Emergency endovascular repair of ruptured abdominal aortic aneurysms - our experience

Transcription

1 Emergency endovascular repair of ruptured abdominal aortic aneurysms - our experience Poster No.: C-0837 Congress: ECR 2011 Type: Scientific Paper Authors: D. Kuhelj, M. Baraga, P. Popovi#, T. Klju#evšek, M. Stankovi#, P. Berden, V. Salapura; Ljubljana/SI Keywords: Interventional vascular, Arteries / Aorta, Emergency, Catheter arteriography, CT-Angiography, Stents, Arterial access, Aneurysms, Hemorrhage, Acute DOI: /ecr2011/C-0837 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 22

2 Purpose Introduction Rupture of an abdominal aortic aneurysm (raaa) is usually a catastrophic event with dismal prognosis. Nearly two thirds of the patients die before reaching a hospital (1). Perioperative mortality in patients who survive long enough to undergo open surgery for aortic repair (OR) is still high at close to 50%, despite the long history of this procedure (2). Endovascular aortic repair (EVAR) is an established alternative to OR in treating nonruptured abdominal aneurysms with several randomized control trials (RCT) showing a reduced perioperative mortality associated with EVAR. Emergency EVAR Since 1994 EVAR has been used increasingly also in treatment of ruptured abdominal aneurysms. The procedure is feasible under emergency conditions and single centre observational studies from several institutions have shown considerably reduced mortality after implementation of protocols favoring emergency EVAR (eevar) in their treatment of raaa in anatomically suitable patients (e.g. 30- day perioperative mortality 35,3% v. 57,8% (1), and 13% v. 39% (3)). Systematic reviews, meta-analyses, and a large multicentre cohort study (4) are currently the best evidence available showing that eevar could be a better treatment than OR, however a definite proof in the form of RCT is still lacking (5). The only published small scale RCT (6) has failed to show any benefit of eevar. There is an ongoing debate whether a large scale RCT is needed. Some authorities accept the available data from meta-analyses and large pooled datasets, despite the inherent bias of each of the contributing studies; others will accept only evidence from a large, multicentre RCT. At least three RCT are currently underway (7). Aim Page 2 of 22

3 In this report we present a series of six patients presenting with raaa that were treated endovascularly at the Clinical Institute of Radiology, University Medical Centre Ljubljana, Slovenia. Methods and Materials At our institution an interventional radiologist is available on-call 24/7. All of them are experienced in performing elective EVAR. Since early 2007 bifurcated aortic endoprostheses have been available in stock at our institutution. Patients From March 2007 to February 2010 six patients with raaa that was confirmed with CTA were treated endovascularly. Four of the patients presented to our emergency department with sudden abdominal pain and hypotension, three of them with clinical signs of hypovolemic shock. One had a history of aortic surgery due to AAA. In the rest there was no known aortic disease. In all three an abdominal ultrasound was requested by the emergency physician, which showed AAA, in 2 with evidence of rupture. CTA was performed to confirm the diagnosis. Page 3 of 22

4 Fig.: CT angiography of abdominal aorta showing a raaa with fresh retroperitoneal hematoma and active contrast extravasation. References: M. Baraga; Institute of Radiology, Univeristy Medical Centre Ljubljana, Ljubljana, SLOVENIA Page 4 of 22

5 Fig.: Volume rendered images of the same patient with excellent anatomy for EVAR. References: M. Baraga; Institute of Radiology, Univeristy Medical Centre Ljubljana, Ljubljana, SLOVENIA One patient with known AAA presented with dispnea and was initially evaluated for pulmonary embolism (PE). CTA was performed after deterioration with hypotension which showed ruptured AAA and no PE. A patient with a history of arterial occlusive disease and aortobifemoral bypass surgery presented one week after left hemicolectomy due to large bowel ischemia. CTA showed Page 5 of 22

6 an irregular (pseudo)aneurysm of infrarenal aorta above the bypass anastomosis with aortoduodenal fistula at the site of aneurysm. Fig.: Patient after aortobifemoral bypass surgery with irregular infrarenal (pseudo)aneurysm proximal to the anastomosis. References: M. Baraga; Institute of Radiology, Univeristy Medical Centre Ljubljana, Ljubljana, SLOVENIA Page 6 of 22

7 Fig.: Aorto-duodenal fistula at the site of (pseudo)aneurysm. References: M. Baraga; Institute of Radiology, Univeristy Medical Centre Ljubljana, Ljubljana, SLOVENIA eevar There was no established protocol for triaging patients to OR or eevar. The decision was reached jointly with a vascular surgeon in each case. Page 7 of 22

8 One patient was judged as anatomically unsuitable (short neck of AAA), but eevar was performed successfully after patient was rejected by surgeon due to poor condition. Fig.: CTA of abdominal aorta showing a raaa with unfavorable anatomy (short infrarenal neck, measuring less than 5 mm). References: M. Baraga; Institute of Radiology, Univeristy Medical Centre Ljubljana, Ljubljana, SLOVENIA Page 8 of 22

9 Fig.: Follow-up CTA 1 month later, confirming the successful placement of stentgraft with preservation of both renal arteries despite difficult anatomy. Note also the partial thrombosis of the stentgraft that extended into the right limb. Clinically there were signs of right leg ischemia. References: M. Baraga; Institute of Radiology, Univeristy Medical Centre Ljubljana, Ljubljana, SLOVENIA Procedures were performed under general anaesthesia, with limited fluid resuscitation permissive hypotension in order to achieve hypotensive hemostasis. Supracoeliac balloon occlusion was not used. Percutaneus vascular access closure device was used when possible. Page 9 of 22

10 Images for this section: Fig. 1: CT angiography of abdominal aorta showing a raaa with fresh retroperitoneal hematoma and active contrast extravasation. Page 10 of 22

11 Fig. 2: Volume rendered images of the same patient with excellent anatomy for EVAR. Page 11 of 22

12 Fig. 3: Patient after aortobifemoral bypass surgery with irregular infrarenal (pseudo)aneurysm proximal to the anastomosis. Page 12 of 22

13 Fig. 4: Aorto-duodenal fistula at the site of (pseudo)aneurysm. Page 13 of 22

14 Fig. 5: CTA of abdominal aorta showing a raaa with unfavorable anatomy (short infrarenal neck, measuring less than 5 mm). Page 14 of 22

15 Fig. 6: Follow-up CTA 1 month later, confirming the successful placement of stentgraft with preservation of both renal arteries despite difficult anatomy. Note also the partial thrombosis of the stentgraft that extended into the right limb. Clinically there were signs of right leg ischemia. Page 15 of 22

16 Results One female and 5 male patients were treated. Mean age of the patients was 71 (range 58-76). Mean time from presentation to CTA was 169 minutes (range ). Mean time to stentgraft deployment was 475 minutes (range , the latter being in the patient with aortoduodenal fistula which was recognized only after review of CT images). All eevar procedures were technically successful, with no signs of extravasation or endoleak on angiography. Page 16 of 22

17 Page 17 of 22

18 Fig.: Successful eevar in our first patient treated for raaa. References: M. Baraga; Institute of Radiology, Univeristy Medical Centre Ljubljana, Ljubljana, SLOVENIA Four procedures were completed entirely percutaneously, including the vascular access site closure. In two cases vascular surgeon exposed and closed femoral artery access sites. Mortality None of the patients died intraoperatively. 24-hour mortality was 1 of 6 (17%) with possibly recurrent bleeding and irreversible hypovolemic shock with multiple organ failure as the cause. 30-day mortality was 2 of 6 (33%). Cause of death in the other patient was sepsis due to ischemic injury of lower extremities. Images for this section: Page 18 of 22

19 Page 19 of 22

20 Fig. 1: Successful eevar in our first patient treated for raaa. Page 20 of 22

21 Conclusion Emergency EVAR is feasible at our institution with 24/7 availability of interventional radiologist experienced in elective EVAR using commercial of-the-shelf devices. Despite the small number of patients in our series and quite a heterogeneous group (including patients with previous aortic surgery) initial results are encouraging. Unfortunately comparison with OR results for our hospital is not yet available. With adoption of a structured algorithm for managing patients with RAAA, including prompt CTA instead of initial US, avoidance of general anaesthesia, use of additional balloons to control aortic hemorrhage and vigorous postoperative care (abdominal compartment syndrome) there is still room to improve our results (1, 4, 7). References 1. Starnes BW et al. Management of ruptured abdominal aortic aneurysm in the endovascular era. J Vasc Surg Jan;51(1): Bown MJ, Sutton AJ, Bell PR, Sayers RD. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair. Br J Surg Jun;89(6): Sadat U, Hayes PD, Kullar PJ, Cousins C, Varty K, Boyle JR. An emergency EVAR service reduces mortality in ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg Feb;37(2): Veith FJ,et al. Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms. Ann Surg 2009;250: Foster J, Ghosh J, Baguneid M. In patients with ruptured abdominal aortic aneurysm does endovascular repair improve 30-day mortality? Interact CardioVasc Thorac Surg 2010;10: Hinchliffe RJ, Bruijstens L, MacSweeney STR, Braithwaite BD. A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm: results of a pilot study and lessons learned for future studies. Eur J Vasc Endovasc Surg 2006;32: Page 21 of 22

22 7. Veith FJ, Powell JT, Hinchliffe RJ. Is a randomized trial necessary to determine whether endovascular repair is the preferred management strategy in patients with ruptured abdominal aortic aneurysms? J Vasc Surg Oct;52(4): Personal Information M. Baraga is a resident of radiology and coauthors are interventional radiologists at Clinical Institute of Radiology, University Clinical Centre Ljubljana, Slovenia. Page 22 of 22