The Management and Treatment of Ruptured Abdominal Aortic Aneurysm (RAAA)

Transcription

1 The Management and Treatment of Ruptured Abdominal Aortic Aneurysm (RAAA) Disclosure Speaker name: Ren Wei, Li Zhui, Li Fenghe, Zhao Yu Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University 1# Youyi Road, Yuzhong Dist, Chongqing, China We do not have any potential conflict of interest to report

2 Background... The prompt recognition and effective management of RAAA still have significant challenges in case of emergency Either delay in recognition of or failure to adequately manage RAAA remains very common in a few centers Mortality associated with RAAA is still remarkably high

3 ... A latest review shows more than 190,000 patients with RAAA died from hemorrhage annually worldwide # RAAA is the second cause of hemorrhage-related death after trauma # Cannon JW. hemorrhagic shock. N Engl J Med

4 Data and experience from our center... Between 2007 and 2017, 121 patients with RAAA admitted to our center, 38 (31.4%) patients were died before treatment. Among 83 treated patients: 57 cases underwent EVAR, 26 cases with open surgical repair (OSR). Age ranged from 64 to 81, average age: 72.9 ± 8.1 years 97 male and 24 female, the ratio of male/female: 5:1 The mean aneurysm diameter : 73.1 ±30.5mm (CT scan)

5 ... Most of RAAA patients combined with other diseases: e.g. coronary artery disease, hypertension, diabetes, and so on Table 1. Comorbidities of patients with RAAA Characteristics N=121 Coronary artery disease 58(47.9%) Chronic renal insufficiency 4(3.3%) Hypertension 62(51.2%) Chronic obstructive pulmonary disease 41(33.8%) Diabetes 35(28.9%) Hyperlipidemia 78(64.5%)

6 ... Sonography was used to rapidly confirm aneurysm presence in the clinical sign of a patient suspected rupture, then a multisliced computed tomography angiography (CTA) of the entire aorta from neck to groins is performed immediately

7 ... RAAA patients with shock were resuscitated using a permissive hypotensive regimen Patients with unstabe haemodynamics were treated with laparotomy operation

8 ... Aortic balloon occlusion employed occasionally,but not routinely for control of bleeding before OSR or EVAR Swift, definite and complete bleeding control by finger pressure or clamping during OSR absolutely essential

9 ... Indications of EVAR for RAAA includes: Relatively stable haemodynamics. Good anatomical morphology:aneurysmal neck diameter < 32 mm, Enough anchor area for stent: Infrarenal segment length >10 mm, Access assessment: Iliofemoral diameter >6 mm, Aortic neck angulation of aneursym< 60

10 ... Coil embolization was frequently used to promote thrombosis in sac during EVAR, and to prevent the stent migration as well as to avoid the development of type II endoleak

11 ... Stent graft ( such as Endrant II Medtronic ) with characteristics of smooth delivery and precise positioning were considered as preferred selection for the patients with hostile and difficult anatomical morphology

12 ... Results A total of 54 patients died among 121 cases Mortality of EVAR (22.8%) patients In 24-hours after operation was greater than that ( 15.4% ) of OSR No significant difference of 30 days mortality between these two groups (3.5% in EAVR V.S. 3.8% in OSR)

13 ... Table 2. Postoperative outcomes for patients undergoing EVAR and OSR for RAAA Group EVAR (n=57) OSR (n=26) P value 24 hours mortality % 22.8 (9/57) 15.4 (4/26) days mortality % 3.5 (2/57) 3.8 (1/26) Operation time, min 274±17 151± Blood transfusion, ml 1810± ± ICU stay, days 7.5± ± ACS % 12.3 (7/57) 7.7 (2/26) 0.022

14 ... Independent risk factors for death related to operation (both EVAR and OSR) include Hemoglobin, Blood loss, Rutherford classification Table 3. High risk factors of death related to operation Risk factors HR P value 95% CI Age 70 years Gender, male Hemoglobin<9.0 g/dl AAA size 7cm Blood loss >2000ml Bowel ischemia Rutherford classification (level 3, 4)* # Rutherford classification of Hemodynamic status: level 3: incomplete response to resuscitation, with persistent or recurrent hypotension and/or no restoration of urine output; and level 4: negligible response to resuscitation.

15 Discussion... The 1st 50 years of RAAA publications noted that the mortality rate for ruptured repair has fallen only 3.5% per decade since the initial successful repairs were reported. Bown MJ, et al: Br J Surg 89: , 2002.

16 ... A meta-analysis of publications between 1991 and 2006 suggested no signicant overall change in mortality with OSR during this period. Hoornweg L Eur J Vasc Endovasc Surg 35: , 2008.

17 ... The proportion of RAAA treated by EVAR had increased to 31% during 2002 to Whereas open survivors require few graft-related interventions, up to 23% of EVAR patients will require reintervention for endoleaks or graft migration. * Mehta M et al. J Vasc Surg. 2013

18 ... Observational studies demonstrated the EVAR patients had a significantly lower all-cause mortality in than that of the OSR patients study cases mortality complications EVAR/OSR EVAR OSR EVAR OSR Giles KA, et al /446 24% 36% 47% 62% Mandawat A, et al /207 18% 36% 66% 78% Nedeau AE, et al / % 49% Gupta PK, et al / % 52.8% Von Meijenfeldt GC, /138 24% 40% 58% 76% Giles KA, et al. J Endovasc Ther Jun. Nedeau AE, et al. J Vasc Surg Jul. Mandawat A, et al. J Endovasc Ther Feb. Gupta PK, et al. J Vasc Surg Aug. Von Meijenfeldt GC, et al. Eur J Vasc Endovasc Surg May.

19 ... The widespread preference for endovascular techniques for elective vascular surgery coupled with fewer and fewer open vascular surgery cases However, the coveted benefits of EVAR for RAAA in operative mortality have not been supported by randomized controlled trial (RCT)

20 ... Nottingham, Amsterdam and IMPROVE randomized trial revealed that there are no significant difference in mortality and complication rate between EVAR and OSR group

21 ... Compared with RCT, potential biases are likely to be greater for observational studies In fact, the choice of treatment options more depends on hemodynamic status of patients, expertise of surgeon and commercially available products.

22 ... The implementation of a ultrasonography screening program has been suggested to decrease the incidence of ruptured aneurysms The use of ultrasound scanning for people older than 50 years could reduce the incidence rate of rupture by 49%

23 ... Although the progression of AAA is lentitude, its development is irreversible. When high risk factors such as hypertension or arteriosclerosis are combined, rupture may soon occur In addition, there are some RAAA with a diameter of less than 5cm Whether the interventions, such as the EVAR, a minimally invasive treatment, should be performed to the AAA patients who with the high risk factors of rupture, despite the diameter is less than 5 cm?

24 Summary and Conclusion... Effective management of RAAA requires team members with both skill and experience in open vascular surgery and the capability to perform timely endovascular techniques Every effort to maintain preoperative hemodynamic stability, to reduce volumes of blood loss in operation, and to minimize postoperative deterioration of organ functions would be essential to improve patient survival Continued recognition of patients of non-ruptured aneurysm and repair in the elective setting with low mortality rate remains the ideal treatment, either with open or endovascular management

25 Thanks for your attention!

26 The Management and Treatment of Ruptured Abdominal Aortic Aneurysm (RAAA) Disclosure Speaker name: Ren Wei, Li Zhui, Li Fenghe, Zhao Yu Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University 1# Youyi Road, Yuzhong Dist, Chongqing, China We do not have any potential conflict of interest to report