Title: Vascular Emergency: Ruptured Abdominal Aortic Aneurysm and Similar Aortic Pathologies
1Vascular Emergency Ruptured Abdominal Aortic
Aneurysm and Similar Aortic Pathologies
- Mark F. Fillinger, MD
- Dartmouth-Hitchcock Medical Center
- Section of Vascular Surgery
- Cardiovascular Emergencies Symposium
- Hanover, NH December 4, 2006
2What is an Aortic Aneurysm?
Abdominal Aortic Aneurysm (AAA)
Thoracic Aortic Aneurysm (front view)
3Ruptured Abdominal Aortic Aneurysm
- Over 15,000 deaths annually due to ruptured AAA
in the United States (Year 2000 15,810) - 84 in patients over age 65
- 93 in patients over age 55
- 10th leading cause of death in men over age 65
- 15th leading cause of death in all patients gt65
years old - Incidence 34/100,000 in those over 65
- Screening reduces the incidence of rupture by
gt50 in prospective, randomized trials - MASS, Lancet 3601531-9, 2002.
- Lindholt et al. Cost-effectiveness analysis of
screening for abdominal aortic aneurysms based on
five year results from a randomised hospital
based mass screening trial. Eur J Vasc Endovasc
Surg. Jul 200632(1)9-15.
4Heavy Toll from Rupture of Abdominal Aortic
Aneurysm (AAA)
- Lucille Ball
- Conway Twitty
- George C. Scott
- Albert Einstein
- Others with AAAs or aortic aneurysms
- Bob Dole, Rodney Dangerfield, James Garner, John
Huston, Joe DiMaggio, Quincy Jones, Charles
DeGaulle, Roy Rogers, Duke of Windsor
U.S. - 15th leading cause of death for those over
age 55
5Ruptured AAA Often Unexpected, Fatal
- Aneurysms are generally asymptomatic prior to
rupture - Sudden and catastrophic structural failure
- Most patients dont survive to reach the hospital
- For those who reach the hospital, mortality is
50 - Elective repair mortality 2-5
6Sudden Catastrophic Failure
7Sudden Catastrophic Failure
8Clinical Presentation of Ruptured AAA
- Classic Triad
- Abdominal or back pain
- Hypotension
- Pulsatile mass (often obscured due to obesity)
- Other common symptoms
- Groin or flank pain
- Hematuria
- Groin hernia (increased intra-abdominal pressure)
- CHF, abdominal bruit, hematuria aneurysm rupture
into IVC with aorto-caval fistula (rare)
9Differential Diagnosis
- Patient 50 or older with hypotension, pain
- Renal colic
- Diverticulitis
- Pancreatitis
- GI hemorrhage (typically from ulcer)
- Perforated duodenal or gastric ulcer
- Ischemic bowel
- Other aortic emergency (dissection, IMH)
- Inferior wall myocardial infarction
- Lumbar compression fracture
- Immediate diagnosis by the first physician
examining the patient 23 of the time
10Correct Dx vs Misdiagnosis rAAA
11Diagnostic Studies for Ruptured AAA
- Plain abdominal, lumbar x-rays
- Calcification of wall beyond normal limits 65
- Loss of psoas shadow 75
- Some indication 90 (in retrospect)
- Ultrasound
- Good to identify aneurysm
- not good for determining rupture
- CT scan
- Most accurate for ruptured AAA
- Helps w other diagnoses (CTA vs non-contrast)
12Resuscitation and Transfer
- Large Bore IV
- Type and Cross
- Arrange Immediate Transfer w DHART
- Goals of resuscitation
- Foley (dont do art line if it delays transport)
- Fluids only to keep SBP above 80 mm Hg
- Trauma studies suggest modest hypotension prior
to control of hemorrhage site is better (38 v
30) - Animal studies suggest same
- Elderly patients may require slightly higher SBP
13Predictors of Early Mortality in rAAA
- Pre-operative variables (anuria/oliguria, arrest,
H/H, Hospital size, LOC, hx CHF, cross-clamp
site) - Prospective Canadian Aneurysm Study
- Pre-induction blood pressure
- 70 mm Hg or less 36 30 day survival
- 70-119 mm Hg 38 30 day survival
- 120 mm Hg or more 75 30 day survival
- Pre-operative Creatinine gt1.3
- 1.3 or lower 77 30 day survival
- gt1.3 47 30 day survival
- BPlt70 and Creat lt1.3 25 survival to discharge
Johnston KW. J Vasc Surg 19888-900,1994.
14Long-term Survival After rAAA Repair
Johnston KW. J Vasc Surg 19888-900,1994.
15Long-term Survival After rAAA Repair Including
Peri-operative Factors
Johnston KW. J Vasc Surg 19888-900,1994.
16Prognosis for Survivors of rAAA
- Long-term survival rate is different for elective
and emergent (ruptured) AAA repair - 5 year survival for elective repair (if alive 30
d postop) 71 - 5 year survival for rupture repair (if alive 30 d
postop) 54 - Most of the difference is in the first year
- Cardiac, pulmonary, cancer, cerebrovascular,
renal - After the first 12-18 months, mortality/year is
similar to elective AAA repair, still lower than
general population
17Survival After Repair rAAA vs Non-ruptured
Johnston KW. J Vasc Surg 19888-900,1994.
18Risk of Rupture
19Aneurysm Wall Stress Analysis
20Aneurysm Wall Stress Analysis
- Finite Element Method
- Aneurysm geometry
- Mechanical properties (aneurysm wall)
- Blood pressure (peak systolic pressure)
21Results 3D Stress Analysis
Maximum Diameter 5.5 cm
Maximum Diameter 5.5 cm
22Rupture at Location of Peak Wall Stress
23ROC Analysis
Sensitivity
Specificity
24Rate of Rupture Diameter and Stress
Plt.0001
25Aneurysm Wall Stress Analysis
- Available in the context of clinical study
- Better predictor of rupture than diameter
- Works for Thoracic aortic aneurysms
- Affects a significant number of patients with
both small and large diameter aneurysms - Still more work to do, but already a clinically
useful tool
26Types of Procedures
- Abdominal Aortic Aneurysms
27Endovascular Aortic Aneurysm Repair
28Endovascular Aortic Aneurysm Repair
29Open Aortic Aneurysm Repair
30Endovascular Aortic Aneurysm Repair
Pre-repair
Post-repair
31Open vs Endovascular AAA RepairElective
- Open Repair
- ICU stay 1-2 days
- Hospital 5-8 days
- OK at 1 month
- Full recovery 3-6 months
- Endovascular Repair
- No ICU stay
- Hospital 1-2 days
- OK at 1 week
- Full recovery 3-6 weeks
Lower Mortality
Durable
32 Preoperative Measurements
333-D Models, CAD Geometry
34Open vs Endovascular AAA RepairRuptured AAA
- Graft sizing an issue (CTA, IVUS, marker cath)
- rAAA patients typically have worse anatomy for
endovascular repair than elective AAA - With large inventory of grafts, approx 33-50 of
patients may be treated with commercially
available endografts - Mortality rates 10-45 (average 20)
- Colon ischemia, MSOF, abd compartment syndrome
- Largest benefit is not in the most critically ill
patients, but in intermediate group
35Juxtarenal Aortic Aneurysm
36Juxtarenal Aortic Aneurysm Fenestrated Endograft
37Mimics of Ruptured AAAand Similar Aortic
Emergencies(Distal to the Aortic Arch)
38Thoracic Aortic Aneurysm
Pre
1 mo post
12 mo post
39Open vs Endovascular Thoracic Aneurysm Repair
40Thoracic Endograft Deployment
41Thoracic Endograft Deployment
42Open vs Endovascular TAA Repair
- Open Repair
- 6 mortality
- 14 paraparesis
- ICU stay 3-7 days
- Hospital 1-3 weeks
- Normal activity 3 months
- Endovascular Repair
- 1 mortality
- 3 paraparesis
- ICU stay 1-3 days
- Hospital 1-5 days
- Normal activity 1 month
Lower Mortality Less paraplegia
Durable
43Descending Thoracic Aortic Rupture
Pre-endograft
3 days Post-endograft
44Thoracic Aortic Dissection (Type B)
Presentation MR
Presentation 3-D Study
45Thoracic Aortic Dissection (Type B)
Presentation
3 days max medical tx
46Thoracic Aortic Dissection (Type B)
Presentation MR
1 year Post Endo Repair
47Thoracic Aortic Intramural Hematoma
Pre-repair
Post-repair
48Thoracic Aortic Intramural Hematoma
Pre-repair
Post-repair
49Traumatic Thoracic Aortic Aneurysm
50Traumatic Thoracic Aneurysm Post-op
51Summary
- Diagnose
- Hx, PE, US or CT (non-contrast OK)
- Initiate hypotensive resuscitation
- Large bore IV, TC, foley
- Goal SBP 80-100 mm Hg
- Immediate transfer (DHART)
52Thank You!