Current Management of Ruptured AAA: A New Approach at MMC

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Current Management of Ruptured AAA A New
Approach at MMC

• Christopher T. Healey, M.D.
• Maine Surgical Care Group
• Maine Medical Center
• Maine ACS Meeting
• June 8th, 2008

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Historical Data on Treatment of Ruptured AAA

• First Attempts at open repair in 1950s.
• Over last 50-60 years mortality has declined for
  elective AAA to 5 or less.
• This has not occurred for ruptured AAAs (rAAA).
• Incidence of rAAA increasing 70s and 80s 5.6
  per 100,000 now 10.6 per 100,000.
• Increasing rAAA rates despite increasing number
  of elective repairs.
• Peri-operative rAAA mortality has been quite
  stable at 40-50 over last 2 decades.

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Newer ConceptsPotential Ways to Improve Outcomes
for rAAA

• 1.) Screening.
• 2.) Permissive Hypotension.
• 3.) Endovascular rAAA Repair.
• 4.) Multi Disciplinary protocols for management
  of rAAA.
• 5.) The Development of an MMC protocol for the
  management of rAAA.

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Screening for AAAs

• AAAs are like U-boats deep silent, dangerous
  but detectable by Ultrasound
• Dr K. Craig Kent NY Prebyterian
• When is screening good?
• Test is cheap, quick, and non-invasive.
• Prevalence of disease is high.
• Disease dangerous if undetected.
• Treatment is highly effective and cheap.

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Screening for AAAsCost Effectiveness
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Screening for AAAsWho Should be Screened?

• US Preventive Services Task Force 2005 (Medicare)
• Men aged 65-75 who have ever smoked
• People with 1st degree relative
• Society of Vascular Surgery Consensus Statement
  (2004)
• All men 60-85
• Women 60-85 with cardiovascular risk factors
• Men and women with family history gt50.
• Aorta lt3.0 cm no further testing.
• Aorta 3-4 cm yearly ultrasound.
• Aorta 4-4.5 cm ultrasound every 6 months.
• Aorta gt4.5 referral to vascular specialist.

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Permissive Hypotension

• Stay Calm Avoid the Aneurysm Reflex,
  Historically Fluids poured in and taken directly
  to OR.
• There is evidence to suggest that a more
  controlled thoughtful but expeditious approach is
  feasible and likely beneficial.
• JVS 2004 Feasibility of pre-op CT with ruptured
  AAA, 1995-2003 Leicester, England.
• 56 patients decided not to have rAAA repaired.
• 87.5 died more than 2 hours after admission.
• Median interval between onset of symptoms and
  admission 2 hours and 30 minutes.
• Median interval between admission and death gt10
  hours.

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Permissive Hypotension

• Stay Calm Avoid the Aneurysm Reflex
• Permissive Hypotension a state of consciousness
  with a Systolic Blood Pressure gt85.
• In animal models of uncontrolled hemorrhage
  (swine, dogs, sheep, and rats) noted increased
  hemmorrhage and many decreased survival when nl
  SBP is goal of recusitation.
• In theory inceased fluid recusitation leads to
  increased bleeding because of increased arterial
  and venous pressure, dilution of clotting
  factors, and decreased blood viscosity.
• Not proven to improve survival in people for AAA
  or trauma in people but most every ruptured AAA
  protocol in literature employs a policy of
  permissive hypotension.
• Goal at MMC Recusitate to SBP of gt85 and
  talking.

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Endovascular rAAA Repair

• First EVAR 1991, Juan Parodi.
• Decreased perioperative morbidity and mortality
  in properly selected elective AAA repair.
• Nottingham Group reports 1st
  report of EVAR for treatment
  of rAAA, homemade stent graft.
• 1999 Ohki reports on series of
  12 ruptures treated with aort-uni
  homemade graft with 16 mortality.
• Theoretically EVAR avoids the additional surgical
  insult to physiology that comes with laparotomy
  and Open Repair. Endovascular Damage Control

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Endovascular rAAA Repair

• University Hospital Zurich, 2005
• 37 patients had rEVAR 1997 to 2003
• 10.8 30 day mortality.
• 35 secondary intervention rate.
• Aristotle Medical School Greece, 2005
• 23 patients 1998 to 2004 (61 of ruptures)
• 22/23 technical success.
• 39 30 day mortality.
• Modena, Italy, 2006
• 124 patients, 33 EVAR
• 96 technical success.
• 30 30 day mortality vs. 46 open

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Endovascular rAAA Repair

• University of FL, August 2004
• 1997 to 2001, all open 19 patients (EARLY Group)
• 2002 to 2004, 4 open and 13 EVAR (LATE Group)

Differences not statistically significant
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Endovascular rAAA Repair

• Results in a community Hospital 2007
• Buffalo 2007, Hospital very similar in size,
  volume, and referral pattern to MMC.
• 30 of 40 ruptures had attempt at EVAR
• 17 vs 40 mortality EVAR vs. Open
• Predictors of perioperative mortality were
• Hypotension, loss of consciousness, and need for
  balloon occlusion.
• This can be accomplished at MMC, but How?

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rAAA Protocols

• JVS 2007 Moore et al.
• Study designed to demonstrate improved survival
  after introduction of Protocol.
• Assessed 126 pts. With rAAA. Primary outcome
  peri-op mortality.
• Comparison of all open vs EVAR 5 vs. 28.
• Unstable patients trend EVAR 14 vs. 56.
• Open before 30 vs. after 25.
• A predefined strategy including EVAR is
  associated with improved mortality.

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Canadian Protocol
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rAAA Protocols

• Canadian Protocol
• They did broaden the anatomic inclusion criteria
  for EVAR, accepted shorter more angled necks.
• Occlusion balloon only if needed.
• Unstable patients did unilateral groin cutdown
  under local to place balloon.
• Consider EVAR treatment of choice.
• Very High volume elective EVAR caseload.
• Large inventory available liberal use of aorto
  uni with fem-fem crossover.

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rAAA Protocols

• Albany Protocol
• Recognized limiting factor to rEVAR was lack of
  endovascular trained staff in OR/ED.
• Multi disciplinary approach including vascular
  surgeons, ED physicians, anesthesiologists,
  radiology techs, as well as industry to supply
  full array of stent grafts.
• Rehearsed the procedure from ED to PACU with all
  staff.
• 5 patients with symptomatic but not r-AAA had
  treatment from ED to PACU.
• All performed in OR under general.

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Albany Protocol
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rAAA Protocols

• Accepted a neck of 5 mm as candidate.
• Late in experience did not heparinize patients,
  found increased risk of abdominal compartment
  syndrome.
• Prepared to convert to aortuni when unstable.
• Mean transfer time from ED to OR 20 minutes
  including CT.
• Oversized 20-25 routinely.
• 40/42 technical success.
• 12 need for secondary intervention mean
  follow-up 17 months.

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rAAA Protocols

• Albany Midterm outcomes
• Looking at all r-AAA.
• EVAR usage increased with time 2002-12,
  2003-45, 2004-60, 2005-65, 2006-71.
• 66 EVAR, 81 Open.
• EVAR had higher comorbidities but 30 day
  mortality was 17 vs. 40 for Open.
• Overall mortality similar in stable and unstable
  patients.

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Expanding Use of EVAR for rAAA Nationwide
Perspective. JVS June 2008

• Examined Nationwide Inpatient Sample Data
• 2001 to 2004, EVAR 6 to 11 for emergency.
• Mortality for EVAR declined from 43 to 29.
• Mortality for Open staying the same.

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Proposed MMC Protocol
ED Provider Suspects rAAA
OSH Suspects rAAA
Alert Vascular Team Purple Surgery Resident and
Vascular Attending Review Outside films if
available electronically Recusitate to SBPgt85 and
talking
Alert the OR
Hemodynamically Stable SBPgt80, Talking
Hemodynamically Unstable SBPlt80
Urgent CT Ruptured AAA Protocol
Operating Room Ready for EVAR or Open Repair PT
Supine on Vascular Bed Prepped for Open Local
Anesthesia to Begin if unstable at all
Femoral Cutdown Long 16 French Sheath
Contra Occlusion Balloon in Distal Thoracic
Aorta Aortagram
Aortic Occlusion Balloon in Thoracic
Aorta Laparotomy for Open repair
Unsuitable Neck
Suitable Neck
EVAR
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Emergency Department Care
Goal Make Diagnosis and Get Patient Safely to
OR, in 20-30 minutes

• Things to Do
• If diagnosis suspected initiate rAAA protocol.
• 2 large Bore IVs.
• Labs to be sent(Dont need any Results) Type and
  Cross,CBC, CMP, Coags
• Recusitate to SBP 85 and talking.
• Use Blood and crystalloid.
• Intubate if patient unable to protect airway. Do
  not if patient talking.
• Transfer to CT and OR as expeditiously as
  possible.

• Things not Needed
• Central line
• Other labs unless diagnosis in question.
• EKG unless diagnosis in question.
• CXR.
• Arterial line.
• Ultrasound.

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Anatomic Criteria for EVAR

• Standard
• Aortic Neck lt26 mm.
• Infrarenal neck length gt15 mm.
• Neck angulation lt45 degrees
• Calcium or thrombus in neck.
• Iliac diameter 8-18.5 mm.
• Distal seal zone of 10 mm.

• Extended rAAA Criteria
• Aortic Neck lt32 mm.
• Infrarenal neck length gt10 mm.
• Neck Angulation lt60 degrees. (perhaps greater)
• Calcification lt40.
• Non reverse funnel shaped neck.
• Iliac diameter 5-21 mm.
• Ability to preserve one hypogastric.

Vascular Attending Responsible for Determining
Suitability for EVAR and Need to repeat outside
films.
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Operating Room Care

• Anasthesia
• General
• 2 large IVs and art line if possible.
• Foley
• No anasthesia until patient prepped and draped.
• OR
• EVAR table, C arm in room, x ray in room prior to
  arrival of pt or simultaneous.
• Default plan will be to try EVAR, on occasion may
  know patient not candidate from outside CT and
  will inform OR.
• Open Rupture Box, surgeon to select grafts.

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Development of MMC rAAA Protocol

• Raise Awareness! Educate Caregivers.
• Initial Grand Rounds.
• Visiting Professor in Spring.
• Present information and preliminary results at
  Maine ACS meeting.
• Perhaps Grand Rounds at Referring Institutions.
• Develop appropriate inventory.
• Stock of grafts in OR Now.
• Goal to have additional grafts on shelf to treat
  more difficult anatomy, neck size up to 32 mm
  within month. Coming Talent graft just approved.

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Development of MMC rAAA Protocol

• Maximize Elective Experience
• Perform as many as possible if not all EVAR in
  MMC OR.
• 2 Vascular Attending Staff initially for all
  cases.
• May not have capacity initially 24 hours a day
  but close.
• Open Lines of Communication/ Learn from every
  Case
• I will be MMC rAAA Point Man.
• Systematically review each case to look for
  opportunities for improvement.
• Debriefing with all involved caregivers within 72
  hours of each case, summary of events OFIs then
  distributed to all.
• Welcome questions and suggestions from anyone who
  helps to care for these patients.

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