ENDOVASCULAR TREATMENT OF RUPTURED ABDOMINAL AORTIC
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1 UNIVERSITA DEGLI STUDI DEL PIEMONTE ORIENTALE DIPARTIMENTO DI DISCIPLINE MEDICO-CHIRURGICHE SEZIONE DI RADIODIAGNOSTICA CATTEDRA DI RADIOLOGIA DIRETTORE: PROF. A. CARRIERO Novara, ITALY ENDOVASCULAR TREATMENT OF RUPTURED ABDOMINAL AORTIC ANEURYSM: 3-YEARS 3 EXPERIENCE G. Guzzardi,, P. Brustia*,, R. Cassatella*, I. Divenuto, D. Moniaci*,, M. Martelli*,, A. Carriero Institute of Vascular and Interventional Radiology, A. Avogadro University Novara, Italy *Division of Vascular Surgery, Maggiore della Carità Hospital Novara, Italy
2 Emergency treatment of ruptured abdominal aortic aneurysm Mortality rate Conventional open repair 30-70% 4 10 times higher than elective repair Moore R et al: Improved survival after introduction of an emergency endovascular therapy protocol for rupture abdominal aortic aneurysm. JVS 2007; 45 (3): EVAR 18-42% Lee WA et al. Impact of endovascular repair on early outcom of rupture abdominal aortic aneurysm. JVS 2004; 40: Arya N et al. Endovascular repair policy may reduce overall mortality in rupted abdominal aortic aneurysm. JVS 2006; 44 (3): K. Lesperance et al. Expanding use of emergency endovascular repair for ruptured abdominal aortic aneurysm. J Vasc Surg 2008;47:
3 OUR EXPERIENCE From January 2005 to December raaa % 70% % 53% 47% OPEN EVAR % open repair (71%) 27 EVAR (29%) 21 haemodynamically stable 6 shock
4 1 st DIAGNOSTIC-THERAPEUTIC FLOW-CHART Jan Aug 2007 raaa Haemodynamically stable (SBP 80 mmhg) Shock (SBP<80 mmhg) CT OPEN EVAR OPEN
5 2 st DIAGNOSTIC-THERAPEUTIC FLOW-CHART Sept today raaa Haemodynamically stable (SBP 80 mmhg) Shock (SBP<80 mmhg) CT EVAR If unfit EVAR OPEN OPEN
6 ENDOVASCULAR TREATMENT Patients 27 Risk factors M/F Age (years) age > 75 ischemic heart disease respiratory disease hostile abdomen renal failure 25:2 mean:78,6 (range:67-91) 65% 61% 52% 54% 14%
7 ENDOVASCULAR TREATMENT 25 bifurcated Zenith Cook 10 Excluder Gore 2 Talent Medtronic 2 uni-iliac iliac (1 femoral crossover by-pass) 1 Zenith Cook 1 Talent Medtronic Additional procedures Proximal cuff Distal extension Iliac PTA Occlusion balloon Conversion (bifurcated to uni-iliac) 2/27 (7 %) 6/27 (22%) 1/27 (4%) 2/27 (7%) 0/27 (0%)
8 METHODS Technical success: 96% (26/27) Anesthesia 11 general 9 regional (spinal/epidural) 7 local Surgical cutdown Bilateral groin 26/27 (96%) Unilateral groin 1/27 (4%) Mdc 140 ml (mean) Duration of procedure 175 min. (range( range: min)
9 An aorto-uni-iliac device is used in the case of occlusion of vessel access
10
11
12 Aorto-caval fistula: presenting features Hematuria Loud abdominal bruit No congestive heart failure No pain
13 Aorto-caval fistula: reformat cor plane
14 Aorto-caval fistula: after procedure
15 PRIMARY OUTCOME Successful graft deployment Immediate conversion Severe systemic complications ICU stay Length of hospital stay (days) Type I and III endoleak Type II endoleak Post-operative reintervention rate (groin surgical review) In-hospital mortality rate 30-day mortality rate 96% (26/27) 4% (1/27) 2 MOF (fatal) 1 ACS (fatal) (abdominal compartment syndrome) 2 Acute renal failure 2 Cardiac failure (fatal) Nr patients: 7 Range: 1-8 days 7.9 days 0% (0/27) 19% (5/27) 5% (1/27) 18% (5/27) 22% (6/27)
16 OUTCOME Follow-up mean days (range: ) 6.3 months (range: 2-17) Type I and III Endoleak 0/27 (0%) Type II Endoleak 4/27 (15%) Overall reintervention rate 1/27 (5%) Conversion at a distance 1/27 (4%) Overall mortality rate 9/27 (33%)
17 There is no high quality evidence to support the use of EVAR in the treatment of RAAA. Endovascular treatment for ruptured abdominal aortic aneurysm (Review) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
18 However, evidence from prospective controlled studies without randomisation, prospective studies,, and retrospective case series suggest that EVAR is feasible in selected patients, with outcomes comparable to best conventional open surgical repair for the treatment of RAAA. Furthermore, endovascular repair in selected patients may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, and mortality. Endovascular treatment for ruptured abdominal aortic aneurysm (Review) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
19 EVAR CONCLUSIONS Team s experience Correct planning Dedicated operating room Bifurcated stent-graft: chosen device Multidisciplinary team (24/24 h) Large volume hospitals EVAR is a good option for treatment of raaa, with a lower mortality rate than surgery
20 Don't stop yourself from learning... Thanks for your attention
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