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Yunus RA, Saeed S, Levy N, Di Fenza R, Sharkey A, Pobywajlo S, Liang P, Schermerhorn M, Mahmood F, Matyal R, Neves S. A Multidisciplinary Protocolized Approach for Ruptured Abdominal Aortic Aneurysm Management: A Retrospective Before-After Study. J Cardiothorac Vasc Anesth 2024; 38:755-770. [PMID: 38220517 DOI: 10.1053/j.jvca.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/01/2023] [Accepted: 12/11/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVES To investigate whether implementation of a multidisciplinary protocol for ruptured abdominal aortic aneurysm (rAAA) management reduces rates of adverse complications. DESIGN A retrospective before-after study. SETTING A tertiary-care academic hospital. PARTICIPANTS Adult patients who underwent open or endovascular rAAA repair; data were stratified into before-protocol implementation (group 1: 2015-2018) and after-protocol implementation (group 2: 2019-2022) groups. INTERVENTION The protocol details the workflow for vascular surgery, anesthesia, emergency department, and operating room staff for a rAAA case; training was accomplished through yearly workshops. MEASUREMENTS AND MAIN RESULTS The primary outcome was in-hospital mortality. Secondary outcomes included all-cause morbidity and other major complications. Differences in postoperative complication rates between groups were assessed using Pearson's χ2 test. Of the 77 patients included undergoing rAAA repair, 41 (53.2%) patients were in group 1, and 36 (46.8%) patients were in group 2. Patients in group 2 had a significantly shorter median time to incision (1.0 v 0.7 hours, p = 0.022) and total procedure time (180.0 v 160.5 minutes, p = 0.039) for both endovascular and open repair. After protocol implementation, patients undergoing endovascular repair exhibited significantly lower rates of mortality (46.2% v 20.0%, p = 0.048), all-cause morbidity (65.4% v 44.0%, p = 0.050), and renal complications (15.4% v 0.0%, p = 0.036); patients undergoing open repair for a rAAA exhibited significantly lower rates of mortality (53.3% v 27.3%, p = 0.018) and bowel ischemia (26.7% v 0.0%, p = 0.035). CONCLUSIONS Implementation of a multidisciplinary protocol for the management of a rAAA may reduce rates of adverse complications and improve the quality of care.
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Affiliation(s)
- Rayaan A Yunus
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Shirin Saeed
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nadav Levy
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Raffaele Di Fenza
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Aidan Sharkey
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Susan Pobywajlo
- The CardioVascular Institute, Beth Israel Deaconess Medical Center, Boston, MA
| | - Patric Liang
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Marc Schermerhorn
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Robina Matyal
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Sara Neves
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
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Abdominal Compartment Syndrome-When Is Surgical Decompression Needed? Diagnostics (Basel) 2021; 11:diagnostics11122294. [PMID: 34943530 PMCID: PMC8700353 DOI: 10.3390/diagnostics11122294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022] Open
Abstract
Compartment syndrome occurs when increased pressure inside a closed anatomical space compromises tissue perfusion. The sudden increase in pressure inside these spaces requires rapid decompression by means of surgical intervention. In the case of abdominal compartment syndrome (ACS), surgical decompression consists of a laparostomy. The aim of this review is to identify the landmarks and indications for the appropriate moment to perform decompression laparotomy in patients with ACS based on available published data. A targeted literature review was conducted on indications for decompression laparotomy in ACS. The search was focused on three conditions characterized by a high ACS prevalence, namely acute pancreatitis, ruptured abdominal aortic aneurysm and severe burns. There is still a debate around the clinical characteristics which require surgical intervention in ACS. According to the limited data published from observational studies, laparotomy is usually performed when intra-abdominal pressure reaches values ranging from 25 to 36 mmHg on average in the case of acute pancreatitis. In cases of a ruptured abdominal aortic aneurysm, there is a higher urgency to perform decompression laparotomy for ACS due to the possibility of continuous hemorrhage. The most conflicting recommendations on whether surgical treatment should be delayed in favor of other non-surgical interventions come from studies involving patients with severe burns. The results of the review must be interpreted in the context of the limited available robust data from observational studies and clinical trials.
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Choo SJ, Jeon YB, Oh SS, Shinn SH. Outcomes of emergency endovascular versus open repair for abdominal aortic aneurysm rupture. Ann Surg Treat Res 2021; 100:291-297. [PMID: 34012947 PMCID: PMC8103156 DOI: 10.4174/astr.2021.100.5.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/19/2021] [Accepted: 02/16/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Ruptured abdominal aortic aneurysm (rAAA) is one of the most common aortic emergencies in vascular surgery and is associated with high operative mortality and morbidity rates despite recent treatment advances. We evaluated operative mortality risks for the outcomes of emergency endovascular aneurysm repair (eEVAR) vs. open repair in rAAA. Methods Twenty patients underwent eEVAR (n = 12) or open repair (n = 8) for rAAA between 2016 and 2020. We adopted the EVAR first strategy since 2018. Primary endpoints included in-hospital mortality and 1-year survival. The outcome variables were analyzed with Fisher exact, Mann-Whitney test, and linear by linear association. The Kaplan-Meier method was used to estimate survival. Results There were 13 males (65.0%) and the median age of the study cohort was 78.0 years (range, 49–88 years). In-hospital mortality occurred in 7 patients (35.0%); 5 (50.0%) in the early period and 2 (20.0%) in the later period of this series. According to the procedure type, 4 (50.0%) and 3 (25.0%) in-hospital mortalities occurred in the open repair and eEVAR patients, respectively. In 6 patients (50.0%), eEVAR was performed on unfavorable anatomy. The 1-year survival of eEVAR vs. open repair group was 75% ± 12.5% and 50% ± 17.7%, respectively. On univariate analysis, preoperative high-risk indices, postoperative acute renal failure requiring dialysis, pulmonary complications, and prolonged mechanical ventilation were associated with higher operative mortality. Conclusion The current data showed relatively superior outcomes with eEVAR vs. open repair for rAAA, even in some patients with unfavorable anatomy supporting the feasibility, efficacy, and safety of EVAR first strategy.
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Affiliation(s)
- Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yang-Bin Jeon
- Department of Traumatology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Sam-Sae Oh
- Department of Thoracic and Cardiovascular Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Sung Ho Shinn
- Department of Thoracic and Cardiovascular Surgery, Cheju Halla General Hospital, Jeju, Korea
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Jernigan EG, Nguyen Tran N, Qato K, Giangola G, Carroccio A, Conway AM. Outcomes of chimney/snorkel endovascular repair for symptomatic and ruptured abdominal aortic aneurysms. J Vasc Surg 2021; 74:1117-1124. [PMID: 33848555 DOI: 10.1016/j.jvs.2021.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 03/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Symptomatic and ruptured abdominal aortic aneurysms (AAAs) are increasingly being managed with endovascular aneurysm repair (EVAR). We aimed to identify the outcomes of symptomatic and ruptured AAAs that had undergone EVAR with a chimney or snorkel technique (ChEVAR). METHODS A retrospective cohort study was performed using the Vascular Quality Initiative registry from March 2013 to July 2019. All patients with symptomatic and ruptured AAAs with a proximal aortic zone of disease from 6 to 9 who had undergone ChEVAR were included. The outcomes were analyzed in accordance with the Society for Vascular Surgery reporting standards for EVAR. RESULTS ChEVAR was performed in 77 patients (ruptured, 35 [45.5%]; symptomatic, 42 [54.5%]). The median age was 73.0 years (interquartile range [IQR], 67.0-81.0 years), and 54 patients (70.1%) were men. The median maximum aneurysm diameter was 67.5 mm (IQR, 54.5-83.3 mm). All patients had American Society of Anesthesiologists class ≥III. For the patients with ruptured AAAs, the mean lowest preoperative systolic blood pressure was 95.3 ± 29.3 mm Hg. The fluoroscopy time was 57.4 minutes (IQR, 41.2-79.0 minutes). The proximal aortic zone of disease was zone 6 in 9 (11.7%), zone 7 in 21 (27.3%), zone 8 in 36 (46.8%), and zone 9 in 11 (14.3%) patients. ChEVAR involved more than one vessel in 55 patients (71.4%). No significant difference was found in 30-day mortality between the patients with ruptured vs symptomatic AAAs (11.4% vs 7.1%; P = .695). Reintervention was required for 10 patients (13.0%) at a median of 9 postoperative days, 2 (20.0%) of whom died. Postoperatively, 31 patients (40.3%) had experienced a major complication. A type I endoleak had occurred in nine patients (11.7%), two (22.2%) of whom died. Long-term follow-up data were available for 38 patients (49.4%) at a median of 406.5 days (IQR, 326.8-602.0 days) postoperatively. Of the 18 patients with long-term radiographic data, sac growth was detected in 4 (22.2%). A total of 14 patients had died at a median of 26.5 days (IQR, 3.0-468.5 days). CONCLUSIONS ChEVAR for symptomatic and ruptured AAAs can be performed with acceptable rates of morbidity and mortality. Long-term data are needed to determine the durability.
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Affiliation(s)
| | - Nhan Nguyen Tran
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Khalil Qato
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Gary Giangola
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Alfio Carroccio
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Allan Marc Conway
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
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Multiple Chimney Endografts (ChEVAR) for Ruptured Pararenal Aortic Aneurysm. Ann Vasc Surg 2021; 75:531.e1-531.e6. [PMID: 33836225 DOI: 10.1016/j.avsg.2021.01.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 12/31/2020] [Accepted: 01/24/2021] [Indexed: 11/21/2022]
Abstract
We present a ruptured pararenal abdominal aortic aneurysm repaired with a complex three-vessel chimney EVAR . This technique allows for rapid sealing of the aneurysm with branch preservation and avoids complex open aortic surgery. This case report highlights techniques and pitfalls from complex three-vessel chimney EVAR repair in the emergency setting.
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Mehmedovic A, Konstantinou N, Jerkku T, Pichlmaier M, Kölbel T, Rantner B, Banafsche R, Tsilimparis N. [Aortic Aneurysm: Fenestrated/Branched Endovascular Aortic Repair (EVAR) and Fenestrated/Branched Thoracic Endovascular Aortic Repair (TEVAR). Is Total Endovascular Repair Already Here?]. Zentralbl Chir 2020; 145:432-437. [PMID: 32659798 DOI: 10.1055/a-1186-2554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Five years after the first endovascular aortic repair (EVAR), Park et al. reported the first implantation of a fenestrated endoprosthesis. In the meantime, advanced generations of new fenestrated and branched endografts evolved. Endografts for complex pathologies are either so-called "off-the-shelf" grafts with predetermined length, width, diameter and clock position of the branches and fenestrations, predetermined by the manufacturer, "custom-made" grafts which need to be sized and planned individually for patients with specific thoracoabdominal anatomy. Open aortic repair in the treatment of thoracoabdominal aortic aneurysm (TAAA) still remains challenging and is associated with high morbidity and mortality, even in the elective setting. The ongoing development of endovascular treatment modalities, such as fenestrated and branched endovascular aneurysm repair (F-EVAR, B-EVAR), enables less invasive procedures for more challenging aortic pathologies. In recent years, extensive endovascular treatment of the aortic arch to the thoracoabdominal segment has become more and more important, but its outcomes have not been completely evaluated. The aim of this is article is to provide an overview of the currently available endovascular treatment options for complex aortic aneurysms requiring extensive coverage from the aortic arch to the infrarenal aorta.
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Affiliation(s)
- Aldin Mehmedovic
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Nikolaos Konstantinou
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Thomas Jerkku
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Maximilian Pichlmaier
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Tilo Kölbel
- Klinik und Poliklinik für Gefäßmedizin, Universitäres Herzzentrum Hamburg-Eppendorf, Deutschland
| | - Barbara Rantner
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Ramin Banafsche
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
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SÁ P, Oliveira-Pinto J, Mansilha A. Abdominal compartment syndrome after r-EVAR: a systematic review with meta-analysis on incidence and mortality. INT ANGIOL 2020; 39:411-421. [PMID: 32519533 DOI: 10.23736/s0392-9590.20.04406-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Endovascular aneurysm repair for ruptured abdominal aortic aneurysms (r-EVAR) sometimes complicates with abdominal compartment syndrome (ACS) due to extensive retroperitoneal hematoma, with significant prognostic implications. This systematic review aimed to analyze the incidence of the syndrome and assess the impact of ACS on mortality. Mortality after decompressive laparotomy was also assessed. EVIDENCE ACQUISITION Two databases were searched: Medline and Web of Science. The search was conducted through October 2019. The titles and abstracts of the retrieved articles were independently reviewed. All studies reporting on the ACS incidence after r-EVAR were initially included. From each study, eligibility was determined and descriptive, methodological, and outcome data was extracted. The incidence was calculated with summary proportion. Odds ratio was used to compare the mortality rate. Meta-analysis was performed with fixed effect model when calculating the ACS incidence in r-EVAR patients and when assessing the impacts of ACS and DL in the mortality rate. EVIDENCE SYNTHESIS A total of 46 studies were included, with a cumulative cohort of 3064 patients. Two hundred and fifty-two (8.2%) patients developed ACS. The ACS pooled incidence was 9% with a 95% confidence interval of [0.08; 0.11]. Among the 46 included studies, 19 studies reported data on the mortality rate, corresponding to 1825 of the 3064 patients. Of these, 169 (9.3%) had developed ACS and 94 (55.6%) of them died by multi organ failure. Among the 1656 patients without ACS, 328 died (19.8%). The mortality odds ratio meta-analysis was 6.25 with a 95% confidence interval of [4.44, 8.80]. Decompressive laparotomy was performed in 41 patients, decreasing mortality in 47%. CONCLUSIONS ACS affects approximately 9% of patients submitted to r-EVAR, and significantly increases perioperative mortality. Close postoperative surveillance to clinical signs of ACS is vital in these patients.
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Choi C, Ahn S, Min SI, Ahn M, Ha J, Yoon HJ, So R, Choi SH, Min SK. Nationwide Epidemiologic Study of Abdominal Aortic Aneurysms in Korea: A Cross-Sectional Study Using National Health Insurance Review and Assessment Service Data. Vasc Specialist Int 2019; 35:193-201. [PMID: 31915663 PMCID: PMC6941766 DOI: 10.5758/vsi.2019.35.4.193] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/03/2019] [Accepted: 12/06/2019] [Indexed: 11/20/2022] Open
Abstract
Purpose The prevalence and treatment patterns of abdominal aortic aneurysm (AAA) vary according to ethnicity and region. This study analyzed nationwide data on the epidemiology, practice patterns, and mortality rates of AAA in Korea. Materials and Methods Data from patients treated for AAA from 2012 to 2016 were extracted from the Korean Health Insurance Review and Assessment (HIRA) database. Results A total of 30,766 patients in Korea had treatment codes for AAA and 2,618 patients were treated for ruptured AAA. Of the 6,356 patients treated surgically, 1,849 and 4,507 underwent open surgical aneurysmal repairs (OSAR) or endovascular aneurysmal repairs (EVAR), respectively. The number of surgical treatments performed annually for AAA increased from 1,129 cases in 2012 to 1,501 cases in 2016. The number of EVAR cases increased from 753 to 1,109 during these five years, while the number of OSAR cases remained similar, at 376 and 392, respectively. The 30-day mortality rates after EVAR and OSAR were 4.2% and 10.6%, respectively. The mortality rates were significantly higher in patients with hypertension, dyslipidemia, chronic renal disease, diabetes mellitus, and congestive heart failure. There were significant differences in the prevalence, proportion of EVAR, and mortality rates according to the regional area. Conclusion The prevalence of AAA and the proportion of EVAR in Korea increased in the past 5 years, while the rupture rate and the proportion of OSAR remained similar. To minimize mortality and regional discrepancies, nationwide registry and treatment standardization are needed.
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Affiliation(s)
- Chanjoong Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Sanghyun Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-il Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Moonsang Ahn
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Jin Yoon
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea
| | - Rina So
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Hyouk Choi
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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