Ruptured Abdominal Aortic Aneurysms

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Ruptured Abdominal Aortic Aneurysms

• Eliza Long

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Treatment of the Ruptured Abdominal Aortic
Aneurysm

• Diagnosis
• Clinical
• Imaging
• Resuscitation
• Surgery
• Different options
• Complications

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DiagnosisClinical Presentation

• Classic triad
• Severe abdominal pain
• Hypotention
• An episode of syncope may be a hint
• Pulsatile mass
• Large girth may obscure
• Less common symptoms
• Groin/flank pain, hematuria, groin hernia all
  secondary to increased intra-abdominal pressure
• Congestive Heart Failure with JVD and abdominal
  bruit if patient has ruptured into the Vena Cava

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14 x 8 cm abdominal aortic aneurysm arising from
the supraceliac aorta and extending to just above
the take off of the left renal artery is
visualized with extensive thrombus but also
extensive flow
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DiagnosisClinical Presentation

• RAAA is misdiagnosed 16 - 30 of the time
• Common misdiagnosis
• Renal colic, perforated viscous, diverticulitis,
  gastrointestinal hemorrhage and ischemic bowel
• Mortality rates for correctly diagnosed was 58,
  and 44 for misdiagnosed
• Likely due to fact that less severe ruptures have
  a more subtle presentation and can survive longer
  before going to OR

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DiagnosisImaging

• Plain Films
• Enlarged outline of calcified aortic wall
• A retrospective review showed that 65 of x-rays
  form RAAA had calcified aortic wall
• Loss of psoas shadow
• Abdominal U/S
• Sensitive in detecting aneurysm but not in
  detecting rupture
• Abdominal CT
• Most accurate method
• See presence of retroperitoneal blood (77
  sensitive and 100 specific)

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Enlarged outline of calcified aortic wall
Loss of psoas shadow
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Sensitive in detecting aneurysm but not in
detecting rupture
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See presence of retroperitoneal blood. Here
there is not a large retroperitoneal hematoma,
but stranding of blood into surrounding tissues
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Resuscitation

• If suspecting rAAA
• 2 Large bore IVs
• Type and Cross for at least 6 Units of pRBCs
• Confirmed rAAA
• Transfer to Operating room (transfer to center
  with experienced surgeons prepared for rAAA)
• Establish art line and foley
• Prep and drape before and during anesthetic
  induction

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Resuscitation

• Actual Pre-Op resuscitation
• Controversial
• Aggressive crystalloid can elevate BP and cause
  rupture of temporary aortic seal that forms after
  initial rupture
• Minimally resuscitate to maintain
  conconsciousness (80 systolic) and use blood
• No randomized trials testing the different
  degrees of resuscitation with rAAA
• Animal studies show increased mortality when
  resuscitation occurs before control of hemorrhage

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Surgery

• OPEN TRANSPERITONEAL
• OPEN RETROPERITONEAL
• ENDOVASCULAR

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SurgeryOpen Repair
No Hypotension
Hypotension
Inspect Retroperitoneum Reflect bowel and duodenum
Supraceliac Clamp
Pararenal Extensive Hematoma
No Hematoma
Careful Dissection for Infrarenal Control
Uncontrolled Bleeding Develops
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SurgeryOpen Repair ? TRANSPERITONEAL

• Transperitoneal allows the fastest and easiest
  approach for Supraceliac clamp
• Retract the left lobe of the liver to right to
  show supraceliac aorta at diaphragm
• NG tube identifies esophagus and proximal stomach
  and retracts to the left
• Enter lesser sac by opening gastrohepatic omentum
• Aorta is found between crura of diaphragm and is
  clamped
• Can reposition clamp to infrarenal neck of
  aneurysm once aneurysm is opened
• or can make first anastamosis in aneurysm sac and
  then transfer clamp to graft to reperfuse kidneys
  and viscera.

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Retract the left lobe of the liver to right to
show supraceliac aorta at diaphragm
NG tube identifies esophagus and proximal stomach
and retracts to the left
Enter lesser sac by opening gastrohepatic omentum
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Sometimes crura may need to be split with
electrocautery for appropriate visualization
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Aorta is found between crura of diaphragm and is
clamped
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SurgeryOpen Repair ? TRANSPERITONEAL

• Supraceliac Clamp
• Coordinate with anesthesia
• after clamp crank up the resuscitation
• before releasing supraceliac clamp prepare for
  hypotension
• Advantages
• quick solution to severe hypotension from
  intraperitioneal rupture.
• avoids injury to renal and gonadal vein injury
  from blind dissection of infrarenal neck
• Disadvantage
• ischemic injury injury to liver, bowel, and
  kidneys

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SurgeryOpen Repair ? RETROPERITONEAL

• ESPECIALLY for pararenal or suprarenal RAAA
• 10th interspace incision
• 1) Left colon mobilized to incise lateral
  peritoneal attachments.
• 2) Colon, pancreas, spleen, and kidney are
  elevated ? access diaphragmatic crura.
• 3) Divide crura ? access entire intra-abdominal
  aorta and visceral and renal vessels
• 4) May need a thoracoabdominal incision, or extra
  thoracic incision for the larger people, or the
  hostile abdomen

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SurgeryOpen Repair ? Extras

• Brachial/femoral cut-down for occlusive balloon
  into aorta
• Aortic compressor to supraceliac aorta if rapid
  control needed before establishing exposure for
  clamp
• Aortocaval fistula ? direct digital pressure
  above and below the fistula and suture of the
  fistula from within the sac
• If iliac aneurysms are present leave alone unless
  ruptured, if so repair easiest first (allow for
  pelvic reperfusion)
• Use cellsaver, its use is justified if anticipate
  large blood loss

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Aortic compressor to supraceliac aorta if rapid
control needed before establishing exposure for
clamp
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SurgeryOpen Repair ? Anatomic abnormalities

• Venous anomalies that can cause bleeeding during
  clamping
• Retroaortic renal vein
• Circumaortic renal vein
• Left-sided vena cava
• Duplicate inferior vena cava
• Horseshoe kidney
• If at neck of aneurysm it prevents adequate
  exposure (another reason to perform supraceliac
  clamping)
• Isthmus often contains renal tissue, collecting
  system and blood supply
• If known before surgery, retroperitoneal approach

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SurgeryOpen Repair

• Closing
• 25-30 cases, the abdomen cannot be closed
  without significant tension from swollen bowel or
  retroperitoneal hematoma
• Abdominal compartment syndrome (ACS) is bladder
  presser gt 30cm H2O or 25mm Hg
• Use early mesh to reduce incidence of multi organ
  failure from ACS
• Especially with pre-op anemia, prolonged shock,
  pre-op cardiac shock, pre-op cardiac arrest,
  massive resuscitation, profound hypothermia, or
  severe acidosis
• Use nonabsorbable mesh covered with plolyurethane
• Early mesh closure vs takeback mesh resulted in
  6 and 40 colon ischemia respectively

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SurgeryEndovascular Repair

• Institution requirements
• 1) Rapid CT scanning
• For neck diameter, angulation, and iliac size
• Only about 20-46 of rAAA are suitable for EVAR
• 2) Training
• 3) Devices
• 4) Suite for Endovascular procedure

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SurgeryEndovascular Repair

• Stratagies for Repair
• Aorto-unifemoral graft ? ipisalateral internal
  iliac exclusion and a femorofemoral crossover
  graft (Montefiore group)
• Modular aortouniiliac and aortobiiliac
• Now rupture kits for repair

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Aorto-unifemoral graft
Endovascular Grafts and Other Image-Guided
Catheter-Based Adjuncts to Improve the Treatment
of Ruptured Aortoiliac AneurysmsTakao Ohki and
Frank J. VeithAnn Surg. 2000 October 232(4)
466479.
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Modular aortouniiliac and aortobiiliac
Early Experience with the Talent Stent-Graft
System for Endoluminal Repair of Abdominal Aortic
AneurysmsFrank J. Criado, MD, Eric P. Wilson, MD,
Eric Wellons, MD, Omran Abul-Khoudoud, MD, and
Hari Gnanasekeram, MD Tex Heart Inst J. 2000
27(2) 128135.
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SurgeryEndovascular Repair

• Anesthesia
• Can use local (unless patients are squirming)
• Dont loose the sympathetic tone that can
  maintain pressure
• Some start under local and convert to general for
  positioning and release of graft

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SurgeryEndovascular Repair

• Mortality Rates ? 10 to 45, but limited numbers
  of patients
• Causes ?
• Colon ischemia
• MOF
• Continued hemorrage
• Endoleaks are a much bigger problem in this
  setting as hemorrhage isnt controlled

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Table 102-1. Reported Data on Ruptured Abdominal
Aortic Aneurysms (RAAA) Treated by Endovascular
Aneurysm Repair
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ComplicationsLocal

• Postoperative bleeding related to coagulapathy
  from hypothermia (12-14)
• Limb ischemia ? embolization from aortic debris,
  or clot formed in illiacs if retrograde flushing
  is not performed
• Colonic ischemia (3-13) leads to mortality in
  73-100 of time
• Degree and duration of hypotension
• Patency of IMA
• Collateral supply
• Site of hematoma
• Spinal Cord Injury incidence 2.3.
• Interuption of pelvic blood supply, prolonged
  aortic cross-clamping, introperative hypotension,
  aortic embolization, internal iliac interuption

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ComplicationsSystemic

• Respiratory Failure ?
• 26-47 (mortality up to 68)
• High O2 requirements, increased lung
  permeability, decrease in lung compliance
• Factors that predispose
• Large shifts in fluid and blood
• Pre-existing pulmonary dysfunction
• Long cross-clamp time
• Renal Dysfunction ?
• Incidence is 26-42 in patients in symptomatic
  aneurysms or rAAA
• Higher with suprarenal cross-clamp, longer
  duration of cross-clamp, pre-existing renal
  dysfunction, shock, old age

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ComplicationsSystemic

• Irreversible Shock ?
• 10-15 of rAAA mortality
• Irreversible state in which aortic clamping,
  aggressive fluid resuscitation, and inotropic
  support can fail to reverse hypotension
• Cardiac Complications ?
• MI mortality of 19-66
• Arrhythmias mortality 46
• Cardiac arrest mortality 81-100
• CHF mortality of 41
• Common as patients usually have simultaneous
  cardiac dz

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ComplicationsSystemic

• Liver Failure ?
• Due to hypoxic injury
• Although the liver is robust can deal with a
  large degree of hypoxic injury it still must
  reabsorb hematoma and the increase in metabolism
  that is required to do this
• Patients usually develop jaundice on day 7
• Multisystem Organ Failure ?
• Incidence of 64
• Most common cause of death after 48 hrs
• Also referred to as a systemic inflammatory
  syndrome

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ComplicationsSystemic

• Multisystem Organ Failure ?
• Two hit hypothesis
• 1) Hemorrhagic shock first ischemic insult
  primes the inflammatory response
• 2) Aortic Clamping second ischemic insult
• 3) Resuscitation first reperfusion insult
• 4) Aortic unClamping second reperfusion insult
• Animal models support
• PMNs primed by pre-op hemorrhage, and after
  operative repair there was further activation
  with elevations of oxidative burst.
• These patients are walking into the hospital with
  oxidative injury

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Mortality

• Between 43 to 70 depending on the study
• Predictors ?
• Scoring systems
• POSSUM 12 physiologic variables and 6 operative
  variables for calculated risk
• Hardman index Based on age, creatinine,
  hemoglobin, EKG evidence of ischemia, h/o loss of
  consciousness
• Multiple Organ dysfunction score (based on
  respiratory, renal, hepatic, hematologic,
  neurologic, and cardiac)
• Deaths bimodal
• Those that died 48 after repair had sig increases
  in MODS
• Renal failure followed by hepatic failure at Day
  10 are at highest risk for mortality

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Table 102-2. Logistic Regression Model Showing
the Interaction of Significant Preoperative and
Intraoperative Variables That Predicted Early
Survival After Ruptured Abdominal Aortic Aneurysm
Repair
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Logistic Regression Model Showing the Interaction
of Significant Postoperative Complications That
Predicted Early Survival After Ruptured Abdominal
Aortic Aneurysm
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Conclusions

• Diagnosis Have RAAA on the differential, dont
  miss the diagnosis
• Resuscitation Less is more until aorta is
  clamped
• Surgery Quick, safe exposure. Use a method
  that you are experienced with.
• Complications Expect them

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I would like to end with one more aorta
mine
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If substantial hematoma prevents distal
dissection use occlusive balloons placed from
inside the aneurysm
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SurgeryOpen Repair ? TRANSPERITONEAL
Hypotention
Supraceliac Clamp
If no hypotension
Inspect Retroperitoneum Reflect bowel and duodenum
Pararenal Extensive Hematoma
SupraceliacClamp
If no hematoma
Careful Dissection for Infrarenal Control
Uncontrolled Bleeding Developes
SupraceliacClamp
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• She was evaluated for an intra-abdominal process
  because of abdominal pain. The patient was
  signed out to me by Dr. Lynn at the end of his
  shift. The patient suddenly called out to the
  nurse and was noted to be unresponsive. She was
  breathing shallow. I was called to the bedside.
  The patient appeared pale to me with pale
  conjunctivae. She was breathing shallow. Pulse
  oximetry was 100. She had a paced rhythm of
  about 60. Blood pressure was 175/64. Her
  abdomen was mildly distended but otherwise soft.
  Because of the patient's shallow breathing and
  her low cognitive function, I immediately
  obtained an Accu-Chek, which was 120. I was
  concerned about anemia, but the hemoglobin was
  10. On the other hand, while we were assessing
  her, I got a call from the radiologist, who
  reported that the patient had a ruptured AAA.
  Advance directives did not show any DNR status.
  The patient was immediately updated to room 5 for
  resuscitation. Vascular Surgery was called and
  immediately came down. We were giving the
  patient oxygen, attempting a central line
  placement. O negative blood was ordered. The
  patient, however, was taken immediately up to a
  waiting operating room by the vascular surgeons.
  Transfer nurse helped take the patient up.
  Oxygen was given 100.