how to implement a successful programme for evar … · zoran rancic md, phd, febvs clinic for...
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HOW TO IMPLEMENT A SUCCESSFUL PROGRAMME FOR EVAR OF RUPTURED
ANEURYSMS
Zoran Rancic MD, PhD, FEBVS Clinic for Cardiovascular Surgery
University Hospital Zurich, Switzerland On behalf of Vascular Specialists UHZ
Disclosure
Speaker name: Zoran Rancic
I have the following potential conflicts of interest to report:
X Consulting
Medtronic Academia
Clinical experience UHZ
• 1997-‐2014
• 330 repairs for acute AAA presenta=on
• 42% OR and 58% ER
UHZ rAAA experience 1997-‐2014
30-‐day mortality
rOR
33%
rEVAR
17%
RRR
58%
Define
Standard opera=ng procedure!
Hemodynamic
Imaging
Procedures ACS
TEAM
Hemodynamic
Imaging
Procedures ACS
TEAM
Hypotensive hemostasis
stable 50%
shock <70 33%
shock <50 17%
– permissive hypovolemia • No or liWle infusions
– controled hypotension • MAP -‐ >50 mmHg • SBP -‐ 70mmHg
Management of blood pressure
normal or high
low
stable unstable pharmacological lowering
target BP <90mmHg
fluid restriction target BP ≥70mmHg
catecholamines fluids
target BP ≥70mmHg
ENDOCLAMPING in case of hemodynamic crash
HOW TO IMPLEMENT Hemodynamic
FOR SUCCESSFUL PROGRAME?
Imaging
Procedures ACS
TEAM
It is a package
Pre-hospital
YOU DETERMINE THE OUTCOME
All the Staff INVOLVED IN TREATMENT AND REFFERAL OF PTS WITH RAAA has to know!
Hemodynamics
Imaging
Procedures ACS
TEAM
Preopera=ve CTA -‐ confirms diagnosis -‐ planing
Preopera=ve CTA -‐ confirm diagnosis
4 !/350 (1%)
CTA: to define the anatomy and suitability for rEVAR
Exclusion criteria
for REVAR
Proximal neck
Distal access
Good anatomy and suitable rEVAR
"
Anatomical Limita=ons for „simple“ rEVAR
Chimney and Periscope Grad
" " "
„Addi=onal oversizing“
Hemodynamics
Imaging
Procedures ACS
TEAM
Logis=cs @ UHZ
Manpower – 24h/day
• Anaesthe=sts, • radiologists, • ICU doctors, • nurses
– On call (30’) • Interven=onal radiologists (n=3) • surgeons (n=3)
Logis=cs @ UHZ
1997-‐2012 1997-‐2012
2010 2011
Standard devices
Infrarenal fixation devices Excluder
Transrenal fixation devices Endurant/Zenith/Evita
Hybrid devices Excluder/Endurant/Zenith/Evita
Chimney technique is standardized!
Hemodynamics
Imaging
Procedures ACS
TEAM
Author Year Treatment n= ACS (%)
30-day mortality ACS - ACS +
Starnes 2009 OR EVAR
24 27
25 7
44% 16%
83% 50%
Mayer 2009 EVAR 102 22 9% 26%
Mehta 2005 EVAR 30 20 13% 57%
Papavassiliou 2003 OR 22 27 25% 100%
Foy 2003 OR 21 20 5x
Rasmussen 2002 OR 135 33 9% 56%
Oehlschlager 1997 OR 38 21 50% 73%
Fietsam 1989 OR 100 4 First description
ACS is frequent!
ACS is a serial killer!
Abdominal Compartment Syndrome
UHZ algorithm for ACS is defined
Hemodynamics
Imaging
Procedures
HOW TO IMPLEMENT
ACS FOR
SUCCESSFUL TREATMENT?
TEAM
1. BE AWARE!
1. BE AWARE! 2. MEASURE AN URINARY BLADDER PRESSURE!
3. IN CASE OF DECOMPRESSION BLEEDING: PATCH ON RUPTURE SITE
Hemodynamics
Imaging
Procedures ACS
TEAM
Surgeon
TEAM WORK
Preop • Vascular surgeon • Radiologist • Anaestesiologist
Intraop • Vascular surgeon • Interven=onal radiologist
• Anaestesiologist • Scrub nurse
Postop • Vascular surgeon • Radiologist • ICU staff
Communica=on example • No infusions/systolic BP 70-‐90 mm Hg Referral hospital
• rAAA is coming Anaesthe=st
• IC bed available ICU
• TA EVAR CT protocol/EVAR TEAM Radiologist
• Emergency Room/Theatre Trauma Surgeon
• Must be free and ready Vascular Surgery Resident
Significant decrease of rAAA @ UHZ
0 5 10 15 20 25 30 35
1997
1999
2001
2003
2005
2007
2009
2011
2013
REVAR TEAM UHZ 1998-‐2014
Radiologists • Thomas PfammaWer • Ulrich Blum • Paul Hilfiker • Ursula Wolfensberger • Roger Pfiffner • Lukas Hechelhammer • Susanne Abderhalden • Michael Glenck • Gilbert Puippe
Surgeons • Mario Lachat • Jürg Schmidli • Andreas Künzli • Michael SzenteVarga • Dieter Mayer • Jean-‐Marc Gauer • Markus Wilhelm • Alberto Weber • Simone Hofer • Zoran Rancic • Felice Pecoraro • Daniel Becker • Philippe Ghibu
REVAR TEAM UHZ 1997-‐2014
Radiologists • Thomas PfammaWer • Ulrich Blum • Paul Hilfiker • Ursula Wolfensberger • Roger Pfiffner • Lukas Hechelhammer • Susanne Abderhalden • Michael Glenck • Gilbert Puippe
Surgeons • Mario Lachat • Jürg Schmidli • Andreas Künzli • Michael SzenteVarga • Dieter Mayer • Jean-‐Marc Gauer • Markus Wilhelm • Alberto Weber • Simone Hofer • Zoran Rancic • Oliver Graubitz • Felice Pecoraro • Roberto Tunesi
Hemodynamics
Imaging
Procedures ACS
HOW TO IMPLEMENT
TEAM FOR
SUCCESSFUL TREATMENT?
Training of technical skills: Generic or Pa=ent-‐specific Rehearsal
Training of human factor skills: ORCAMP
Mixed Reality
Conclusion
1. EVAR is beWer, based on literature
Conclusion
1. EVAR is beWer, based on literature 2. Iden=fy the pa=ent popula=on and cri=cal
key points
Conclusion
1. EVAR is beWer, based on literature 2. Iden=fy the pa=ent popula=on and cri=cal
key points 3. Elaborate protocols and necessary logis=cs
and get protocols accepted by partners
Conclusion
1. EVAR is beWer, based on literature 2. Iden=fy the pa=ent popula=on and cri=cal
key points 3. Elaborate protocols and necessary logis=cs
and get protocols accepted by partners 4. Teach medical partners (IR in Zurich) all
medical care supporters (first aid-‐medical students)
Conclusion
1. EVAR is beWer, based on literature 2. Iden=fy the pa=ent popula=on and cri=cal
key points 3. Elaborate protocols and necessary logis=cs
and get protocols accepted by partners 4. Teach medical partners (IR in Zurich) all
medical care supporters (first aid-‐medical students)
5. Consider =me horizon of about 2-‐5years
HOW TO IMPLEMENT A SUCCESSFUL PROGRAMME FOR EVAR OF RUPTURED ANEURYSMS
Zoran Rancic MD, PhD, FEBVS Clinic for Cardiovascular Surgery
University Hospital Zurich, Switzerland On behalf of Vascular Specialists UHZ