% Mortality 03/29/2016. Advances in Repair of Aortic Aneurysms: Open

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1 OPEN REPAIR OF RUPTURED ABDOMINAL AORTIC ANEURYSM THE GOLD STANDARD Daniel H. Benckart, MD % Mortality Advances in Repair of Aortic Aneurysms: Open Surgeons experienced 2. Anesthetic management 3. Grafts 4. Retraction 5. Resuscitation 6. Critical care 7. Blood products 1

2 Advances in Repair of Aortic Aneursyms: Open Imaging planning 9. Improved management of complications dialysis 2-3% mortality Early EVAR results compared to that Vascular Surgeons Experts at open elective AAA resection Excellent Results Juxtrarenal Thoracoabdominal Mortality < 10% Advances in the Treatment of Ruptured AAA - Open 1. All the same advances for elective 2. Rapid helicopter based transport 3. Massive transfusion protocols 4. Coagulation adjuncts 5. Balloon occlusion 6. Protocols, rooms, teams 7. Delayed closure, open abdomen Experienced Surgeons High Volume Centers 2

3 Journal of Vascular Surgery 2014 Edwards, et al. Medicare Patients ,998 patients 1126 EVAR 9872 Open Mortality 33.8% 47.7% EVAR mortality may improve Open likely will not Ruptured AAA 4000/year in the US 11% of all AAA repairs VQI EVAR for ruptured AAA % % Acute Ascending Aortic Dissection Mortality 1970 >60% % % Ruptured Abdominal Aortic Aneurysm Mortality % % % 3

4 Improved Mortality Acute Ascending Aortic Dissection Ruptured Abdominal Aortic Aneurysm Open 1. Retrograde Cardioplegia 2. Cerebral Perfusion? Endografts 3. Circulatory Arrest Open Repair Why the continued results? It s too hard. 1. No planning preoperatively 2. No rest intraoperatively - no cardiopulmonary bypass 3. Difficult and distorted - anatomy 4. Catastrophic bleeding 5. Comorbid conditions Open Repair of Ruptured Abdominal Aortic Aneurysms Failed Experiment No reason the results likely to improve Less open surgery-next generation not likely to be more experienced at open repair. 4

5 Allegheny General Results June 2011 August 2015 Mortality Open 37% (33) EVAR 12% (27) Dr. Benckart 8 open 4 died 6 EVARs 1 died EVAR = 90% of Ruptured AAA Mario Lachat Since ruptures 4 open 21% chimney 70 EVAR Mortality 22% 5

6 Lachat Technical Innovations 1. Physician modified stent graft 2. Nellix 3. Expandable sheaths 4. Trivascular 5. Endospan European Trials Mortality IMPROVE - EVAR 35% Open 37% AJAX - EVAR 21% Open 25% No unstable patients had to consent preop. Problems: EVAR 90% 1. European referral systems often different. 2. Not all ruptured AAA will end up at high volume referral center. 3. Wide disparity in technical skills. 4. Wide disparity in hospital resources. 6

7 Is This the Answer EVAR for every ruptured AAA AGH - 50% open 5 years 50 % EVAR Journal of Vascular Surgery July 2015 Ali, et al VQI Worcester, MA USGNE RAAA Risk Score Age > 76 2 Preop cardiac arrest 2 Loss of consciousness 1 Suprarenal aortic clamp Low risk Medium risk High risk Mortality Mortality Mortality EVAR 10% 37% 95% Open 15% 48% 79% EVAR mortality 25% Open mortality 33% 1. Can we improve on open repair of ruptured aneurysms? 2. Are there subgroups where it may be the procedure of choice? 7

8 Open Repair: Ruptured AAA Can we make it a better operation? Incremental improvement over 40 years but limited Experienced surgeons/high volume institution Rapid transport Aortic teams Specialized rooms Balloon occulsion Make the procedure resemble an elective case 1. Rapid transport pre hospital on arrival directly to O.R. 2. Dedicated cardiovascular anesthesiologists Rapid line placement Permissive hypotension Appropriate use of blood products Management of inotropes TEE 3. Dedicated operating room staff 4. Adequate exposure 5. Retroperioneal/thoracoabdominal exposure 6. Open abdomen 7. SICU care/intensivists 8

9 Who is an open candidate? Hemodynamically Hemodynamically Hemodynamically Unstable Stable Stable Arrest EVAR suitable EVAR unsuitable CPR Anatomy Anatomy BP <60 Subgroups that would benefit from open repair Perhaps? Hemodynamically stable patients with imperfect anatomy for EVAR. What s imperfect One we wouldn t do electively Iliac aneurysm Anatomy: 1. Short neck 2. Angulation 3. Severe access disease 4. Complex iliac aneurysmal disease Will depend on experience and skill of surgeon 9

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67 Page 199 Open Repair - Number will decrease as endovascular skill set improves. -90% may be unrealistic target in the United States. -Trainees must have excellent open skills challenge in the future. Demanding for the attending surgeon High Risk Group Multiple Definitions Shock hemodynamic collapse often without imaging Ali, et al. mortality EVAR 95% Open 79% This group presents the greatest challenge for either type of repair. 67

68 High Risk Group 1. Perhaps should not be operated on. 2. Damage control EVAR coverage of renal arteries. 3. Unlikely either repair the answer here. Open Aneurysm Repair The Future 1. All stable patients with appropriate anatomy EVAR 2. All stable patients without good anatomy Open Repair Conclusion 1. EVAR the procedure of choice 2. EVAR will increase as treatment 3. Open repair for selected cases 4. Imperative that open skills be stressed in fellowship 5. High risk patients still likely to have unfavorable outcomes 68