Promising first experience of endovascular treatment of ruptured abdominal aortic aneurysms Stevo Duvnjak, EBIR,FCIRSE Tomas Balezantis Jes Lindholdt
Faculty disclosure Stevo Duvnjak, Tomas Balezantis, Jes Lindholdt have no financial relationships to disclose.
The protocol: collaboration by interventional radiologists, vascular surgeons and anesthesiologists. 24 h/ 7 days on call Interventional Radiologist + vascular surgical and anesthesiology staff on duty, Hemodynamic status blod pressure min. 80 mmhg CT aneurysms morphology
Ruptured AAA- OUH from 1 st of October 2012 until December 2013 53 patients were treated due to raaa or iliac aneurysmsonly two pts. in EVAR group. 27 ( patients were treated with EVAR and 26 by open repair. 89% ( 24 patients ) were men and 11% ( 3) women mean age - 74.4 years (raged 65-86 ). Average AAA diameter - 8.12 cm ( ranged 6-12 cm).
Neck angulations - 60 and 90 degree A bifurcated stent graft was deployed in 26 pts. - 96% of the cases. In one case (4%), an aortouniiliac stent graft followed by femoral crossover bypass was performed. Neck length - 7-22 mm. Six (26%) patients were converted to general anesthesia In five (20%) patients percutaneous approach from one side, and in one (4%) case total percutaneous approach was performed. In all other cases (76%) bilateral groin cutdown were performed due to severe calcifications.
Technical success and peri-operative secondary interventions Two patients (7%) were converted to open surgery due to endoleak type 1 and/or type 3. Technical success was 84% Four patients (16%) had additionally peri-operative interventions In two cases with endoleak type1a, an extra aortic cuff was successfully placed In the third patient, a plaque occluded the right renal artery - transbrachial access, was re-opened In the fourth patient, a Chimney stent was placed into the left renal artery.
The primary outcome was 30 days postoperative mortality Two patients (7%) died within the first 30 days postoperatively after REVAR. One patient died peri-operatively due to myocardial infarction verified by autopsy. The other one died due to massive coagulopathy and multiorgan failure shortly after the procedure. The mortality of all patients treated for rupture at our institution was 19%, (95% CI: 0.09-0.29) compared to 32%, (95% CI: 0.23-0.37) in Denmark, the year before (Chi square test: p=0.10) (The Danish Vascular Registry) In the same period in OS group- 7 patients died (30.7 %) within the 30 days. Two patients died due to myocardial infarction. Three patients died because of bowel ischemia. The remaining two patients died due to multi-organ failure and bleeding.
Complications Four patients (16%) developed compartment syndrome (def.: abdominal pressure >28mmHg and clinically multiorgan deterioration) All except one had ischemic changes of colon and underwent evacuation of hematoma, colectomy and colostomy. All 4 patients stayed over one month in the intensive care unit. Two of them died 55 and 61 days after REVAR due to respiratory insufficiency Other major complications Renal insufficiency- in three patients temporary dialysis Pneumonia in one patient
The First 30 days stent graft and access site related complications In 91% of cases there were no stent graft related complications in early 30 days period One patient had left prosthesis leg thrombosis, 5 days after primary intervention which after unsuccessful trombectomy was converted to successfully surgical femoro-femoral crossover bypass. Two other patients developed wound complications in the groin treated successfully with debridement and antibiotic treatment.
FOLLOW -UP Mean follow up period - 5.5 months (ranged 1-12 months) Two patients died- no EVAR or aneurysm related (heart infarct and urological operation- complicated afterwards) There was no secondary interventions related to EVAR procedure during the follow up period
crossing boundary
Conclusion A Center with a Department with EVAR experience can carry out endovascular as well as open surgery in acutte settings, providing a high standard of treatment by using them to supplement each other rather than as competing treatments.