Disclosures. Harborview Medical Center. Ruptured Aortic Aneurysms. April 6, Copyright UPM-Kymmene Group 1. Co-Founder: AORTICA Corporation
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1 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 Vascular Surgery Professor and Chief; Division of Vascular Surgery University of Washington Seattle, WA Ruptured Aortic Aneurysms Overall Mortality 85% (95% CI 80-91) 66% die before reaching hospital or without operation Bengtsson et al. JVS 1993;18: Peri-operative mortality open repair 41-48% Brown et al. Br J Surg 2002;89: Visser et al. Eur J Vasc Endovasc Surg 2005;30: Mortality after open repair of raaa has not improved significantly in the past 20 years Harborview Medical Center Copyright UPM-Kymmene Group 1
2 30-40 raaa per year Dramatic Example: Ruptured AAA Harborview N= Ruptured A3 September 22, yo male- acute onset of abdominal and LB pain. Family called 911 Medic One- Hypotensive SBP 70 in field- fluid responsive On arrival; HR 90, SBP 92, Temp 37.2 CTA 12.0cm Aorto-Iliac Aneurysm Copyright UPM-Kymmene Group 2
3 Copyright UPM-Kymmene Group 3
4 What Have We Learned? ra 3 Methods Data on all raaa between January 1, 2004 and October 31, 2015 Six Data Abstractors Pre-hospital, Hospital, Op reports, Laboratory Over 40,000 variables 95,751 images reviewed from 215 evaluable CT scans 30-day and long-term outcome data Lesson #1 15 Lessons Learned Systems and Protocols Make a Difference Algorithms serve as surrogates for an organized approach to raaa s and can be an overall marker for good quality care Copyright UPM-Kymmene Group 4
5 Mortality 2012 REVAR protocol 80 July 2007 IRB-approved protocol % 25.3% P< Overall REVAR 16.3% 2010 Lesson #2 Local or No anesthesia makes a difference 90 REVARS GETA- 30 day mortality= 25.5% Local- 30 day mortality= 16.3% } p=0.2 Br J Surg Feb;101(3): Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm. Copyright UPM-Kymmene Group 5
6 Lesson #3 Aortic Occlusion Balloons make a difference and Bide Time 12 Fr 55cm Sheath CODA (Cook, Inc) Placed from straightest iliac Lesson #4 73% Qualify for EVAR 95,751 images 215 raaa CTs Aortic Neck determines candidacy most often Iliac Access rarely an exclusion criteria with newer devices Copyright UPM-Kymmene Group 6
7 PMEG Subject Copyright UPM-Kymmene Group 7
8 Lesson #5 Admission ph < 7.2, Age > 76, Creat >2.0 and Pre-op SBP < 70mmHg predict death 100% of the time! Harborview Risk Score for raaa ph < 7.2 Age > 76 Creat > 2.0 Pre-op SBP < 70mmHg AUC 0.76* Compared with 0.64 for Robinson Glasgow and Edinburg Scores * Based on Linear Discriminant Analysis Prediction of EVAR 30 day Survival Prediction of Open 30 day Survival 72% 91% 63% 70% 70% 30% 0% 20% 18% 0% Copyright UPM-Kymmene Group 8
9 Lesson #6 Permissive Hypotension Works! Lesson #7 Mean neck Diam is 26.7mm and Length 17.2mm 95,751 images 215 raaa CTs Standard Grafts mm Inventory helps Average size is large at 82.4mm (r:37 to 182mm) Lesson #8 Pulse Pressure Variation (PPV) is THE BEST method of resuscitating these patients in OR! Goal < 11% PPV Lesson #9 The incidence of Ischemic Colitis has essentially evaporated for raaa s in the Endovascular Era Copyright UPM-Kymmene Group 9
10 Results: 303 raaa 190 Open Repair 90 REVAR 23 died in ED or en route Lesson #10 Imaging and Image Transfer Technology has Revolutionized Systems of Care Ischemic Colitis N=40 (21%) Ischemic Colitis N=6 (6.7%) P= 0.03 Lesson #11 Bifurcated Endografts are more durable than an AUI/ Fem-Fem Strategy Copyright UPM-Kymmene Group 10
11 Lesson #12 Type 2 Endoleaks don t matter after REVAR Lesson #13 Type 1 Endoleaks after REVAR do matter, are rapidly fatal and must be ruled out with any challenging aortic neck anatomy. Copyright UPM-Kymmene Group 11
12 raaa who were candidates for EVAR raaa who were NOT candidates for EVAR Lesson #14 Patients who are not EVAR candidates and undergo an attempt at EVAR die. raaa who were candidates for EVAR raaa who were NOT candidates for EVAR Lesson #15 The More You Do, The Better Your Results! raaa who were candidates for EVAR Procedure Number (%) 30-day mortality EVAR 85 (54%) 22.4% Open 71 (46%) 49.2% 156 P= raaa who were NOT candidates for EVAR Procedure Number (%) 30-day mortality EVAR 5 (9%) 100% Open 49 (91%) 46.9% 54 p=0.024 ICU Nursing Considerations The REVAR patients are JUST AS SICK as those undergoing open repair Aggressive resuscitation Low Index of Suspicion for: Abdominal Compartment Syndrome Ischemic Colitis Transfer Guidelines Copyright UPM-Kymmene Group 12
13 Copyright UPM-Kymmene Group 13
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