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Than LX, Quang NN, Hung PM. Aortic Balloon Occlusion in Repair of Ruptured Abdominal Aortic Aneurysm. JACC Case Rep 2024; 29:102331. [PMID: 38601839 PMCID: PMC11002862 DOI: 10.1016/j.jaccas.2024.102331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/07/2023] [Accepted: 11/20/2023] [Indexed: 04/12/2024]
Abstract
This case report details a novel technique implemented in Vietnam. When full equipment is unavailable, we adapt it by using aortic balloon occlusion to enhance the patient's hemodynamics and mitigate the risk of intraprocedural exsanguination. This approach effectively addresses the rupture of abdominal aortic aneurysms in patients with unstable hemodynamic conditions.
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Affiliation(s)
- Le Xuan Than
- Vietnam National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam
| | | | - Pham Manh Hung
- Vietnam National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam
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Lauridsen SV, Bøtker MT, Eldrup N, Juhl-Olsen P. Prehospital point-of-care ultrasound in ruptured abdominal aortic aneurysms-a retrospective cohort study. Acta Anaesthesiol Scand 2024; 68:693-701. [PMID: 38415353 DOI: 10.1111/aas.14393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/14/2024] [Accepted: 02/04/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Patients with ruptured abdominal aortic aneurysm (rAAA) require immediate vascular treatment to survive. The use of prehospital point-of-care ultrasound (POCUS) may support clinical assessment, correct diagnosis, appropriate triage and reduce system delay. The aim was to study the process of care and outcome in patients receiving prehospital POCUS versus patients not receiving prehospital POCUS in patients with rAAA, ruptured iliac aneurysm or impending aortic rupture. METHODS We performed a retrospective cohort study in patients diagnosed with rAAA in the Central Denmark Region treated by a prehospital critical care physician from 1 January 2017 to 31 December 2021. Performance of prehospital POCUS was extracted from the prehospital electronic health records. System delay was defined as the time from the emergency phone call to the emergency medical service dispatch centre until the start of surgery. Data on patients primary hospital admission to a centre with/without vascular treatment expertise, treatments and complications including death were extracted from electronic health records. RESULTS We included 169 patients; prehospital POCUS was performed in 124 patients (73%). Emergency surgical treatment was performed in 71 patients. The overall survival in the POCUS group was 39% versus 16% in the NO POCUS group (hazard ratio (HR) (95% 0.60, 95% CI: 0.41-0.89, p = .011). In the POCUS group 99/124 (80%) were directly admitted to a vascular surgical centre versus 25/45 (56%) in the NO POCUS, RD 24% (95% CI: 8-40)), (p = .002). In the POCUS group, system delay was a median of 142 minutes (interquartile range (IQR) 121-189) and a median of 232 minutes (IQR 166-305) in the NO POCUS group (p = .006). In a multivariable analysis incorporating age, sex, previously known rAAA, and typical clinical symptoms of rAAA, the HR for death was 0.57, 95% CI 0.38-0.86 (p = .008) favouring prehospital POCUS. CONCLUSIONS Prehospital POCUS was associated with reduced time to treatment, higher chance of operability and significantly higher 30-day survival in patients with rAAA, ruptured iliac aneurysm or impending rupture of an AAA in this retrospective study. Residual confounding cannot be excluded. This study supports the clinical relevance of prehospital POCUS of the abdominal aorta.
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Affiliation(s)
- Signe Voigt Lauridsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Research and Development, Prehospital Emergency Medical Service, Central Denmark Region, Aarhus, Denmark
| | - Morten Thingemann Bøtker
- Department of Research and Development, Prehospital Emergency Medical Service, Central Denmark Region, Aarhus, Denmark
- Department of Anaesthesiology, Randers Region Hospital, Randers, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Juhl-Olsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Berchiolli R, Troisi N, Bertagna G, D’Oria M, Mezzetto L, Malquori V, Artini V, Motta D, Grosso L, Grando B, Badalamenti G, Calvagna C, Mastrorilli D, Veraldi GF, Adami D, Lepidi S. Intraoperative Predictors and Proposal for a Novel Prognostic Risk Score for In-Hospital Mortality after Open Repair of Ruptured Abdominal Aortic Aneurysms (SPARTAN Score). J Clin Med 2024; 13:1384. [PMID: 38592197 PMCID: PMC10934212 DOI: 10.3390/jcm13051384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/30/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Several mortality risk scores have been developed to predict mortality in ruptured abdominal aortic aneurysms (rAAAs), but none focused on intraoperative factors. The aim of this study is to identify intraoperative variables affecting in-hospital mortality after open repair and develop a novel prognostic risk score. (2) Methods: The analysis of a retrospectively maintained dataset identified patients who underwent open repair for rAAA from January 2007 to October 2023 in three Italian tertiary referral centers. Multinomial logistic regression was used to calculate the association between intraoperative variables and perioperative mortality. Independent intraoperative factors were used to create a prognostic score. (3) Results: In total, 316 patients with a mean age of 77.3 (SD ± 8.5) were included. In-hospital mortality rate was 30.7%. Hemoperitoneum (p < 0.001), suprarenal clamping (p = 0.001), and operation times of >240 min (p = 0.008) were negative predictors of perioperative mortality, while the patency of at least one hypogastric artery had a protective role (p = 0.008). Numerical values were assigned to each variable based on the respective odds ratio to create a risk stratification for in-hospital mortality. (4) Conclusions: rAAA represents a major cause of mortality. Intraoperative variables are essential to estimate patients' risk in surgically treated patients. A prognostic risk score based on these factors alone may be useful to predict in-hospital mortality after open repair.
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Affiliation(s)
- Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Mario D’Oria
- Vascular and Endovascular Surgery Unit, Cardio-Thoraco-Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy; (B.G.); (G.B.); (C.C.); (S.L.)
| | - Luca Mezzetto
- Unit of Vascular Surgery, Department of Cardio-Thoraco-Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, 37134 Verona, Italy; (L.M.); (L.G.); (D.M.); (G.F.V.)
| | - Vittorio Malquori
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Valerio Artini
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Duilio Motta
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Lorenzo Grosso
- Unit of Vascular Surgery, Department of Cardio-Thoraco-Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, 37134 Verona, Italy; (L.M.); (L.G.); (D.M.); (G.F.V.)
| | - Beatrice Grando
- Vascular and Endovascular Surgery Unit, Cardio-Thoraco-Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy; (B.G.); (G.B.); (C.C.); (S.L.)
| | - Giovanni Badalamenti
- Vascular and Endovascular Surgery Unit, Cardio-Thoraco-Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy; (B.G.); (G.B.); (C.C.); (S.L.)
| | - Cristiano Calvagna
- Vascular and Endovascular Surgery Unit, Cardio-Thoraco-Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy; (B.G.); (G.B.); (C.C.); (S.L.)
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Department of Cardio-Thoraco-Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, 37134 Verona, Italy; (L.M.); (L.G.); (D.M.); (G.F.V.)
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Department of Cardio-Thoraco-Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, 37134 Verona, Italy; (L.M.); (L.G.); (D.M.); (G.F.V.)
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Sandro Lepidi
- Vascular and Endovascular Surgery Unit, Cardio-Thoraco-Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy; (B.G.); (G.B.); (C.C.); (S.L.)
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Chen S, Xia S, Song C, Lu Q. Emergency EVAR for Abdominal Aortic Aneurysm Ruptured Into the Duodenum With an Aortic Dissection. JACC Case Rep 2024; 29:102188. [PMID: 38361560 PMCID: PMC10865111 DOI: 10.1016/j.jaccas.2023.102188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/21/2023] [Accepted: 12/06/2023] [Indexed: 02/17/2024]
Abstract
We report a case of aortoduodenal fistula formed after an abdominal aortic aneurysm ruptured into the duodenum. There is also an aortic dissection involving the celiac trunk, superior mesenteric artery and renal arteries. Successful treatment was achieved through endovascular aortic repair, followed by anti-infective and supportive therapy over 3 months.
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Affiliation(s)
- Shihan Chen
- Department of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Shibo Xia
- Department of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Chao Song
- Department of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qingsheng Lu
- Department of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
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Duran M, Arnautovic A, Kilic C, Rembe JD, Mulorz J, Schelzig H, Wagenhäuser MU, Garabet W. The Comparison of Endovascular and Open Surgical Treatment for Ruptured Abdominal Aortic Aneurysm in Terms of Safety and Efficacy on the Basis of a Single-Center 30-Year Experience. J Clin Med 2023; 12:7186. [PMID: 38002798 PMCID: PMC10672125 DOI: 10.3390/jcm12227186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE Ruptured abdominal aortic aneurysm (rAAA) is a critical condition with a high mortality rate. Over the years, endovascular aortic repair (EVAR) has evolved as a viable treatment option in addition to open repair (OR). The primary objective of this study was to compare the safety and efficacy of EVAR and OR for the treatment of rAAA based on a comprehensive analysis of our single-centre 30-year experience. METHODS Patients treated for rAAA at the Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Germany from 1 January 1993 to 31 December 2022 were included. Relevant information was retrieved from archived medical records. Patient survival and surgery-related complications were analysed. RESULTS None of the patient-specific markers, emergency department-associated parameters, and co-morbidities were associated with patient survival. The 30-day and in-hospital mortality was higher in the OR group vs. in the EVAR group (50% vs. 8.7% and 57.1% vs. 13%, respectively). OR was associated with more frequent occurrence of more severe complications when compared to EVAR. Overall patient survival was 56 ± 5% at 12 months post-surgery (52 ± 6% for OR vs. 73 ± 11% for EVAR, respectively) (p < 0.05). Patients ≥70 years of age showed poorer survival in the OR group, with a 12-month survival of 42 ± 7% vs. 70 ± 10% for patients <70 years of age (p < 0.05). In the EVAR group, this age-related survival advantage was not found (12-month survival: ≥70 years: 67 ± 14%, <70 years: 86 ± 13%). Gender-specific survival was similar regardless of the applied method of care. CONCLUSION OR was associated with more severe complications in our study. EVAR initially outperformed OR for rAAA regarding patient survival while re-interventions following EVAR negatively affect survival in the long-term. Elderly patients should be treated with EVAR. Gender does not seem to have a significant impact on survival.
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Affiliation(s)
- Mansur Duran
- Department of Vascular and Endovascular Surgery, Marienhospital Gelsenkirchen, Teaching Hospital of Ruhr-University Bochum, Virchowstraße 135, 45886 Gelsenkirchen, Germany;
| | - Amir Arnautovic
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
| | - Cem Kilic
- Department of Vascular and Endovascular Surgery, KLINIKUM Westfalen GmbH, Am Knappschaftskrankenhaus 1, 44309 Dortmund, Germany;
| | - Julian-Dario Rembe
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
| | - Joscha Mulorz
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
| | - Hubert Schelzig
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
| | - Markus Udo Wagenhäuser
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
| | - Waseem Garabet
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
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Yücel SM, Çalışkan F. Pre-operative predictors of mortality in ruptured abdominal aortic aneurysms: is the Harborview Medical Center mortality risk score enough? ULUS TRAVMA ACIL CER 2023; 29:1261-1268. [PMID: 37889027 PMCID: PMC10771243 DOI: 10.14744/tjtes.2023.82770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/11/2023] [Accepted: 10/02/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND We aimed to evaluate the reliability of the Harborview Medical Center (HMC) mortality risk scoring system in predicting post-operative in-hospital mortality after open repair (OR) of a ruptured abdominal aortic aneurysm (rAAA) and to inves-tigate the presence of other possible mortality risk factors. METHODS Patients who underwent OR for rAAA between January 01, 2004, and December 31, 2021, were retrospectively included in this single-center cohort study. The 30-day hospital mortality risk was calculated using the HMC risk scoring system. We as-sessed the relationship between mortality and other perioperative variables. Logistic regression analysis was performed to determine the factors affecting mortality. Receiver operating characteristic curve analysis was utilized to obtain the predictive value of the HMC mortality risk score. RESULTS A total of 91 patients were included in this study. A statistically significant difference existed between the patients who survived and those who died. Univariate logistic regression analysis of the pre-operative patient data revealed that the hematocrit, lactate, shock index values, admission type, loss of consciousness, and HMC risk score significantly affected post-operative mortal-ity. However, in the multivariate logistic regression analysis, only the HMC risk score was associated with post-operative mortality (P<0.001). The HMC risk score could predict 30-day mortality, with an AUC of 0.912 for all patients. CONCLUSION Our study showed that the HMC risk score could reliably predict in-hospital mortality, but it did not reveal any other parameters that further increased the reliability of this scoring system without compromising on its straightforward and practical calculation.
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Affiliation(s)
- Semih Murat Yücel
- Department of Cardiovascular Surgery, Ondokuz Mayıs University, Faculty of Medicine, Samsun-Türkiye
| | - Fatih Çalışkan
- Department of Emergency Medicine, Ondokuz Mayıs University, Faculty of Medicine, Samsun-Türkiye
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Troisi N, Bertagna G, Torri L, Canovaro F, D’Oria M, Adami D, Berchiolli R. The Management of Ruptured Abdominal Aortic Aneurysms: An Ongoing Challenge. J Clin Med 2023; 12:5530. [PMID: 37685601 PMCID: PMC10488063 DOI: 10.3390/jcm12175530] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND despite improvements in the diagnosis and treatment of elective AAAs, ruptured abdominal aortic aneurysms (RAAAs) continue to cause a substantial number of deaths. The choice between an open or endovascular approach remains a challenge, as does postoperative complications in survivors. The aim of this manuscript is to offer an overview of the contemporary management of RAAA patients, with a focus on preoperative and intraoperative factors that could help surgeons provide more appropriate treatment. METHODS we performed a search on MEDLINE, Embase, and Scopus from 1 January 1985 to 1 May 2023 and reviewed SVS and ESVS guidelines. A total of 278 articles were screened, but only those with data available on ruptured aneurysms' incidence and prevalence, preoperative scores, and mortality rates after emergency endovascular or open repair for ruptured AAA were included in the narrative synthesis. Articles were not restricted due to the designs of the studies. RESULTS the centralization of RAAAs has improved outcomes after both surgical and endovascular repair. Preoperative mortality risk scores and knowledge of intraoperative factors influencing mortality could help surgeons with decision-making, although there is still no consensus about the best treatment. Complications continue to be an issue in patients surviving intervention. CONCLUSIONS RAAA still represents a life-threatening condition, with high mortality rates. Effective screening and centralization matched with adequate preoperative risk-benefit assessment may improve outcomes.
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Affiliation(s)
- Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Lorenzo Torri
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Francesco Canovaro
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Mario D’Oria
- Vascular Surgery Unit, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy;
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
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Omran S, Schawe L, Konietschke F, Angermair S, Weixler B, Treskatsch S, Greiner A, Berger C. Identification of Perioperative Procedural and Hemodynamic Risk Factors for Developing Colonic Ischemia after Ruptured Infrarenal Abdominal Aortic Aneurysm Surgery: A Single-Centre Retrospective Cohort Study. J Clin Med 2023; 12:4159. [PMID: 37373851 DOI: 10.3390/jcm12124159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/04/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: This retrospective study evaluated perioperative and intensive care unit (ICU) variables to predict colonic ischemia (CI) after infrarenal ruptured abdominal aortic aneurysm (RAAA) surgery. (2) Materials and Methods: We retrospectively analyzed the data of the patients treated for infrarenal RAAA from January 2011 to December 2020 in our hospital. (3) Results: A total of 135 (82% male) patients were admitted to ICU after treatment of infrarenal RAAA. The median age of all patients was 75 years (IQR 68-81 years). Of those, 24 (18%) patients developed CI, including 22 (92%) cases within the first three postoperative days. CI was found more often after open repair compared to endovascular treatment (22% vs. 5%, p = 0.021). Laboratory findings in the first seven PODs revealed statistically significant differences between CI and non-CI patients for serum lactate, minimum pH, serum bicarbonate, and platelet count. Norepinephrine (NE) was used in 92 (68%) patients during ICU stay. The highest daily dose of norepinephrine was administered to CI patients at POD1. Multivariable analysis revealed that NE > 64 µg/kg (RD 0.40, 95% CI: 0.25-0.55, p < 0.001), operating time ≥ 200 min (RD 0.18, 95% CI: 0.05-0.31, p = 0.042), and pH < 7.3 (RD 0.21, 95% CI: 0.07-0.35, p = 0.019), significantly predicted the development of CI. A total of 23 (17%) patients died during the hospital stay, including 8 (33%) patients from the CI group and 15 (7%) from the non-CI group (p = 0.032). (4) Conclusions: CI after RAAA is a sever complication occurring most frequently within the first 3 postoperative days. Our study identified many surrogate markers associated with colonic ischemia after aortic RAAA, including norepinephrine dose > 64 µg/kg, operating time ≥ 200 min, and PH < 7.3. Future studies are needed to support these results.
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Affiliation(s)
- Safwan Omran
- Department of Vascular Surgery, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Larissa Schawe
- Department of Vascular Surgery, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Frank Konietschke
- Institute of Medical Biometrics and Clinical Epidemiology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), Charité-Universitätsmedizin Berlin, 10178 Berlin, Germany
| | - Stefan Angermair
- Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Benjamin Weixler
- Department of General and Visceral Surgery, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Christian Berger
- Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
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10
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Reutersberg B, Metschl S, Salvermoser M, Eckstein HH, Knappich C, Maegdefessel L, Jaroslav P, Busch A. CXCR4 - a possible serum marker for risk stratification of abdominal aortic aneurysms. VASA 2023; 52:124-132. [PMID: 36519232 DOI: 10.1024/0301-1526/a001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Abdominal aortic aneurysm (AAA) rupture is still associated with a mortality rate of 80-90%. Imaging techniques or molecular fingerprinting for patient-specific risk stratification to identify pending rupture are still lacking. The chemokine (C-X-C motif) receptor (CXCR4) activation by CXCL12 ligand has been identified as a marker of inflammation and atherosclerosis, associated with AAA. Both are highly expressed in the aortic aneurysm wall. However, it is still unclear whether different expression levels of CXCR4 and CXCL12 can distinguish ruptured AAAs (rAAA) from intact AAAs (iAAA). Patients and methods: Abdominal aortic tissue samples (rAAA: n=29; iAAA: n=54) were excised during open aortic repair. Corresponding serum samples from these patients (n=9 from rAAAs; n=47 from iAAA) were drawn pre-surgery. Healthy aortic tissue samples (n=8) obtained from adult kidney donors during transplantation and serum samples from healthy adult volunteers were used as controls (n=5 each). Results: CXCR4 was mainly expressed in the media of the aneurysmatic tissue. Focal positive staining was also observed in areas of inflammatory infiltrates within the adventitia. In tissue lysates, no significant differences between iAAA, rAAA, and healthy controls were observed upon ELISA analysis. In serum samples, the level of CXCR4 was significantly increased in rAAA by 4-fold compared to healthy controls (p=0.011) and 3.0-fold for rAAA compared to iAAA (p<0.001). Furthermore a significant positive correlation between aortic diameter and serum CXCR4 concentration was found for both, iAAA and rAAA (p=0.042). Univariate logistic regression analysis showed that increased CXCR4 serum concentrations were associated with AAA rupture (OR: 4.28, 95% CI: 1.95-12.1, p=0.001). Conclusions: CXCR4 concentration was significantly increased in serum of rAAA patients and showed a significant correlation with an increased aortic diameter. The level of CXCR4 in serum was associated with a more than 4-fold risk increase for rAAA and thus could possibly serve as a biomarker in the future. However, further validation in larger studies is required.
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Affiliation(s)
- Benedikt Reutersberg
- Department for Vascular and Endovascular Surgery, Munich Vascular Biobank, Munich Aortic Center (MAC), University Hospital Klinikum rechts der Isar, Technical University of Munich, Germany.,Department for Vascular Surgery, University Hospital Zurich, Switzerland
| | - Susanne Metschl
- Department for Vascular and Endovascular Surgery, Munich Vascular Biobank, Munich Aortic Center (MAC), University Hospital Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Michael Salvermoser
- Department for Vascular and Endovascular Surgery, Munich Vascular Biobank, Munich Aortic Center (MAC), University Hospital Klinikum rechts der Isar, Technical University of Munich, Germany.,Department of Pulmonary and Allergy, Dr. von Hauner Children's Hospital, LMU University of Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Munich Vascular Biobank, Munich Aortic Center (MAC), University Hospital Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery, Munich Vascular Biobank, Munich Aortic Center (MAC), University Hospital Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Lars Maegdefessel
- Department for Vascular and Endovascular Surgery, Munich Vascular Biobank, Munich Aortic Center (MAC), University Hospital Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Pelisek Jaroslav
- Department for Vascular and Endovascular Surgery, Munich Vascular Biobank, Munich Aortic Center (MAC), University Hospital Klinikum rechts der Isar, Technical University of Munich, Germany.,Department for Vascular Surgery, University Hospital Zurich, Switzerland
| | - Albert Busch
- Department for Vascular and Endovascular Surgery, Munich Vascular Biobank, Munich Aortic Center (MAC), University Hospital Klinikum rechts der Isar, Technical University of Munich, Germany.,Division of Vascular and Endovascular Surgery, Department for Visceral-, Thoracic and Vascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technische Universität Dresden, Germany
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11
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Blair R, Harkin D, Johnston D, Lim A, McFetridge L, Mitchell H. Open Surgery for Abdominal Aortic Aneurysm: 980 Consecutive Patient Outcomes from a High-Volume Centre in the United Kingdom. Vasc Endovascular Surg 2023:15385744221149585. [PMID: 36714998 DOI: 10.1177/15385744221149585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Controversy persists regarding the optimal treatment for large abdominal aortic aneurysm (AAA), highlighted by the publication of the National Institute for Health and Care Excellence (NICE) guideline (NG156) on March 2020. The pendulum of opinion swings once more from endovascular to open surgical treatment. We report our experience over the last 15 years in treating consecutive AAA by open surgery. METHODS A retrospective review of a prospectively collected vascular database of all patients undergoing infra-renal open abdominal aortic aneurysm repair (OR) repair from 2004 to 2019 at the largest aneurysm centre in the United Kingdom. OR for elective and emergency (ruptured and symptomatic) outcomes included early morbidity and 30-day mortality, and long-term survival. RESULTS 1017 patients underwent OR between 2004-2019, on application of our inclusion-criteria 994 patients formed our cohort for analysis (81.2% male) with a mean age 73.6 ± 7.8 years treated by OR for AAA. In that group 672 were elective and 308 were emergency (for ruptured or symptomatic). Overall 30 day mortality was 11.3%, elective 30 day mortality was 2.5%, and emergency 30 day mortality was 29.9%. 30 day re-intervention rate was 9.5%, (elective 7.0%, emergency 15.9%). Survival at 1000 days for elective repair was 72 v 46.7% for emergency and at 2000 days was 43.4% for elective v 25% for emergency. CONCLUSION Our data confirm that open surgery for AAA can be performed in large volume centres quite safely. Elective and Emergency surgery does affect early 30 day mortality but does not influence long-term outcome.
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Affiliation(s)
- Robert Blair
- Belfast Vascular Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Denis Harkin
- Belfast Vascular Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK.,Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | - Dorothy Johnston
- Belfast Vascular Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Adrian Lim
- Belfast Vascular Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Lisa McFetridge
- Mathematical Sciences Research Centre, 227990Queen's University Belfast, Belfast, UK
| | - Hannah Mitchell
- Mathematical Sciences Research Centre, 227990Queen's University Belfast, Belfast, UK
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12
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Ye SL, Xiang GY, Liu Z, Li WD, Tang T, Qian AM, Li XQ, Sun LL. The controlling nutritional status score predicts postoperative mortality in patients with ruptured abdominal aortic aneurysm: a retrospective study. Front Cardiovasc Med 2023; 10:1129255. [PMID: 37180787 PMCID: PMC10172476 DOI: 10.3389/fcvm.2023.1129255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
Background Ruptured abdominal aortic aneurysms (rAAAs) are challenging for vascular surgeons because they have a high mortality rate. In many diseases, nutritional status is closely associated with prognosis. The Controlling Nutritional Status (CONUT) screening tool score is a prognostic factor in some malignant and chronic diseases; however, the impact of nutritional status on rAAA has not yet been reported. In this study, we explored the relationship between the CONUT score and the postoperative prognosis of patients with rAAA. Methods This was a retrospective review of 39 patients with rAAA who underwent surgical treatment from March 2018 to September 2021 at one center. Patient characteristics, nutritional status (CONUT score), and postoperative status were recorded. The patients were divided into groups A and B based on the CONUT score. The baseline characteristics of the two groups were compared, and Cox proportional hazards and logistic regression analyses were used to determine independent predictors of mid-term mortality and complications, respectively. Results The overall mid-term mortality rate was 28.21% (11/39). Compared with group A, group B had higher intraoperative (P = 0.047) and mid-term mortality (P = 0.033) rates. The univariate analysis showed that age [hazard ratio (HR), 1.098; 95% confidence interval (CI), 1.019-1.182; P = 0.014], CONUT score (HR, 1.316; 95% CI, 1.027-1.686; P = 0.03), and surgical procedure (HR, 0.127; 95% CI, 0.016-0.992; P = 0.049) were associated with mid-term mortality, whereas the multivariate analysis showed that the CONUT score (HR, 1.313; 95% CI, 1.009-1.710; P = 0.043) was an independent predictor of mid-term mortality. The multivariate logistic regression analysis did not reveal any associations with complications. The Kaplan-Meier curves showed that group B had a lower mid-term survival rate (log-rank P = 0.024). Conclusion Malnutrition is closely associated with the prognosis of patients with rAAA, and the CONUT score can be used to predict mid-term mortality.
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Affiliation(s)
- Sheng-Lin Ye
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Guang-Yuan Xiang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital Clinical College of Jiangsu University, Nanjing, China
| | - Zhao Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Wen-Dong Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Tao Tang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Ai-Min Qian
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Correspondence: Li-Li Sun Xiao-Qiang Li Ai-Min Qian
| | - Xiao-Qiang Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Correspondence: Li-Li Sun Xiao-Qiang Li Ai-Min Qian
| | - Li-Li Sun
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Correspondence: Li-Li Sun Xiao-Qiang Li Ai-Min Qian
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13
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Dang VC, Osztrogonacz PJ, Haddad P, Sharma S, Corr SJ, Rahimi M. Houston Methodist Ruptured Abdominal Aortic Aneurysm Guidelines. Methodist Debakey Cardiovasc J 2023; 19:78-89. [PMID: 36910549 PMCID: PMC10000315 DOI: 10.14797/mdcvj.1177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/07/2023] [Indexed: 03/09/2023] Open
Abstract
Ruptured abdominal aortic aneurysm (RAAA) is an acute aortic condition that requires emergent intervention and appropriate continuity of care to optimize patient outcomes. We describe the standardized RAAA protocol at the Houston Methodist Hospital Acute Aortic Treatment Center, developed to navigate critical patient transfer periods safely and efficiently, make crucial decisions about surgical intervention, and clearly communicate these plans with other care team providers. Our workflow is organized into five phases: prehospital, preoperative, intraoperative, postoperative, and post-discharge. We identify the transfer center, anesthesia, operating room nursing staff, surgeons, and intensive care unit as key entities of our acute aortic pathology care team. This systematic protocol for the management of acute aortic emergencies such as RAAA identifies critical decision points, potential complications at each stage, and recommendations for best practice.
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Affiliation(s)
- Vy C Dang
- Texas A&M School of Medicine, Bryan, Texas, US
| | | | - Paul Haddad
- Houston Methodist Hospital, Houston, Texas, US
| | | | - Stuart J Corr
- Houston Methodist Hospital, Houston, Texas, US.,Rice University, Houston, Texas, US.,Swansea University Medical School, Swansea, United Kingdom.,Weill Cornell Medical College, New York, New York, US
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14
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Tay S, Zaghloul MS, Shafqat M, Yang C, Desai KA, De Silva G, Sanchez LA, Zayed MA. Totally percutaneous endovascular repair for ruptured abdominal aortic aneurysms. Front Surg 2022; 9:1040929. [PMID: 36338637 PMCID: PMC9634472 DOI: 10.3389/fsurg.2022.1040929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose The PEVAR Trial demonstrated that compared to open femoral exposure, elective percutaneous endovascular AAA repair (ePEVAR) is associated with decreased perioperative morbidity and access site complications. We hypothesized that PEVAR for ruptured AAA (rPEVAR) may also improve perioperative morbidity compared to open femoral exposure (rEVAR). There are currently no reports that evaluate the utility and outcomes of rPEVAR. Materials and methods From 2015 to 2021, all patients who underwent an endovascular repair of a ruptured AAA at a single institution were included in the study and grouped into rPEVAR and rEVAR. Demographics, procedural details (successful preclose technique, conversion to femoral cutdown), postoperative variables (blood transfusion, ICU and hospital length of stay) and short-term outcomes (30-day major adverse events (30-day MAE) and 30-day femoral access-site complications (30-day FAAC)) were collected and compared with 50 historical ePEVAR patients from the PEVAR Trial. Statistical significance was determined using χ 2 or Fisher's exact test for categorical variables, and Mann-Whitney U-test for continuous variables. Results 35 patients were identified (21 rPEVAR; 14 rEVAR), 86% were male with a mean age of 72 ± 9 years. All patients underwent emergent endovascular aortic repair with 100% technical success. Seventeen patients (49%) presented with evidence of hemorrhagic shock and 22 patients (63%) had blood transfusion. 30-day MAE occurred in 12 patients (34%) (7 rPEVAR; 5 rEVAR). There was no difference in demographic, perioperative outcomes and 30-day MAE rate between rPEVAR and rEVAR patients. Compared to ePEVAR patient (from PEVAR trial), rPEVAR patients had higher rate of 30-day MAE (34% vs. 6%; p < 0.006) but no difference in 30-day FAAC (19% vs. 12%; p = 0.54). The success rate of the preclose technique was higher in ePEVAR compared to rPEVAR (96% vs. 76%; p = 0.02), but the rate of conversion to femoral cutdown was similar between the two groups (10% vs. 4%; p = 0.57). Conclusion Emergent rPEVAR appears to have similar outcomes when compared to rEVAR. Although patients undergoing rPEVAR have higher 30-day major adverse events rate compared to ePEVAR, the method of percutaneous femoral cannulation does not appear to increase the overall procedural or 30-day femoral artery access-site complications.
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Affiliation(s)
- Shirli Tay
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Mohamed S. Zaghloul
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Mehreen Shafqat
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Chao Yang
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kshitij A. Desai
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Gayan De Silva
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Luis A. Sanchez
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Mohamed A. Zayed
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
- Division of Molecular Cell Biology, Washington University School of Medicine, St. Louis, MO, United States
- McKelvey School of Engineering, Department of Biomedical Engineering, Washington Univesrity, St. Louis, MO, United States
- Department of Surgery, Veterans Affairs St. Louis Health Care System, St. Louis, MO, United States
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15
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Fujimoto R, Ogawa T, Hayashida T, Kato G, Yamamoto S, Shichijo T. Ruptured Abdominal Aortic Aneurysm Complicated with Occlusion of Bilateral Common Iliac Arteries. Vasc Endovascular Surg 2022; 56:790-792. [PMID: 35815649 DOI: 10.1177/15385744221114276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a case of ruptured abdominal aortic aneurysm complicated with occlusion of bilateral common iliac arteries. A 68-year-old man complained of sudden onset of lower abdominal and back pain. A contrast-enhanced computed tomography showed ruptured abdominal aortic aneurysm of about 80 mm in diameter and a giant retroperitoneal hematoma, as well as occlusion of both common iliac arteries. We performed Y-grafting, concomitant with thrombectomy of both iliac arteries from inside the aneurysm. Postoperative course was uneventful without ischemic findings of the legs and the patient was discharged on the 17th postoperative day.
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Affiliation(s)
- Ryo Fujimoto
- Department of cardiovascular surgery, 26317Kagawa Prefectural Central Hospital, Kurashiki, Japan
| | - Tatsuya Ogawa
- Department of cardiovascular surgery, 26317Kagawa Prefectural Central Hospital, Kurashiki, Japan
| | - Tomohiro Hayashida
- Department of cardiovascular surgery, 26317Kagawa Prefectural Central Hospital, Kurashiki, Japan
| | - Gentaro Kato
- Department of cardiovascular surgery, 26317Kagawa Prefectural Central Hospital, Kurashiki, Japan
| | - Shu Yamamoto
- Department of cardiovascular surgery, 26317Kagawa Prefectural Central Hospital, Kurashiki, Japan
| | - Takeshi Shichijo
- Department of cardiovascular surgery, 26317Kagawa Prefectural Central Hospital, Kurashiki, Japan
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16
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Kim W, Slipak SH, Webber A, Ata A, Canete JJ, Chismark AD, Valerian BT, Darling RC, Lee EC. Detection of Ischemic Colitis on Routine Lower Endoscopy and Its Implications After Repair of Ruptured Abdominal Aortic Aneurysm. Am Surg 2022:31348221101520. [PMID: 35574985 DOI: 10.1177/00031348221101520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ischemic colitis (IC) is a known significant complication after repair of a ruptured abdominal aortic aneurysm (rAAA). Lower endoscopy (colonoscopy or flexible sigmoidoscopy) is a helpful adjunct to aid decision making for surgical exploration. We believe routine use of lower endoscopy after rAAA repair provides better patient care through expeditious diagnosis and surgical care. METHODS We performed a retrospective chart review of rAAA repairs from 2008 to 2019. All patients undergo screening lower endoscopy after rAAA repair at our institution. The incidence of IC, mortality, and diagnostic characteristics of routine lower endoscopy was analyzed. RESULTS Of these, 182 patients underwent rAAA repair, among which 139 (76%) underwent routine lower endoscopy. Ischemic colitis of any grade was diagnosed in 25% of patients. The 30-day mortality was 11% compared to 19% in those without lower endoscopy. The presence of IC portended a 4-fold increase in mortality rate compared to those without (26% vs 6%, P = .005). Surgical exploration rate was 8% after routine lower endoscopy. Grade III ischemia on lower endoscopy had a sensitivity of 50% (95% CI 12-88) and specificity of 99% (95% CI 94-100) for transmural necrosis. DISCUSSION We found increased incidence of IC and reliable diagnostic characteristics of routine lower endoscopy in predicting the presence of transmural colonic ischemia. There was decreased mortality with use of routine lower endoscopy but this was not statistically significant.
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Affiliation(s)
- Woihwan Kim
- Department of Surgery, 138207Albany Medical Center, Albany, NY, USA
| | - Sasha H Slipak
- Section of Colon and Rectal Surgery, 138207Albany Medical Center, Albany, NY, USA
| | - Alexis Webber
- Department of Surgery, 138207Albany Medical Center, Albany, NY, USA
| | - Ashar Ata
- Department of Surgery, 138207Albany Medical Center, Albany, NY, USA
| | - Jonathan J Canete
- Section of Colon and Rectal Surgery, 138207Albany Medical Center, Albany, NY, USA
| | - A David Chismark
- Section of Colon and Rectal Surgery, 138207Albany Medical Center, Albany, NY, USA
| | - Brian T Valerian
- Section of Colon and Rectal Surgery, 138207Albany Medical Center, Albany, NY, USA
| | - Ralph C Darling
- Division of Vascular Surgery, 138207Albany Medical Center, Albany, NY, USA
| | - Edward C Lee
- Section of Colon and Rectal Surgery, 138207Albany Medical Center, Albany, NY, USA
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17
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Phillips AR, Andraska EA, Reitz KM, Gabriel L, Salem KM, Sridharan ND, Tzeng E, Liang NL. Any Postoperative Surveillance Improves Survival after Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2022; 80:50-59. [PMID: 34775012 PMCID: PMC8897248 DOI: 10.1016/j.avsg.2021.09.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) has advanced the care of patients with ruptured abdominal aortic aneurysms (rAAA) with improved early postoperative morbidity and mortality. However, this comes at the cost of a rigorous postoperative surveillance schedule to monitor for further aneurysmal degeneration. Adherence to surveillance recommendations is known to be poor in the elective setting, but has yet to be studied in the ruptured population. The aim of this study is to investigate predictors of incomplete surveillance after EVAR for rAAA (rEVAR) and examine how adherence impacts outcomes. METHODS This was a retrospective case control study of patients undergoing rEVAR at a multiple hospital single healthcare center (2003-2020). Patients were excluded if they underwent open conversion during their index hospitalization or died within 60 days of surgery. Follow-up was broadly categorized as complete surveillance (60-day postoperative visit and annually thereafter) or incomplete surveillance, comprising both patients with less than recommended surveillance (minimal surveillance) and completely lost to follow-up (LTF). Any follow-up was defined as patients with complete or minimal surveillance. We investigated predictors of complete versus incomplete surveillance by multivariate logistic regression. Secondary outcomes included overall survival and cumulative incidence of reintervention controlling for the competing risk of mortality, generating hazard ratios (HR) and subdistribution hazard ratios (SHR). RESULTS One-hundred and sixty patients (mean age 74 ± 10.1 years, 81.2% male) out of 673 total rAAA met study inclusion criteria. Complete surveillance was seen in 41.3% of our cohort, with the remainder with minimal surveillance (29.4%) or LTF (29.4%). Incomplete surveillance was associated with male sex (odds ratio [OR] 2.56; 95% CI 1.02-6.43), lack of a primary care provider (PCP; OR 0.20; 95% CI 0.04-0.99), and longer driving distance from home to treating hospital (OR 2.37; 95% CI 1.08-5.20). Survival was not different between complete and incomplete surveillance groups, however any follow-up conferred improved survival over LTF (HR 0.57; 95% CI 0.331-0.997; P = 0.049). Reintervention was associated with incomplete surveillance (SHR 0.29; 95% CI 0.11-0.75), and discharge to a facility (SHR 0.25; 95% CI 0.067-0.94). CONCLUSIONS Incomplete surveillance was observed in over 50% of patients who underwent rEVAR and was associated with male sex, lack of PCP, and longer driving distance. Any follow-up conferred a survival benefit, yet incomplete surveillance was associated with a lower risk of reintervention. Targeted strategies to prevent LTF, and less stringent, personalized follow-up plans that may confer similar survival benefit with better patient adherence should be investigated.
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Affiliation(s)
- Amanda R. Phillips
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Elizabeth A. Andraska
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Katherine M. Reitz
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Lucine Gabriel
- University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Karim M. Salem
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Natalie D. Sridharan
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Edith Tzeng
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Nathan L. Liang
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
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18
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Ho VT, Rothenberg KA, George EL, Lee JT, Stern JR. Female sex is independently associated with in-hospital mortality after endovascular aortic repair for ruptured aortic aneurysm. Ann Vasc Surg 2021; 81:148-153. [PMID: 34752855 DOI: 10.1016/j.avsg.2021.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Endovascular aortic repair (EVAR) can treat anatomically compatible ruptured abdominal aortic aneurysms (rAAA), but registry data suggests that women undergo more open abdominal aneurysm repairs than men. We evaluate in-hospital outcomes of EVAR for rAAA by sex. METHODS The Vascular Quality Initiative (VQI) registry was queried from 2013 to 2019 for rAAA patients treated with EVAR. Univariate analysis was performed with Student's t-test and chi-squared tests. Multivariable logistic regression was then performed to assess the association between female sex and inpatient mortality. RESULTS 1775 patients were included (23.8% female). Female rAAA patients were older (p < 0.01) and weighed less (p < 0.01). They were less likely to have smoked (p <. 001) and had lower creatinine (1.29 vs 1.43, p <0.01) and hemoglobin (10.7 vs 11.7, p < 0.01). Women had smaller maximum aortic diameters (74 vs 66 mm, p < 0.01) and were less likely to have iliac aneurysms (p <.001). Women were more likely to have concomitant femoral endarterectomy (8.5% vs 4.6%, p=.03). Despite having no significant difference in complication or reintervention rates, women had higher rates of in-hospital mortality (45.9% vs 34.5%, p < 0.01). In a logistic regression model for predictors of in-hospital mortality (χ2 < .01), increased age (OR 1.08, p < 0.01), female sex (OR 1.7, p=0.02), preoperative cardiac arrest (OR 5.29, p<0.01), concurrent iliac stenting (OR 2.38, p =0.02), postoperative mesenteric ischemia (OR 2.51, p<0.01) and postoperative transfusion (OR 1.06, p <0.01) were independently associated with in-hospital mortality. Increased preoperative hemoglobin was protective (OR 0.89, p < 0.01) CONCLUSIONS: Female sex is independently associated with in-hospital mortality after EVAR for rAAA, suggesting a relationship beyond anatomical, biochemical, and procedural covariates.
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Affiliation(s)
- Vy T Ho
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
| | - Kara A Rothenberg
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA; Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth L George
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Jordan R Stern
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
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Steenberge SP, Sorour AA, Sundaram A, Bena J, Kirksey L. Comparative outcomes of open abdominal therapy after ruptured abdominal aortic aneurysm via open and endovascular approaches. Ann Vasc Surg 2021:S0890-5096(21)00478-7. [PMID: 34411674 DOI: 10.1016/j.avsg.2021.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/12/2021] [Accepted: 05/01/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Open abdomen therapy is sometimes a necessary lifesaving procedure after repair of ruptured abdominal aortic aneurysm (rAAA). OAT aims to prevent or treat abdominal compartment syndrome (ACS). This study aims to evaluate our experience with open abdomen therapy (OAT) after repair of ruptured abdominal aortic aneurysms (rAAAs). DESIGN Retrospective cohort study METHODS: Medical records were retrieved for ruptured abdominal aortic aneurysm patients who underwent open surgical repair (OS) or endovascular aneurysm repair (EVAR) between January 1, 2008 and December 12, 2015 from a single center. Univariate and multivariate analysis were performed with statistical significance. RESULTS The study included 171 patients. Thirty-three patients (19.3%) required OAT. A smaller percentage of patients required OAT after EVAR (9.8%) compared to OS (23.3%) (P = 0.05). Patients with OAT also had a significantly longer operation (257 vs. 202.7 minutes; P < 0.05), required more intra-operative fluids (15,700 vs. 8,050 mL; P < 0.05), had a longer hospital stay (20 vs. 8.5 days; P < 0.05), and had a higher peri-operative mortality rate (48.5% vs 25.4%; P < 0.05). On multivariate logistic regression analysis, a lower preoperative SBP (OR 0.9, P = 0.01) and history of hypertension (OR 0.3, P = 0.02) were protective against OAT, while longer operative duration increased the risk of OAT (OR: 1.27, P = 0.05). Mean duration of OAT prior to closure was 4.76 days. Comparing OS patients (transperitoneal and retroperitoneal) that underwent OAT closure, patients who had a retroperitoneal repair received less intra-operative fluids (13.79 vs. 19.11 L; P = 0.212), had earlier return of bowel function (10 vs. 16.9 days; P = 0.08), and a shorter hospital stay (19.9 vs. 32.2 days; P = 0.03). CONCLUSIONS OAT is a lifesaving procedure that is associated with higher morbidity and mortality following OS and EVAR for rAAA. Patients with longer operations and extensive fluid resuscitation are at higher risk for OAT following rAAAs. Preoperative permissive hypotension may be protective against OAT. OAT following the RP approach to rAAA is associated with earlier abdominal wall closure, earlier bowel recovery, and shorter hospital stay.
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20
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Pirouzram A, Hamam L, Wallin G, Larzon T, Nilsson KF. Novel Experimental Technique to Create Size-Controlled Retroperitoneal Bleeding in the Infrarenal Aorta of Anesthetized Pigs. Innovations (Phila) 2021; 16:379-385. [PMID: 34077271 DOI: 10.1177/15569845211013803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Rupture of abdominal aortic aneurysm (rAAA) with a contained retroperitoneal hematoma is potentially fatal. Physiological studies are difficult to perform in patients suffering from life-threatening conditions such as rAAA. A translational model of the condition is therefore needed. The aim was to develop and validate an endovascular animal model for retroperitoneal bleeding of the abdominal aorta with contained hematoma. METHODS In anesthetized pigs, a puncture hole was made in the posterolateral portion of the infrarenal aorta by an Outback re-entry catheter device. The hole was gradually enlarged using angioplasty balloons to a specific diameter of either 4 mm (n = 6), 6 mm (n = 7), or 8 mm (n = 6). Onset of bleeding was verified by angiography and macroscopically examined on completion of the experiments. Survival up to 180 min was the primary outcome. Hemodynamic and metabolic markers in arterial blood were secondary outcomes. RESULTS Aortic injury with a contained retroperitoneal hematoma was achieved in all animals. Survival rate at 180 min after onset of bleeding was higher in the 4 mm group compared to the 6 mm (P = 0.021) and 8 mm groups (P = 0.002), but not when comparing the 6 mm and 8 mm groups. Systemic hypotension, arterial acidosis, and lactatemia were provoked in the 6 mm and 8 mm groups but not in the 4 mm group. CONCLUSIONS A porcine model for a controlled contained left posterolateral retroperitoneal bleeding was created using endovascular methods and validated. This model makes it possible to study the pathophysiology of a retroperitoneal hematoma.
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Affiliation(s)
- Artai Pirouzram
- 56750 Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Sweden
| | - Leonardo Hamam
- Department of Surgery, Höglandssjukhuset Eksjö, Region Jönköping County Council, Sweden
| | - Göran Wallin
- 6233 Department of Surgery, Faculty of Medicine and Health, Örebro University, Sweden
| | - Thomas Larzon
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Sweden
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21
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Mikati N, Phillips AR, Corbelli N, Guyette FX, Liang NL. The Effect of Blood Transfusion during Air Medical Transport on Transport Times in Patients with Ruptured Abdominal Aortic Aneurysm. PREHOSP EMERG CARE 2021; 26:255-262. [PMID: 33439068 DOI: 10.1080/10903127.2020.1868636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Patients presenting with a diagnosis of ruptured abdominal aortic aneurysm (RAAA) to community hospitals must be transported to tertiary care centers, where necessary resources are available. Unfortunately, guidelines for treatment of RAAA lack high-level evidence on the optimal resuscitation of RAAA patients during transport. We hypothesized that transfusion of packed red blood cells (PRBCs) during transport would not delay transport times in patients with RAAA. Methods: We performed a retrospective analysis of a prospective registry including prehospital data of patients with RAAA presenting to a single academic hospital in Western Pennsylvania between 2001 and 2019. Our primary outcomes were prehospital transport times: "transport interval" and "total interval." "Transport interval" is the duration from patient pickup at the outside hospital (OSH) to arrival at the receiving facility. "Total interval" is the duration from dispatch of the air medical transport to arrival of the patient to the receiving facility. We then compared two groups of patients, stratified by the receipt of PRBCs in transit, by reporting mean difference (95% confidence interval: CI) for continuous variables and percent difference (95% CI) for categorical variables. We performed two multivariate linear regression models to test if there was any effect of the receipt of PRBCs in transit on transport times. Results: We included 271 patients with RAAA transported by our air ambulance system who underwent an operation at the receiving facility, 99 (37%) of whom received PRBCs in transit. Mean ± standard deviation (SD) of the total intervals were 67 ± 28 and 71 ± 42 minutes, among patients who received or did not receive PRBCs in transit respectively, with no significant difference (p = 0.437). Following adjusted analysis, the receipt of PRBCs during transport was not associated with increased transport times, after accounting for age, hypotension, endovascular aneurysm repair (EVAR), and PRBC transfusion at the OSH. Conclusion: PRBC transfusion during air medical transport in patients with RAAA did not delay transport times.
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Affiliation(s)
- Nancy Mikati
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (NM, FXG); Department of Surgery, Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (ARP, NLL); College of General Studies, University of Pittsburgh, Pittsburgh, Pennsylvania (NC)
| | - Amanda R Phillips
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (NM, FXG); Department of Surgery, Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (ARP, NLL); College of General Studies, University of Pittsburgh, Pittsburgh, Pennsylvania (NC)
| | - Neal Corbelli
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (NM, FXG); Department of Surgery, Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (ARP, NLL); College of General Studies, University of Pittsburgh, Pittsburgh, Pennsylvania (NC)
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (NM, FXG); Department of Surgery, Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (ARP, NLL); College of General Studies, University of Pittsburgh, Pittsburgh, Pennsylvania (NC)
| | - Nathan L Liang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (NM, FXG); Department of Surgery, Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (ARP, NLL); College of General Studies, University of Pittsburgh, Pittsburgh, Pennsylvania (NC)
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22
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Liang TW, Wang SK, Dimusto PD, McAninch CM, Acher CW, Timsina LR, Dalsing MC, Motaganahalli RL. Association Between Body Mass Index and Perioperative Mortality After Repair of Ruptured Abdominal Aortic Aneurysms. Vasc Endovascular Surg 2020; 54:573-578. [PMID: 32643559 DOI: 10.1177/1538574420939356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The attempt to repair a ruptured abdominal aortic aneurysm carries a significant risk of perioperative mortality. The relationship between body mass index (BMI) and outcomes after repair of ruptured abdominal aortic aneurysms (AAAs) has not been well defined. We report the association of BMI with outcomes after ruptured AAA repair. METHODS Patients undergoing ruptured AAA repairs between 2008 and 2017 at 2 tertiary academic centers were included in this retrospective study. Demographics (including BMI), type of repair, length of stay, and admission mortality risk scores were gathered and analyzed using bivariate and multivariate logistic regressions. Adjusted odds ratio (AOR) was reported with 95% CIs and P values from the multivariate analysis. The primary outcome was 30-day mortality. Akaike information criterion (AIC) and c-statistics were used to assess the predictive power of models including physiologic score with or without BMI. RESULTS A total of 202 patients underwent repair of ruptured AAA. In bivariate relationship, increased BMI was significantly associated with 30-day mortality. With multivariate analysis, adjusting for demographics, type of procedure, and physiologic score, for each kg/m2 increase in BMI, an 8% increase in the likelihood of perioperative mortality (AOR = 1.08, 95% CI: 1.01-1.17; P = .04) was observed. CONCLUSION When adjusted for admission risk score, type of procedure, and demographics, obesity was associated with increased 30-day mortality. With BMI as an additional data point, the c-statistics and AIC comparisons indicated that we would have a greater ability to preoperatively estimate mortality after ruptured AAA repair. Consideration could be made to include BMI in future mortality risk scoring systems for ruptured AAA.
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Affiliation(s)
- Tiffany W Liang
- Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - S Keisin Wang
- Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Paul D Dimusto
- Division of Vascular Surgery, 5228University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christopher M McAninch
- Division of Vascular Surgery, 5228University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Charles W Acher
- Division of Vascular Surgery, 5228University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Lava R Timsina
- Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael C Dalsing
- Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
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23
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Barakat HM, Shahin Y, Din W, Akomolafe B, Johnson BF, Renwick P, Chetter I, McCollum P. Perioperative, Postoperative, and Long-Term Outcomes Following Open Surgical Repair of Ruptured Abdominal Aortic Aneurysm. Angiology 2020; 71:626-632. [PMID: 32166957 PMCID: PMC7436436 DOI: 10.1177/0003319720911578] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We investigated factors that affected perioperative, postoperative, and long-term outcomes of patients who underwent open emergency surgical repair of ruptured abdominal aortic aneurysms (RAAA). All patients who underwent open emergency surgical repair from 1990 to 2011 were included (463 patients; 374 [81%] male; mean age 74.7 ± 8.7years). Logistic and Cox regression analyses were performed to explore the association of variables with outcomes. Preoperatively, median (interquartile range) hemoglobin was 11.2 (9.5-12.8) g/dL, and median creatinine level was 140 (112-177) µmol/L. Intraoperatively, the median operative time was 2.25 (2-3) hours, and median estimated blood loss was 1.5 (0.5-3) L; 250 (54%) patients required intraoperative inotropes, and a median of 6 (4-8) units of blood was transfused. Median length of hospital stay was 11 (7-20) days. In-hospital mortality rate was 35.6%, and 5-year mortality was 48%. Age, distance traveled, operation duration, postoperative myocardial infarction (MI), and multi-organ failure (MOF) were predictors of in-hospital mortality and long-term outcome. Additionally, postoperative acute renal failure predicted in-hospital mortality. In patients with RAAA undergoing open surgical repair, the strongest predictors of in-hospital mortality and long-term outcome were postoperative MOF and MI and operative duration.
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Affiliation(s)
- Hashem M Barakat
- Academic Vascular Surgical Unit, University of Hull & Hull York Medical School, Hull, United Kingdom
| | - Yousef Shahin
- Academic Vascular Surgical Unit, University of Hull & Hull York Medical School, Hull, United Kingdom
| | - Waqas Din
- Academic Vascular Surgical Unit, University of Hull & Hull York Medical School, Hull, United Kingdom
| | - Bankole Akomolafe
- Department of Vascular Surgery, Hull Royal Infirmary, Hull, United Kingdom
| | - Brian F Johnson
- Department of Vascular Surgery, Hull Royal Infirmary, Hull, United Kingdom
| | - Paul Renwick
- Department of Vascular Surgery, Hull Royal Infirmary, Hull, United Kingdom
| | - Ian Chetter
- Academic Vascular Surgical Unit, University of Hull & Hull York Medical School, Hull, United Kingdom.,Department of Vascular Surgery, Hull Royal Infirmary, Hull, United Kingdom
| | - Peter McCollum
- Academic Vascular Surgical Unit, University of Hull & Hull York Medical School, Hull, United Kingdom.,Department of Vascular Surgery, Hull Royal Infirmary, Hull, United Kingdom
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24
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Wessels LE, Calvo RY, Sise MJ, Bowie JM, Butler WJ, Bansal V, Sise CB. Association of Operative Repair Type and Trauma Center Designation With Outcomes in Ruptured Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2020; 54:325-332. [PMID: 32079508 DOI: 10.1177/1538574420907193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Open repair of ruptured abdominal aortic aneurysm (rAAA) has shown improved outcomes at trauma centers. Whether the benefit of trauma center designation extends to endovascular repair of rAAA is unknown. METHODS Retrospective cohort study using the California Office of Statewide Health Planning and Development 2007 to 2014 discharge database to identify patients with rAAA. Data included demographic and admission factors, discharge disposition, International Classification of Diseases, Ninth Revision, Clinical Modification codes, and hospital characteristics. Hospitals were categorized by trauma center designation and teaching hospital status. The effect of repair type and trauma center designation (level I, level II, or other-other trauma centers and nondesignated hospitals) was evaluated to determine rates and risks of 9 postoperative complications, in-hospital mortality, and 30-day postdischarge mortality. RESULTS Of 1941 rAAA repair patients, 61.2% had open and 37.8% had endovascular; 1.0% had both. Endovascular repair increased over the study interval. Hospitals were 12.0% level I, 25.0% level II, and 63.0% other. A total of 48.7% of hospitals were teaching hospitals (level I, 100%; level II, 42.2%; and other, 41.8%). Endovascular repair was significantly more common at teaching hospitals (41.5% vs 34.3%, P < .001) and was the primary repair method at level I trauma centers (P < .001). Compared with open repair, endovascular repair was protective for most complications and in-hospital mortality. The risk for in-hospital mortality was highest among endovascular patients at level II trauma centers (hazard ratio 1.67, 95% confidence interval [CI]: 0.95-2.92) and other hospitals (hazard ratio 1.66, 95% CI: 1.01-2.72). CONCLUSIONS Endovascular repair overall was associated with a lower risk of adverse outcomes. Endovascular repair at level I trauma centers had a lower risk of in-hospital mortality which may be a result of their teaching hospital status, organizational structure, and other factors. The weight of the contributions of such factors warrants further study.
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Affiliation(s)
| | | | - Michael J Sise
- Trauma Service, Scripps Mercy Hospital, San Diego, CA, USA
| | - Jason M Bowie
- Trauma Service, Scripps Mercy Hospital, San Diego, CA, USA
| | | | - Vishal Bansal
- Trauma Service, Scripps Mercy Hospital, San Diego, CA, USA
| | - C Beth Sise
- Trauma Service, Scripps Mercy Hospital, San Diego, CA, USA
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25
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Galanakis N, Kontopodis N, Tavlas E, Tsetis D, Ioannou CV. Does a previous aortic endograft confer any protective effect during abdominal aortic aneurysm rupture? Systematic review and meta-analysis of comparative studies. Vascular 2020; 28:241-250. [PMID: 31937207 DOI: 10.1177/1708538119896464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Whether prior endovascular aneurysm repair confers a protective effect in patients with ruptured abdominal aortic aneurysm (rAAA) is not known. We aimed to systematically review and compare the outcomes of rAAA in patients with and without prior endovascular aneurysm repair. METHODS We performed a systematic review that conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analysis. We selected studies comparing the outcomes in patients with rAAA after prior endovascular aneurysm repair (group 1) and those with de novo rAAAs (group 2). We conducted a proportion meta-analysis of perioperative mortality and obtained summary estimates of odds ratios (ORs) and 95% confidence intervals (CIs) using random-effects models. RESULTS We included four studies (retrospective observational studies) in quantitative synthesis reporting a total of 719 patients (group 1 (89) group 2 (630)). The perioperative mortality in groups 1 and 2 was 30.4% and 41%, respectively, and there was no statistical significant difference between the groups (OR 0.66, 95% CI 0.30-1.43, P = 0.29, I2=58%). However, patients presenting with rAAA following previous endovascular aneurysm repair were more hemodynamically stable (OR 0.33, 95% CI 0.12-0.90, P = 0.03, I2=74%). The choice between endovascular or open surgery treatment in group 1 did not affect the perioperative mortality (OR 1.12, 95% CI 0.41-3.04 P = 0.82, I2=0%). Endoleak types I and III were the main causes of rAAA in group 1. CONCLUSIONS Perioperative mortality was similar for rAAA either de novo or after prior endovascular aneurysm repair. However, ruptures in patients with prior endovascular aneurysm repair presented hemodynamically more stable.
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Affiliation(s)
- Nikolaos Galanakis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Heraklion, Greece
| | - Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, Heraklion, Greece
| | - Emmanouil Tavlas
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, Heraklion, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, Heraklion, Greece
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26
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Nakayama H, Toma M, Kobayashi T, Ohno N, Okada T, Ueno G, Sato Y. Ruptured Abdominal Aortic Aneurysm Treated by Double-Balloon Technique and Endovascular Strategy: Case Series. Ann Thorac Cardiovasc Surg 2019; 25:211-214. [PMID: 29491195 PMCID: PMC6698718 DOI: 10.5761/atcs.cr.17-00189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose: Mortality in patients with ruptured abdominal aortic aneurysms (rAAAs) has remained high despite advances in interventions. Endovascular aneurysm repair (EVAR) was recently developed for treatment of rAAAs. In this study, we assessed our endovascular strategy including a double-balloon technique for rAAA. Methods: We analyzed 12 consecutive patients with rAAAs who were treated by our double-balloon technique and endovascular strategy from March 2013 to July 2016. Results: The 30-day and 1-year mortality rates were both 17%. The mean times from admission to arrival at the hybrid operating room, from admission to aortic occlusion, and from admission to completion of EVAR were 46.8, 63.5, and 110.0 minutes, respectively. Conclusion: This study indicates that the herein-described double-balloon endovascular technique is feasible for use in the management of rAAA.
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Affiliation(s)
- Hiroyuki Nakayama
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Taishi Kobayashi
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Nobuhisa Ohno
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Tatsuji Okada
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Go Ueno
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
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27
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Gabriele P, Emanuele G, Grilli Cicilioni C, Sara S, Luciano C. Ruptured Abdominal Aortic Aneurysm and Horseshoe Kidney: Isthmus Sectioning By Endo GIA. Vasc Endovascular Surg 2019; 53:599-601. [PMID: 31262229 DOI: 10.1177/1538574419859451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION A 90-year-old patient was admitted with a hemorrhagic shock from a huge ruptured abdominal aortic aneurysm with an unfavourable infrarenal aortic neck and a horseshoe kidney (HSK). REPORT We decided on an open surgical approach: the HSK isthmus was sectioned with an Endo GIA 45 mm, and we performed a suprarenal aortic cross-clamping and an aortic graft reconstruction. Postoperatively, no urinary leakage was detected, and renal function showed no impairment. The patient died on the 10th postoperative day from pneumonia. CONCLUSION We believe that the sectioning of the HSK isthmus with Endo GIA is a fast and simple maneouvre.
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Affiliation(s)
- Pagliariccio Gabriele
- 1 Department of Vascular Surgery, Azienda Ospedali Riuniti Ancona, Via Conca, Ancona, Italy
| | - Gatta Emanuele
- 1 Department of Vascular Surgery, Azienda Ospedali Riuniti Ancona, Via Conca, Ancona, Italy
| | - Carlo Grilli Cicilioni
- 1 Department of Vascular Surgery, Azienda Ospedali Riuniti Ancona, Via Conca, Ancona, Italy
| | - Schiavon Sara
- 1 Department of Vascular Surgery, Azienda Ospedali Riuniti Ancona, Via Conca, Ancona, Italy
| | - Carbonari Luciano
- 1 Department of Vascular Surgery, Azienda Ospedali Riuniti Ancona, Via Conca, Ancona, Italy
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Abstract
This report presents the case of a 43-year-old man with inferior vena cava (IVC) compression caused by a retroperitoneal hematoma following an abdominal aortic aneurysm (AAA) rupture. Preoperative computed tomography scans revealed an infrarenal AAA with a retroperitoneal hematoma nearly occluding the IVC. After emergency aortic grafting, IVC thrombosis, deep venous thrombosis (DVT), and pulmonary thromboembolism (PTE) arose. Anticoagulation therapy resolved these thrombotic complications. Disappearance of the hematoma and IVC recanalization were confirmed 3 months postoperatively. Although IVC compression caused by a retroperitoneal hematoma is temporary, careful attention should be paid to IVC thrombosis, DVT, and PTE as possible complications.
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Affiliation(s)
- Akihiko Ikeda
- Department of Cardiovascular Surgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan.,Department of Cardiovascular Surgery, Teikyo Chiba Medical Center, Ichihara, Chiba, Japan
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Saito J, Tokita T, Takashima R, Kawaguchi J, Midorikawa Y, Noguchi S, Hahisba E, Hirota K. Usefulness of Continuous Renal Replacement Therapy During an Intra-Aortic Balloon Occlusion in Patients With Ruptured Abdominal Aortic Aneurysms. J Cardiothorac Vasc Anesth 2018; 33:2237-2240. [PMID: 30401597 DOI: 10.1053/j.jvca.2018.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Junichi Saito
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - Takaharu Tokita
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Ryo Takashima
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Jun Kawaguchi
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yoko Midorikawa
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Satoko Noguchi
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiji Hahisba
- Division of Intensive Care Unit, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Wang T, Zhao J, Yuan D, Ma Y, Huang B, Yang Y, Zeng G. Comparative effectiveness of open surgery versus endovascular repair for hemodynamically stable and unstable ruptured abdominal aortic aneurysm. Medicine (Baltimore) 2018; 97:e11313. [PMID: 29979402 PMCID: PMC6076075 DOI: 10.1097/md.0000000000011313] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Several observational studies and randomized trials have compared open surgery (OS) and endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). However, none of these studies addressed optimal management of hemodynamically (hd) unstable patients. Our objective was to compare perioperative outcomes in patients undergoing OS vs EVAR for hd-stable and hd-unstable rAAAs.This retrospective study was conducted in West China Hospital from January 2005 to December 2015. Unstable patients were defined as those who have at least 1 of the following: preoperative shock, preoperative transfusion >4 units, preoperative intubation, cardiac arrest, or unconsciousness. Univariable and multivariable logistic regression analyses were performed.Of the 102 patients, 70.6% underwent OS and 29.4% EVAR. About 46.1% were unstable, and for these patients, OS was performed in 70.2% and EVAR in 29.8%. The 30-day mortality was 23.6% (OS, 25.6%; EVAR, 18.8%; P = .585) for hd-stable patients and was 42.6% (OS, 45.5%; EVAR, 35.7%; P = .537) for hd-unstable patients. Patients with OS had longer operative time and more transfusion. Amongst hd-stable patients, OS subgroup had a higher rate of pneumonia (33.3% vs 6.3%, P = .045), longer intensive care unit (ICU) stay (43.2 vs 15.2 hours, P = .02), and length of stay (11.6 vs 8.6 days, P = .041). Among hd-unstable patients, OS subgroup had a longer ICU stay (134.3 vs 63.8 hours, P = .047). Hospitalization costs of OS group were significantly lower than those of EVAR group, regardless of hemodynamic stability.Approximately one-third of patients with rAAA were treated by EVAR at our institution. EVAR may be the preferred approach for anatomically suitable rAAAs. However, patients treated by EVAR had a similar mortality compared with those treated by OS. In addition, OS is not an independent factor for a higher 30-day mortality, and the costs of OS were much cheaper than those of EVAR. Therefore, OS is difficult to replace, especially in developing countries.
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Kurç E, Sokullu O, Akansel S, Sargın M. Late open conversion in ruptured abdominal aortic aneurysm after endovascular repair. J Vasc Bras 2018; 17:66-70. [PMID: 29930684 PMCID: PMC5990265 DOI: 10.1590/1677-5449.008017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Despite technological advances, the long-term outcomes of endovascular aortic aneurysm repair (EVAR) are still debatable. Although most endograft failures after EVAR can be corrected with endovascular techniques, open conversion may still be required. A 70-year-old male patient presented at the emergency unit with abdominal pain. Twice, in the third and fourth years after the first repair, a stent graft had been placed over a non-adhesive portion of the stent graft due to type Ia endoleaks. In the most recent admission, a CT scan showed type III endoleak and ruptured aneurysm sac. On this occasion the patient underwent late open conversion. The failure was repaired with total preservation of the main endovascular graft body and interposition of a bifurcated dacron graft. This case demonstrates that lifelong radiographic surveillance should be considered in this subset of patients. Late open conversion following EVAR of ruptured abdominal aortic aneurysms can be performed safely.
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Affiliation(s)
- Erol Kurç
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Onur Sokullu
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Serdar Akansel
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Murat Sargın
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
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Lunen TB, Johansson PI, Jensen LP, Homburg KM, Roeder OC, Lonn L, Secher NH, Helgstrand U, Carstensen M, Jensen KB, Lange T, Sillesen H, Swiatek F, Nielsen HB. Administration of platelets to ruptured abdominal aortic aneurysm patients before open surgery: a prospective, single-blinded, randomised study. Transfus Med 2018; 28:386-391. [PMID: 29781549 DOI: 10.1111/tme.12540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/20/2018] [Accepted: 04/20/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND In patients undergoing open surgery for a ruptured abdominal aortic aneurysm (rAAA), survivors demonstrate a high platelet count, and proactive administration of platelets (and fresh frozen plasma) appears to influence mortality. OBJECTIVES This trial investigated the effect of platelets administered before transport to surgery. METHODS In a prospective study design, patients were randomised to receive platelets (intervention; n = 61) or no platelets (control; n = 61) before transport to vascular surgery from 11 local hospitals. The study was terminated when one of the vascular surgical centres implemented endovascular repair for rAAA patients. RESULTS Thirty days after surgery, mortality was 36% for patients with intervention vs 31% for controls (P = 0·32). Post-operative thrombotic events (14 vs 15; P = 0·69), renal failure (11 vs 10; P = 0·15) and pulmonary insufficiency (34 vs 39; P = 0·15) were similar in the two groups of patients. No adverse reactions to platelet administration were observed. In addition, length of stay in the intensive care unit was unaffected by intervention. CONCLUSIONS For patients planned for open repair of a rAAA, we observed no significant effect of early administration of platelets with regard to post-operative complications and stay in the ICU or in hospital and also no significant effect on mortality.
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Affiliation(s)
- T B Lunen
- Department of Anesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Anesthesiology, SUH Zealand University Hospital Koege, Region Zealand, Denmark
| | - P I Johansson
- Department of Transfusion Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Surgery, University of Texas Health Medical School, Houston, Texas, USA
| | - L P Jensen
- Department of Anesthesiology, SUH Zealand University Hospital Koege, Region Zealand, Denmark.,Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - K M Homburg
- Department of Clinical Immunology, Naestved Sygehus, Naestved, Denmark
| | - O C Roeder
- Department of Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - L Lonn
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - N H Secher
- Department of Anesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - U Helgstrand
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - M Carstensen
- Vascular Surgery, Region Zealand, Slagelse Hospital, Slagelse, Denmark
| | - K B Jensen
- Department of Statistics, Panum Institutet, University of Copenhagen, Copenhagen, Denmark
| | - T Lange
- Department of Statistics, Panum Institutet, University of Copenhagen, Copenhagen, Denmark.,Center for Statistical Science, Peking University, Beijing, China
| | - H Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - F Swiatek
- Department of Anesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - H B Nielsen
- Department of Anesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Sanos as, Sanos Clinic, Herlev, Denmark
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Abstract
Aortocaval fistula (ACF) is a rare complication. Endovascular repair is an option for this fatal condition. However, endoleak and persistent fistula may occur and lead to technical failure. We performed endovascular repair for 3 cases of challenging ACF with hostile anatomy. Patient 1 was an 80-year-old man who complained of abdominal distension and lower limb edema for 15 days. He had renal and cardiac dysfunction. Computed tomography angiography (CTA) showed an ACF and extreme tortuosity of right iliac artery. The super-stiff guidewire could not pass the right iliac artery. We performed endovascular repair and an occluder was used to block the right external iliac artery. Postoperative CTA showed migration of the occluder, and we ligated the right external iliac artery. The patient survived for 5 years. Patient 2 was a 78-year-old man who complained of an acute abdominal pain for 30 hours. Computed tomography angiography showed great neck angulation (63.3°) and a huge aneurysm (9.9 cm in diameter). A type 1A endoleak occurred and an aortic cuff was deployed at the proximal seal zone. Meanwhile, a type 3 endoleak occurred because of the migration and detachment of the left iliac limb. Another stent-graft was deployed to connect the iliac limb. The patient was followed up for 1 year and remained in a good condition. Patient 3 was a 74-year-old man who experienced severe abdominal pain for 1 day. Computed tomography angiography showed great neck angulation (66°) and a huge aneurysm (10.1 cm in diameter). A type 1A endoleak occurred, and an aortic cuff was deployed at the proximal seal zone. The patient was followed up for 6 months. In conclusion, ACF is a rare but a fatal condition. Acute cases and chronic cases with instable hemodynamics need urgent diagnosis and surgical intervention. Endovascular repair is an efficacious alternative to the traditional open repair.
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Affiliation(s)
- Yuewei Wang
- 1 Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wenjuan Yu
- 2 Department of Pathology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yongxin Li
- 1 Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Haofu Wang
- 1 Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Aoki C, Kondo N, Saito Y, Taniguchi S, Fukuda W, Daitoku K, Fukuda I. Improved Outcomes for Ruptured Abdominal Aortic Aneurysms Using Integrated Management Involving Endovascular Clamping, Endovascular Replacement, and Open Abdominal Decompression. Ann Vasc Dis 2017; 10:22-28. [PMID: 29034016 PMCID: PMC5579800 DOI: 10.3400/avd.oa.16-00110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/10/2017] [Indexed: 11/13/2022] Open
Abstract
Objective: Endovascular repair has become the treatment of choice for ruptured abdominal aortic aneurysms (RAAAs). To improve surgical outcomes, preoperative management is important. In 2011, we introduced integrated management, which involves endovascular aneurysm repair, stabilization of hemodynamics by endovascular clamping, and open abdominal decompression to address abdominal compartment syndrome (ACS). Methods: To evaluate the efficacy of this management strategy, 62 patients who had undergone emergency surgery for an RAAA were analyzed retrospectively: group A (n=39), where an old strategy was used, and group B (n=23), where integrated management was introduced. Patient characteristics and 30-day mortality rates were compared between the two groups. Results: The average patient age was 67.7 years and 74.7 years for groups A and B, respectively (P=0.032). Group B patients required more frequent use of vasopressors (P=0.035). Other patient characteristics did not differ between the two groups. The duration of surgery was significantly shorter in group B than in group A (P=0.001). The total amount of transfused blood did not differ between the two groups. No patients showed symptoms of ACS. Early mortality rates were 12.8% and 8.7% in groups A and B, respectively. The number of wound infections was significantly fewer in group B than in group A. Conclusion: Although group B patients were significantly older and had a higher rate of vasopressor use, early mortality was improved in both groups. Morbidity was significantly better in group B with respect to the duration of surgery and number of wound infections than in group A.
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Affiliation(s)
- Chikashi Aoki
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Norihiro Kondo
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yoshiaki Saito
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Satoshi Taniguchi
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Wakako Fukuda
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kazuyuki Daitoku
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Ikuo Fukuda
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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Chen X, Zhao J, Huang B, Yuan D, Yang Y, Ma Y. Abdominal compartment syndrome after endovascular repair for ruptured abdominal aortic aneurysm leads to acute intestinal necrosis: Case report. Medicine (Baltimore) 2016; 95:e5316. [PMID: 27893667 PMCID: PMC5134860 DOI: 10.1097/md.0000000000005316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Abdominal compartment syndrome (ACS) after endovascular repair (EVAR) of rupture abdominal aortic aneurysm (rAAA) is a rare emergency situation, which has a high mortality. However, the progression of ACS is rapid and the diagnosis is usually been delayed, which increase the difficulties in treatment and affect the prognosis. We describe a case of a sever complication (acute intestinal necrosis) resulting from ACS after endovascular repair of rAAA. CLINICAL FINDING An elderly man, 81 years old, complained a sudden lower abdominal and back pain without any predisposing cause. He had a history of hypertension for 20 years without any regular anti-hypertensive therapy. Physical Examination revealed that the blood pressure was 89/54 mmHg, pulse was 120/min, oxygen saturation was 91%. The abdominal ultrasound and the CTA (computed tomography angiography) scan revealed a rAAA. Emergency EVAR under general anesthesia was performed for this patient. DIAGNOSIS Fourteen hours after endovascular repair, sudden decreased of blood pressure (70/50 mmHg) and oxygen saturation (70%) was observed. ACS or bleeding of retroperitoneal space was diagnosed. INTERVENTIONS Abdominal laparotomy was immediately performed. ACS was verified and a severe complication (acute intestinal necrosis) was observed, intestinal resection was performed for this patient. OUTCOMES Unfortunately, this patient died after operation because of multi-organ failure in a very short period, which is very rare regarding to this condition. Surgical pathology, diagnosis and management were discussed. CONCLUSION ACS was occurred with a severe complication (acute intestinal necrosis) in a very short period, which is very rare regarding to this condition after EVAR, it reminds us the severe result of ACS and more methods to prevent it happened after surgical management.
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Lewis TL, Fothergill RT, Karthikesalingam A. Ambulance smartphone tool for field triage of ruptured aortic aneurysms (FILTR): study protocol for a prospective observational validation of diagnostic accuracy. BMJ Open 2016; 6:e011308. [PMID: 27797986 PMCID: PMC5093389 DOI: 10.1136/bmjopen-2016-011308] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Rupture of an abdominal aortic aneurysm (rAAA) carries a considerable mortality rate and is often fatal. rAAA can be treated through open or endovascular surgical intervention and it is possible that more rapid access to definitive intervention might be a key aspect of improving mortality for rAAA. Diagnosis is not always straightforward with up to 42% of rAAA initially misdiagnosed, introducing potentially harmful delay. There is a need for an effective clinical decision support tool for accurate prehospital diagnosis and triage to enable transfer to an appropriate centre. METHODS AND ANALYSIS Prospective multicentre observational study assessing the diagnostic accuracy of a prehospital smartphone triage tool for detection of rAAA. The study will be conducted across London in conjunction with London Ambulance Service (LAS). A logistic score predicting the risk of rAAA by assessing ten key parameters was developed and retrospectively validated through logistic regression analysis of ambulance records and Hospital Episode Statistics data for 2200 patients from 2005 to 2010. The triage tool is integrated into a secure mobile app for major smartphone platforms. Key parameters collected from the app will be retrospectively matched with final hospital discharge diagnosis for each patient encounter. The primary outcome is to assess the sensitivity, specificity and positive predictive value of the rAAA triage tool logistic score in prospective use as a mob app for prehospital ambulance clinicians. Data collection started in November 2014 and the study will recruit a minimum of 1150 non-consecutive patients over a time period of 2 years. ETHICS AND DISSEMINATION Full ethical approval has been gained for this study. The results of this study will be disseminated in peer-reviewed publications, and international/national presentations. TRIAL REGISTRATION NUMBER CPMS 16459; pre-results.
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Affiliation(s)
- Thomas L Lewis
- St George's Vascular Institute, St George's University of London, London, UK
| | - Rachael T Fothergill
- Clinical Audit & Research Unit, London Ambulance Service NHS Trust, 8-20 Pocock Street, London, UK
| | | | - Alan Karthikesalingam
- St George's Vascular Institute, St George's University of London, London, UK
- Cardiovascular and Cell Sciences Institute, St George's University of London, London, UK
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Liu M, Wang H. Endovascular stent-graft repair of spontaneous aorto-caval fistula secondary to a ruptured abdominal aortic aneurysm: An emergency management of hostile anatomy. SAGE Open Med Case Rep 2016; 4:2050313X16646526. [PMID: 27489717 PMCID: PMC4927212 DOI: 10.1177/2050313x16646526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/24/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Although endovascular aneurysm repair of aorto-caval fistula offers a safe and efficient approach compared to traditional open repair, endovascular techniques for the treatment of aorto-caval fistula with ruptured abdominal aortic aneurysms in emergency circumstance are not well established. This study aims to evaluate the effect of endovascular repair of aorto-caval fistula of a patient with ruptured abdominal aortic aneurysm and hostile anatomy. METHODS we report a case of an aorto-caval fistula endovascular repaired in a 78-year-old male using a hybrid stent-graft technique. RESULTS The patient had an uneventful recovery and CTA follow up showed no sign of ACF or any endoleak. CONCLUSION This case highlights ACF might be managed by composite endograft implantation with careful and solid sealing of anchoring zones on the two sides.
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Affiliation(s)
- Mingyuan Liu
- Peking University Health Science Center and Department of Vascular Surgery, Peking University People's Hospital, Beijing, The People's Republic of China
| | - Haofu Wang
- Division of surgery, The medical school of Qingdao University, Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, P.R. China
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Portelli Tremont JN, Cha A, Dombrovskiy VY, Rahimi SA. Endovascular Repair for Ruptured Abdominal Aortic Aneurysms has Improved Outcomes Compared to Open Surgical Repair. Vasc Endovascular Surg 2016; 50:147-55. [PMID: 26975604 DOI: 10.1177/1538574416637442] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Ruptured abdominal aortic aneurysm (rAAA) remains a critical diagnosis, and research is needed to address outcomes following surgical repair. The purpose of this study was to compare nationwide outcomes for patients who received either endovascular repair (EVAR) or open surgical repair (OSAR) for rAAA. METHODS The Medicare Provider Analysis and Review file from 2005 to 2009 was used to identify patients diagnosed with rAAA and treated with either EVAR or OSAR. Those patients with both procedures were excluded. Primary outcomes included mortality, postoperative complications, and readmission rates. Secondary outcomes included hospital resource utilization and length of stay (LOS). RESULTS A total of 8480 patients with rAAA who underwent EVAR (n = 1939) or OSAR (n = 6541) were identified. On multivariate regression, the likelihood of dying in the hospital after OSAR compared to EVAR was significantly greater (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.74-2.18). There was significantly greater frequency of postoperative complications after OSAR compared to EVAR (OR = 2.1, 95%CI = 1.86-2.37, P < .0001). Freedom from readmission after OSAR was significantly greater than that after EVAR. Total hospital cost for all services after EVAR was greater than that after OSAR (US$100 875 vs US$89 035; P < .0001), but intensive care unit (ICU) cost for EVAR was significantly less than that for OSAR (US$5516 vs US$8600; P < .0001). Total hospital and ICU LOS were shorter in EVAR compared to OSAR (P < .0001 for both). DISCUSSION EVAR for rAAA has shown mortality benefits over OSAR as well as reduced ICU and total LOS. This data suggest EVAR is associated with a greater survival benefit, fewer postoperative complications, and may help improve hospital resource utilization.
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Affiliation(s)
| | - Andrew Cha
- Division of Vascular Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Viktor Y Dombrovskiy
- Division of Vascular Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Saum A Rahimi
- Division of Vascular Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Ogawa Y, Nishimaki H, Chiba K, Ro D, Ono H, Sakurai Y, Fujiwara K, Murakami K, Hamaguchi S, Yagihashi K, Miyairi T, Nakajima Y. Life-Saving Embolization in a Patient with Recurrent Shock Due to a Type II Endoleak after Endovascular Aortic Repair for a Ruptured Abdominal Aortic Aneurysm. Ann Vasc Dis 2015; 8:131-4. [PMID: 26131038 DOI: 10.3400/avd.cr.15-00015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 04/17/2015] [Indexed: 11/13/2022] Open
Abstract
A man in his 80s underwent urgent endovascular aortic repair (EVAR) for a ruptured abdominal aortic aneurysm (RAAA). Surgery was completed without apparent complications, and the patient was returned to the Cardiac Care Unit. Two hours later, he again developed shock, and contrast-enhanced Computed Tomography showed extravasation from a type II endoleak (T2EL) involving the IMA. Transcatheter arterial embolization (TAE) was immediately performed, and the patient's vital signs stabilized soon after embolization. Abdominal compartment syndrome was suspected during the procedure, so a retroperitoneal hematoma evacuation was performed. The patient's postoperative course was satisfactory, and he transferred to another hospital. EVAR for RAAA would be useful, but it is necessary to be considered that T2EL can cause the aggravation of unstable circulation.
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Affiliation(s)
- Yukihisa Ogawa
- Department of Radiology, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
| | - Hiroshi Nishimaki
- Department of Cardiovascular Surgery, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
| | - Kiyoshi Chiba
- Department of Cardiovascular Surgery, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
| | - Daijun Ro
- Department of Cardiovascular Surgery, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
| | - Hirokuni Ono
- Department of Cardiovascular Surgery, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
| | - Yuka Sakurai
- Department of Cardiovascular Surgery, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
| | - Keishi Fujiwara
- Department of Radiology, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
| | - Kenji Murakami
- Department of Radiology, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
| | - Shingo Hamaguchi
- Department of Radiology, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
| | - Kunihiro Yagihashi
- Department of Radiology, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
| | - Takeshi Miyairi
- Department of Cardiovascular Surgery, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
| | - Yasuo Nakajima
- Department of Radiology, St. Marianna University, School of Medicine, Kawasaki, Kanagawa, Japan
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Azhar B, Patel SR, Holt PJE, Hinchliffe RJ, Thompson MM, Karthikesalingam A. Misdiagnosis of ruptured abdominal aortic aneurysm: systematic review and meta-analysis. J Endovasc Ther 2015; 21:568-75. [PMID: 25101588 DOI: 10.1583/13-4626mr.1] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To quantitatively summarize the incidence of misdiagnosis of ruptured abdominal aortic aneurysms (rAAA), the most common presenting features, and the commonest incorrect differential diagnoses. METHODS A systematic search according to PRISMA guidelines was performed using EMBASE and MEDLINE databases to identify studies reporting the initial rate of misdiagnosis of patients with rAAA. Random-effects meta-analyses were performed to estimate the rate of misdiagnosis, presenting features, and commonest differential diagnoses. A sensitivity analysis was performed for studies reporting after 1990. RESULTS Nine studies comprising 1109 patients contributed to the pooled analysis, which found a 42% incidence of rAAA misdiagnosis (95% CI 29% to 55%). In studies reporting after 1990, misdiagnosis was seen in 32% (95% CI 16% to 49%). The most common erroneous differential diagnoses were ureteric colic and myocardial infarction. Abdominal pain, shock, and a pulsatile mass were presenting features in 61% (49%-72%), 46% (32%-61%), and 45% (29%-62%) of rAAAs, respectively. CONCLUSION The rate of misdiagnosis of rAAA has remained consistent over time and is concerning. There is a need for an effective clinical decision tool to enable accurate diagnosis and triage at the scene of the emergency.
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Affiliation(s)
- Bilal Azhar
- Department of Outcomes Research, St George's Vascular Institute, St George's Hospital NHS Trust, London, UK
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Tulga UA, Fahrettin K, Erdal S, Sarper O, Serkan M, Mustafa O, Ahmet S, Kerem V, Levent B. Ruptured abdominal aortic aneurysm treatment in the stent graft era. Vasc Endovascular Surg 2014; 48:503-8. [PMID: 25487249 DOI: 10.1177/1538574414561232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We aim to decrease mortality and morbidity by early diagnosis and endovascular aneurysm repair (EVAR) or by using open surgery. METHODS The patients who had underwent open surgery and EVAR with a diagnosis of ruptured abdominal aortic aneurysms were evaluated retrospectively. Patients with EVAR were separated as group I and the patients with surgical operations constituted group II. The risk factors, duration of the operation, blood product usage, drainage amounts, complications, mortality, and morbidity rates were evaluated. RESULTS The duration of the operation and the required blood and blood products were lower in group I (P < .05). There is no any significant difference between the groups in terms of mortality, complications, short-, and long-term results. CONCLUSION We support the idea that better results can be obtained by showing regard to suitable patient, suitable clinical condition, and suitable anatomy together with the correct choice of operation type.
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Affiliation(s)
- Ulus A Tulga
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Kucukay Fahrettin
- Department of Radiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Simsek Erdal
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Oktem Sarper
- Department of Radiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Mola Serkan
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Ozdemir Mustafa
- Department of Radiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Saritas Ahmet
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Vural Kerem
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Birincioglu Levent
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
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Franz RW, Nardy VJ, Burkdoll D. Endovascular repair of a large ruptured abdominal aortic aneurysm using monitored anesthesia care and local anesthesia. Int J Angiol 2014; 23:121-4. [PMID: 25075165 DOI: 10.1055/s-0034-1376884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Over the last decade, there has been a paradigm shift in the treatment of ruptured abdominal aortic aneurysm (AAA) from open repair to endovascular aneurysm repair (EVAR). Regardless of the method used during emergent rupture, open verses endovascular repair, the overall mortality remains high. Recent studies have compared patient outcomes using different types of anesthesia during elective EVAR procedures. The data show that during an elective EVAR, monitored anesthesia care (MAC) with local anesthesia is not only just as safe as general anesthesia, but it offers other potential benefits as well. There is limited data in regards to patient outcomes using MAC and local anesthesia during cases of large ruptured aneurysms that are treated with EVAR. This case report discusses the treatment of a patient who presented with a large 13 cm ruptured AAA which was successfully repaired using EVAR with MAC and local anesthesia.
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Uchida K, Io A, Akita S, Munakata H, Hibino M, Fujii K, Kato W, Sakai Y, Tajima K, Mizobata Y. Recent risk factors for open surgical mortality in patients with ruptured abdominal aortic aneurysm. Acute Med Surg 2014; 1:207-213. [PMID: 29930850 DOI: 10.1002/ams2.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 02/24/2014] [Indexed: 11/06/2022] Open
Abstract
Aim We examined recent relevant prognostic factors for the outcome of open surgical treatment of ruptured abdominal aortic aneurysm. Methods Between 2006 and 2012, 35 patients received emergency open surgical treatment for ruptured abdominal aortic aneurysm at our institute. We reviewed ambulance activity logs and clinical records of 34 infrarenal ruptured abdominal aortic aneurysm patients retrospectively. Univariate and multivariate logistic regression analyses were carried out to identify risk factors for surgical outcomes. Results Eight patients died during surgery or within a few hours following surgery completion. Through univariate analysis, body mass index, serum lactate level, arterial blood pH, base excess, platelet count, prothrombin time-international normalized ratio, activated partial thromboplastin time, type of ruptured aneurysm, response to i.v. fluid resuscitation within 2,000 mL in the initial therapy, and volume of blood loss during surgery were detected to be significant variants. Multivariate logistic regression analysis revealed the patients who were hemodynamically stabilized after primary volume loading had a 13.2 times higher possibility of survival. Body mass index, high serum lactate level, and volume of blood loss were also found to be independent risk factors of mortality. Conclusion The risk factors of open surgical ruptured abdominal aortic aneurysm repair, body mass index, lactate level, volume of intraoperative blood loss, and response to initial 2,000 mL fluid resuscitation were correlated to survival.
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Affiliation(s)
- Kenichiro Uchida
- Department of Cardiovascular Surgery Nagoya Daini Redcross Hospital Nagoya Japan
| | - Akinori Io
- Department of Cardiovascular Surgery Nagoya Daini Redcross Hospital Nagoya Japan
| | - Sho Akita
- Department of Cardiovascular Surgery Nagoya Daini Redcross Hospital Nagoya Japan
| | - Hisaaki Munakata
- Department of Cardiovascular Surgery Nagoya Daini Redcross Hospital Nagoya Japan
| | - Makoto Hibino
- Department of Cardiovascular Surgery Nagoya Daini Redcross Hospital Nagoya Japan
| | - Kei Fujii
- Department of Cardiovascular Surgery Nagoya Daini Redcross Hospital Nagoya Japan
| | - Wataru Kato
- Department of Cardiovascular Surgery Nagoya Daini Redcross Hospital Nagoya Japan
| | - Yoshimasa Sakai
- Department of Cardiovascular Surgery Nagoya Daini Redcross Hospital Nagoya Japan
| | - Kazuyoshi Tajima
- Department of Cardiovascular Surgery Nagoya Daini Redcross Hospital Nagoya Japan
| | - Yasumitsu Mizobata
- Department of Traumatology, and Critical Care Medicine Graduate School of Medicine Osaka City University Osaka Japan
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Kunishige H, Ishibashi Y, Kawasaki M, Morimoto K, Inoue N. Risk factors affecting survival after surgical repair of ruptured abdominal aortic aneurysm. Ann Vasc Dis 2013; 6:631-6. [PMID: 24130620 DOI: 10.3400/avd.cr.13-00035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 07/24/2013] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The purpose of this study is to identify the risk factors affecting the high mortality rates associated with the treatment of ruptured abdominal aortic aneurysm (AAA). METHODS In this retrospective study, the subjects consisted of 105 patients who underwent repair of ruptured AAA at our institution from December 1984 to March 2012. We compared the patients of ruptured AAA in survival group with those in death group to evaluate the clinical factors in ruptured AAA mortality. RESULTS The operative and in-hospital mortality of ruptured AAA patients was 22.9% compared with 1.9% for that of non-ruptured AAA patients. The mean hemoglobin level was significantly lower in death group than in survival group. Intraoperative bleeding volume was significantly higher in death group than in survival group. Cox proportional hazard analysis showed that level 3 or 4 according to the Rutherford classification, preoperative hemoglobin level of less than 9.0 g/dl, intraoperative blood loss volume of more than 3000 ml, postoperative bowel ischemia and class 3 or 4 according to the Fitzgerald classification were significantly associated with high mortality. CONCLUSION These findings showed that every effort to maintain preoperative hemodynamic stability reduce volumes of blood loss in operation, and to minimize postoperative deterioration of organ functions would be essential to improve patient survival.
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Affiliation(s)
- Hideyuki Kunishige
- The Division of Cardiovascular Surgery, National Hospital Organization Hokkaido Medical Center, Sapporo, Hokkaido, Japan
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Schuld J, Kollmar O, Schuld S, Schommer K, Richter S. Impact of meteorological conditions on abdominal aortic aneurysm rupture: evaluation of an 18-year period and review of the literature. Vasc Endovascular Surg 2013; 47:524-31. [PMID: 23883786 DOI: 10.1177/1538574413497109] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine the influence of local meteorological conditions on the onset of ruptured abdominal aortic aneurysms (AAA). METHODS A review of 6551 consecutive days with a total of 191 ruptured AAA was performed between January, 1994 and December, 2011. Days with and without ruptured AAA were compared considering local meteorological data. A systematic review of the literature was performed. RESULTS Atmospheric pressure, cloudiness, relative humidity, precipitation, and water vapor pressure were comparable at event and nonevent days. The 4-day variance of atmospheric pressure prior to event days was significantly higher compared to nonevent days. Maximal and average temperature and water vapor pressure were significant lower at event days. Binary regression analysis identified a higher 4-day variance in atmospheric pressure as an independent factor for ruptures. CONCLUSIONS Further studies-collected at different geographic and climate areas-are necessary to prove that meteorological conditions may trigger the incidence of ruptured AAA.
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Affiliation(s)
- Jochen Schuld
- 1Department of General, Visceral, Vascular and Paediatric Surgery, University Hospital of Saarland, Homburg/Saar, Germany
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Abstract
Abdominal aortic aneurysm (AAA) has a reported prevalence rate of 1.4% in the US. AAA rupture accounts for an estimated 15,000 deaths per year, rendering it the 10th leading cause of death in men over the age of 55. Endovascular repair (EVR) has proliferated in the last two decades as an increasingly popular alternative to traditional open surgery, and is now the default treatment in the majority of centres worldwide. This review article outlines the evidence supporting this stance. The development of EVR is reviewed, alongside trends in utilisation of this therapy over time. The evidence for the relative short-term and long-term outcomes of EVR and open AAA repair is discussed, and ongoing controversies surrounding the use of EVR are considered.
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Affiliation(s)
- Sandeep S Bahia
- Department of Cardiovascular Sciences, St George's Vascular Institute, London.
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Unosawa S, Kimura H, Niino T. Surgical repair of ruptured abdominal aortic aneurysm with non-bleeding aortocaval fistula. Ann Vasc Dis 2013; 6:209-11. [PMID: 23825505 DOI: 10.3400/avd.cr.12.00106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 03/07/2013] [Indexed: 11/13/2022] Open
Abstract
We present a case of an aortocaval fistula (ACF) without bleeding because a clot was covering the fistula. A 60-year-old man was diagnosed as having a ruptured abdominal aortic aneurysm (AAA) and an aortocaval fistula, by enhanced computed tomography (CT). After the aneurysm had been opened, the fistula was detected, but there was no bleeding because it was covered with clot. After graft repair, bleeding from the fistula occurred when the clot was removed by suction. Direct closure of the fistula was achieved after bleeding was controlled by digital compression.
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Affiliation(s)
- Satoshi Unosawa
- Department of Cardiovascular Surgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
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Abstract
Introduction Few modern population-based estimates of the prognosis of ruptured abdominal aortic aneurysm (rAAA) exist. Methods and materials From 1994–2008, a total of 6954 rAAA cases were identified in Danish nationwide population-based registries. Results Of 3148 (45%) surgery cases, 1454 (46%) died within 30 days of surgery. The overall mortality risk of rAAA was 76%. The proportion of patients who received surgery increased from 44%, in the first study period, to 47% in the last study period; the 30-day postoperative mortality rate decreased from 51% to 42%; and the overall mortality risk declined significantly from 77% to 74% (odds ratio: 0.86: 95% confidence interval: 0.77–0.97). However, the age-adjusted mortality rate remained unchanged, due to the increased incidence of rAAA.
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Affiliation(s)
- Jes S Lindholt
- Vascular Research Unit, Department of Vascular Surgery, Viborg Hospital, Clinical Institute, University of Aarhus, Denmark
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Ito T, Koyanagi T, Kawaharada N, Kurimoto Y, Uzuka T, Uehara M, Hagiwara T, Yanase Y, Maeda T, Higami T. Conversion to Open Repair from Emergency EVAR in a Patient with Ruptured AAA: Report of a Case. Ann Vasc Dis 2012; 5:454-7. [PMID: 23641270 DOI: 10.3400/avd.cr.12.00043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 08/25/2012] [Indexed: 11/13/2022] Open
Abstract
A 77-year-old woman with a ruptured abdominal aortic aneurysm (AAA) was transferred to our hospital. Due to a severe comorbidity, endovascular aortic repair of the ruptured AAA was proposed. During the operation, although a Zenith(®) AAA endovascular graft was deployed, digital subtracted angiography revealed an enhancement of the endoleak, and the patient became hemodynamically unstable. Therefore, we decided to convert to graft replacement of the abdominal aorta through a median laparotomy. During the postoperative period, the patient suffered from ischemic colitis, which resolved with conservative therapy. She was discharged after 33 postoperative days.
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Affiliation(s)
- Toshiro Ito
- Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University, School of Medicine, Sapporo, Hokkaido, Japan
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Takahashi K, Fukui D, Wada Y, Terasaki T, Ohtsu Y, Komatsu K, Fuke M, Takano T, Amano J. Indicators of survival after open repair of ruptured abdominal aortic aneurysms and an index for predicting aneurysmal rupture potential. Ann Vasc Dis 2011; 4:209-17. [PMID: 23555455 DOI: 10.3400/avd.oa.11.00002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 04/08/2011] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aims of this study were to assess variables associated with survival in patients undergoing ruptured abdominal aortic aneurysm (RAAA) repair and to develop an index other than the aneurysmal diameter to predict rupture potential. METHODS This study included 43 consecutive patients who underwent open surgery for RAAAs. RESULTS The mortality rate was 18.6% (8/43). The ratio between the maximum aneurysmal diameter and the length (along the central axis) from the aneurysmal neck to the point at which the diameter was three-fourth of the maximum aneurysmal diameter was used as an index to predict aneurysmal rupture potential. The index score was 2.7 ± 1.2 in the RAAA and 1.9 ± 0.9 in the EAAA (p = 0.018). For aneurysms of ≤ 6-cm diameter, the index score was 3.0 ± 1.0 in the RAAA and 1.8 ± 0.9 in the EAAA (p = 0.03). All patients in the EAAA except one had an index score of < 2.3 and 6 of the 7 patients with RAAA had a score of > 3. CONCLUSIONS The results suggest that patients with AAA having scores of > 3 are at high risk of rupture. This index would be useful for decision making regarding repair of AAA, especially in the borderline cases.
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Affiliation(s)
- Kohei Takahashi
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
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