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Dick F, Diehm N, Opfermann P, von Allmen R, Tevaearai H, Schmidli J. Endovascular suitability and outcome after open surgery for ruptured abdominal aortic aneurysm. Br J Surg 2012; 99:940-7. [DOI: 10.1002/bjs.8780] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2012] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Endovascular repair of ruptured abdominal aortic aneurysm (rAAA) has rapidly gained popularity, but superior results may be biased by patient selection. The aim was to investigate whether suitability for endovascular repair predicted survival, irrespective of technique of repair.
Methods
Two blinded investigators independently evaluated preoperative computed tomography angiograms of a consecutive cohort of patients with rAAA. Patients were categorized either ‘suitable’ or ‘unsuitable’ for endovascular repair, if assessments agreed. If assessments disagreed, they were classified ‘borderline suitable’. Correlations between endovascular suitability and clinical outcome were adjusted for suspected confounding factors and tested for robustness using sensitivity analyses.
Results
A total of 248 patients with rAAA from January 2001 to December 2010 were included, of whom 237 (95·6 per cent) underwent open repair. Seventy patients (28·2 per cent) were classified as ‘suitable’ and 100 (40·3 per cent) as ‘unsuitable’ for endovascular repair; 63 (25·4 per cent) were considered ‘borderline suitable’. Fifteen (6·0 per cent) could not be assessed and were included in the sensitivity analyses. The postoperative 30-day mortality rate was 15·3 per cent (38 deaths). Multiple logistic regression demonstrated that the odds of perioperative death increased 9·21 (95 per cent confidence interval 2·16 to 39·23) fold for ‘unsuitable’ rAAA (P = 0·003) and 6·80 (1·47 to 31·49) fold for ‘borderline’ rAAA (P = 0·014), compared with ‘suitable’ rAAA. This selection effect was robust across sensitivity analyses and sustained for at least 5 years of follow-up.
Conclusion
Endovascular suitability was an independent and strongly positive predictor of survival after open repair of rAAA.
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Affiliation(s)
- F Dick
- Department of Cardiovascular Surgery, Swiss Cardiovascular Centre, University Hospital Berne, Freiburgstrasse, 3010 Berne, Switzerland
| | - N Diehm
- Division of Diagnostic and Interventional Angiology, Swiss Cardiovascular Centre, University Hospital Berne and University of Berne, Berne, Switzerland
| | - P Opfermann
- Department of Cardiovascular Surgery, Swiss Cardiovascular Centre, University Hospital Berne, Freiburgstrasse, 3010 Berne, Switzerland
| | - R von Allmen
- Department of Cardiovascular Surgery, Swiss Cardiovascular Centre, University Hospital Berne, Freiburgstrasse, 3010 Berne, Switzerland
- Imperial College Vascular Surgery Research Group, Division of Surgery, Oncology, Reproductive Biology and Anaesthetics, Charing Cross Hospital, London, UK
| | - H Tevaearai
- Department of Cardiovascular Surgery, Swiss Cardiovascular Centre, University Hospital Berne, Freiburgstrasse, 3010 Berne, Switzerland
| | - J Schmidli
- Department of Cardiovascular Surgery, Swiss Cardiovascular Centre, University Hospital Berne, Freiburgstrasse, 3010 Berne, Switzerland
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Hörer T, Skoog P, Pirouzram A, Larzon T. Tissue Plasminogen Activator–Assisted Hematoma Evacuation to Relieve Abdominal Compartment Syndrome After Endovascular Repair of Ruptured Abdominal Aortic Aneurysm. J Endovasc Ther 2012; 19:144-8. [DOI: 10.1583/11-3699.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Ferreira J, Canedo A, Barreto P, Vaz A. Abdominal compartment syndrome after endovascular repair of ruptured iliac artery aneurysm. Interact Cardiovasc Thorac Surg 2012; 14:897-9. [PMID: 22374290 DOI: 10.1093/icvts/ivs030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Abdominal compartment syndrome is a possible complication after aneurysm repair and has a high mortality rate. Although there has been an increment in patient survival rates after aneurysm repair, there has also been an increase in this entity. However, there are few data about the incidence and management of this complication after endovascular repair of a ruptured iliac artery aneurysm. The objective of this report is to describe a case of abdominal compartment syndrome after endovascular correction of a ruptured iliac artery aneurysm, emphasizing the importance of the accurate monitoring of intra-abdominal pressure, medical therapy and timely laparotomy. An 85-year old male was submitted to the endovascular repair of a ruptured iliac artery aneurysm. On the first day after the intervention, he developed abdominal compartment syndrome which did not resolve with medical therapy. Consequently, on the second postoperative day, a decompressive laparotomy was performed, removing the retroperitoneal haematoma, which was the main cause of the high intra-abdominal pressure and the abdominal compartment syndrome. At 12 months of follow-up, there was no evidence of complications. This case stresses the importance of early recognition of abdominal compartment syndrome.
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Affiliation(s)
- Joana Ferreira
- Department of Vascular Surgery, Hospital Vila Nova de Gaia/Espinho, Vila Nova de Gaia/Espinho, Portugal.
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54
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Intra-abdominal hypertension and abdominal compartment syndrome in association with ruptured abdominal aortic aneurysm in the endovascular era: vigilance remains critical. Crit Care Res Pract 2012; 2012:151650. [PMID: 22454763 PMCID: PMC3290801 DOI: 10.1155/2012/151650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 10/30/2011] [Indexed: 11/18/2022] Open
Abstract
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are common complications of ruptured abdominal aortoiliac aneurysms (rAAAs) and other abdominal vascular catastrophes even in the age of endovascular therapy. Morbidity and mortality due to systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) are significant. Recognition and management of IAH are key critical care measures which may decrease morbidity and improve survival in these vascular patients. Two strategies have been utilized: expectant management with prompt decompressive laparotomy upon diagnosis of threshold levels of IAH versus prophylactic, delayed abdominal closure based upon clinical parameters at the time of initial repair. Competent management of the abdominal wound with preservation of abdominal domain is also an important component of the care of these patients.
In this review, we describe published experience with IAH and ACS complicating abdominal vascular catastrophes, experience with ACS complicating endovascular repair of rAAAs, and techniques for management of the abdominal wound. Vigilance and appropriate management of IAH and ACS remains critically important in decreasing morbidity and optimizing survival following catastrophic intra-abdominal vascular events.
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55
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Dubose JJ, Lundy JB. Enterocutaneous fistulas in the setting of trauma and critical illness. Clin Colon Rectal Surg 2011; 23:182-9. [PMID: 21886468 DOI: 10.1055/s-0030-1262986] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
One of the most devastating complications to develop in the general surgical patient is an enterocutaneous fistula (ECF). Critically ill patients suffering trauma, thermal injury, infected necrotizing pancreatitis, and other acute intraabdominal pathology are at unique risk for this complication as well. By using decompressive laparotomy for abdominal compartment syndrome and leaving the abdomen open temporarily for other acute processes, survival in some instances may be improved. However, the exposed viscera are at risk for fistulization in the presence of an open abdomen, a newly defined entity termed the enteroatmospheric fistula (EAF). The purpose of this article is to describe the epidemiology of ECF in the setting of trauma and critical illness, nutrition in injured/critically ill patients with ECF, pharmacologic adjuncts to decrease fistula effluent, wound care, surgical management of the EAF/ECF, and techniques for prevention of these dreaded complications in patients with an open abdomen.
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Affiliation(s)
- Joseph J Dubose
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Air Force Center for Sustainment of Trauma Readiness Skills, Baltimore, Maryland
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56
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Comment on “Intra-abdominal Hypertension and Abdominal Compartment Syndrome after Endovascular Repair of Ruptured Abdominal Aortic Aneurysm”. Eur J Vasc Endovasc Surg 2011; 42:712. [DOI: 10.1016/j.ejvs.2011.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 07/04/2011] [Indexed: 11/23/2022]
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Björck M, Djavani Gidlund K, Wanhainen A. Response to Comment on "Intraabdominal hypertension and abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysm". Eur J Vasc Endovasc Surg 2011; 43:132. [PMID: 22032968 DOI: 10.1016/j.ejvs.2011.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 10/06/2011] [Indexed: 11/15/2022]
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Djavani Gidlund K, Wanhainen A, Björck M. Intra-abdominal Hypertension and Abdominal Compartment Syndrome after Endovascular Repair of Ruptured Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2011; 41:742-7. [DOI: 10.1016/j.ejvs.2011.02.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 02/17/2011] [Indexed: 10/18/2022]
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Acosta S, Bjarnason T, Petersson U, Pålsson B, Wanhainen A, Svensson M, Djavani K, Björck M. Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction. Br J Surg 2011; 98:735-43. [PMID: 21462176 DOI: 10.1002/bjs.7383] [Citation(s) in RCA: 139] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2010] [Indexed: 12/19/2022]
Abstract
BACKGROUND Damage control surgery and temporary open abdomen (OA) have been adopted widely, in both trauma and non-trauma situations. Several techniques for temporary abdominal closure have been developed. The main objective of this study was to evaluate the fascial closure rate in patients after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) for long-term OA treatment, and to describe complications. METHODS This prospective study included all patients who received VAWCM treatment between 2006 and 2009 at four hospitals. Patients with anticipated OA treatment for fewer than 5 days and those with non-midline incisions were excluded. RESULTS Among 151 patients treated with an OA, 111 received VAWCM treatment. Median age was 68 years. Median OA treatment time was 14 days. Main disease aetiologies were vascular (45 patients), visceral surgical disease (57) and trauma (9). The fascial closure rate was 76·6 per cent in intention-to-treat analysis and 89 per cent in per-protocol analysis. Eight patients developed an intestinal fistula, of whom seven had intestinal ischaemia. Intestinal fistula was an independent factor associated with failure of fascial closure (odds ratio (OR) 8·55, 95 per cent confidence interval 1·47 to 49·72; P = 0·017). The in-hospital mortality rate was 29·7 per cent. Age (OR 1·21, 1·02 to 1·43; P = 0·027) and failure of fascial closure (OR 44·50, 1·13 to 1748·52; P = 0·043) were independently associated with in-hospital mortality. CONCLUSION The VAWCM method provided a high fascial closure rate after long-term treatment of OA. Technique-related complications were few. No patient was left with a large planned ventral hernia.
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Affiliation(s)
- S Acosta
- Vascular Centre, Skane University Hospital, Lund University, Malmö, Sweden.
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60
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Hechelhammer L, Rancic Z, Pfiffner R, Mayer D, Meier T, Lachat M, Pfammatter T. Midterm outcome of endovascular repair of ruptured isolated iliac artery aneurysms. J Vasc Surg 2010; 52:1159-63. [DOI: 10.1016/j.jvs.2010.06.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Revised: 06/01/2010] [Accepted: 06/03/2010] [Indexed: 11/26/2022]
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61
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Powell J, Hinchliffe R. Part One: For the Motion. Eur J Vasc Endovasc Surg 2010; 40:421-4. [DOI: 10.1016/j.ejvs.2010.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 06/07/2010] [Indexed: 11/28/2022]
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62
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Veith FJ, Powell JT, Hinchliffe RJ. Is a randomized trial necessary to determine whether endovascular repair is the preferred management strategy in patients with ruptured abdominal aortic aneurysms? J Vasc Surg 2010; 52:1087-93. [DOI: 10.1016/j.jvs.2010.05.142] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 05/26/2010] [Accepted: 05/26/2010] [Indexed: 01/26/2023]
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63
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Veith F. Part Two: Against the Motion. Eur J Vasc Endovasc Surg 2010; 40:424-7. [DOI: 10.1016/j.ejvs.2010.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 06/07/2010] [Indexed: 11/27/2022]
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Björck M, Wanhainen A. Nonocclusive mesenteric hypoperfusion syndromes: recognition and treatment. Semin Vasc Surg 2010; 23:54-64. [PMID: 20298950 DOI: 10.1053/j.semvascsurg.2009.12.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The main focus when discussing acute or chronic mesenteric ischemia is on occlusive disease, arterial or venous. This article reviews present knowledge on mesenteric nonocclusive hypoperfusion syndromes. The following three clinical entities are reviewed: (1) Intraabdominal hypertension (IAH), or abdominal compartment syndrome (ACS), is important after ruptured abdominal aortic aneurysm repair. IAH >20 mm Hg occurs in approximately 50% of patients after open repair and in 20% after endovascular repair of ruptured abdominal aortic aneurysm, but these patients are different and no randomized data exists yet. A consensus issued by the World Society of Abdominal Compartment Syndrome provides guidance. Early conservative treatment of IAH and, alternatively, abdominal closure devices for leaving the abdomen partially open temporarily are discussed and a treatment algorithm is suggested. (2) Colonic ischemia after abdominal aortic surgery, its risk factors, clinical presentation, and treatment are discussed. A significant number of such patients develop IAH and reducing the abdominal perfusion pressure affects the left colon, the sentinel organ in these patients. (3) Nonocclusive mesenteric ischemia (NOMI); most often such patients suffer from severe cardiac failure requiring massive inotropic support. The condition is difficult to define. Early diagnosis with multidetector row computed tomography is a worthwhile alternative when angiography presents difficulties. A stenosis of the superior mesenteric artery is frequently enough that it should be ruled out because endovascular treatment can be lifesaving. New knowledge on these three different mesenteric hypoperfusion syndromes is reviewed. Success in treating these difficult patients is benefited from a multidisciplinary approach.
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Affiliation(s)
- Martin Björck
- Department of Vascular Surgery, Institution of Surgical Sciences, University Hospital, Uppsala, Sweden.
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65
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Early results after treatment of open abdomen after aortic surgery with mesh traction and vacuum-assisted wound closure. Eur J Vasc Endovasc Surg 2010; 40:60-4. [PMID: 20359914 DOI: 10.1016/j.ejvs.2010.02.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 02/25/2010] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study aimed to describe the use of vacuum-assisted wound closure (VAWC) and mesh traction to repair an open abdomen after aortic surgery. DESIGN Prospective clinical study. MATERIAL AND METHODS From October 2006 to April 2009, nine consecutive patients were treated; seven of the patients received laparostomy following abdominal compartment syndrome (ACS), while two wounds were left open initially. The indication for laparostomy was intra-abdominal pressure (IAP) > 20 mmHg or abdominal perfusion pressure (APP) < 60 mmHg and development of organ failure. V.A.C. therapy (KCI, San Antonio, TX, USA) was initiated with the laparostomy, and supplemented with a fascial mesh after 2 days. The wound was then closed stepwise with mesh traction and VAWC. RESULTS All wounds could be closed following a median interval of 10.5 (range: 6-19) days after laparostomy. A median of four (range: 2-7) dressing changes were performed. One patient died on the seventh postoperative day. Two other patients died 38 and 50 days after final closure, respectively. Left colonic necrosis was seen in two patients while incisional hernia was observed in two patients. Mean follow-up duration was 17 (range: 2-36) months. CONCLUSION VAWC with mesh traction was successful in terms of early delayed primary closure and is a useful tool in the treatment of open abdomen after aortic surgery.
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Collected World and Single Center Experience With Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms. Ann Surg 2009; 250:818-24. [PMID: 19809296 DOI: 10.1097/sla.0b013e3181bdd7f5] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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