects raaa Alert Vascular, Anaesthetist, OT stable Urgent CTA at AED unstable OT: Ready for endovascular & open surgical repair Aortic Occlusion Balloon (Local anaesthesia) Aortogram to decide if suitable for EVAR EVAR Open surgical repair

18 Feasibility Technical expertise & facilities Patient s clinical situation Proper resuscitation permissive hypotension Pre-operative imaging/intraoperative aortography Aneurysmal anatomy Neck morphology Iliac involvement Access issue

19 Aortic Balloon Insertion Initial step Performed under local anaesthesia Place the aortic balloon at supra celiac level Supported by 16Fr 35/45cm long sheath

20 Continuous aortic control Important for rupture cases Especially aim for bifurcated stent graft Early restoration of the mesenteric perfusion by reposition of the balloon

21 Our result 55 patients with emergency EVAR for rupture AAA since 2010 Rejection rate 13.5% 60 rejection rate % rejection rate %

22 Our series 3 Open conversion none of them survive Failed balloon placement Failed chimney Prolonged operation with stent-graft thrombosis 3 Patients underwent direct open repair All survive Overall 30 day mortality 31.1% (19/61) revar 30 day mortality 29% (16/55)

23 Difficult neck Angulated neck Palmaz Stent Specfic stentgraft for 90 degree Aorfix Anacoda

24 Difficult neck Angulated neck Short neck

25 EndoAnchor System Pictures provided by Medtronic

26 Abdominal Compartment Syndrome More significant in revar Up to 20% in revar ECAR Trial 14% EVAR vs 2% OR Inadequate correction of coagulopathy Prolonged procedure J Vasc Surg 2009;50:1e7 Persistent type II endoleak Early Recognition, close monitoring and decompressive laparotomy EJVES June 2011 Volume 41, Issue 6,

27 Decompressive laparotomy

28 On-going type II leak Cause of mortality even successful EVAR Difficult to determine Under-resuscitation Exclusion of persistent type 1 leak Abdominal compartment syndrome Myocardial infarction Bowel ischaemia

29 On going type II leak To perform CT scan earlier if in doubt Open surgery with plication of bleeders Endovascular intervention

30 Direct open repair Never a failure Acute angulated and narrow neck Known unfavourable anatomy Facilities, expertise or the team is not ready

31 Lesson we learnt EVAR 1 st Protocol to streamline the workflow Be decisive when to go for direct open EVAR and open repair are complementary to each other

32 Conclusion EVAR first protocol is feasible for managing rupture AAA Know our limitation and be decisive EVAR and open repair are complementary to each other

33 How to select ruptured AAA for EVAR or open repair? Dr. Skyi Pang Associate Consultant Division of Vascular Surgery Department of Surgery Pamela Youde Nethersole Eastern Hospital Hong Kong SAR, China