1 / 35

Rupture AAA – Any NEW advances?

Rupture AAA – Any NEW advances?. Dr Karen Tung Lok Man PYNEH. Epidemiology in HK. ~ 900 new cases AAA diagnosed every year 10% presented as rupture Operative mortality rate : Elective 10% Rupture 54%. Stephen W.K. Cheng World J. Surg 2003. Rupture AAA.

misha
Download Presentation

Rupture AAA – Any NEW advances?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Rupture AAA – Any NEW advances? Dr Karen Tung Lok Man PYNEH

  2. Epidemiology in HK • ~ 900 new cases AAA diagnosed every year • 10% presented as rupture • Operative mortality rate : • Elective 10% • Rupture 54% Stephen W.K. Cheng World J. Surg 2003

  3. Rupture AAA • 50% die before reaching hospital • 30% who reached hospital die before operation • Operative mortality : 50% Overall mortality rate : 80 -90%

  4. Open AAA repair • 30 days operative mortality rate : • 48% in 1998  41% in 2001 Are we satisfied with this improvement ? M.J. Bown British Journal of Surgery 2002

  5. Title • Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Vivamus et magna. Fusce sed sem sed magna suscipit egestas. • Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Vivamus et magna. Fusce sed sem sed magna suscipit egestas. Room for improvement ?

  6. Endovascular AAA repair (EVAR) • EVAR was first performed in human by Dr Juan Parodi in 1991

  7. Benefits of EVAR on elective AAA  30 days mortality rate  Long term aneurysm-related death  ICU stay and total hospital stay R M Greenhalgh Lancet 2005 Jan D. Blankensteijin New Eng J Med 2005 R. E. Lovegrove British Journal of Surgery 2008

  8. EVAR in rupture AAA ? • 1st EVAR was performed in 1994 on a 61-year-old man with 6cm rupture AAA • Duplex scan on day 6 : no leakage • Discharged on day 7 S W Yusuf The Lancet 1994

  9. Technique of emergency EVAR • LA common femoral artery cutdown • Placement of large sheath • Aortic occlusion balloon is inserted in supra-renal position Manish Mehta J Vasc Surg 2010

  10. Technique of emergency EVAR • GA • Stent graft main body is inserted on the contra-lateral side • Arteriogram is done on ipslateral side with aortic balloon temporaily deflated • Stent graft main body is rapidly deployed Manish Mehta J Vasc Surg 2010

  11. Technique of emergency EVAR • Aortic balloon advances back and inflats below renal artery • Contra-lateral limb extension is deployed • Aortic balloon is removed • Ipsilateral limb extension is deployed Manish Mehta J Vasc Surg 2010

  12. Anatomic suitability for elective EVAR >=15mm < 30mm < 60o >=7mm

  13. Anatomic suitability for rAAA EVAR Dieter Mayer Annuals of Surgery 2009 Loosen Anatomic criteria Randy Moore J Vasc Surg 2007

  14. Current AAA management Permissive Hypotension : NO fluid resuscitation unless SBP < 80mmHg or  mentation K.Roberts Eur J Vas 2006 N Rupture AAA Stable Open repair Y SBP >80 mmHg & Normal mentation Permissive Hypotension N Spiral CTA Endo Candidate EVAR Y

  15. Retrospective Studies

  16. Retrospective studies • 90 rupture AAA patients with EVAR done in 7 years • 30 days mortality : 27% J.Hoist Eur J Vasc Endovasc Surg 2009 • 102 rupture AAA patients with EVAR done in 10 years • 30 days mortality : 13% Dieter Mayer Annuals of Surgery 2009

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

  18. Systematic review • 1 RCT and 33 non-randomised case series (24 retrospective and 9 prospective) reports were identifed D.W. Harkin Eur J Vasc Endovasc Surg 2007

  19. Systematic review  Mortality ( EVAR : 17% , Open : 34%) D.W. Harkin Eur J Vasc Endovasc Surg 2007

  20. Selection Bias • EVAR groups were more stable than open groups • EVAR groups had technically easier anatomy (e.g. longer aortic neck) • CT delayed treatment for open AAA repair

  21. NO level I evidence !

  22. 1st RCT EVAR Vs Open repair • Sept 2002 – Dec 2004 • Single centre prospective randomized controlled trial R.J. Hinchliffe Eur J Vasc Endovasc Surg 2006

  23. 1st RCT EVAR Vs Open repair Failed to demonstrate superiority of EVAR over open repair

  24. Advantages of emergency EVAR • Avoid vasodilating and negatively inotropic effects of GA • Avoid large midline laparotomy on muscle wall tone which lead to circulatory compromise • Decreased surgical dissection blood loss • Avoid aortic cross-clamping and potential reperfusion injury

  25. Limitations of EVAR in rupture AAA • Anatomical issue • Logistical issue – Lack of availability of EVAR trained staff and appropiate endograft components • EVAR specific complications need re-intervention

  26. Is EVAR superior to open repair for rupture AAA ? Can we improve outcome of rupture AAA patients by incorporating EVAR into our protocol?

  27. Rupture AAA protocol AIM : To demonstrate any improved survival (30 days mortality) after introduction of an rupture AAA protocol 2001 2004 2006 Randy Moore J Vasc Surg 2007

  28. Result Randy Moore J Vasc Surg 2007

  29. Result Randy Moore J Vasc Surg 2007

  30. Conclusion • Mortality rate for open repair of rupture AAA remains high • Emergency EVAR for treatment of rupture AAA is feasible • Introduction of rupture AAA repair protocol includes EVAR can improve mortality rate

  31. What is going on... 3 Randomized controll trials currently undergoing The Amsterdam Acute Endovascular Treatment To Imporve Outcome of Rupture Aorta-Iliac Aneuysm trial (AJAX) The Rupture Aorta-Iliac Aneuysm Endo vs Surgery (ECAR) trial Immediate Management of the Patient with Rupture: Open Versus Endovascular Repair (IMPROVE) trial

  32. THANK YOU

More Related