a protocol to facilitate evar for ruptured aaa - ucsf … · 4/8/2011 1 a protocol to facilitate...

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A Protocol to Facilitate EVAR for Ruptured AAA

Manish Mehta MD MPHThe Vascular Group, Albany Medical Center

UCSF Vascular Symposium 2011

Research Grants/ Advisory Board/ Speaker/ honorarium:

WL Gore

Medtronic Ave

Cook Inc

Aptus

Trivascular

Cordis

Disclosures

UCSF Vascular Symposium 2011 UCSF Vascular Symposium 2011

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• Rupture AAA repair has evolved significantly

• EVAR for ruptured AAA

– Well documented and beyond feasibility

– Associated with significant reduction in morbidity & mortality

– Evolving to become the new ‘Gold Standard’

EVAR for Ruptured AAA EVAR for Ruptured AAA

• Limitations

– Availability of trained staff at all times

– Availability of equipment at all times

– The need for preoperative CT, particularly in hemodynamically unstable patients

– Surgeon bias and comfort level with EVAR under emergent circumstances

EVAR for Ruptured AAA

“Our first case”………2002Established Protocol

Multidisciplinary Approach

Endovascular Repair of Ruptured Aortic Aneurysms Albany Vascular Institution Experience (2002 – Present)

Vascular surgeons ER physicians

Anesthesiologists OR staff

Radiology techs.

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Established Protocol


Adequate Equipment




Radiology techs.

+Stentgrafts Wires

& Catheters

Established Protocol


Adequate Equipment


5 Patients Symptomatic AAA

Simulation: Patients presenting with ruptured AAA



Radiology techs.

+ Stentgrafts Wires & Catheters

ER physician suspects r-AAA

Protocol: Ruptured AAA

Alerts Vascular Surgery On-Call Team




Hemodynamically Stable SBP ≥ 80 mm Hg

Hemodynamically Unstable SBP < 80 mm Hg

Emergent CTA in ER

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Hemodynamically Stable SBP ≥ 80 mm Hg

Hemodynamically Unstable SBP < 80 mm Hg

Emergent CTA in EROR: Ready for EVAR and

Open Surgical Repair

‘Surgeon Bias’

• Simulation: “Ruptured AAA”

• “Hypotensive Hemostasis”

• Unilateral femoral access• Wire access into thoracic aorta

• Sheath placement (12Fr)

• Aortic occlusion balloon

• In unstable patients, Inflate occlusion balloon

• Contralateral femoral access

• Endovascular repair

EVAR for Ruptured AAA Albany Vascular Institution Experience (2002 – Present)



















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Ruptured Aortic Aneurysms: Endo. vs. Open Repair Albany Vascular Institution Experience (2002 – 2010)

372 Ruptured Aortic Aneurysms

59 r-TAA313 r-AAA



59 r-TAA313 r-AAA

46 TEVAR 13 Open136 EVAR 177 Open



59 r-TAA313 r-AAA

46 TEVAR 13 Open136 EVAR 177 Open

130 (96%)

Technically Successful

6 (4%)

Open Conversion

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Ruptured AAA: Endovascular vs. Open Surgical Repair Albany Vascular Institution Experience (2002 – 2010)

Endo Open P-value

n 136 177

Male 71% 68% NS

Age (mean) 74 yrs. 73 yrs. NS

CAD 67% 44% <0.05

CRI 19% 8% <0.05

COPD 28% 12% <0.05


Endo Open P-value

N 136 177

Preop. CT Available 80% 84% NS

Hemodynamically Unstable 25% 26% NS

Aortic Occlusion Balloon 20% N/A -

Aorto-uni-iliac & Fem-fem 16% N/A -

Blood Loss (mean) 464 cc 2791 cc <0.05

Operative Time (mean) 82 min 194 min <0.05

EVAR for Ruptured AAA Albany Vascular Institution Experience (2002 – 2010)


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Wire-path along aortic neck:Gentle curve


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Forward traction on stiff wire




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Endo Open P-value

N 136 177

Myocardial Infarction 3% 16% <0.05

Ischemic Colitis (Grade 1-3) 6% 22% <0.05

ACS 16% 0 <0.05

Respiratory Failure 6% 9% NS

Renal Failure 5% 9% NS

Mean Hospital LOS (range) 11 (2-83) 17 (4-74) NS

• ACS: Abdominal Compartment Syndrome

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Ruptured AAA: Endovascular vs. Open Surgical Repair Albany Vascular Institution Experience (2002 –2009)

Endo Open P-value

N 136 177

Overall Mortality 16% 42% <0.01


N 136

Overall Mortality (EVAR r-AAA) 16% (22/136)

Mortality without ACS 9% (11/117)

Mortality with ACS 53% (10/19)P<0.05

ACS No ACS P-value

N 11 53

Operative Time (mean) 75 min 85 min NS

Aortic Occlusion Balloon 8 (73%) 3 (6%) < 0.01

Blood Transfusion 8 Units 2 Units < 0.01

aPTT 128 sec 52 sec < 0.01

Death 6 (55%) 4 (8%) < 0.05

EVAR for Ruptured AAAAbdominal Compartment Syndrome, Subset Analysis*

Mehta et al. JVS 2005

Endovascular Repair of Ruptured AAA

0

20

40

60

80

100

2002 2003 2004 2005 2006 2007 2008 2009 2010

%

13%

>75%

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0

20

40

60

80

100

2002 2003 2004 2005 2006 2007 2008 2009 2010

%

EVAR

Open Surgical

All Ruptured AAA52%

22%

EVAR and Open Repair of Ruptured AAA Operative Mortality

0

20

40

60

80

100

1 mo 1 yr 2 yr 3 yr 4 yr 5 yr

EVAR r-AAA Open r-AAA

Ruptured AAA: Endovascular vs. Open Surgical Repair Cumulative Survival

%

EVAR 102 64 43 22 12 7

Open 72 57 39 16 11 5@ Risk

P<0.05

• With standardized team approach, hemodynamically stable and unstable patients can be treated by endovascular means

• Preoperative CT scan is not an absolute necessity

• Single center experiences indicate EVAR for r-AAA has a significant midterm survival advantage when compared to open repair.

• With increasing experience, expanding the device IFU may increase the utility of EVAR in r-AAA patients

Take Home Message!

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a protocol to facilitate evar for ruptured aaa - ucsf … · 4/8/2011 1 a protocol to facilitate...

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