Endovascular Stent-Graft Repair of Ruptured Aortic Aneurysms

Transcription

1 J ENDOVASC THER 447 CLINICAL INVESTIGATION Endovascular Stent-Graft Repair of Ruptured Aortic Aneurysms Reinhard Scharrer-Pamler, MD; Thomas Kotsis, MD; Xaver Kapfer, MD; Johannes Görich, MD; and Ludger Sunder-Plassmann, MD Department for Thoracic and Vascular Surgery, Ulm University Hospital, Ulm, Germany Purpose: To demonstrate the endovascular approach to the management of ruptured abdominal aortic aneurysms (AAA). Methods: From 1995 to 2001, 24 patients (21 men; mean age 69 years, range 26 92) underwent emergency endovascular treatment for ruptured AAA. The average interval between onset of symptoms and admission to the hospital was 8.0 hours; the mean time between admission and the operation was 2.3 hours. No suprarenal occluding catheter was used. The stent-graft configurations were 19 bifurcated, 4 tube, and 1 aortomonoiliac. Results: Stent-graft placement was successful in 23 (96%) cases. Failed limb extension deployment prompted conversion to open surgery in the remaining patient. One case was converted to open surgery. Mean duration of treatment was 122 minutes. Three (12.5%) patients died in-hospital. The median hospital stay was 12 days. The rate of endoleaks (all type I) was 16.7%. The overall technical success rate was 77%. The 3-year actuarial survival rate was 75%. Conclusions: Our experience shows excellent results in emergency patients with ruptured AAAs treated with endovascular surgery. In order to verify these promising results, a broader-scale clinical study must be conducted. J Endovasc Ther Key words: abdominal aortic aneurysms, aneurysm rupture, endovascular repair, stentgraft, outcome analysis, mortality, endoleak, survival The results of elective surgical treatment of abdominal aortic aneurysms (AAA) have markedly improved in the last 50 years, but mortality rates of 24% to 70% are still reported in emergency operations on ruptured aneurysms. 1 5 In our department, the hospital mortality for 159 ruptured AAAs treated from 1970 to 1989 was 45%. Since the surgical techniques for repairing ruptured aneurysm is not likely to improve much further, attention has turned to electively administering prophylactic treatment before a rupture occurs. The introduction of endovascular techniques for AAA repair has led to a marked change in vascular surgery since Although the medium and long-term results with stent-graft implantation for elective AAA repair are not yet established, the technique nevertheless offers attractive options in the treatment of at-risk patients. Such a less invasive method would provide major advantages, especially in emergency patients with a ruptured aneurysm. However, experience with emergent endovascular aneurysm repair is still relatively limited We began elective endovascular AAA repair in 1996 at our institution; 2 years later, we initiated a protocol of treat ruptured AAAs with Address for correspondence and reprints: Reinhard Scharrer-Pamler, MD, University of Ulm, Department for Thoracic and Vascular Surgery, Steinhoevelstr. 9, D Ulm, Germany. Fax: ; reinhard.pamler@medizin.uni-ulm.de 2003 by the INTERNATIONAL SOCIETY OF ENDOVASCULAR SPECIALISTS Available at

2 448 RUPTURED AORTIC ANEURYSMS J ENDOVASC THER Figure(A) Axial CT scan and (B) multiplanar CT reconstruction showing a ruptured infrarenal AAA. Note the retroperitoneal hematoma ( ) and right paravertebral escape of contrast ( ) in B. (C) After endovascular repair with a Talent stent-graft. stent-grafts as our first choice therapy depending on the endovascular experience of the surgical team on duty. In the present paper, we report our experience with this emergency protocol for endovascular repair of ruptured AAAs over a period of 6 years. METHODS From 1995 to 2001, 183 AAA patients admitted to our hospital underwent elective endovascular repair. An additional 67 patients presented with ruptured AAA; 43 had conventional urgent surgery, but 24 patients (21 men; mean age 69 years, range 26 92) underwent emergent endovascular treatment under a protocol approved by the Institutional Review Board. Two thirds of the ruptures were contained, but 8 extended into the peritoneal cavity. The majority of aneurysms (20, 83%) were true; there were also 2 traumatic and 2 anastomotic aneurysms. The mean aneurysm diameter was 7.2 cm (range 5 11). Major comorbidities included hypertension (11), coronary artery disease (7), chronic obstructive pulmonary disease (7), congestive heart failure (5), prior myocardial infarction (2), and diabetes (2). One patient had renal insufficiency, another had a chronic cerebral disorder, and a third had non-hodgkin lymphoma. One patient with a pseudoaneurysm was an accident victim. Two patients with a symptomatic nonruptured aneurysm also underwent emergency endovascular treatment, but they are not included in this review. All patients were transferred to the emergency department after admission to the hospital. While there, the lowest recorded systolic blood pressure was 90 mmhg in 7 patients and 70 mmhg in 9; 2 patients had a systolic blood pressure 50 mmhg. Four unstable patients were in circulatory shock. Hypotensive

3 J ENDOVASC THER RUPTURED AORTIC ANEURYSMS 449 hemostasis was initiated to stabilize blood pressure, 8 and fluid resuscitation was minimized as long as the systolic pressure did not fall below 50 mmhg. The diagnosis was established by ultrasonography and computed tomography (CT), which was available in the emergency department. CT scanning was feasible in 22 (92%) patients. After diagnosis, the patients were immediately transferred to the adjacent operating theater. Written informed consent to perform the endovascular repair was obtained from all patients or their relatives. All procedures were carried out in a surgical operating theater by either a surgery/radiology team (12 cases) or by a purely surgical team (14 cases). Only 3 operations were performed during standard work hours. General anesthesia was induced as in elective cases. No occluding catheter was used in any patient. Bifurcated stent-grafts were implanted preferentially: 13 Talent Endoluminal Stent-Grafts (Medtronic World Medical, Sunrise, FL, USA), 5 Excluder Endoprostheses (W.L. Gore & Associates, Flagstaff, AZ, USA), and 1 Zenith stent-graft (Cook Inc., Bloomington, IN, USA). Four tube stent-grafts were used to repair 2 traumatic false aneurysms and 2 anastomotic aneurysms: 1 AneuRx (Medtronic AVE, Santa Rosa, CA, USA), 2 Corvita Endoluminal Grafts (Corvita Europe SA, Brussels, Belgium), and 1 Vanguard (Boston Scientific, Natick, MA, USA). In 1 case, a Talent aortomonoiliac stent-graft was used, but a pre-existing occlusion of the left iliac artery eliminated the need for a crossover bypass. RESULTS The median time between onset of symptoms and admission to the hospital was 8.0 hours in the 24 patients. After admission, the interval to operation was 2.3 hours (compared to 1.8 hours for conventionally treated rupture cases during this same time period). The time needed for the CT scan averaged only 25 minutes because the scanner was located in the emergency department. The stent-graft was successfully positioned in 23 (96%) patients. In 1 (4%) case, it was not possible to dock the contralateral limb of a bifurcated stent-graft, and the procedure was converted to open repair (4% conversion rate). The average duration of the operation was 122 minutes (range ). An average fluoroscopy time of 18.8 minutes was required during stent-graft implantation (compared to an average 23 minutes for elective cases in our department). The amount of contrast administered in the operation was 145 ml (compared to 170 ml in concurrent elective operations). Blood loss during endovascular treatment averaged 505 ml. One patient died in the operating theater 45 minutes after technically correct stent-graft implantation; she was already in circulatory shock at the beginning of the operation (blood pressure 50 mmhg). In the case converted to open surgery, the patient died of multiorgan failure on the 30th postoperative day. A further patient died on the 7th postoperative day of cardiac decompensation in pre-existing coronary heart disease (12.5% inhospital mortality). After discharge from the hospital, 2 patients died of myocardial infarction within 30 days for a periprocedural mortality of 20.8%. There were 11 (45.5%) major and 13 (54.2%) minor complications. Besides the 2 deaths and 1 conversion, there were 4 (17%) type I endoleaks (1 proximal and 3 distal) among the major sequelae. After CT diagnosis, the single proximal and 2 of the 3 distal endoleaks were successfully closed with stentgraft extensions. The fourth distal endoleak was in a 92-year-old patient, who refused a second operation; she died 13 months later from a new aneurysm rupture. The other 4 major complications included a tracheostomy in a patient with required prolonged ventilation, a case of cholecystitis successfully treated with cholecystectomy, a small intestinal perforation caused by a toothpick swallowed preoperatively, and perioperative drainage of a retroperitoneal hematoma to deal with persistent ileus. No abdominal compartment syndrome was observed. The median stay in hospital was 12 days (mean 21). Over a mean 30-month follow-up (range 2.8 8), there were no further deaths. The 3-year actuarial survival was 75%.

4 450 RUPTURED AORTIC ANEURYSMS J ENDOVASC THER DISCUSSION In the last 4 years, in particular, our experience has shown that endovascular treatment of ruptured aortic aneurysms can be carried out successfully even in unstable patients, achieving a low in-hospital mortality rate of 12.5%. In comparison with a contemporaneous group of ruptured AAAs repaired with standard surgical procedures in the same department, the hospital mortality was 40%. However, this comparison cannot be made without some qualification. By preference, highly unstable patients underwent an open operation at the beginning of our endovascular program. Despite the fact that there was no randomization in this study, we are convinced that the minimally invasive endovascular method is the better treatment in ruptured AAA. Mortality rates reported for patients with open operation are 24% to 70%. 1 5 Quality control for operations on ruptured AAAs conducted by the German Society of Vascular Surgery revealed a nationwide hospital mortality of 43% in By contrast, Okhi and Veith 8 reported only 10% mortality in a series of 20 patients who received emergency endovascular surgery. In this group, only 14 patients had a ruptured aortic aneurysm; 6 had a ruptured iliac aneurysm. Minimally invasive endovascular aneurysm exclusion shows unequivocal advantages, especially in high-risk patients. The less pronounced surgical trauma for endovascular patients is no doubt related to the short duration of the operation (2 hours). Furthermore, only 2 inguinal accesses are required in contrast to the median laparotomy usually employed; this lower invasiveness favors earlier postoperative mobilization and return to a normal diet. The lower blood loss in an endovascular treatment is also likely to contribute to a more favorable prognosis. 20,21 In open surgery on ruptured AAA, mean estimated blood loss was 3.21 L in survivors and 5.45 L in nonsurvivors. 20 The case that contributed to the longer mean inpatient stay was the patient with an intestinal perforation due to a toothpick; he was treated as an inpatient for 120 days. In statistical terms, the 12-day median value better reflects the true average length of stay and is certainly much shorter than the mean 31- day hospitalization following conventional open treatment in our department. As a rule, the periaortic hematoma left behind does not have a negative effect in ruptured AAA patients, but in one of our cases we had to partially clear the hematoma on the 3rd postoperative day via a retroperitoneal access because of a protracted ileus. Followup CT scans showed that a retroperitoneal hematoma may remain for up to 6 months after the operation, but it eventually is completely resorbed. In elective endovascular aneurysm repair in our own department, endoleaks occurred with a frequency of 18%, which is similar to the 16.7% rate in the ruptured AAA group. It was striking, though, that only type I endoleaks occurred. The reason why we did not see any type II endoleak is probably because the lumbar arteries were compressed by the retroperitoneal hematoma, perhaps the inferior mesenteric artery as well. The cause for the single proximal type I endoleak was too distal placement of the stent-graft owing to difficulties with the fluoroscopy. In the distal leaks, the iliac limb of the stent-graft was too short or its lumen too small at the end of the limb. Lengthening the stent-graft easily rectified this problem. In the one failed case, it was not possible to cannulate the docking site for the contralateral limb. A crossover maneuver also could not be successfully concluded. The idea to convert the bifurcated stent-graft to an aortomonoiliac stent-graft was discussed but not performed. Rather, conversion to open surgery was decided upon so as not to lose further time. An aortomonoiliac system would doubtless have prevented this complication, which is why this stent-graft configuration is preferred by various authors for ruptured cases. 6,8 Theoretically, the aortoiliac circulation is also restored more quickly, at least on one side, and the rupture site is sealed. By comparison, open operation gives rise to intense retrograde bleeding from the iliofemoral arteries after infrarenal clamping of the proximal neck even in the rupture stage. Thus, occlusion of the second iliofemoral artery with coils or a balloon (occluder) is necessary to

5 J ENDOVASC THER RUPTURED AORTIC ANEURYSMS 451 completely stop bleeding from the ruptured aorta. This confirms our decision not to use an aortic occlusion balloon, as some have recommended. 22 Although elective endovascular aneurysm repair is widely used throughout the world, emergent stent-graft repair has been confined to large referral centers and university hospitals, due in part to the need to keep a large range of stent-grafts in stock, which is very expensive. An aortomonoiliac prosthesis is a viable alternative. Manufactured in 3 sizes, it can satisfactorily cover the entire range of aneurysms. We used this type of prosthesis successfully in one of our cases, and because of a chronic pre-existing occlusion of the contralateral iliofemoral artery, a crossover bypass was not necessary. Generally speaking, however, we prefer to use a bifurcated stent-graft, which can be implanted in the same time required for an aortomonoiliac device with crossover bypass. We keep a range of conventional stent-graft sizes from 23 to 40 mm (proximal neck diameter) in stock in a consignment store. In conclusion, our experience shows that emergency patients with ruptured AAA treated by endovascular surgery appear to fare better than those who receive open surgery. To verify these promising results, a broaderscale clinical study must be conducted. However, should other centers report far better results for emergent stent-graft repair of ruptured AAA compared to conventional surgery, it may call into question the ethical use of open repair in these emergent cases. REFERENCES 1. Wakefield TW, Whitehouse WM, Wu SC. Abdominal aortic rupture: statistical analysis of factors affecting outcome of surgical treatment. Surgery. 1982;91: Donaldson MC, Rosenberg JM, Buchnam CA. Factors affecting survival after ruptured abdominal aortic aneurysm. J Vasc Surg. 1985;2: Crawford ES. Ruptured abdominal aortic aneurysm: an editorial. J Vasc Surg. 1991;2: Marty-Ane CH, Alric P, Picot MC, et al. Ruptured abdominal aortic aneurysm: influence of intraoperative management on surgical outcome. J Vasc Surg. 1995;22: Dardik A, Burleyson GP, Bowman H, et al. Surgical repair of ruptured abdominal aortic aneurysms in the state of Maryland: factors influencing outcome among 527 recent cases. J Vasc Surg. 1998;28: Yusuf SW, Whitaker SC, Chuter TAM, et al. Emergency endovascular repair of leaking aortic aneurysm [Letter]. Lancet. 1994;344: Scharrer-Pamler R, Görich J, Orend KH, et al. Emergent endoluminal repair of delayed abdominal aortic rupture after blunt trauma. J Endovasc Surg. 1998;5: Ohki T, Veith FJ, Sanchez, LA, et al. Endovascular graft repair of ruptured aortoiliac aneurysms. J Am Coll Surg. 1999;189: Schönholz C, Donnini F, Naselli G, et al. Acute rupture of an aortic false aneurysm treated with a stent-graft. J Endovasc Surg. 1999;6: Greenberg RK, Srivastava SD, Ouriel K, et al. An endoluminal method of hemorrhage control and repair of ruptured abdominal aortic aneurysms. J Endovasc Ther. 2000;7: Hinchliffe RJ, Hopkinson BR. Ruptured abdominal aortic aneurysm. Time for a new approach. J Cardiovasc Surg (Torino). 2002;43: Hinchliffe RJ, Yusuf SW, Macierewicz JA, et al. Endovascular repair of ruptured abdominal aortic aneurysm a challenge to open repair? Results of a single centre experience in 20 patients. Eur J Vasc Endovasc Surg. 2001;22: Rodriguez JA, Olsen DM, Ramaiah V, et al. A ruptured abdominal aortic aneurysm repaired with a bifurcated unibody endoluminal graft. Eur J Vasc Endovasc Surg. 2001;22: Kumar W, Campbell JH, Andy OJ, et al. Emergent repair of a ruptured abdominal aortic aneurysm using an AneuRx stent-graft. J Endovasc Ther. 2002;9: Lachat ML, Pfammatter T, Witzke HJ, et al. Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms. Eur J Vasc Endovasc Surg. 2002;23: Teijink JAW, Odink HF, Bendermacher B, et al. Ruptured AAA in a patient with a horseshoe kidney: emergent treatment using the Talent acute endovascular aneurysm repair kit. J Endovasc Ther. 2003;10: Yilmaz N, Peppelenbosch N, Cuypers PWM, et al. Emergency treatment of symptomatic or ruptured abdominal aortic aneurysms: the role

6 452 RUPTURED AORTIC ANEURYSMS J ENDOVASC THER of endovascular repair. J Endovasc Ther. 2002; 9: van Sambeek MRHM, van Dijk LC, Hendriks JM, et al. Endovascular versus conventional open repair of acute abdominal aortic aneurysm: feasibility and preliminary results. J Endovasc Ther. 2002;9: Umscheid T, Eckstein HH, Noppeney T, et al. Quality management infrarenal aortic aneurysms of the German Society of Vascular Surgery results 2000 [in German]. Gefässchirurgie. 2001;4: Halpern VJ, Kline RG, D Angelo AJ, et al. Factors that affect the survival rate of patients with ruptured abdominal aortic aneurysms. J Vasc Surg. 1997;26: Harris LM, Faggioli GL, Fiedler R, et al. Ruptured abdominal aortic aneurysms: factors affecting mortality rates. J Vasc Surg. 1991;14: Ohki T, Veith FJ. Endovascular grafts and other image-guided catheter-based adjuncts to improve the treatment of ruptured aortoiliac aneurysms. Ann Surg. 2000;232: