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uptured Abdominal Aortic Aneurysm:ndovascular Program Development and Resultsanish Mehta, MD, MPH, Paul B. Kreienberg, MD, Sean P. Roddy, MD, Philip S.K. Paty, MD,

ohn B. Taggert, MD, Yaron Sternbach, MD, Jeffery Hnath, MD, Kathleen J. Ozsvath, MD,enjamin B. Chang, MD, Dhiraj M. Shah, MD, R. Clement Darling, III, MD

Improvements in endovascular technology and techniques have allowed us to treat patients inways we never thought possible. Today endovascular treatment of ruptured abdominal aorticaneurysms is associated with markedly decreased morbidity and mortality when compared tothe open surgical approach, yet there are several fundamental obstacles in our ability to offerthese endovascular techniques to most patients with ruptured aneurysms. This article willfocus on the technical aspects of endovascular aneurysm repair for rupture, with particularattention to developing a standardized multidisciplinary approach that will help ones ability todeal with not just the technical aspects of these procedures, but also address some of thechallenges including: the availability of preoperative CT, the choice of anesthesia, percutane-ous vs. femoral cut-down approach, use of aortic occlusion balloons, need for bifurcated vs.aorto-uniiliac stentgrafts, need for adjunctive procedures, diagnosis and treatment of abdom-inal compartment syndrome, and conversion to open surgical repair.Semin Vasc Surg 23:206-214 © 2011 Elsevier Inc. All rights reserved.

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HE EVOLUTION OF endovascular aneurysm repair(EVAR) has lead to improvements in our treatment of ab-

ominal aortic aneurysms (AAA) under elective as well as emer-ent circumstances when patients present with rupture.1-3

hen considering these endovascular techniques for treatinguptured AAA, one has to prepare for the challenges of stream-ining patient care from the emergency room to the operatingoom and subsequent endovascular procedure that often re-uires a multidisciplinary approach and a change in paradigmnd local cultures. This article will focus on a comprehensivend standardized technical approach for treating ruptured AAAy endovascular means that can maximize our ability to offerhis treatment to most patients presenting with AAA rupture.

undamentaloncerns When Evolving

o EVAR for Ruptured AAA1. Availability of preoperative imaging (computed tomo-

graphic angiography) in all patients with ruptured AAA.

he Vascular Group, PLLC, The Institute for Vascular Health and Disease,Albany, NY.

ddress reprint requests to Manish Mehta, MD, MPH, The Vascular Group,PLLC, 43 New Scotland Avenue MC157, Albany, NY 12208. E-mail:

cmehtam@albanyvascular.com

06 0895-7967/$-see front matter © 2011 Elsevier Inc. All rights reserved.doi:10.1053/j.semvascsurg.2010.10.003

2. Availability of dedicated staff and equipment to per-form emergent EVAR 24 hours a day, 7 days aweek.

3. Anatomical suitability of ruptured AAA to undergoEVAR.

4. Experience and ability to manage unexpected scenariosunder emergent circumstances.

elevant Outcomes1. The feasibility of treating hemodynamically stable and

unstable patients by EVAR.2. Broader nationwide application and expected results of

rupture EVAR in academic as well as community hos-pitals.

3. Cost implications.

etting Startedlthough one or more of these limitations might have some

mpact on ability to incorporate endovascular techniques inanaging patients with ruptured AAA, the fundamentals for

uccess begin from establishing an infrastructure of a stan-ardized approach that is multidisciplinary and inclusive ofhe emergency room (ER) physicians, the anesthesiologists,he operating room (OR) nurses, technologists, and the vas-

ular surgeons.

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Ruptured AAA 207

To get started, the surgeon/ interventionist should:

1. Become comfortable performing EVAR under electivecircumstances.

2. Obtain an inventory of standard equipment (wires,catheters, sheaths, balloons, particularly the compliantaortic occlusion balloons, and fluoroscopic equipment)that is needed to perform elective EVAR safely.

3. Choose the stent grafts that you are most comfortable usingand acquire select stent graft sizes to match the largest aorticneck diameter and the shortest aneurysm length, with a va-riety of iliac extensions to treat most if not all AAA.

4. Become comfortable with adjunctive procedures suchas iliac interventions that might be needed to facilitateaccess, use of compliant aortic occlusion balloon, andplacement of Palmaz stents at the aortic neck.

5. Only treat hemodynamically stable patients with pre-operative computed tomography (CT) scans. With in-creasing experience one can easily modify their inclusionand exclusion criteria for EVAR of ruptured AAA that canaccommodate even hemodynamically unstable patients.

VAR for Ruptured AAA:Standardized Approach

reatment of ruptured AAA patients involves a multidisci-linary approach that is inclusive of ER staff, anesthesiolo-ists, OR staff, radiology technologists, and the vascular sur-eons/interventionist, and therefore requires a standardized

ER Physician Susp

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Aortic Occlus

Aortoiliac Morphology Not Amenable To EVAR

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Figure 1 Albany Vascular Group standardized protocol f

inal aortic aneurysm (r-AAA). BP, blood pressure; CTA, comp

pproach that engages all parties and facilitates a seamlessransition of the patient from the emergency room to theperating room for EVAR. Although the standardization ofny approach will vary from hospital to hospital, the funda-entals are simple in that success depends on the early diag-osis of ruptured AAA, the ability to have an expeditious CTcan to evaluate the aortoiliac morphology, and quick tran-ition of patient from the ER to the OR, which is equipped toerform endovascular as well as open surgical repair underhese emergent circumstances.

In 2002, at the Vascular Institute for Health and Diseasen Albany, we developed a standardized approach4 thatas enabled us to use endovascular approach as the first-

ine therapy for all patients who present with rupturedAA, and this has resulted in a significant improvement inatient survival (Fig 1). The fundamentals of the protocol

nclude a heightened awareness among the ER staff touspect ruptured AAA and notify the on-call vascular sur-eon and the OR staff. In the emergency room, hemody-amically stable patients undergo expeditious CT scannd are subsequently transferred to the OR, and hemody-amically unstable patients are directly transferred to theR without a preoperative CT scan for endovascular-first

pproach and conversion to open surgical repair aseeded.

R Setupecause not all patients with ruptured AAA can undergondovascular repair, all OR/hybrid endovascular/OR suites

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modynamically Unstable Patients

Operating Room: Endovascular & Open Surgical Repair n Supine Position, Prepped & Draped

Percutaneous Femoral Access esthesia and Femoral Artery Cutdown

loon as Needed

Aortoiliac Morphology Amenable To EVAR

EVAR

ovascular aneurysm repair (EVAR) of ruptured abdom-

ects r-A

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uted tomographic angiography; ER, emergency room.

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208 M. Mehta et al

hould be set up to facilitate endovascular as well as openurgical repair. Depending on the size of the room and theuoroscopic equipment that can be fixed or portable withiewing screens and power injectors, one has to customizehe layout of the OR suite that is conducive for endovascularnd open surgical repair; we have found it best to set up theoom for endovascular repair with standard needles, wires,atheters, and sheaths open on a sterile table, have the surgi-al instruments in the room if needed, situate the patient onhe OR table, and as the anesthesiology team prepares theatient setup, the fluoroscopic equipment, and supplies.

undamental Techniquesdequate resuscitation of patients with ruptured AAA is vital

o a successful outcome. As long as the patients maintain aeasurable blood pressure, the techniques of “hypotensiveemostasis,” by limiting the resuscitation to maintain a de-ectable blood pressure, can help minimize ongoing hemor-hage. The patient is prepped and draped in supine positionnd via a femoral artery cutdown ipsilateral access is obtainedsing a needle, floppy guide wire, and a guiding catheter. Theoppy guide wire is exchanged for a super-stiff wire that cane used to place a large sheath (12F to 14F � 45 cm length)

n the ipsilateral femoral artery and the sheath advanced up tohe juxtarenal abdominal aorta so it is ready to be used toeliver and support the aortic occlusion balloon if needed. Aompliant occlusion balloon should always be available inhese procedures, and in hemodynamically unstable patients,he occlusion balloon is advanced through the ipsilateralheath over the super-stiff wire into the supraceliac abdomi-al aorta under fluoroscopic guidance, and the balloon is

nflated as needed. In our experience of �100 rupturedVARs, the aortic occlusion balloon is needed in �25% ofases. Access is subsequently obtained from contralateralemoral artery cutdown in similar fashion, and a “markerush-catheter” advanced to the juxtarenal aorta for an arte-iogram.

The placement of the stent graft main body is plannedased on the aortoiliac morphology that is best suited forVAR. Unless prohibitive, in hemodynamically stable pa-

ients, after the initial arteriogram, the aortic occlusion bal-oon is removed from the initial ipsilateral side and the stentraft main body advanced under fluoroscopic guidance; thisimits the number of catheter exchanges. In hemodynami-ally unstable patients that require inflation of the aortic oc-lusion balloon, the marker flush-catheter is exchanged forhe stent graft main body, which is delivered up to the renalrteries. An arteriogram is done via the sheath that is used toupport the aortic occlusion balloon, the tip of the stent graftain body is aligned with the lowermost renal artery, the

cclusion balloon is subsequently deflated and withdrawnack with the delivery sheath into the AAA, and the stentraft main body deployed. The remainder of the EVAR pro-edure is performed similar to elective circumstances: (1) theip of the stent graft main body aligned with the lowermostenal artery; (2) the contralateral gate aligned to facilitate

xpeditious “gate-cannulation”; and (3) the ipsilateral and c

ontralateral iliac extensions planned and deployed aseeded.There are several important technical aspects that merit

iscussion, including (1) availability of preoperative CT; (2)hoice of anesthesia and percutaneous versus femoral cut-own approach; (3) aortic occlusion balloons; (4) bifurcatedersus aorto-uniiliac (AUI) stent grafts; (5) adjunctive proce-ures; (6) abdominal compartment syndrome; and (7) con-ersion to open surgical repair.

vailability of Preoperative CT Scanhe hemodynamic status of the ruptured AAA patient gener-lly dictates the need for a preoperative CT scan and, al-hough while planning for this emergent open surgical repairpreoperative CT is not considered a necessity, while plan-ing an emergent EVAR, most would agree that we would

ike to have a CT scan for evaluating the feasibility of EVAR asell as for stent graft sizing. So the question is whether oneas the time to get an emergent CT scan before EVAR and, ifot, are there other tools available that might help us managehese hemodynamically unstable patients by endovasculareans? Lloyd et al published data on a time to death study inatients with ruptured AAA who did not undergo treatment.5

heir findings indicated that 88% (49 of 56) patients died �2ours after admission with the diagnosis of ruptured AAA.he median time interval from the onset of symptoms todmission to the hospital was 2.5 hours, and the intervaletween hospital admission with the diagnosis of rupturedAA and death was 10.5 hours. These data would clearlyuggest that majority of patients with ruptured AAA have theime to undergo an emergent CT scan, particularly if there isn established protocol that facilitates early diagnosis andransfer of patient from the ER to the OR. The obvious ques-ion that remains is, how often are ruptured AAAs suitable forndovascular repair? Recently, we tried to answer just that byvaluating CT scans of 50 consecutive patients who pre-ented with ruptured AAA and had an available CT scan. Thendovascular anatomical inclusion criteria were slightlyodified from the standard indications for use as defined by

ach of the US Food and Drug Administration�approvedevices and focused on feasibility of EVAR for ruptured AAA;his included aortic neck length �10 mm, aortic neck diam-ter �32 mm, aortic neck angulation �75 degrees, and bi-ateral iliac artery diameter �5 mm. Using these criteria, ourndings indicated that 80% of ruptured AAA patients coulde considered anatomically suitable for EVAR, and this isomparable to our clinical findings of treating �120 rup-ured AAA patients by endovascular means. When evaluatingatients with ruptured AAA, even if one were to adheretrictly to the stent graft indications for use that were useduring the pivotal trials that lead to US Food and Drug Ad-inistration approval of the device, approximately 60% of

he patients would be considered anatomically suitable tondergo rupture EVAR.6

hoice of Anesthesia and Approachepending on comfort level and logistics, EVAR for rupture

an be performed with a variety of approaches from local

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Ruptured AAA 209

nesthesia via percutaneous approach to general anesthesiand femoral artery cutdown. The potential benefits of localnesthesia and percutaneous approach is that they help avoidoss of sympathetic tone in the compromised ruptured AAAatients.7 The percutaneous techniques have several limita-ions because currently available stent grafts are deliveredhrough large sheath sizes, ranging from 18F to 24F, and oneust be comfortable with obtaining percutaneous access andsing closure devices in patients who might be hemodynam-

cally unstable with difficult to palpate femoral pulses. Onelso needs to be comfortable utilizing preclose techniquesith ProStar XL and Perclose ProGlide Suture-Mediated Clo-

ure System (Abbott Vascular, Santa Clara, CA).8 In hemody-amically stable patients, particularly in the hands of experi-nced operators, these percutaneous procedures are quiteeasible. However, it has been our standard approach to per-orm EVAR for rupture under general anesthesia with femoralrtery cutdown. We have found that femoral access via cut-own can be accomplished within minutes and this approach

s easier to standardize than the percutaneous approach.We have reserved the percutaneous approach for endovas-

ular aneurysm repair of ruptured abdominal aortic aneu-ysm in select patients who are considered to be hemody-amically unstable, are conscious, and can cooperate withhe anesthesiologist and the vascular surgeon/interventional-sts. In these patients, we prefer to access the femoral arteryercutaneously without a closure device; advance an appro-riately sized sheath, 18F to 22F as needed; and carry out thendovascular aneurysm repair procedure. At the completionf the endovascular procedure, the femoral sheaths are re-oved via femoral artery cutdown and direct femoral artery

epair. Of course, the preclose technique for totally percuta-eous EVAR for ruptured aneurysms is most certainly uti-

ized. This approach needs to be individualized on the basisf the patient’s hemodynamic status.

ortic Occlusion Balloonhe appropriate use of aortic occlusion balloons in hemody-amically unstable patients is vital to the success of EVAR inhese emergent circumstances. Our preferred method forlacing aortic occlusion balloons is to use the femoral ap-roach, and we have found this to have several advantages:1) it allows the anesthesia team to have access to both upperxtremities for arterial and venous access; (2) the patientsho require the aortic occlusion balloon are often hypoten-

ive and, in these patients, percutaneous brachial access cane difficult and more time consuming than femoral cutdown;nd (3) the currently available aortic occlusion balloons re-uire at least a 12F sheath, which requires a brachial arteryutdown and repair, and stiff wires and catheters across theortic arch without earlier imaging under emergent circum-tances might lead to other arterial injuries and/or emboliza-ion causing stroke.

There are several important points to consider during pro-edures that require inflation of the aortic occlusion balloonso maintain hemodynamic stability. To facilitate stabilization

f the balloon catheter during inflation and maintain aortic m

cclusion at the suprarenal/supraceliac level, the sheath sup-orting the balloon should be advanced and supported fully

nto the aortic neck before inflation of the occlusion balloons this will prevent downward displacement and prolapse ofhe occlusion balloon into the AAA (Fig 2). Inability to fullyngage the sheath into the aortic neck due to the presence ofignificant aortoiliac stenosis, calcifications, or tortuosityight result in downward displacement of the inflated occlu-

ion balloon; this often required forward traction on the in-ated balloon catheter to maintain adequate position at theuprarenal/supraceliac aorta (Fig 3).

If inflation of the aortic balloon is required to maintain aiable blood pressure, then the remainder of the EVARhould be conducted expeditiously to limit the time of aorticcclusion, and further limit development of complications ofngoing bleeding, such as abdominal compartment syn-rome and multisystem organ failure. During the procedure,

ust before deployment of the stent graft main body, theortic occlusion balloon should be deflated from the supra-enal level and withdrawn. The stent graft main body is sub-equently deployed; this will avoid trapping the compliantortic occlusion balloon between the aortic neck and thetent graft. This temporary deflation of the aortic occlusionalloon rarely results in hemodynamic collapse and is usuallyf little consequence. In hemodynamically unstable patients,he occlusion balloon can be redirected into the aortic neckrom the side ipsilateral to the stent graft main body andeinflated at the infrarenal aortic neck within the stent graftain body; this allows for aortic occlusion and does not

nterfere with the remainder of the endovascular procedureFig 4A-E).

Currently, there are four different compliant occlusionalloons that are readily available, with subtle differencesTable 1). Occlusion balloons are composed of compliant

igure 2 The sheath supporting the aortic occlusion balloon shoulde advanced and supported fully into the aortic neck to preventownward displacement and prolapse of the occlusion balloon intohe abdominal aortic aneurysm.

aterials such as polyurethane latex or silicone and have low

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urst pressures of �5 atm. Their primary function is notngioplasty, but molding to the surrounding aortic wall withentle inflation and they also function in the capacity of ob-aining proximal aortic occlusion during EVAR for rupturedAA, and should be in the armamentarium of all vascularpecialists treating AAA.

ifurcated Versus AUItent Grafts for Ruptured AAAlthough the decision to use a particular stent graft type andize is determined by the patient’s aortoiliac morphology,here are several factors that predispose our decisions to useifurcated versus AUI stent grafts in these aortic emergencies,g, inability to access the contralateral gate expeditiously andnability to access the contralateral iliac artery due to signifi-ant occlusive disease and/ or tortuosity. When using bifur-ated stent grafts even in patients that maintain adequateemodynamic status, there is the potential for ongoing bleed-

ng until adequate proximal and distal fixation in the aorticeck and iliac arteries is obtained. During the procedure, ifapid gate cannulation is not obtained, particularly in hemo-ynamically unstable patients, the bifurcated stent graftshould be converted to AUI devices by using stent grafts suchs the Renu device (Cook Inc., Bloomington, IN) or placingortic cuffs or a second stent graft main body across the stentraft flow-divider to divert all blood flow to the ipsilateralliac artery. This does require subsequent interruption of flowrom the contralateral common iliac artery into the AAA via atent graft occluder and a femoral-femoral bypass.

In our experience of �120 EVAR for ruptured AAA, ap-roximately 16% require emergent conversion of bifurcatedtent grafts into AUI devices. To facilitate contralateral gateannulation during EVAR, we routinely cross the stent graftimbs to align them with the contralateral sheath, which issually crossed and anterior to the ipsilateral sheath. Withhis approach, gate cannulation can usually be achievedithin minutes.

djunctive Proceduresecause of the obvious emergent nature of ruptured AAA,reoperative planning can be less than ideal, which can leado the need for additional unexpected adjunctive procedures.o discuss all adjunctive procedures that might be neededuring EVAR for ruptured AAA is beyond the scope of thisrticle; however, use of Palmaz stents at the aortic neck forreatment of type I endoleaks is a technique that should be inne’s armamentarium.9 Our standard approach includes theollowing: (1) a Palmaz 4910 stent is hand-crimped and cen-ered on a 20- to 25-mm noncompliant Maxi-LD balloonCordis, Miami Lakes, FL); (2) both ends of the Maxi-LDalloon with the Palmaz stent are slightly inflated to avoidwatermelon seed” displacement of the Palmaz stent duringeployment; (3) a 16F to 18F delivery sheath is advanced

nto the straight and nontortuous main body of the stentraft; (4) the Palmaz stent loaded on the balloon is deliveredo the juxtarenal aorta and aligned for deployment partially in

igure 3 Inability to fully engage the sheath into the aortic neck dueo the presence of significant aortoiliac stenosis, calcifications, orortuosity might result in downward displacement of the inflatedcclusion balloon (A, B, C); this often required forward traction onhe inflated balloon catheter to maintain adequate position at the

he stent graft main body and the native aortic neck, and

Ruptured AAA 211

Figure 4 (A) Managing the aortic occlusion balloon during stent graft deployment. Inflated suprarenal aortic occlusionballoon via left femoral approach, the stent graft main body via right femoral approach, and arteriogram done throughthe left femoral sheath supporting the occlusion balloon. (B) Managing the aortic occlusion balloon during stent graftdeployment. The aortic occlusion balloon is deflated and retracted back from the aortic neck, and the stent graft mainbody subsequently deployed; this avoids trapping of the compliant aortic occlusion balloon between the aortic neckand the stent graft. (C) Managing the aortic occlusion balloon during stent graft deployment. In hemodynamicallyunstable patients, the occlusion balloon can be redirected into the aortic neck from the side ipsilateral to the stent graftmain body and reinflated at the infrarenal aortic neck within the stent graft main body before contralateral gatecannulation. (D) Managing the aortic occlusion balloon during stent graft deployment. After reinflation of the occlusionballoon in the stent graft main body in hemodynamically unstable patients, the contralateral stent graft gate can becannulated and contralateral stent graft extensions placed as needed. Managing the aortic occlusion balloon duringstent graft deployment. After contralateral iliac extension and ruptured AAA exclusion, the occlusion balloon can be

removed, prior to completion angiogram (E).

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eployed under fluoroscopic guidance; and 5) the Maxi-LDalloon is exchanged for a compliant aortic occlusion bal-

oon, described earlier, and the Palmaz stent is molded tonchor the stent graft to the aortic wall.

ssessing forbdominal Compartment Syndromeith the increasing use of endovascular techniques for treat-

ng ruptured AAA, there is an increased recognition of newomplications, such as abdominal compartment syndromeACS).10 The pathophysiology of ACS after EVAR for rup-ured AAA is multifactorial: (1) the retroperitoneal hema-oma is a space-occupying lesion and a significant factor con-ributing to intraabdominal hypertension; (2) ongoingleeding from lumbar and inferior mesenteric arteries intohe disrupted aneurysm sac in the setting of severe coagu-opathy might be a contributing factor; and (3) the shocktate associated with ruptured AAA is associated with alter-tions in microvascular permeability that can lead to visceralnd soft-tissue edema.

Most published data would suggest that the incidence ofCS after EVAR for ruptured AAA varies and is probablyependent on the hemodynamic status of the patients beingreated. In our own series of EVAR for ruptured AAA inemodynamically stable and unstable patients, the incidencef ACS was noted to be 18%, and several variables weredentified as significant contributing factors. These includese of aortic occlusion balloon; need for massive blood trans-usions (mean of 8 U packed red blood cells); and coagulopa-hy with elevated activated partial prothrombin time at com-letion of case. In our experience, patients who developedCS had significantly increased mortality (67%) when com-ared to those without ACS (10%). As a result of these ob-ervations, our protocol for the endovascular treatment ofuptured AAA has evolved. Systemic heparinization, whichas used earlier in our experience during EVAR for rupture,

s avoided and coagulation studies are aggressively correcteduring the perioperative period to help limit the ongoingleeding from collateral vessels. Furthermore, bladder pres-ures are recorded on an hourly basis during the procedure asell as in the postoperative period. If the bladder pressures

re increased, regardless of the presence of other associatedactors, we emphatically recommend that patients undergoecompression laparotomy. However, the question is howany factors need to be present in the absence of increased

ladder pressures to accurately predict ACS? In our clinicalractice, regardless of the presence of increased bladder pres-

able 1 Properties of Compliant Aortic Occlusion Balloons

Occlusion balloon Sheath Size (F

-50 12eliant (Medtronic Ave.) 12oda (Cook Inc.) 14qualizer (Boston Scientific Corp.) 14-16

ures, if patients have more than one risk factor for develop- i

ng ACS (eg, aortic occlusion balloon, massive blood trans-usion, or coagulopathy), have abdominal distention, andanifest signs of end-organ dysfunction, they undergo on-

able laparotomy. It is our belief that taking these measuresight help identify and treat ACS and decrease the associatedorbidity and mortality.

onversion topen Surgical Repair

egardless of all the improvements in endovascular tech-iques, there are times when on-table conversion to openurgical repair is needed and this approach should be in thermamentarium of all surgeons/interventionalists involved inreating ruptured AAA patients. A comprehensive discussionf open surgical repair is beyond the scope of this article, buthere are a few key points that need to be mentioned here.

hen on-table surgical conversion is needed, the use of aor-ic occlusion balloon can be extremely valuable in maintain-ng hemodynamic stability; the techniques of aortic occlusionalloon have been discussed here. In addition, at the time of

aparotomy and open surgical conversion, it is crucial toaintain the position of the aortic occlusion balloon and itselivery sheath; failure to do so might result in aortic occlu-ion balloon prolapse into the AAA and loss of aortic occlu-ion. If open surgical conversion is needed subsequent totent graft deployment, the exact approach should be tailoredo the type of stent graft, the type of proximal and distalxation, including suprarenal versus infrarenal stents andarbs.

elevant Outcomesoday, the vascular literature has ample evidence that goesell beyond the feasibility of rupture EVAR. Collected world

uptured EVAR experience with collaboration from 49 cen-ers indicates the overall 30-day mortality after EVAR in,037 patients to be 21%, provided that they have favorablenatomy, adequate endovascular skills, facilities, and proto-ols available.11 To date, two prospective trials, one random-zed and other nonrandomized, have failed to demonstratehe benefits of EVAR to open surgical repair for rupturedAA, and an additional two prospective randomized con-

rolled trials evaluating endovascular versus open surgicalepair of ruptured AAA are underway.12-15 There are severalimitations of these trials that failed to demonstrate the ben-fit of EVAR, including a significant delay in treatment in an

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Ruptured AAA 213

esulted in equally poor outcomes of EVAR when comparedo open surgical repair (EVAR 53% v open surgical 53%). Ineal-world clinical scenarios, with currently available data on1,000 patients demonstrating favorable outcomes of rup-

ured EVAR, one can argue whether randomized prospectiverials on EVAR versus open surgical repair offer any benefit.

During the past decade, the proportion of ruptured AAAatients being treated by endovascular means is steadily in-reasing and rupture EVAR is evolving from being performedn academic tertiary medical centers only to community hos-itals. Anain and colleagues were early adopters of a stan-ardized EVAR-first approach for ruptured AAA in a commu-ity hospital setting; their findings indicate that, regardless ofhe hemodynamic status, 75% of patients with ruptured AAAan undergo EVAR, with a technical success of �90% and aarked improvement in survival (EVAR 83% v open repair

0%, P � .05).16 Although earlier reports using the Nation-ide Inpatient Sample database indicate that the mortality of

upture EVAR continues to be significantly higher in non-eaching community hospitals when compared to academicedical centers (55% v 21%, P � .05), with establishment of

tandardized rupture EVAR protocols, current nationwideiterature suggest wider adoption of rupture EVAR approxi-

ating 25% of all ruptured AAA with improved out-omes.17,18 Implementation of a standardized protocol formergent rupture EVAR has been demonstrated to improveutcomes and allow for emergent treatment of hemodynam-cally unstable patients in our experience as well as others;

oore et al have demonstrated evidence of a significanteduction in mortality (17.9% v 30%, P � .05) after intro-uction of an emergency endovascular therapy protocol foruptured AAA.19 Their findings also suggest that hemody-amically unstable patients show trends toward improvedurvival after rupture EVAR when compared to open surgicalepair. A significant percentage of patients with rupturedAA present with hemodynamic instability and, without atandardized protocol, these patients are often not consid-red suitable for EVAR and undergo open surgical repair.20 Its these hemodynamically unstable patients who have theighest mortality with open surgical repair and might expe-ience the greatest benefit of EVAR and so additional studiesn hemodynamically unstable ruptured AAA patients areeeded. Lastly, health care cost implications play a major role

n evolution of treatments and technology and a recent reporty Hayes and colleagues in the cost-effectiveness analysis ofndovascular versus open surgical repair of ruptured AAAased on worldwide experience indicates significant cost re-uction and improvements in quality-adjusted life-years inatients who undergo EVAR.21

he Bottom Linendovascular repair of ruptured AAA is evolving and offers

he potential for improved patient survival. Unlike electiveVAR, during emergent EVAR the time for preoperative plan-ing is limited and often preoperative imaging is less than

deal; under these circumstances one often has to get creative

nd use more of a problem-solving approach to address chal- 1

enging issues that might arise during these emergent circum-tances. A standardized multidisciplinary approach can benstrumental in organizing pathways that can accommodatendividual practices and hospital infrastructure, and facilitateseamless transition of these often hemodynamically unsta-le patients from the time of diagnosis to successful EVAR.here are several important technical aspects that includehoice of anesthesia, percutaneous versus femoral cutdownpproach, use of aortic occlusion balloons, use of bifurcatedersus AUI stent grafts, and adjunctive procedures that needo be well understood when performing these procedures.

eferences1. Ohki T, Veith FJ: Endovascular grafts and other image guided catheter

based adjuncts to improve the treatment of ruptured aortoiliac aneu-rysms. Ann Surg 232:466-479, 2000

2. Veith FJ, Ohki T, Lipsitz EC, et al: Endovascular grafts and other cath-eter-directed techniques in the management of ruptured abdominalaortic aneurysms. Semin Vasc Surg 16:326-331, 2003

3. Egorova N, Giacovelli J, Greco G, et al: National outcomes of treatmentof ruptured AAA: comparison of open versus endovascular repair. JVasc Surg 48:1092-1100, 2008

4. Mehta M, Taggert J, Darling RC III, et al: Establishing a protocol forendovascular treatment of ruptured abdominal aortic aneurysms: out-comes of a prospective analysis. J Vasc Surg 44:1-8, 2006

5. Lloyd GM, Brown MJ, Norwood MGA, et al: Feasibility of preoperativecomputed tomography in patients with ruptured AAA: a time to deathstudy in patients without operation. J Vasc Surg 39:788-791, 2004

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