AAA Repair

Justin Brown4 September 2014

• 82 yo W transfer from OSH with ruptured Abdominal Aortic Aneurysm– Presented with acute onset of abdominal pain– Non contrast CTA obtained and found to have

incidental 6.8cm AAA– Found to have UTI

RESIDENT #1

Define the terms1.

aneurysm2

ectasia3.

arteriomegaly

• aneurysm is a permanent, focal dilation of an artery that exceeds 1.5 times the normal

• ectasia - diameter is increased by less than 50% of the normal expected diameter

• arteriomegaly refers to a diffuse (nonfocal) enlargement of several arterial segments with increases in diameter greater than 50% of the normal expected diameter

http://portal.surgicalcore.org

RESIDENT #2

All of the following metalloproteases have been

implicated in the biochemistry of aortic aneurysm formation

exceptMMP-1MMP-2MMP-3MMP-8MMP-9

http://portal.surgicalcore.org

• Contrast CT obtained following increase of abdominal pain

• Transferred directly to OR for repair• Developed PEA arrest following induction for

intubation– 2 rounds CPR– Return of pulses and pressure noted

• Open AAA repair

• LoT opened• Infrarenal clamp• Aneurysm opened and

clot removed• Dacron graft sewn in• Abthera placed• Taken for washout and

closure 2 Sept

RESIDENT #3

In this picture what transverse structure usually defines the

most superior aspect of the aortic

dissection?Can you ligate this structure and if so what needs to be

preserved?

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Rutherford's Vascular Surgery, 7th ed.

RESIDENT #4

Is it proven to reimplant the IMA?

IMA Reimplanted

• may be reimplanted into either the body of the graft or the left limb if it is patent. Seeger et al. reported that routine reimplantation of the inferior mesenteric artery resulted in decreased rates of colonic infarction and death after aortic reconstruction.

• More recent randomized controlled trial demonstrated no benefit in terms of morbidity or mortality, although the authors suggested it may be beneficial for older patients and those with increased blood loss.

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AAA Repair

AAA Repair

• Open vs Endovascular (EVAR)– EVAR1

• RCT from UK• 1252 pts age > 60, AAA >5.5cm

– DREAM• RCT Netherlands• 351 pts

– OVER• RCT in VA system• 881 pts age >49, AAA> 4.5cm

- ACE- RCT from France- 306 low to medium risk pts

AAA Repair

• Open vs Endovascular (EVAR)– Mortality• Short term - 4.2% vs 1.4% P<0.0001• Intermediate – 17% vs 15.8% P=0.40• Long term – 37.8% vs 37.3% P=0.78

– Reintervention rate• Intermediate - • Long term – 13.1% vs 23.4%

rAAA Repair

rAAA Repair

• NSQIP database 2005-2010• 1447 rAAA Open 65.5% EVAR34%, • Incidence of mortality and MI in OAR vs EVAR

in elective and ruptured abdominal aortic aneurysms

• Found statistically significant reduction in 30-D mortality, MI and average hospital LOS In EVAR

rAAA Repair

rAAA Repair

• From the data available there is no difference in the outcomes evaluated in this review between EVAR and open repair, specifically 30-day mortality

• Not enough information was provided for complications in order to make a well informed conclusion at this time

• Long-term data are lacking for both survival and late complications