Surgery Interesting Cases
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1 Stanford Division of Vascular Surgery Interesting Cases 11/15/2010 Vascular Surgery
2 HPI: 57yoM h/o HTN, HLD, tobacco use, anxiety, and family hx of ruptured AAA. Developed sudden onset severe abdominal pain radiating to the back at 11:30 Pm the evening PTA. The next morning he experienced a syncopal episode. At that time he called an ambulance and was taken to the PAVA. Vascular Surgery
3 PmHx: 1)Hyperlipidemia p 2)Hypertension 3)Tobacco Use 4)Anxiety 5) Aortic Regurgitation PsHx: Unknown Meds: UTO Vascular Surgery
4 PE: On presentation 6:30am Vitals HR 112 BP 110/59 SpO2 98% Pale, in pain, speech clear Tachycardia CTA B Abd: Obese/Slight Distention/Periumbilical pain with rebound and guarding Extremities Cool DP/PT non palpable but present by Doppler No femoral pulses palpated Labs: WBC 18.7, HCT 35.7, PLT 209 Cr 1.35 Lactate 4.0 CXR: Negative AXR: Large right sided mass Vascular Surgery
5 AXR Vascular Surgery
6 ER course Over the course of his work up, he becomes hypotensive SBP in the 80 s Total of 3 L Crystalloid given with improvement in his SBP to 110 s 7:30 Am He now appears pale, diaphoretic, and uncomfortable, However he remains AOx3 and continues to make jokes. Abdomen remains tender with guarding. Extremities are cool. Lactate increases to 4.75 CTA C/A/P Obtained Vascular Surgery
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45 Vascular Surgery consulted 8:12A Resuscitation started with prbc Permissive Hypotension SBP s. Emergently to OR OR front desk contacted OR Room contacted directly. Specific instructions given to Scrub Anesthesia contacted directly CT Tech contacted directly. Given specific list of materials needed for AOB Device rep called Physically transport patient from ED to OR by vascular and anesthesia team OR Course In OR 8:45 Am Time out 9:05 Am AOB up 9:12 Am under local anesthesia SBP improve to 110 s Intubated 9:16 Am AAA Repaired with Gore Endograft Vascular Surgery
46 Endoluminal Control Vascular Surgery
47 Aortogram with balloon occlusion Vascular Surgery
48 Positioning of Main Body Vascular Surgery
49 Balloon occlusion within main body Vascular Surgery
50 Completion Angiogram Vascular Surgery
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79 Post Op Course: Transported to MSICU in stable condition. No pressors. Pulses palpable p distally Volume resuscitated overnight Extubated POD 1 Diuresis started POD 3 Transferred out of ICU POD 6 Low grade WBC elevation, treated with emperic Abx for presumed dpna Low grade elevation of amylase and lipase in the s Treated conservatively with clear liquid diet Lipase trended down By POD 15 tolerating regular diet, Abdominal pain resolved, WBC normal Discharged home POD 16 Vascular Surgery
80 Over all mortality of raaa 85% 2/3 will die before reaching the hospital Of those that survive to reach the hospital the peri-operative p mortality rate for open repair has been 41-48%. Unchanged for the past 2 decades Since the advent of EVAR, repair of ruptured AAA via EVAR (revar) has decreased the mortality rate to between 24-46% Large population based studies analyzing 28,123 admissions for raaa in utilization of revar has increased form 6%- >11% with a decline in mortality from 43% to 29% Mortality from open repair has not changed and remains between 40-43% 43% Vascular Surgery
81 Starnes et al. Showed that Implementation of a rupture algorithm Decreased overall 30 day mortality from 57.8% to 35.3% 3% (absolute RR 22.5%) EVAR 30 day mortality 18% Open 30 day mortality 54.2% No difference in survival once patients were outside the perioperative period Over the study yp period, increased utilization of revar from 46.3% in the 1 st year, to 63.2% in the 2 nd year Mortality from revar vs. Open was lower for all age groups Never having a SBP <80% was associated with 100% survival in the post-protocol era Factors associated with >90% likelihood of death Age >80 Female gender HCT<25 Transfusion requirement >15 units No patient undergoing CPR survived >24 hrs Vascular Surgery
82 Ruptured AAA Hemodynamically Stable Mentating SBP>80mHg Hemodynamicaly Unstable Not Mentating SBP <80mmHg CTA Operating Room Prepped Awake Permissive Hypotension 12Fr Sheath and AOB +/- Preclose Unsuitable Anatomy AOB GETA and Open Repair Suitable Anatomy Awake REVAR Vascular Surgery
83 Important Specific Considerations Pre-hospital/ED Early Notification is Paramount Permissive Hypotension >SBP 80mmHg Warming Avoidance of Intubation In Hospital Experienced staff Communication Availability of appropriately sized components Streamlining of instrument sets Vascular Surgery
84 Reflections What was done well Communication/Coordination Permissive hypotension prbc available quickly and Resuscitation with Blood and FFP in 2:1 ratio OR available, set up and Rapid transport to OR Once in OR Established goals/priorities with OR team. Awake groin access» Anesthesia placing central venous and arterial access simultaneously Groin access and aortic occlusion balloon» Lidocaine» Micropuncture set» Benson wire» Dilators» 12 or 16Fr Sheath preferably 45 cm» Heparinized saline» Coda balloon» 180 Amplatz» Contrast» 60cc syringe» Perclose x 2 Once AOB up» Resuscitation» Intubation» Set up for remainder of the case Availability of supplies Vascular Surgery
85 Reflections Considerations/Improvements No Rupture kit at the VA, required device rep Place AOB higher than you think Place AOB opposite side of your planned main body If using Gore consider a 16Fr sheath if possible. Eliminates the need for additional sheath exchange May also allow placing AOB and Pigtail simultaneously up the same side 35cm sheath in this case was not long enough to reach above the renal arteries 180 Amplatz wires were not long enough for the 32mm and 40mm (120cm shaft) Coda balloon Repositioning of the AOB resulted in losing balloon position above the renals due to the balloon being on the floppy portion of the wire and buckling.» Consider using a 260 length stiff wire preferably Consider Percutaneous Closure Despite open femoral access, extra time/blood loss spent with poor Vascular exposure/control If possible obtain contra-lateral wire access before inflation of AOB After AOB inflation, Femoral pulses disappear and percutaneous access may be difficult. Wire access past AOB on the main body side will allow simultaneous positioning of the main body and pigtail (via the contralateral side) for rapid deployment, avoiding an additional exchange of the wire for the pigtail and main body. Communication with anesthesia before manipulation of AOB Allow the pressure to catch up before each manipulation Consider having 2 occlusion balloons open- allows rapid exchange of occlusion balloon from contralateral to ipsilateral side. 2 marking catheters open- allows simultaneous measurements Vascular Surgery
Disclosures. Harborview Medical Center. Ruptured Aortic Aneurysms. April 6, Copyright UPM-Kymmene Group 1. Co-Founder: AORTICA Corporation
EVAR for Ruptured Abdominal Aortic Aneurysm How I Do It and What Are the Results? Disclosures Co-Founder: AORTICA Corporation Benjamin W. Starnes MD, FACS The Alexander Whitehill Clowes Endowed Chair of
Stanford Division of Vascular Surgery
Stanford Division of Vascular Surgery Interesting Cases 10/11/10 Vascular Surgery HPI: 62yoM with h/o CAD, HTN, ETOH abuse. S/P EVAR in 5/08 for 6cm AAA and right CIA aneurysm. Cook 30x96mm Main Body 24
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