SOS A ORTASOS A ORTASOS A ORTASOS A ORTASOS A ORTASOS A ORTAA 24/7program forA orticEm ergencies

in« IledeFrance»

SOS A ORTASOS A ORTAA 24/7program forA orticEm ergencies

in« IledeFrance»in« IledeFrance»in« IledeFrance»

P aulACHO U H,M D,P hDP aulACHO U H,M D,P hDP aulACHO U H,M D,P hD

DirectorofT horacicAorticS urgery P rogramEuropeanHospitalGeorgesP om pidou

P aulACHO U H,M D,P hD

DirectorofT horacicAorticS urgery P rogramEuropeanHospitalGeorgesP om pidouEuropeanHospitalGeorgesP om pidou

& P aris-DescartesU niversity,P aris,FranceEuropeanHospitalGeorgesP om pidou

& P aris-DescartesU niversity,P aris,France

Suspected orcon firm ed aorticSuspected orcon firm ed aorticem ergen ciesem ergen ciesem ergen ciesem ergen cies

Acute aortic syndroms Acute aortic syndroms

Complicated or symptomatic aorticaneurysms

Traumatic aortic rupture Traumatic aortic rupture

100-200 type A dissection/y in IDF

12 012 Km2

Mortality 1% / h

12 012 Km2

Pop. 12 millions

200 ruptured AAA /y

Mortality = 48 % ** Meta-analysis of 171 studies since 1955. Brown et al. Br J surg 2002

1500 severe polytrauma patients/ y 1500 severe polytrauma patients/ y

Before SOS Aorta

Cases are scattered around different hospitals

Lower case-volume per hospital …. longer learning

curve …curve …

Multidisciplinary approach is not available in most of Multidisciplinary approach is not available in most of

these hospitals

Before SOS Aorta

No defined contact nor phone number

No dedicated unit

No decisionnal algorythms No decisionnal algorythms

No standardized diagnosis workup or treatment No standardized diagnosis workup or treatment

Loss of time… loss of means …

… loss of lives?

SOS Aorta

01 56 09 25 55: One phone number, dedicated to aorticemergencies, 24/7 (senior physician)

SSPI (Trauma Unit) : One dedicated admission Centre,specialized in dealing with vital emergencies & unstablepatientspatients

On-call senior aortic/CV surgeon, with a dedicated phonenumber 56 09number 56 09

CV-ICU : Dedicated cardiovascular ICU

On-site lifeflights

Multidisciplinary approach cardiovascular surgeon, Multidisciplinary approach cardiovascular surgeon,endovascular surgeon, cardiologists, on-site anesthesist,cardiovascular radiologists…) …

SOS AORTA call 01 56 09 25 55

Pt accepted immediatly & unconditionnally,Pt accepted immediatly & unconditionnally,(unless ethical issues or surgical team unavailable

Surgeon ( 5609)

Admission flow initiated

Surgeon ( 5609)

CV-OR

Emergency CT scan

Pré-admission

Radio follow-up

Arrival of pt Immediate assesment

CV-ORVital emergency

CV-OR

Imaging

Vital emergency« minutes »

Vital emergency« hours »« hours »

Other diagnosisReorientation

Work-up

Diagnosis

Treatment protocoles

SOS Aorte

Prospective registry since Feb 2010

SOS Aorte

• Information campaign to ER mobileunits (SAMU) & ER departmentsunits (SAMU) & ER departments

• Internet for general public &professionnalsprofessionnals

• French television documentary

• « Post-university teaching » sessions

• Oral presentations• Oral presentations

SOS A orte

Nb pts

133

159174

186 180

140

160

180

200

Nb pts

55

84

133

60

80

100

120

140

0

20

40

60

2010 2011 2012 2013 2014 2015 20162010 2011 2012 2013 2014 2015 2016

Impact of SOS Aorta on referral & mortalityImpact of SOS Aorta on referral & mortality

461 patients referred for aortic emergencies over a 6 year-periodperiod

SOS aorte

174 patients 287 patients

20063 yrs

2009 20113 yrs

174 patients 287 patients

Impact of SOS Aorta on referral & mortality

Number pts Before SOS Aorta After SOS Aorta

All aortic emergencies 58±6,6 96±17 p<0,05

Impact of SOS Aorta on referral & mortality

All aortic emergencies 58±6,6 96±17 p<0,05

Type A Dissection 28±3 42±3,6 p<0,05

Type B Dissection 18±3,2 23±5,2 p=0,1

Ruptured aneurysm 10±1,5 21±6,1 p<0,05

Traumatic rupture of the aorta 6±1 9±3,1 p=0,07

Mortality Before SOS Aorta After SOS Aorta

All aortic emergencies 36,4±1,84% 21,6% p<0,01

Type A Dissection 53% 30% p<0,01Type A Dissection 53% 30% p<0,01

Type B Dissection 12% 9% p=0,1

Ruptured aneurysm 50% 23% p<0,05

Traumatic rupture of the aorta 22% 9% p<0,05

Impact of SOS Aorta on referral & mortalityImpact of SOS Aorta on referral & mortality

Before SOS Aorta After SOS Aorta

Mean age 64 y(33-88)

68 y(20-93)(33-88) (20-93)

Hemodynamicinstability

12% 31%instability

Neurologic deficit @presentation

3,1% 6%

Deep hypothermic 45% 62%Deep hypothermiccirculatory arrest

45% 62%

Impact of SOS Aorta on referral & mortality

Geographic distribution of referred cases

Impact of SOS Aorta on referral & mortality

Geographic distribution of referred cases

00Outside IDFOutside IDF

12%

ParisIDF (outside Paris)

28%

11%

0

Paris

Outside IDFOutside IDF

50%37%

IDF (outside Paris)28%

61%

IDF (outside Paris)

BeforeS O S aorta A fterS O S aortaBeforeS O S aorta A fterS O S aorta

SOS A orte

SOS Aorta Registry :2/2/2010 16/08/2016: 900 pts2/2/2010 16/08/2016: 900 pts

• Mean age 66 ans (16-100)• Mean age 66 ans (16-100)

• ♂ 68%

• Unstable 22 %

• Cardiac arrest 5%

(1,8% non recuperated)

• SAPS2 mean 38,3 ± 25,2• SAPS2 mean 38,3 ± 25,2(New Simplified acute physiology score)

SOS A orte

Fin ald iagn osis

Other CVOther CV21%

Non CV12%

Aortic67%

SOS A orte

Fin ald iagn osis

Type Adissection

Type Bdissection

18%dissection

38%

AAAAAA27%

IMH B

PAU1%

DT/TAAA8%

TAR1%

Asc/Arch3%IMH A

2%

IMH B2%

1%

SOS A orte

Geographic distribution

Primary referral (ER Mobile U)Primary referral (ER Mobile U)

Outside IDF2%

Ile de France

Paris51%

Ile de France(Outside

Paris)47%

SOS A orte

Pain

Thoracic44%

Abdominal44%

Abdominal30%

Thoraco-abdominalOtherNo pain abdominal

9%Other

6%

No pain11%

SOS A orte

Neurological deficit

No ND80,3%

Hemiplegia2,8%

Other4,9% 2,8%

Monoplegia3,5%

Paraplegia1,8%Coma

6,6%

4,9%

SOS A orte

Hemodynamics

Stable53%

HTN25%

53%

UnstableUnstable22%

SOS A orte

%

Results

80

100

%

20

40

60

22,9

4.9 7.7 22.442.1

0

20 4.9 7.7 22.4

SOS A ORTA

S urgicaltreatm ent

Surgery duringUrgent surgery

(before nextday)41%

Surgery duringhospitalisation

12%

Delayed41% Delayedsurgery

4%

No surgery

Emergent

No surgery41%

Emergent(under CPR)

2%

Median time to urgent surgery = 54 min

A com plete & m ultid isciplin arym an agem en tm an agem en t

Emergencyservices

CV surgeryCV Rehabilitation

Follow-upAcute management

CV surgery

Aortic

CV Rehabilitation

Blood pressuremanagementCV-ICU

Endovascular team

Cardiovascularradiology

Aorticemergency

management

Vascular Medecine

CV-ICUGenetic counseling

Interventionnalcardiology

INSERMINSERMRESEARCH

UMR 970-PARCC

Nextstep

01 56 09 25 5501 56 09 25 55