1. Rupture AAA – Any NEW advances?
Good morning, the topic that I will present today is rupture AAA – any new advance ?
Dr Karen Tung Lok Man
PYNEH

2. Epidemiology in HK ~ 900 new cases AAA diagnosed every year
10% presented as rupture
Operative mortality rate :
Elective 10%
Rupture 54%
Every year, 900 new cases of AAA is diagnosed in HK while 10% of them will present as rupture. And the overall operative mortality rate is reported to be 10% for elective AAA repair and 54% for ruptured one.
Stephen W.K. Cheng World J. Surg 2003

3. Rupture AAA 50% die before reaching hospital
30% who reached hospital die
before operation
Operative mortality : 50%
Rupture of abdominal aortic aneuysm is a sudden catastrophic event presented with severe abdominal or back pain and circulatory collapse. About 50% of the patients die before reach hoospital. Another 30% of patient did reach hospital but die before operation. While the remaining patients undergone standard open repair in the past with a mortality rate ~50%, making overall mortality with rupture aaa to be 80% to 90%.
Overall mortality rate : %

4. Are we satisfied with this improvement ?
Open AAA repair
30 days operative mortality rate :
48% in 1998  41% in 2001
Are we satisfied with
this improvement ?
With the advancement of operative technique and improvement of critical care over the past 50 yrs, is there any improvement in operative mortality for conventional open repair for rupture AAA. A meta-analysis of open repair was published in demonstrated the 30 day mortality decreased from 48% in 1998 to 41% in So are we satisfied with this improvement?
M.J. Bown British Journal of Surgery 2002

5. Room for improvement ? Title
Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Vivamus et magna. Fusce sed sem sed magna suscipit egestas.
Room for improvement ?
Is there any rooms for improvement for the management for rupture AAA?

6. Endovascular AAA repair (EVAR)
EVAR was first performed in human by Dr Juan Parodi in 1991
Endovascular AAA repair was first performed by Dr Juan Parodi in 1991, the fundamental goal of EVAR is exclusion of the anueysm from the systemic circulation by means of a pre-operatively sized stent graft, preventing further aneuysm expansion and therefore eliminating rupture risk.

7. Benefits of EVAR on elective AAA
 30 days mortality rate  Long term aneurysm-related death  ICU stay and total hospital stay
Since the adventure of EVAR in 1991 for treatment of elective and asymptomatic AAA, lots of large prospective randomized and multi-centred trials for EVAR have demonstrated significant reductions in peri-operative mortality, long term aneuysm related death and total hospital stay on elective AAA.
R M Greenhalgh Lancet 2005
Jan D. Blankensteijin New Eng J Med 2005
R. E. Lovegrove British Journal of Surgery 2008

8. EVAR in rupture AAA ?
1st EVAR was performed in 1994 on a 61-year-old man with 6cm rupture AAA
Duplex scan on day 6 : no leakage
Discharged on day 7
In 1994, there was a innovative surgon performed the first EVAR on a 61 year old man with 6cm rupture AAA with succesful outcome.
S W Yusuf The Lancet 1994

9. Technique of emergency EVAR
LA common femoral artery cutdown
Placement of large sheath
Aortic occlusion balloon is inserted in supra-renal position
The technique of emergency EVAR is the same as elective one except with little modification.
Firstly, ipsilateral common femoral artery cutdown was performed under LA, large sheath was placed into the artery and advanced up to juxtarenal aorta, aortic occulsion balloon was inserted via the sheath into supra-renal position to control bleeding
Manish Mehta J Vasc Surg 2010

10. Technique of emergency EVARGA
Stent graft main body is inserted on the contra-lateral side
Arteriogram is done on ipslateral side with aortic balloon temporaily deflated
Stent graft main body is rapidly deployed
The procedure will then be converted to GA when haemodynamically improved. The Stent graft main body is inserted on the contra-lateral side
Arteriogram done on ipslateral side with aortic balloon temporaily deflated and can even be removed if the patient is haemodynamically stable at this juncture, stent graft main body is rapidly deployed with the tip aligned at lowermost renal artery as usual
Manish Mehta J Vasc Surg 2010

11. Technique of emergency EVAR
Aortic balloon advances back and inflats below renal artery
Contra-lateral limb extension is deployed
Aortic balloon is removed
Ipsilateral limb extension is deployed
After the deploying of main body, the aortic balloon was advanced back in case if the patient is still haemodynamically unstable but inflated below renal artery in order to minimizeds the clamping time of mesenteric and renal arteries. Contra-lateral limb and ipsilateral limb extension were deployed as usual and aortic balloon was removed.
Manish Mehta J Vasc Surg 2010

12. Anatomic suitability for elective EVAR
>=15mm
< 30mm
< 60o
There is a standard anatomical criteria for elective EVAR which includes a neck with limited angulation <60 degree, at least 15mm in length, no more than 30mm in diameter and without significant mural thrombus. In addition, the iliac arteries should be >=7mm in order to facilitate the passage of delivery apparatus.
>=7mm

13. Anatomic suitability for rAAA EVAR
Dieter Mayer Annuals of Surgery 2009
Loosen
Anatomic criteria
As for emergency EVAR, different hospital had different anatomic inclusion or exclusion criteria. But the common consense is that most of the vascular surgeon will boarden the anatomic criteria by accepting those shorter neck length, more angulated neck in order to achieve control of life-threatening haemorrhage as part of the damage control concept.
Randy Moore J Vasc Surg 2007

14. Current AAA management
Open
repair N
Rupture
AAA
Stable
Permissive
Hypotension Y N
Permissive Hypotension :
NO fluid resuscitation unless SBP < 80mmHg or  mentation
K.Roberts Eur J Vas 2006
SBP >80 mmHg &
Normal mentation
So in many of the hospitals world wide including my own hospital, now we can offer both conventional open repair as well as EVAR to ruptured AAA patient under this protocol.
All the patients with a diagnosis of ruptured AAA will be initially separated in stable and unstable group. Haemodynamically stable was defined as conscious mentation with systolic blood pressure >80mmHg. For those unstable patient , they will be taken directly to operating room for open repair. As for those stable one, permisssive hypotension was practiced which means NO fluid resuscitation unless SBP <80 or decreases mentation. Permissive hypotension has already been proved to improve survival rate in ruptured AAA patient because vigorous fluid replacement may exacerabate bleeding by causing dilutional and hypothermic coagulopathy by infusion cold fluid and secondary clot disruption. Then the patient was immediately underwent spiral CTA to evaluate for anatomic endovascular eligibility. Those patients with unfavourable anatomic features will then undergo open repair.
Spiral
CTA
Endo
Candidate
EVAR Y 14

15. Retrospective Studies
So can we achieve similar promising results in the treatment of rupture AAA after introduction of this new minimally invasive technology?
Many case series has been performed to demonstrate the feasibility of EVAR for RAAA. Recently, two large single centre series were published with very low mortality rate for emergency EVAR, further raising new hope for these patients.

16. Retrospective studies
90 rupture AAA patients with EVAR done
in 7 years
30 days mortality : 27%
J.Hoist Eur J Vasc Endovasc Surg 2009
102 rupture AAA patients with EVAR done in 10 years
30 days mortality : 13%
The first paper was published in 2009 in European Journal of vascular surgery.
Altogether 90 rupture AAA patients were operated with EVAR between April 2000 and Oct 2007 in Sweden
The reported 30 days mortality is 27%
While another paper in cluding 102 ruptured AAA patients treated with EVAR reported a even lower mortality rate of 13%
Dieter Mayer Annuals of Surgery 2009

17. New Hope
EVAR is a valid treatment option for rAAA when used as a first-line method for all patients
The usual conclusion they drawn is that EVAR is a valid treatment option for rAAA when used as a first-line method for all patients

18. Systematic review
1 RCT and 33 non-randomised case series (24 retrospective and 9 prospective) reports were identifed
Besides single centred retrospective studies, several systematic reviews again confirmed the potential benefits of EVAR for ruptured AAA.
One of the systematic review was done in And altogether 1 RCT and 33 non-randomized case series were identified
D.W. Harkin Eur J Vasc Endovasc Surg 2007

19. Systematic review  Mortality ( EVAR : 17% , Open : 34%)
While no benefit in the mortality rate was noted in the only RCT, evidence of all other non-randomized studies suggested that emergency EVAR was associated with a statistically significant reduction in blood loss, tranfusion requirement and length of ICU stay. The average 30 days mortality in the EVAR is 17% as compared to 34 % in the open group.
D.W. Harkin Eur J Vasc Endovasc Surg 2007

20. It seems that there is now a wealth of evidence in the literature confirming the potential benefits and feasibility of EVAR for treatment of rupture AAA as compared to open repair. But is it really the truth?

21. Selection Bias EVAR groups were more stable than open groups
EVAR groups had technically easier anatomy (e.g. longer aortic neck)
CT delayed treatment for open AAA repair
Many authors start to question whether the result of comparsion between EVAR with previous or concurrent open repair might be misleading and inappropiate due to selection bias. Firstly, patietns selected for EVAR may be of lower risk as they are haemodymaically more stable than the open group. Moreover, they had technically easier anatomy to manage for example longer aortic neck. A paper published few months ago suggested anatomical suitability for EVAR reduce 30 days mortality rate following open repair for ruptured AAA. In addition, computed tomography (CT) scan is usually required to assess the anatomic suitability of the aneurysm before proceedindgto EVAR , however, this may result in delay treatment for open repair in case the patient is anatomically unsuitable for EVAR and leading to poorer outcome in the open group.

22. NO level I evidence !
Moreover, although the feasibility of EVAR for RAAA has been demonstrated, no level 1 evidence is available to prove the superiorty of EVAR over open repair. Until now, only one small randomized controlled studies have been performed.

23. 1st RCT EVAR Vs Open repair
Sept 2002 – Dec 2004
Single centre prospective randomized controlled trial
The first single centre prospective randomzied controlled trial comparing EVAR and open repair for RAAA was conducted between in UK
R.J. Hinchliffe Eur J Vasc Endovasc Surg 2006

24. Within this period, 103 patients were diagnosed with ruptured AAA, only 32 were recruited and undergone randomization. The others were excluded due to multiple co-morbidity or refusal for treatment. 15 patients were allocated to EVAR group, but 1patient died before CT, 1 found to be anatomically unsuitable for EVAR after CT and 1 attempted EVAR but failed and converted to open repair, so finally altogether 11 EVAR 12 open repair were performed

25. 1st RCT EVAR Vs Open repair
30-day mortality
53 %
53%
Moderate or severe complications
77 %
80%
Hospitial stay
10 days
12 days
Blood loss
200 ml
2100 ml
BloodTransfusion
3 units
6 units
Here comes the result, there was no statistically significant difference can be observed between the two groups in terms of 30-day mortality, moderate or severe post op cx and hospital stay. The only significant finding was EVAR resulted in lesser blood loss and reduction in blood product usage.
So this RCT failed to demonstrate the superiorty of EVAR over open repair
Failed to demonstrate superiority
of EVAR over open repair

26. Advantages of emergency EVAR
Avoid vasodilating and negatively inotropic effects of GA
Avoid large midline laparotomy on muscle wall tone which lead to circulatory compromise
Decreased surgical dissection blood loss
Avoid aortic cross-clamping and potential reperfusion injury
Nevertheless, we must admit that endovascular approach did provide maniford advantages in treating rupture AAA patients. Firstly, emergency EVAR can be performed percutaneously under LA, therefore avoiding the vasodilating and negatively inotropic effects of GA. In addition, transfermoral access can avoid large midline laparotomy that results in loss of muscle wall tone which increases the risk of converting a contained rupture becoming an intra-abdominal haemorrhage. Besides, surgical dissection in the setting of a large retroperitoneal haematoma is avoided and blood loss is minimized. Lastly, most emergency EVAR allows for continuous aortic flow, avoiding the effects of aortic cross-clamping with potential reperfusion injury.

27. Limitations of EVAR in rupture AAA
Anatomical issue
Logistical issue – Lack of availability of EVAR trained staff and appropiate endograft components
EVAR specific complications need re-intervention
However, there were several limitation for emergency EVAR.
Even though we have boarded the inclusion criteria of using EVAR in treating RAAA, there was still a group of patients anatomatically unsuitable for EVAR.
Another problems is logistical issue – Many of the time, lack of availability of EVAR trained staff (surgeon; radiologists; specialized scrub nurses; specialized radiologic technicians) and unavailability of appropiate endograft components will limit the usage of EVAR for treating rupture AAA.
Besides, post EVAR treated patients need regular CT surveillance to detect EVAR specific cx such as endoleak, migration or kinking which may required re-intervention.

28. of rupture AAA patients by incorporating EVAR into our protocol?
Is EVAR superior to
open repair
for rupture AAA ?
Can we improve outcome
of rupture AAA patients by
incorporating EVAR into our protocol?
Every coin has two sides. Instead of keep on asking whether emergency EVAR is superior to open repair for RAAA, we thought that is may be more appropriate to ask”….”

29. Rupture AAA protocol
AIM : To demonstrate any improved survival ( days mortality) after introduction of an rupture AAA protocol
A study was carried out in Canada from 2001 to 2006 to demonstrate any survival benefit after the introduction of ruptured AAA protocol. Before 2004, all the RAAA patients were treated with standard open repair. But afterward, an emergency ruptured AAA repair protocol involving both EVAR and open repair was implementated.
Randy Moore J Vasc Surg 2007

30. The algorithm is similar to the protocol we mentioned before
The algorithm is similar to the protocol we mentioned before. But the patients were firstly differentiated into EVAR a/v or not a/v group.
EVAR not available = oncall surgeon did not have the EVAR privileges, the only treatment option for the patients is open repair.
Another differences is that in case the patient is haemodynamically unstable for spiral CTA, they will still undergo intra-op angiogram to assess the anatomic suitabilibty for EVAR.

31. Result Randy Moore J Vasc Surg 2007
The clinical characteristics such as dermographic features, preoperative Hb level, RFT and systolic BP of patients before and after the introduction of the EVAR protocol are comparable.
Randy Moore J Vasc Surg 2007

32. Result Randy Moore J Vasc Surg 2007
After the introduction of protocol, EVAR was done in 20 out of 56 RAAA patient (36%)
Overall mortality before introduction of protocol is 30% while after is 18%, and result is statistically sign.
There is no evidence of difference in the mortality rate for the open procedure after introduction of protocol, demonstrating that the improved mortality rate was related to the introduction of EVAR into the ruptured AAA protocol
Randy Moore J Vasc Surg 2007

33. Conclusion Mortality rate for open repair of rupture AAA remains high
Emergency EVAR for treatment of rupture AAA is feasible
Introduction of rupture AAA repair protocol includes EVAR can improve mortality rate

34. What is going on... 3 Randomized controll trials currently undergoing
The Amsterdam Acute Endovascular Treatment To Imporve Outcome of Rupture Aorta-Iliac Aneuysm trial (AJAX)
The Rupture Aorta-Iliac Aneuysm Endo vs Surgery (ECAR) trial
Finally, there are three randomized controlled trial currently recruiting patients, and we hope that their result can give us more information on the management of rupture AAA.
Immediate Management of the Patient with Rupture: Open Versus Endovascular Repair (IMPROVE) trial

35. THANK YOU