Experience with Over 300 Ruptured Aortic Aneurysms: What Have We Learned?

Transcription

1 Experience with Over 300 Ruptured Aortic Aneurysms: What Have We Learned? 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

2 Disclosures Co-Founder: AORTICA Corporation

3 SOD Walter Reed years ago 71 yo male admitted to Neurology service for four days with back pain Found down in his room- Code Blue Suspected MI- transferred to MICU Multiple codes- abdomen becoming distended Discussed with VS Attending- CT Scan STAT 45 minutes later in scanner, Arrested and Died

4

5 Hughes. Surg. 1954; 36: 65-8

6

7

8 Clamp Before You Cut: Proximal Aortic Control with Balloon Occlusion CPT Zachary Arthurs MD, CPT Craig See MD, COL(R) Charles Anderson MD, and LTC Benjamin Starnes MD Vascular and Endovascular Surgery Service Madigan Army Medical Center Tacoma, Washington 2002

9 Harborview Medical Center

10 Methods Data on all raaa between January 1, 2004 and October 31, 2014 Six Data Abstractors Pre-hospital, Hospital, Op reports, Laboratory Over 37,000 variables 95,751 images reviewed from 215 evaluable CT scans 30-day and long-term outcome data

11 What Have We Learned? ra 3

12 16 Lessons Learned

13 Lesson #1 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

14 July 2007 IRB-approved protocol

15 Mortality 2012 REVAR protocol % P< % Overall REVAR 16.3%

16

17 Anesthesia R Arm Out Imaging Surgeons Monitor

18 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.

19 Lesson #3 Aortic Occlusion Balloons make a difference and Bide Time 12 Fr 55cm Sheath CODA (Cook, Inc) Placed from straightest iliac

20

21

22 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

23

24

25 PMEG Subject 049

26

27

28 Lesson #5 Admission ph < 7.2, Age > 76, Creat >2.0 and Pre-op SBP < 70mmHg predict death 100% of the time!

29 Prediction of EVAR 30 day Survival 72% 91% 63% 30% 0%

30 Prediction of Open 30 day Survival 70% 70% 20% 18% 0%

31 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

32 Lesson #6 Permissive Hypotension Works!

33 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)

34 Lesson #8 Pulse Pressure Variation (PPV) is THE BEST method of resuscitating these patients in OR! Goal < 11% PPV

35 Lesson #9 The REVAR patients are JUST AS SICK as those undergoing open repair Aggressive resuscitation Low Index of Suspicion for: Abdominal Compartment Syndrome Ischemic Colitis

36 Lesson #10 The incidence of Ischemic Colitis has essentially evaporated for raaa s in the Endovascular Era

37 Results: 303 raaa 23 died in ED or en route 190 Open Repair 90 REVAR Ischemic Colitis N=40 (21%) Ischemic Colitis N=6 (6.7%) P= 0.03

38 Lesson #11 Imaging and Image Transfer Technology has Revolutionized Systems of Care

39

40 Lesson #12 Bifurcated Endografts are more durable than an AUI/ Fem-Fem Strategy

41 Lesson #13 Type 2 Endoleaks don t matter after REVAR

42 Lesson #14 Type 1 Endoleaks after REVAR do matter, are rapidly fatal and must be ruled out with any challenging aortic neck anatomy.

43

44

45 raaa who were candidates for EVAR raaa who were NOT candidates for EVAR Lesson #15 Patients who are not EVAR candidates and undergo an attempt at EVAR die. 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

46 raaa who were candidates for EVAR raaa who were NOT candidates for EVAR Lesson #16 The More You Do, The Better Your Results!

47

48