Rupture AAA – Any NEW advances?

Dr Karen Tung Lok ManPYNEH

Epidemiology in HK

~ 900 new cases AAA diagnosed every year

10% presented as ruptureOperative mortality rate :

Elective 10%Rupture 54%

Stephen W.K. Cheng World J. Surg 2003

Rupture AAA

50% die before reaching hospital 30% who reached hospital die

before operation Operative mortality : 50%

Overall mortality rate : 80 -90%

Open AAA repair

30 days operative mortality rate : 48% in 1998 41% in 2001

M.J. Bown British Journal of Surgery 2002

Title

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Endovascular AAA repair (EVAR) EVAR was first performed in human

by Dr Juan Parodi in 1991

Benefits of EVAR on elective AAA

30 days mortality rate Long term aneurysm-related death ICU stay and total hospital stay

R M Greenhalgh Lancet 2005Jan D. Blankensteijin New Eng J Med 2005R. E. Lovegrove British Journal of Surgery 2008

EVAR in rupture AAA ?

1st EVAR was performed in 1994 on a 61-year-old man with 6cm rupture AAA

Duplex scan on day 6 : no leakageDischarged on day 7

S W Yusuf The Lancet 1994

Technique of emergency EVAR

LA common femoral artery cutdown Placement of large sheathAortic occlusion balloon is inserted in

supra-renal position

Manish Mehta J Vasc Surg 2010

Technique of emergency EVAR

GAStent graft main body is inserted on

the contra-lateral sideArteriogram is done on ipslateral side

with aortic balloon temporaily deflated

Stent graft main body is rapidly deployed

Manish Mehta J Vasc Surg 2010

Technique of emergency EVAR

Aortic balloon advances back and inflats below renal artery

Contra-lateral limb extension is deployed

Aortic balloon is removedIpsilateral limb extension is deployed

Manish Mehta J Vasc Surg 2010

Anatomic suitability for elective EVAR

>=15mm< 30mm

< 60o

>=7mm

Anatomic suitability for rAAA EVAR

Dieter Mayer Annuals of Surgery 2009

Randy Moore J Vasc Surg 2007

SBP >80 mmHg &

Normal mentation

Current AAA management

RuptureAAA Stable

EndoCandidat

e

SpiralCTA

Openrepair

N

N

Permissive

Hypotension

Y

EVARY

Permissive Hypotension :NO fluid resuscitation unless SBP < 80mmHg or mentation

K.Roberts Eur J Vas 2006

Retrospective Studies

90 rupture AAA patients with EVAR done

in 7 years30 days mortality : 27%

Retrospective studies

J.Hoist Eur J Vasc Endovasc Surg 2009

102 rupture AAA patients with EVAR done in 10 years

30 days mortality : 13%

Dieter Mayer Annuals of Surgery 2009

EVAR is a valid treatment option for rAAAwhen used as a first-line method for all patients

New Hope

1 RCT and 33 non-randomised case series (24 retrospective and 9 prospective) reports were identifed

Systematic review

D.W. Harkin Eur J Vasc Endovasc Surg 2007

Mortality ( EVAR : 17% , Open : 34%)

Systematic review

D.W. Harkin Eur J Vasc Endovasc Surg 2007

Selection Bias

1. EVAR groups were more stable than open groups

2. EVAR groups had technically easier anatomy (e.g. longer aortic neck)

3. CT delayed treatment for open AAA repair

NO level I evidence !

1st RCT EVAR Vs Open repair

Sept 2002 – Dec 2004 Single centre prospective randomized

controlled trial

R.J. Hinchliffe Eur J Vasc Endovasc Surg 2006

1st RCT EVAR Vs Open repairEVAR Open

repair30-day mortality 53 % 53%

Moderate or severe

complications77 % 80%

Hospitial stay 10 days 12 daysBlood loss 200 ml 2100 ml

BloodTransfusion

3 units 6 units

Failed to demonstrate superiority

of EVAR over open repair

Advantages of emergency EVAR

1. Avoid vasodilating and negatively inotropic effects of GA

2. Avoid large midline laparotomy on muscle wall tone which lead to circulatory compromise

3. Decreased surgical dissection blood loss4. Avoid aortic cross-clamping

and potential reperfusion injury

Limitations of EVAR in rupture AAA

1. Anatomical issue 2. Logistical issue – Lack of availability

of EVAR trained staff and appropiate endograft components

3. EVAR specific complications need re-intervention

Rupture AAA protocol

AIM : To demonstrate any improved survival (30 days mortality) after introduction of an

rupture AAA protocol

2001 2004 2006

Randy Moore J Vasc Surg 2007

Result

Randy Moore J Vasc Surg 2007

Result

Randy Moore J Vasc Surg 2007

Conclusion

Mortality rate for open repair of rupture AAA remains high

Emergency EVAR for treatment of rupture AAA is feasible

Introduction of rupture AAA repair protocol includes EVAR can improve mortality rate

What is going on...

3 Randomized controll trials currently undergoing

The Amsterdam Acute Endovascular Treatment To Imporve Outcome of Rupture Aorta-Iliac Aneuysm trial (AJAX)

The Rupture Aorta-Iliac Aneuysm Endo vs Surgery (ECAR) trial

Immediate Management of the Patient with Rupture: Open Versus Endovascular Repair (IMPROVE) trial