Print this pageEstablishing A Protocol For Endovascular Management Of Ruptured AAA: Outcomes Of A Prospective Analysis
Purpose: In our transition from endovascular elective to emergent ruptured abdominal aortic aneurysm (AAA) repair, we recognized that emerging complications and the availability of endovascular trained staff in the operating rooms (OR), emergency rooms (ER), and adequate equipment were the limiting factors. To facilitate endovascular repair (EVR) for r-AAA, we established a multidisciplinary protocol that facilitates endovascular ruptured AAA repair.
Methods: In January 2002, we instituted a multidisciplinary approach that included the vascular surgeons (VS), ER physicians, anesthesiologists, OR staff, radiology technicians (RT), and availability of a variety of stentgrafts to expedite EVR of ruptured AAA. Five patients with symptomatic and not ruptured AAA that were suitable for EVR underwent simulation of a patient presenting to the ER with ruptured AAA; ER physicians alerted the VS, emergently performed an abdominal CT scan, and transported the patient to the OR. The VS informed the OR staff to set-up for EVR in an OR equipped with interventional capabilities. The OR set-up was rehearsed with the anesthesiologists, OR staff, and a RT that were knowledgeable of the sequence of steps involved. Since then 28 patients have undergone emergent EVR for r-AAA.
Results: None of the symptomatic (simulation) patients developed any complications, and 27 (96%) r-AAA patients had successful EVR. Aortic occlusion balloon was necessary in 8 (29%) patients, mean blood loss was 680 cc, 2 (7%) patients developed ischemic colitis, 2 (7%) developed myocardial infarction, 6 (22%) developed abdominal compartment syndrome (ACS), and 8 (29%) died. Physiologic and clinical data are summarized below.
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Conclusions: Early results of emergent EVR for r-AAA are promising in majority of patients once a standardized protocol is established. A synchrony of disciplines must be developed to initiate a successful program for endovascular treatment of ruptured AAA. There is a steep learning curve and increased recognition of emerging complications (i.e.: ACS) with endovascular approach. Significant risk factors for the development of ACS include: 1) the need for aortic occlusion, 2) massive blood transfusion requirement, 3) coagulopathy, and 4) elevated bladder pressure.