1. AAA Repair Justin Brown 4 September 2014

2. 82 yo W transfer from OSH with ruptured Abdominal Aortic Aneurysm – Presented with acute onset of abdominal pain – Non contrast CTA obtained and found to have incidental 6.8cm AAA – Found to have UTI

3. RESIDENT #1

4. Define the terms 1. aneurysm 2 ectasia 3. arteriomegaly

5. aneurysm is a permanent, focal dilation of an artery that exceeds 1.5 times the normal ectasia - diameter is increased by less than 50% of the normal expected diameter arteriomegaly refers to a diffuse (nonfocal) enlargement of several arterial segments with increases in diameter greater than 50% of the normal expected diameter http://portal.surgicalcore.org

6. RESIDENT #2

7. All of the following metalloproteases have been implicated in the biochemistry of aortic aneurysm formation except MMP-1 MMP-2 MMP-3 MMP-8 MMP-9

8. http://portal.surgicalcore.org

9. Contrast CT obtained following increase of abdominal pain

19. Transferred directly to OR for repair Developed PEA arrest following induction for intubation – 2 rounds CPR – Return of pulses and pressure noted Open AAA repair

20. LoT opened Infrarenal clamp Aneurysm opened and clot removed Dacron graft sewn in Abthera placed Taken for washout and closure 2 Sept

21. RESIDENT #3

22. In this picture what transverse structure usually defines the most superior aspect of the aortic dissection? Can you ligate this structure and if so what needs to be preserved?

23. http://portal.surgicalcore.org

24. Rutherford's Vascular Surgery, 7th ed.

25. RESIDENT #4

26. Is it proven to reimplant the IMA?

27. IMA Reimplanted may be reimplanted into either the body of the graft or the left limb if it is patent. Seeger et al. reported that routine reimplantation of the inferior mesenteric artery resulted in decreased rates of colonic infarction and death after aortic reconstruction. More recent randomized controlled trial demonstrated no benefit in terms of morbidity or mortality, although the authors suggested it may be beneficial for older patients and those with increased blood loss. http://portal.surgicalcore.org

28. AAA Repair

29. Open vs Endovascular (EVAR) – EVAR1 RCT from UK 1252 pts age > 60, AAA >5.5cm – DREAM RCT Netherlands 351 pts – OVER RCT in VA system 881 pts age >49, AAA> 4.5cm -ACE -RCT from France -306 low to medium risk pts

30. AAA Repair Open vs Endovascular (EVAR) – Mortality Short term - 4.2% vs 1.4% P<0.0001 Intermediate – 17% vs 15.8% P=0.40 Long term – 37.8% vs 37.3% P=0.78 – Reintervention rate Intermediate - Long term – 13.1% vs 23.4%

31. rAAA Repair

32. NSQIP database 2005-2010 1447 rAAA Open 65.5% EVAR34%, Incidence of mortality and MI in OAR vs EVAR in elective and ruptured abdominal aortic aneurysms Found statistically significant reduction in 30-D mortality, MI and average hospital LOS In EVAR

33. rAAA Repair

34. From the data available there is no difference in the outcomes evaluated in this review between EVAR and open repair, specifically 30-day mortality Not enough information was provided for complications in order to make a well informed conclusion at this time Long-term data are lacking for both survival and late complications