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Rupture AAA – Any NEW advances? Dr Karen Tung Lok Man PYNEH.

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Presentation on theme: "Rupture AAA – Any NEW advances? Dr Karen Tung Lok Man PYNEH."— Presentation transcript:

1 Rupture AAA – Any NEW advances? 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% Stephen W.K. Cheng World J. Surg 2003

3 Rupture AAA  5 0% die before reaching hospital  30% who reached hospital die before operation  Operative mortality : 50% Overall mortality rate : %

4 Open AAA repair  30 days operative mortality rate :  48% in 1998  41% in 2001 M.J. Bown British Journal of Surgery 2002

5 Title Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Vivamus et magna. Fusce sed sem sed magna suscipit egestas.

6 Endovascular AAA repair (EVAR)  EVAR was first performed in human by Dr Juan Parodi in 1991

7 Benefits of EVAR on elective AAA  30 days mortality rate  Long term aneurysm-related death  ICU stay and total hospital stay 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 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 Manish Mehta J Vasc Surg 2010

10 Technique of emergency EVAR  GA  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 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 Manish Mehta J Vasc Surg 2010

12 Anatomic suitability for elective EVAR >=15mm < 30mm < 60 o >=7mm

13 Anatomic suitability for rAAA EVAR Dieter Mayer Annuals of Surgery 2009 Randy Moore J Vasc Surg 2007

14 SBP >80 mmHg & Normal mentation Current AAA management Rupture AAA Stable Endo Candidate Spiral CTA Open repair N N Permissive Hypotension Y EVAR Y Permissive Hypotension : NO fluid resuscitation unless SBP < 80mmHg or  mentation K.Roberts Eur J Vas 2006

15 Retrospective Studies

16  90 rupture AAA patients with EVAR done in 7 years  30 days mortality : 27% Retrospective studies J.Hoist Eur J Vasc Endovasc Surg 2009  102 rupture AAA patients with EVAR done in 10 years  30 days mortality : 13% Dieter Mayer Annuals of Surgery 2009

17 EVAR is a valid treatment option for rAAA when used as a first-line method for all patients New Hope

18  1 RCT and 33 non-randomised case series (24 retrospective and 9 prospective) reports were identifed Systematic review D.W. Harkin Eur J Vasc Endovasc Surg 2007

19  Mortality ( EVAR : 17%, Open : 34%) Systematic review D.W. Harkin Eur J Vasc Endovasc Surg 2007

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21 Selection Bias 1. EVAR groups were more stable than open groups 2.EVAR groups had technically easier anatomy (e.g. longer aortic neck) 3.CT delayed treatment for open AAA repair

22 NO level I evidence !

23 1 st RCT EVAR Vs Open repair  Sept 2002 – Dec 2004  Single centre prospective randomized controlled trial R.J. Hinchliffe Eur J Vasc Endovasc Surg 2006

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25 1 st RCT EVAR Vs Open repair EVAROpen repair 30-day mortality 53 % Moderate or severe complications 77 %80% Hospitial stay 10 days12 days Blood loss 200 ml2100 ml BloodTransfusion 3 units6 units Failed to demonstrate superiority of EVAR over open repair

26 Advantages of emergency EVAR 1.Avoid vasodilating and negatively inotropic effects of GA 2.Avoid large midline laparotomy on muscle wall tone which lead to circulatory compromise 3.Decreased surgical dissection blood loss 4.Avoid aortic cross-clamping and potential reperfusion injury

27 Limitations of EVAR in rupture AAA 1.Anatomical issue 2.Logistical issue – Lack of availability of EVAR trained staff and appropiate endograft components 3.EVAR specific complications need re-intervention

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29 Rupture AAA protocol AIM : To demonstrate any improved survival (30 days mortality) after introduction of an rupture AAA protocol Randy Moore J Vasc Surg 2007

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31 Result Randy Moore J Vasc Surg 2007

32 Result 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 undergoi ng 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 Immediate Management of the Patient with Rupture: Open Versus Endovascular Repair (IMPROVE) trial

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