Case Presentation Morbidity and …

1 case PresentationMorbidity and mortalitymorbidity and Mortality ConferenceRavi Dhanisetty, County Hospital Center1 May 20091 May PresentationCase Presentationz53 ear old male b s dri er had a s ncopalz53 year old male bus driver had a syncopal episode and found down to emergency room by EMSzBrought to emergency room by EMSzInitial vitals SBP 70, HR 120szPtitididzPatient regained consciousness and complained of left flank pain radiating to left was aggressively resuscitated and a CT scan of the abdomen was scan of the abdomen was PresentationCase PresentationLaboratory values:yzArterial blood gas - zLactate / Hct / 30 Emergent surgical consultation Exam:{Patient was in extremis pale, diaphoretic, tachypnic {Diffusely distended abdomen{Diffusely distended was taken to OR for CourseOperative CoursezGiant retroperitoneal hematoma extending from the pginguinal ligament to diaphragm with hemoperitoneumzSize of hematoma precluded proximal vascular control outside the the the hematoma and proximal control was attempted by compressing aorta against the spinezLft idddil il ttifdzLeft sided medial visceral rotation was performedzAorta was clamped proximal to a widely ruptured iliac artery aneurysm.}}}

2 YyzA distal clamp was placed on the iliac CourseOperative CoursezBy this time, patient lost signs of lifezBy this time, patient lost signs of life {Coarse on the including antero-lateralzResuscitation including anterolateral thoracotomy with open cardiac massage failed to revive the , patient received 13 unitszIntraoperatively, patient received 13 units of dAbd ilAtiRuptured Abdominal Aortic AneurysmAneurysmRavi Dhanisetty, MDRavi Dhanisetty, MDMay 1, AAA: BackgroundRuptured AAA: BackgroundzSudden unheralded eventzSudden, unheralded eventz13thleading cause of deathzUsually fatal (70-80%)zUsually fatal (7080%).{Only 50% present to hospital repair of ruptured aneurysmszEmergent repair of ruptured aneurysms {Staggering mortality of up to 50% z10 X that of elective repairz10 X that of elective AAA: IncidenceRuptured AAA: Incidence zMureebee et al.}}}

3 JVS Factors for Developing AneurysmszAge peak prevalence of 6% at 80-85zAgepeak prevalence of 6% at 8085 Gender 4-5 x more Gender4 5 x more 8x compared to non-smokerszFamily historyandzFamily historyand {History of inguinal herniazDiabetes and female gender negative risk factorsrisk Risk of Stable Asymptomatic AAApypGreatest Diameter (cm)Annual Rupture Risk (%) 30> 50zElective repair - > cm. Growth > cm/ 6mozBiannual surveillancezCuri et al. Carmeron Factors for Rupture of AAARisk FactorsLow RiskHigh RiskDiameter< 5 cm> 6 cm//Expansion< cm /yr> cm / yrHypertensionNonePoorly HypertensionNoneControlledSmoking / CONone / MildSteroid COPDNone / MildDependentFamily HistoryNonePositiveyyzGloviczki et al. Townsend, HistoryRetrospective review 56 patients with pruptured AAA and no surgical decision made tttnot to operate:{Minimal fluids{Ail{Average survival 10 hours{87% lit 2{87% alive at 2 et al, JVS 2004 & Initial ManagementTwo distinct groups (based on hypotension)Two distinct groups (based on hypotension){Hypotension known history of AAA or ypypulsatile masszFree intra-peritoneal rupture{No hypotension, or responsive to initial resuscitationresuscitationzContained / Retro-peritoneal & Initial ManagementDeRubertis, BG et al.}}}}}}}}

4 Cameron, and Initial ManagementPresentation and Initial ManagementzPatient should be immediately transferred tozPatient should be immediately transferred to operating room and all other tests performed there zHypotensive resuscitation may be considered{level I rapid transfusion system and auto-transfusion device are a and drape patient prior to induction of ManagementSurgical ManagementMost important step control ofMost important step control of hemorrhage by proximal aortic occlusion:occlusion:{Supra-celiac occlusion or clamping{Control of aorta within the hematoma{Control of aorta within the hematoma{Rarely antero-lateral thoracotomy with aortic clamping if patient arrests prior to if patient arrests prior to NOT INFRA-RENAL ??zHematoma obscuring veinsobscuring veinszVenous compression of the supra-celiac aorta against the spinezTemporaryzTemporary control of supra-supraceliac Control of AortaSupraCeliac Control of AortazVeith FJ, et al: Surg Gynecol Obste.}}}}}

5 , Control of AortaSupraCeliac Control of AortazVeith FJ, et al: Surg Gynecol Obste., Control from within the Rt dARuptured AneurysmzIn the case of anzIn the case of an uncontained rupture, a foley catheter can be inflated in the supra-renal aorta to iidilgain rapid proximal ManagementSurgical ManagementzOnce proximal control is achievedzOnce proximal control is achieved{Further dissection can be carried to expose infra-renal portion of aorta to move cross clampinfrarenal portion of aorta to move cross clamp to infra-renal location{Distal control of iliacs most commonly from ywithin the aneurysm lumen.{Repair of aneurysm with prosthetic graft. {Secondary to injury to adjacent veins: zInfra-renal aorta is a large artery surrounded by veinsgyyzLower Extremity Ischemia {Cross clamping embolization distal anastomosis{Cross clamping, embolization, distal Ischemia (40%){Mortality in up to 80% of patients{Mortality in up to 80% of patientszAbdominal Compartment Outcomes: 30 Day Mortality after Ruptured AAA30 Day Mortality after Ruptured AAA RepairzMureebee et al.}}}}}}}}

6 JVS Score to Predict OutcomePrognostic Score to Predict OutcomezEdinburgh Ruptured Aneurysm Score (ERAS)zEdinburgh Ruptured Aneurysm Score (ERAS){Hemoglobin level 9 g/dL{GCS of < 15{Blood pressure of less than 90 mm HgzProspective evaluation with 111 patients and compared pppto other scoring systems (HI, GAS, POSSUM)zERAS only one to accurately stratify peri-operativeERAS only one to accurately stratify perioperative risk zTambyraja et al. World J. Surg Score to Predict OutcomePrognostic Score to Predict Outcome{Tambyraja et al. World J. Factors Affecting OutcomeOther Factors Affecting OutcomeRetrospecti e re ie of 213 patients that nder entRetrospective review of 213 patients that underwent open repair of ruptured AAA at a tertiary referral vs low volume surgeons (20 cases/year)zCho et al. JVS Factors Affecting OutcomeOther Factors Affecting OutcomezCho et al.}}}}

7 Statement in 2004 based on 6zConsensus Statement in 2004 based on 6 prospective randomized studies.{Screening general population for AAAggp p{High compliance{Decreased AAA related mortality (up to 68%){Decrease rupture rate (49%){Kent et al JVS RecommendationsScreening RecommendationszKent et al JVS AAA continues to be a highlyzRuptured AAA continues to be a highly lethal outcomes depend onzSuccessful outcomes depend on establishing correct diagnosis and rapid surgical control of , early detection of aneurysm and elective repair remains most likely pyway to reduce aneurysm-related one of the following is associated with poor outcome in a patient undergoing repair of rAAA? cardiac > blood pressure < 90 mm HgAll f of the abovezRisk factors associated with development of AAA include: of the is recommended in all of the patients year old male with history of year old female with history of MI54ldlith fil hi tf year old male with family history of year old male with aortic diameter of cm on a CT scan a year complications of repair of ruptured AAAzPeri-operative complications of repair of ruptured AAA include all of the following extremity of the evaluation of a hypotensive patientzInitial evaluation of a hypotensive patient with suspected ruptured AAA include:a Rapid assessment and transport to operatinga.}}}}}

8 Rapid assessment and transport to operating roomb. Aggressive resuscitation with fluid andb. Aggressive resuscitation with fluid and pressorsc. CT scan with iv contrastd. None of the : Current Surgical Therapy 9thed 2008zCameron: Current Surgical Therapy. 9thed. et al. Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality. J Vas Surg: 48(1), et al. Surgical Repair of rAAA in the state of Maryland: Factors influencing outcome among 527 recent cases. J Vas Surg 28(3), 1998. zKent et al. Screening for abdominal aortic aneurysm: A consensus statement J Vasc Surg: 39(1) 2004statement. J Vasc Surg: 39(1), et al. Feasibility of pre-operative CT in patients with ruptured abdominal aortic aneurysm: a time-to-death study in patients without operation. J Vasc Surg 2004; 39: l N til Td iiftd AAA JVS 48(5)zMureebe, et al.

9 National Trends in repair of ruptured AAA. JVS: 48(5), A, Murie J, Chalmers R. Predictors of outcome after abdominal aortic aneurysm rupture: Edinburgh Ruptured Aneurysm Score. World J ypgpySurg 2007;31 et al. Prognostic Scoring in Ruptured abdominal aortic aneurysm: a prospective evaluation. J Vas Surg: 47(2), 2008. zTownsend: Sabiston Textbook of Surgery 18thed 2007zTownsend: Sabiston Textbook of Surgery, 18thed. 2007. zVeith FJ, Gupta S, Daly V: Surg Gynecol Obstet 151:497, Factors Affecting OutcomeOther Factors Affecting Factors Affecting Outcome:SVlSurgeon are degenerative:zMost are degenerative:{Interaction of multiple factors is responsible for destruction of media of the aortic wall leading todestruction of media of the aortic wall leading to aneurysm.{The balance of aortic wall remodeling favors gelastin and collagen of Aortic WallComponents of Aortic WallzElastin and collagen are major structural components and act in complementary fashioncomplementary in media{Not synthesized in aorta with{Not synthesized in aorta with half-life of 40 70 yrs.}}}}

10 {Load-bearing and elastic recoilgzCollagen in adventitia{Tensile strength and structural integrity. : Aneurysm FtiFormationzHistology: aneurysm wall thin and markedzHistology: aneurysm wall thin and marked decrease in the amount of elastin and degradation / fragmentation: aneurysmal ggyformation, elongation, and tortuosityzCollagen degradation: aneurysmal ruptureggy pzPrimarily by proteolytic enzymes{Either over expression or decreased expression of protease inhibitor (alpha 1 antitrypsin or tissue inhibitors of MMP (TIMPs)). : : s Law:zLaplace s Law:{T (tangential stress) = P (tangential pressure) x R / zSize and hypertension are important riskzSize and hypertension are important risk factors in the rate of}}}}