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Jones M, Rockley MC, Moore RD. Endovascular Aortic Balloon control versus open Aortic cross Clamp in open ruptured abdominal Aortic aneurysm repair. Ann Vasc Surg 2024; 109:131-134. [PMID: 39029893 DOI: 10.1016/j.avsg.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND To determine 30-day mortality of endovascular aortic balloon control compared with open aortic cross clamp in open surgical repair (OSR) of ruptured abdominal aortic aneurysms (rAAAs). METHODS A retrospective cohort review was performed of all adult patients who underwent OSR of an infrarenal rAAA between 2001 and 2018 at a single tertiary care center. A total of 174 patients were identified, of which 21 patients received endovascular aortic balloon control and 137 patients received an open aortic cross clamp. Primary outcome was 30-day mortality. Two-variable multivariate logistic regression was adjusted for preoperative blood pressure and age. RESULTS Endovascular aortic balloon control was nonsignificantly associated with lower mortality (adjusted odds ratio [OR] = 0.75 (95% confidence interval [CI] 0.24 to 2.38), P = 0.63), and when placed under local anesthesia showed a trend toward improved mortality (adjusted OR = 0.34 (95%CI 0.06 to 1.77), P = 0.19). Balloon placement under general anesthesia was nonsignificantly associated with worse mortality (adjusted OR = 2.50 (95%CI 0.35 to 9.13), P = 0.46). CONCLUSIONS There is no significant difference in mortality with the use of endovascular aortic balloon control in rAAA patients undergoing OSR, and it may be considered as an alternative approach to open aortic cross clamp in properly selected patients.
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Affiliation(s)
- Melissa Jones
- Division of Vascular Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Mark C Rockley
- Division of Vascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Randy D Moore
- Division of Vascular Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Takazawa A, Asakura T, Nakajima H, Yoshitake A. Staged repair of a ruptured thoracoabdominal aortic aneurysm: a case report. J Cardiothorac Surg 2024; 19:212. [PMID: 38616278 PMCID: PMC11017646 DOI: 10.1186/s13019-024-02703-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 03/27/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND A ruptured thoracoabdominal aortic aneurysm (rTAAA) represents a considerable challenge for surgeons. To date, endovascular procedures have not been able to completely replace open repair when debranching is required. CASE PRESENTATION A 73-year-old man was admitted to our hospital after complaining of left lateral abdominal pain. Enhanced computed tomography revealed a left retroperitoneal hematoma and a large, ruptured Crawford type IV TAAA. We first performed emergency resuscitative surgery to close the lacerated foramen. A graft replacement was performed 1 month after the initial surgery when the patient had stabilized. At 5 years postoperatively, neither occlusion nor anastomotic pseudoaneurysm was noted on computed tomography. CONCLUSIONS We provide an update on the perioperative management of patients undergoing open rTAAA repair. This procedure can be considered to ensure complete repair of an rTAAA.
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Affiliation(s)
- Akitoshi Takazawa
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1298-1 Yamane, Hidaka City, Saitama, Japan.
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1298-1 Yamane, Hidaka City, Saitama, Japan
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1298-1 Yamane, Hidaka City, Saitama, Japan
| | - Akihiro Yoshitake
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, 1298-1 Yamane, Hidaka City, Saitama, Japan
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Deser SB, Arapi B, Tel Ustunisik C, Bitargil M, Yuksel A. REBOA Improves Outcomes in Hybrid Surgery for Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2024; 100:8-14. [PMID: 38122969 DOI: 10.1016/j.avsg.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Despite advancements in diagnostic methods and emergency interventions, mortality rates of ruptured abdominal aortic aneurysm (rAAA) continue to remain high. To address this issue, the resuscitative endovascular balloon occlusion of the aorta (REBOA) technique has been designed to provide temporary control of bleeding. We aimed to compare the impact of the REBOA technique during open aortic surgery for rAAA. METHODS Between January 2014 and November 2021, 53 consecutive patients (46 males, 7 females; mean age 71.9 ± 7.9 years; range 51-89 years) who underwent emergency open aortic surgery for rAAA were retrospectively analyzed. Patients were divided into REBOA (21 patients) and non-REBOA (32 patients) groups. The primary outcomes were postoperative 24-hr and 30-day mortality. The secondary outcomes were intensive care unit (ICU) stay, in-hospital stay, bleeding, postoperative renal failure, bowel ischemia, and transient ischemic attack (TIA)/stroke rate. RESULTS The REBOA group showed a significant reduction in mortality rates at both 24 hr (9.5% vs. 37.5%, P = 0.029) and 30 days (14.2% vs. 43.7%, P = 0.035) compared to the non-REBOA group. In-hospital stay (12.8 ± 3.48 vs. 15.6 ± 4.74 days, P = 0.02) and ICU stay (2.42 ± 2.08 vs. 5.09 ± 5.79 days, P = 0.048) were shorter among the REBOA group. Total procedure time and bleeding were reduced among the REBOA group without significant differences in terms of postoperative renal failure, bowel ischemia, and TIA/stroke rate. CONCLUSIONS The REBOA group demonstrated significantly improved survival rates compared to the non-REBOA group, without a significant difference in complication rates. REBOA is considered a less invasive option compared to the traditional method for open aortic cross-clamping. This study demonstrated that the use of REBOA may be considered as a first-line treatment option for open surgery in cases of rAAA particularly when an off-the-shelf endovascular aneurysm repair device is not suitable.
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Affiliation(s)
- Serkan Burc Deser
- Department of Cardiovascular Surgery, Institute of Cardiology, Istanbul University-Cerrahpasa, Istanbul, Turkey.
| | - Berk Arapi
- Department of Cardiovascular Surgery, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Cigdem Tel Ustunisik
- Department of Cardiovascular Surgery, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Macit Bitargil
- Department of Cardiovascular Surgery, Acibadem Hospital, Istanbul, Turkey
| | - Ahmet Yuksel
- Department of Cardiovascular Surgery, City Hospital, Bursa, Turkey
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Koh EY, Fox EE, Wade CE, Scalea TM, Fox CJ, Moore EE, Morse BC, Inaba K, Bulger EM, Meyer DE. Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy are associated with similar outcomes in traumatic cardiac arrest. J Trauma Acute Care Surg 2023; 95:912-917. [PMID: 37381147 PMCID: PMC10755074 DOI: 10.1097/ta.0000000000004094] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive alternative to resuscitative thoracotomy (RT) for patients with hemorrhagic shock. However, the potential benefits of this approach remain subject of debate. The aim of this study was to compare the outcomes of REBOA and RT for traumatic cardiac arrest. METHODS A planned secondary analysis of the United States Department of Defense-funded Emergent Truncal Hemorrhage Control study was performed. Between 2017 and 2018, a prospective observational study of noncompressible torso hemorrhage was conducted at six Level I trauma centers. Patients were dichotomized by REBOA or RT, and baseline characteristics and outcomes were compared between groups. RESULTS A total of 454 patients were enrolled in the primary study, of which 72 patients were included in the secondary analysis (26 underwent REBOA and 46 underwent resuscitative thoracotomy). Resuscitative endovascular balloon occlusion of the aorta patients were older, had a greater body mass index, and were less likely to be the victims of penetrating trauma. Resuscitative endovascular balloon occlusion of the aorta patients also had less severe abdominal injuries and more severe extremity injuries, although the overall injury severity scores were similar. There was no difference in mortality between groups (88% vs. 93%, p = 0.767). However, time to aortic occlusion was longer in REBOA patients (7 vs. 4 minutes, p = 0.001) and they required more transfusions of red blood cells (4.5 vs. 2.5 units, p = 0.007) and plasma (3 vs. 1 unit, p = 0.032) in the emergency department. After adjusted analysis, mortality remained similar between groups (RR, 0.89; 95% confidence interval, 0.71-1.12, p = 0.304). CONCLUSION Resuscitative endovascular balloon occlusion of the aorta and RT were associated with similar survival after traumatic cardiac arrest, although time to successful aortic occlusion was longer in the REBOA group. Further research is needed to better define the role of REBOA in trauma. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Ezra Y. Koh
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Erin E. Fox
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX
| | - Charles E. Wade
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX
| | - Thomas M. Scalea
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD
| | - Charles J. Fox
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Kenji Inaba
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | - David E. Meyer
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX
- Department of Surgery, University of Texas Health Science Center McGovern Medical School, Houston, TX
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Takei Y, Tezuka M, Saito S, Ogasawara T, Seki M, Kato T, Kanno Y, Hirota S, Shibasaki I, Fukuda H. A protocol-based treatment for ruptured abdominal aortic aneurysm contributed to improving aorta-related mortality: a retrospective cohort study. BMC Cardiovasc Disord 2023; 23:436. [PMID: 37658328 PMCID: PMC10474727 DOI: 10.1186/s12872-023-03473-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/25/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Recent guidelines state that improving the survival rate of patients with ruptured abdominal aortic aneurysm (rAAA) requires a protocol or algorithm for the emergency management of these patients. We aimed to investigate whether introducing a protocol treatment for rAAA improves clinical outcomes compared with the pre-protocol strategy. METHODS At our institution, 92 patients treated for rAAA between June 2008 and August 2022 were retrospectively analyzed. In 2014, the protocol-based treatment was introduced comprising a transfer algorithm to shorten the time to proximal control, use of an endovascular occlusion balloon, strict indications for endovascular aortic aneurysm repair (EVAR) or open surgical repair, and perioperative care, including for abdominal compartment syndrome (ACS). Clinical outcomes were compared between the protocol and pre-protocol group, including operative status, all-cause mortality, and rAAA-related death at 30-day, in-hospital, and 1-year postoperative follow-ups. RESULTS Overall, 52 and 40 patients received the protocol-based and pre-protocol treatments, respectively. EVAR was more frequently performed in the protocol group. The rate of achieving time to proximal control was significantly faster, and the transfusion volume was lower in the protocol group. ACS occurred more frequently in the protocol group with a higher EVAR. No difference was found in all-cause mortality between the two groups. The protocol group exhibited fewer rAAA-related deaths than the pre-protocol group during the following time points: 30 days (9.6% vs. 22.5%), during the hospital stay (11.5% vs. 30.0%), and 1 year (14.5% vs. 31.5%). CONCLUSIONS The protocol-based treatment improved the survival rate of patients with rAAA.
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Affiliation(s)
- Yusuke Takei
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan.
| | - Masahiro Tezuka
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Shunsuke Saito
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Takeshi Ogasawara
- Mathematics and Statistics Section, Department of Fundamental Education, Dokkyo Medical University, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Masahiro Seki
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Takashi Kato
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Yasuyuki Kanno
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Shotaro Hirota
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Ikuko Shibasaki
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Hirotsugu Fukuda
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
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7
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Liang M, Li F, Wang Y, Chen H, Tian J, Zhao Z, Schneider KH, Li G. Woven Vascular Stent-Grafts with Surface Modification of Silk Fibroin-Based Paclitaxel/Metformin Microspheres. Bioengineering (Basel) 2023; 10:bioengineering10040399. [PMID: 37106586 PMCID: PMC10136065 DOI: 10.3390/bioengineering10040399] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/29/2023] Open
Abstract
In-stent restenosis caused by tumor ingrowth increases the risk of secondary surgery for patients with abdominal aortic aneurysms (AAA) because conventional vascular stent grafts suffer from mechanical fatigue, thrombosis, and endothelial hyperplasia. For that, we report a woven vascular stent-graft with robust mechanical properties, biocompatibility, and drug delivery functions to inhibit thrombosis and the growth of AAA. Paclitaxel (PTX)/metformin (MET)-loaded silk fibroin (SF) microspheres were self-assembly synthesized by emulsification-precipitation technology and layer-by-layer coated on the surface of a woven stent via electrostatic bonding. The woven vascular stent-graft before and after coating drug-loaded membranes were characterized and analyzed systematically. The results show that small-sized drug-loaded microspheres increased the specific surface area and promoted the dissolution/release of drugs. The stent-grafts with drug-loaded membranes exhibited a slow drug-release profile more for than 70 h and low water permeability at 158.33 ± 17.56 mL/cm2·min. The combination of PTX and MET inhibited the growth of human umbilical vein endothelial cells. Therefore, it was possible to generate dual-drug-loaded woven vascular stent-grafts to achieve the more effective treatment of AAA.
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Affiliation(s)
- Mengdi Liang
- National Engineering Laboratory for Modern Silk, College of Textile and Clothing Engineering, Soochow University, Suzhou 215123, China
- Jiangsu Advanced Textile Engineering Technology Center, Nantong 226007, China
| | - Fang Li
- National Engineering Laboratory for Modern Silk, College of Textile and Clothing Engineering, Soochow University, Suzhou 215123, China
- Jiangsu Advanced Textile Engineering Technology Center, Nantong 226007, China
| | - Yongfeng Wang
- National Engineering Laboratory for Modern Silk, College of Textile and Clothing Engineering, Soochow University, Suzhou 215123, China
- Jiangsu Advanced Textile Engineering Technology Center, Nantong 226007, China
| | - Hao Chen
- National Engineering Laboratory for Modern Silk, College of Textile and Clothing Engineering, Soochow University, Suzhou 215123, China
- Jiangsu Advanced Textile Engineering Technology Center, Nantong 226007, China
| | - Jingjing Tian
- National Engineering Laboratory for Modern Silk, College of Textile and Clothing Engineering, Soochow University, Suzhou 215123, China
- Jiangsu Advanced Textile Engineering Technology Center, Nantong 226007, China
| | - Zeyu Zhao
- Department of Applied Physics, The Hong Kong Polytechnic University, 11 Yukchoi Rd, Hung Hom, Kowloon, Hong Kong 999077, China
| | - Karl H Schneider
- Center for Biomedical Research and Translational Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Gang Li
- National Engineering Laboratory for Modern Silk, College of Textile and Clothing Engineering, Soochow University, Suzhou 215123, China
- Jiangsu Advanced Textile Engineering Technology Center, Nantong 226007, China
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Dang VC, Osztrogonacz PJ, Haddad P, Sharma S, Corr SJ, Rahimi M. Houston Methodist Ruptured Abdominal Aortic Aneurysm Guidelines. Methodist Debakey Cardiovasc J 2023; 19:78-89. [PMID: 36910549 PMCID: PMC10000315 DOI: 10.14797/mdcvj.1177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/07/2023] [Indexed: 03/09/2023] Open
Abstract
Ruptured abdominal aortic aneurysm (RAAA) is an acute aortic condition that requires emergent intervention and appropriate continuity of care to optimize patient outcomes. We describe the standardized RAAA protocol at the Houston Methodist Hospital Acute Aortic Treatment Center, developed to navigate critical patient transfer periods safely and efficiently, make crucial decisions about surgical intervention, and clearly communicate these plans with other care team providers. Our workflow is organized into five phases: prehospital, preoperative, intraoperative, postoperative, and post-discharge. We identify the transfer center, anesthesia, operating room nursing staff, surgeons, and intensive care unit as key entities of our acute aortic pathology care team. This systematic protocol for the management of acute aortic emergencies such as RAAA identifies critical decision points, potential complications at each stage, and recommendations for best practice.
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Affiliation(s)
- Vy C Dang
- Texas A&M School of Medicine, Bryan, Texas, US
| | | | - Paul Haddad
- Houston Methodist Hospital, Houston, Texas, US
| | | | - Stuart J Corr
- Houston Methodist Hospital, Houston, Texas, US.,Rice University, Houston, Texas, US.,Swansea University Medical School, Swansea, United Kingdom.,Weill Cornell Medical College, New York, New York, US
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9
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Jusko M, Kasprzak P, Majos A, Kuczmik W. The Ratio of the Size of the Abdominal Aortic Aneurysm to That of the Unchanged Aorta as a Risk Factor for Its Rupture. Biomedicines 2022; 10:biomedicines10081997. [PMID: 36009543 PMCID: PMC9405575 DOI: 10.3390/biomedicines10081997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 11/20/2022] Open
Abstract
Background: A ruptured abdominal aortic aneurysm is a severe condition associated with high mortality. Currently, the most important criterion used to estimate the risk of its rupture is the size of the aneurysm, but due to patients’ anatomical variability, many aneurysms have a high risk of rupture with a small aneurysm size. We asked ourselves whether individual differences in anatomy could be taken into account when assessing the risk of rupture. Methods: Based on the CT scan image, aneurysm and normal aorta diameters were collected from 186 individuals and compared in patients with ruptured and unruptured aneurysms. To take into account anatomical differences between patients, diameter ratios were calculated by dividing the aneurysm diameter by the diameter of the normal aorta at various heights, and then further comparisons were made. Results: It was found that the calculated ratios differ between patients with ruptured and unruptured aneurysms. This observation is also present in patients with small aneurysms, with its maximal size below the level that indicates the need for surgical treatment. For small aneurysms, the ratios help us to estimate the risk of rupture better than the maximum sac size (AUC: 0.783 vs. 0.650). Conclusions: The calculated ratios appear to be a valuable feature to indicate which of the small aneurysms have a high risk of rupture. The obtained results suggest the need for further confirmation of their usefulness in subsequent groups of patients.
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Affiliation(s)
- Maciej Jusko
- Department of General Surgery, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, 40-055 Katowice, Poland
- Correspondence: ; Tel.: +48-793-777-193
| | - Piotr Kasprzak
- Department of Vascular Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Alicja Majos
- General and Transplant Surgery Department, Medical University of Lodz, 93-338 Lodz, Poland
| | - Waclaw Kuczmik
- Department of General Surgery, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, 40-055 Katowice, Poland
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10
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Lee K, Li CC, Cheng M. Should Open Repair be the Choice in Ruptured Abdominal Aortic Aneurysm Instead of
EVAR
(Endovascular Aortic Repair) ‐ Experience in a Tertiary Referral Vascular Centre. SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kin‐yan Lee
- Consultant Surgeon, CMS Specialist Centre Hong Kong
| | | | - Mina Cheng
- Consultant Surgeon, CMS Specialist Centre Hong Kong
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11
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Maze Y, Tokui T, Murakami M, Kawaguchi T, Inoue R, Nakamura B, Hirano K, Chino S, Nakajima K, Kato N. Treatment Strategies for Improving the Surgical Outcomes of Ruptured Abdominal Aortic Aneurysm: Single-Center Experience in Japan. Ann Vasc Dis 2022; 15:8-13. [PMID: 35432648 PMCID: PMC8958394 DOI: 10.3400/avd.oa.21-00086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/20/2021] [Indexed: 12/16/2022] Open
Abstract
Objective: We aimed to examine the surgical outcomes of ruptured abdominal aortic aneurysm cases at our hospital and considered strategies for improvement. Material and Methods: We examined the preoperative characteristics of hospital mortality, postoperative complications, and long-term outcomes of 91 surgical cases of ruptured abdominal aortic aneurysm performed between January 2009 and December 2020 at our hospital. Results: Of the 91 cases, 24 died at the hospital (mortality, 26.3%). Mortality was mostly due to hemorrhage/disseminated intravascular coagulation and intestinal necrosis. Ten patients required preoperative aortic clamp by thoracotomy or insertion of intra-aortic balloon occlusion, and eight of them died. Ten patients required open abdominal management due to abdominal compartment syndrome, and five of them died. There was no significant difference between the two groups in terms of the long-term results of the open repair and abdominal endovascular aneurysm repair (EVAR). Conclusion: To improve the surgical outcomes of ruptured abdominal aortic aneurysms, it is necessary to start surgery immediately. Therefore, the choice of surgical method (open surgery or EVAR) should be based on the resources and discretion of the hospital. To prevent postoperative intestinal necrosis, risk factors for acute compartment syndrome should be considered, and open abdominal management should be introduced.
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Affiliation(s)
- Yasumi Maze
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Toshiya Tokui
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Masahiko Murakami
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Teruhisa Kawaguchi
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Ryosai Inoue
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Bun Nakamura
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Koji Hirano
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Shuji Chino
- Department of Radiology, Ise Red Cross Hospital
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12
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[Summary of the S3 guideline on abdominal aortic aneurysm from an anesthesiological perspective]. Anaesthesist 2021; 69:20-36. [PMID: 31820017 DOI: 10.1007/s00101-019-00703-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The current article is a summary of the 2018 revised S3 guideline on screening, diagnosis, therapy, and follow-up of the abdominal aortic aneurysm (AAA) from an anesthesiological point of view. It is the only interdisciplinary guideline that describes in particular the perioperative anesthesiological and intensive care management.
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13
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Bath J, Hartwig J, Dombrovskiy VY, Vogel TR. Trends in management and outcomes of vascular emergencies in the nationwide inpatient sample. VASA 2020; 49:99-105. [DOI: 10.1024/0301-1526/a000791] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Summary: Background: To evaluate trends in frequency, mortality and treatment for non-traumatic vascular emergencies (VE) in the US. Methods: VE in the Nationwide Inpatient Sample (2005–2014) were identified. ICD-9 CM diagnosis and procedures codes captured six common VE. Results: 228,210,504 emergency admissions with 317,396 procedures for VE were estimated. Mean age was 67.8 years and were primarily men (56.1 %; p < 0.0001). The commonest VE was Acute Limb Ischemia (ALI) (82.4 %) followed by ruptured AAA (10.8 %) and Acute Mesenteric Ischemia (4.71 %). VE increased from 132.8 per 100,000 admissions in 2005 to 153.6 in 2014 (p < 0.001), with mortality decrease for all VE (13.8 % vs. 9.1 %; p < 0.0001). Length of stay decreased (median 8 vs. 7 days; p < 0.0001) but cost of care increased (median $ 25,443 vs. $ 29,353; p < 0.0001). Endovascular treatment increased overall for VE from 23.7 % in 2005 to 37.2 % in 2014 (p < 0.0001). Hospital mortality for VE decreased overall, except ruptured thoracoabdominal aortic aneurysm with mortality decrease with endovascular treatment (34.3 vs. 11.1; p = 0.04) and mortality increase with open treatment (44.7 vs. 47.6; p = 0.06). ALI overall mortality decreased from 8.1 % to 5.7 % (p < 0.0001) due to reduced open surgical mortality from 9.6 % to 7.4 % (p < 0.0001); endovascular mortality did not improve over time (4.0 % vs. 3.4 %; p = 0.45). Hospital mortality also increased for endovascular treatment of ruptured thoracic aortic aneurysm (rTAA) from 14.9 % to 27.4 % (p = 0.0003) during this period. Conclusions: VE frequency increased with a decrease in overall mortality over time. Overall hospital stay has decreased but with an increase in the cost of care. Open surgical mortality for VE has also decreased overall, suggesting perioperative care improvements, with the exception of ruptured thoracoabdominal aortic aneurysm. Endovascular utilization for VE has significantly increased; associated with lower mortality for most VE, although an increase in hospital mortality after endovascular repair of rTAA was seen. This may be due to an increased implementation of endovascular repair for patients not previously eligible for surgery due to high risk. We recommend careful selection of patients for rTAA treatment as mortality has increased despite endovascular therapy and at an increased cost of care.
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Affiliation(s)
- Jonathan Bath
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri, USA
| | - Jacob Hartwig
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri, USA
| | - Viktor Y. Dombrovskiy
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Todd R. Vogel
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri, USA
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14
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Update and decision making algorithms on the management of ruptured abdominal aortic aneurysms. ANGIOLOGIA 2020. [DOI: 10.20960/angiologia.00138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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15
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Kimura F, Ookubo R, Kobayashi D, Harada H, Baba T. Successful endovascular repair of a ruptured isolated iliac artery aneurysm: A case report. Clin Case Rep 2019; 7:1880-1884. [PMID: 31624601 PMCID: PMC6787856 DOI: 10.1002/ccr3.2385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 11/24/2022] Open
Abstract
While isolated iliac artery aneurysm is rare, its rupture can lead to complete circulatory collapse and possibly death. Herein, we report a case of rupture of a large isolated aneurysm of the right common iliac artery that led to circulatory collapse and rapid endovascular repair saved the patient's life.
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Affiliation(s)
- Fumiaki Kimura
- Department of Cardiovascular SurgeryKushiro Kojinkai Memorial HospitalKushiroJapan
| | - Ryo Ookubo
- Department of Cardiovascular SurgeryKushiro Kojinkai Memorial HospitalKushiroJapan
| | - Daita Kobayashi
- Department of Cardiovascular SurgeryKushiro Kojinkai Memorial HospitalKushiroJapan
| | - Hideyuki Harada
- Department of Cardiovascular SurgeryKushiro Kojinkai Memorial HospitalKushiroJapan
| | - Toshio Baba
- Department of Cardiovascular SurgeryKushiro Kojinkai Memorial HospitalKushiroJapan
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16
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Nakayama H, Toma M, Kobayashi T, Ohno N, Okada T, Ueno G, Sato Y. Ruptured Abdominal Aortic Aneurysm Treated by Double-Balloon Technique and Endovascular Strategy: Case Series. Ann Thorac Cardiovasc Surg 2019; 25:211-214. [PMID: 29491195 PMCID: PMC6698718 DOI: 10.5761/atcs.cr.17-00189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose: Mortality in patients with ruptured abdominal aortic aneurysms (rAAAs) has remained high despite advances in interventions. Endovascular aneurysm repair (EVAR) was recently developed for treatment of rAAAs. In this study, we assessed our endovascular strategy including a double-balloon technique for rAAA. Methods: We analyzed 12 consecutive patients with rAAAs who were treated by our double-balloon technique and endovascular strategy from March 2013 to July 2016. Results: The 30-day and 1-year mortality rates were both 17%. The mean times from admission to arrival at the hybrid operating room, from admission to aortic occlusion, and from admission to completion of EVAR were 46.8, 63.5, and 110.0 minutes, respectively. Conclusion: This study indicates that the herein-described double-balloon endovascular technique is feasible for use in the management of rAAA.
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Affiliation(s)
- Hiroyuki Nakayama
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Taishi Kobayashi
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Nobuhisa Ohno
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Tatsuji Okada
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Go Ueno
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
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17
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Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, ESVS Guidelines Committee, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document reviewers, Björck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57:8-93. [DOI: 10.1016/j.ejvs.2018.09.020] [Citation(s) in RCA: 873] [Impact Index Per Article: 174.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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18
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Hofmeister S, Thomas MB, Paulisin J, Mouawad NJ. Endovascular management of ruptured abdominal aortic aneurysms and acute aortic dissections. VASA 2018; 48:35-46. [PMID: 30407131 DOI: 10.1024/0301-1526/a000760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The management of vascular emergencies is dependent on rapid identification and confirmation of the diagnosis with concurrent patient stabilization prior to immediate transfer to the operating suite. A variety of technological advances in diagnostic imaging as well as the advent of minimally invasive endovascular interventions have shifted the contemporary treatment algorithms of such pathologies. This review provides a comprehensive discussion on the current state and future trends in the management of ruptured abdominal aortic aneurysms as well as acute aortic dissections.
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Affiliation(s)
- Stephen Hofmeister
- 1 McLaren Bay Heart & Vascular, McLaren Bay Region, Bay City, Michigan, USA
| | - Matthew B Thomas
- 1 McLaren Bay Heart & Vascular, McLaren Bay Region, Bay City, Michigan, USA
| | - Joseph Paulisin
- 1 McLaren Bay Heart & Vascular, McLaren Bay Region, Bay City, Michigan, USA
| | - Nicolas J Mouawad
- 1 McLaren Bay Heart & Vascular, McLaren Bay Region, Bay City, Michigan, USA
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19
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Saito J, Tokita T, Takashima R, Kawaguchi J, Midorikawa Y, Noguchi S, Hahisba E, Hirota K. Usefulness of Continuous Renal Replacement Therapy During an Intra-Aortic Balloon Occlusion in Patients With Ruptured Abdominal Aortic Aneurysms. J Cardiothorac Vasc Anesth 2018; 33:2237-2240. [PMID: 30401597 DOI: 10.1053/j.jvca.2018.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Junichi Saito
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - Takaharu Tokita
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Ryo Takashima
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Jun Kawaguchi
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yoko Midorikawa
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Satoko Noguchi
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiji Hahisba
- Division of Intensive Care Unit, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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20
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Jalalzadeh H, van Leeuwen CF, Indrakusuma R, Balm R, Koelemay MJW. Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2018; 68:900-915. [PMID: 30146037 DOI: 10.1016/j.jvs.2018.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/14/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Outcomes after repair of ruptured abdominal aortic aneurysm (RAAA) have improved in the last decade. It is unknown whether this has resulted in a reduction of postoperative bowel ischemia (BI). The primary objective was to determine BI prevalence after RAAA repair. Secondary objectives were to determine its major sequelae and differences between open repair (OR) and endovascular aneurysm repair (EVAR). METHODS This systematic review (PROSPERO CRD42017055920) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. MEDLINE and Embase were searched for studies published from 2005 until 2018. The methodologic quality of observational studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) tool. The quality of the randomized controlled trials (RCTs) was assessed with the Cochrane Collaboration's tool for assessing risk of bias. BI prevalence and rates of BI as cause of death, reoperation, and bowel resection were estimated with meta-analyses with a random-effects model. Differences between OR and EVAR were estimated with pooled risk ratios with 95% confidence intervals (CIs). Changes over time were assessed with Spearman rank test (ρ). Publication bias was assessed with a funnel plot analysis. RESULTS A total of 101 studies with 52,670 patients were included; 72 studies were retrospective cohort studies, 14 studies were prospective cohort studies, 12 studies were retrospective administrative database studies, and 3 studies were RCTs. The overall methodologic quality of the RCTs was high, but that of observational studies was low. The pooled prevalence of BI ranged from of 0.08 (95% CI, 0.07-0.09) in database studies to 0.10 (95% CI, 0.08-0.12) in cohort studies. The risk of BI was higher after OR than after EVAR (risk ratio, 1.79; 95% CI, 1.25-2.57). The pooled rate of BI as cause of death was 0.04 (95% CI, 0.03-0.05), and that of BI as cause of reoperation and bowel resection ranged between 0.05 and 0.07. BI prevalence did not change over time (ρ, -0.01; P = .93). The funnel plot analysis was highly suggestive of publication bias. CONCLUSIONS The prevalence of clinically relevant BI after RAAA repair is approximately 10%. Approximately 5% of patients undergoing RAAA repair suffer from severe consequences of BI. BI is less prevalent after EVAR than after OR.
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Affiliation(s)
- Hamid Jalalzadeh
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands.
| | - Carlijn F van Leeuwen
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Reza Indrakusuma
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Mark J W Koelemay
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
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21
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Borger van der Burg BLS, van Dongen TTCF, Morrison JJ, Hedeman Joosten PPA, DuBose JJ, Hörer TM, Hoencamp R. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg 2018; 44:535-550. [PMID: 29785654 PMCID: PMC6096615 DOI: 10.1007/s00068-018-0959-y] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 04/18/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die before hemorrhage control is achieved. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive surgical or endovascular repair. A systematic review was conducted for the current clinical use of REBOA in patients with hemodynamic instability and to discuss its potential role in improving prehospital and in-hospital outcome. METHODS Systematic review and meta-analysis (1900-2017) using MEDLINE, Cochrane, EMBASE, Web of Science and Central and Emcare using the keywords "aortic balloon occlusion", "aortic balloon tamponade", "REBOA", and "Resuscitative Endovascular Balloon Occlusion" in combination with hemorrhage control, hemorrhage, resuscitation, shock, ruptured abdominal or thoracic aorta, endovascular repair, and open repair. Original published studies on human subjects were considered. RESULTS A total of 490 studies were identified; 89 met criteria for inclusion. Of the 1436 patients, overall reported mortality was 49.2% (613/1246) with significant differences (p < 0.001) between clinical indications. Hemodynamic shock was evident in 79.3%, values between clinical indications showed significant difference (p < 0.001). REBOA was favored as treatment in trauma patients in terms of mortality. Pooled analysis demonstrated an increase in mean systolic pressure by almost 50 mmHg following REBOA use. CONCLUSION REBOA has been used in trauma patients and ruptured aortic aneurysm patients with improvement of hemodynamic parameters and outcomes for several decades. Formal, prospective study is warranted to clarify the role of this adjunct in all hemodynamic unstable patients.
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Affiliation(s)
| | - Thijs T. C. F. van Dongen
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
| | - J. J. Morrison
- R. Adam Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | | | - J. J. DuBose
- Division of Vascular Surgery, David Grant Medical Center, Travis AFB, California, USA
| | - T. M. Hörer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - R. Hoencamp
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
- Division of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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22
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Wang T, Zhao J, Yuan D, Ma Y, Huang B, Yang Y, Zeng G. Comparative effectiveness of open surgery versus endovascular repair for hemodynamically stable and unstable ruptured abdominal aortic aneurysm. Medicine (Baltimore) 2018; 97:e11313. [PMID: 29979402 PMCID: PMC6076075 DOI: 10.1097/md.0000000000011313] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Several observational studies and randomized trials have compared open surgery (OS) and endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). However, none of these studies addressed optimal management of hemodynamically (hd) unstable patients. Our objective was to compare perioperative outcomes in patients undergoing OS vs EVAR for hd-stable and hd-unstable rAAAs.This retrospective study was conducted in West China Hospital from January 2005 to December 2015. Unstable patients were defined as those who have at least 1 of the following: preoperative shock, preoperative transfusion >4 units, preoperative intubation, cardiac arrest, or unconsciousness. Univariable and multivariable logistic regression analyses were performed.Of the 102 patients, 70.6% underwent OS and 29.4% EVAR. About 46.1% were unstable, and for these patients, OS was performed in 70.2% and EVAR in 29.8%. The 30-day mortality was 23.6% (OS, 25.6%; EVAR, 18.8%; P = .585) for hd-stable patients and was 42.6% (OS, 45.5%; EVAR, 35.7%; P = .537) for hd-unstable patients. Patients with OS had longer operative time and more transfusion. Amongst hd-stable patients, OS subgroup had a higher rate of pneumonia (33.3% vs 6.3%, P = .045), longer intensive care unit (ICU) stay (43.2 vs 15.2 hours, P = .02), and length of stay (11.6 vs 8.6 days, P = .041). Among hd-unstable patients, OS subgroup had a longer ICU stay (134.3 vs 63.8 hours, P = .047). Hospitalization costs of OS group were significantly lower than those of EVAR group, regardless of hemodynamic stability.Approximately one-third of patients with rAAA were treated by EVAR at our institution. EVAR may be the preferred approach for anatomically suitable rAAAs. However, patients treated by EVAR had a similar mortality compared with those treated by OS. In addition, OS is not an independent factor for a higher 30-day mortality, and the costs of OS were much cheaper than those of EVAR. Therefore, OS is difficult to replace, especially in developing countries.
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23
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Affiliation(s)
- Jeremy W Cannon
- From the Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and the F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD
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24
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Bath J, Leite JO, Rahimi M, Giglia J, Jain A, Shelton K, Meier GH. Contemporary outcomes for ruptured abdominal aortic aneurysms using endovascular balloon control for hypotension. J Vasc Surg 2017; 67:1389-1396. [PMID: 29248238 DOI: 10.1016/j.jvs.2017.09.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/17/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Ruptured abdominal aortic aneurysm (rAAA) continues to portend significant mortality, despite ruptured endovascular aneurysm repair (rEVAR), enhanced perioperative care, and endovascular balloon control (EBC) for hypotension. We review our academic institution's experience using a protocol of EBC for all hypotensive patients, irrespective of type of repair. METHODS A retrospective review was conducted of 66 cases of rAAA treated at a single academic institution from 2007 to 2016 using EBC for hypotensive patients. Demographics, comorbidities, intraoperative parameters, and clinical outcomes were recorded. Patients were studied with respect to hemodynamic status, rEVAR, or ruptured open aortic repair in the setting of EBC for hypotension. RESULTS rEVAR was performed in 43 patients (65%) and ruptured open aortic repair in 23 patients (35%). rAAA was treated in 51 men (77%). Mean rAAA size was 7.6 mm, and mean age of the patients was 73 years. Perioperative survival was 82%. Overall survival at 30 days, 1 year, and 5 years was 71%, 65%, and 52%. Blood transfusion and severe hypotension were significant predictors of mortality at 30 days on multivariable analysis (odds ratio of 1.2 [P = .08] and 39 [P = .03], respectively). Severe hypotension was defined as a mean arterial blood pressure <65 mm Hg and vasopressor use and was present in 59% of the cohort. Normotension was defined as an absence of these conditions and was present in 12%, with 29% of patients exhibiting moderate hypotension. There was no difference in 30-day survival between normotensive and moderately hypotensive patients. The 30-day survival for severely hypotensive patients was 61% vs 85% for moderately hypotensive patients (P = .003), with a significant difference between groups that persisted at 1 year (85% vs 51%; P = .008) and 5 years (66% vs 51%; P = .017). CONCLUSIONS Good midterm outcomes for moderately hypotensive and normotensive patients can be obtained using an EBC protocol for hypotension with a regionalized transport system directly to the operating room. Severely hemodynamically unstable rAAA patients still pose a significant challenge despite mitigation of hypotension by EBC, suggesting that survival may be compromised by factors other than hypotension alone. We still advocate for the use of EBC for all hypotensive patients as part of a defined rAAA protocol before definitive repair.
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Affiliation(s)
- Jonathan Bath
- Division of Vascular Surgery, University of Missouri Hospital & Clinics, Columbia, Mo.
| | - Jose O Leite
- Division of Vascular Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Maham Rahimi
- Division of Vascular Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Joseph Giglia
- Division of Vascular Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Amit Jain
- Division of Vascular Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Kyla Shelton
- Division of Vascular Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - George H Meier
- Division of Vascular Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
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25
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Embolization of a Previously Excluded Symptomatic Internal Iliac Aneurysm Through the Iliac Vein. Cardiovasc Intervent Radiol 2017; 40:1954-1957. [PMID: 28681223 DOI: 10.1007/s00270-017-1737-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
Abstract
A 69-year-old man was referred urgently for a 58-mm enlarging painful right internal iliac artery (IIA) aneurysm. Since exclusion through proximal IIA coverage and distal IIA branches embolization had been previously performed, aneurysm sac puncture through the iliac vein was decided. The ipsilateral common femoral vein was antegradely punctured, and a 16.5 G Ross modified Colapinto needle from a transjugular intrahepatic access set was used to puncture the sac and fill the aneurysm with coils. Embolization of an IIA aneurysm through the iliac vein may represent an alternative when prior IIA aneurysm exclusion has been performed.
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26
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Aoki C, Kondo N, Saito Y, Taniguchi S, Fukuda W, Daitoku K, Fukuda I. Improved Outcomes for Ruptured Abdominal Aortic Aneurysms Using Integrated Management Involving Endovascular Clamping, Endovascular Replacement, and Open Abdominal Decompression. Ann Vasc Dis 2017; 10:22-28. [PMID: 29034016 PMCID: PMC5579800 DOI: 10.3400/avd.oa.16-00110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/10/2017] [Indexed: 11/13/2022] Open
Abstract
Objective: Endovascular repair has become the treatment of choice for ruptured abdominal aortic aneurysms (RAAAs). To improve surgical outcomes, preoperative management is important. In 2011, we introduced integrated management, which involves endovascular aneurysm repair, stabilization of hemodynamics by endovascular clamping, and open abdominal decompression to address abdominal compartment syndrome (ACS). Methods: To evaluate the efficacy of this management strategy, 62 patients who had undergone emergency surgery for an RAAA were analyzed retrospectively: group A (n=39), where an old strategy was used, and group B (n=23), where integrated management was introduced. Patient characteristics and 30-day mortality rates were compared between the two groups. Results: The average patient age was 67.7 years and 74.7 years for groups A and B, respectively (P=0.032). Group B patients required more frequent use of vasopressors (P=0.035). Other patient characteristics did not differ between the two groups. The duration of surgery was significantly shorter in group B than in group A (P=0.001). The total amount of transfused blood did not differ between the two groups. No patients showed symptoms of ACS. Early mortality rates were 12.8% and 8.7% in groups A and B, respectively. The number of wound infections was significantly fewer in group B than in group A. Conclusion: Although group B patients were significantly older and had a higher rate of vasopressor use, early mortality was improved in both groups. Morbidity was significantly better in group B with respect to the duration of surgery and number of wound infections than in group A.
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Affiliation(s)
- Chikashi Aoki
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Norihiro Kondo
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yoshiaki Saito
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Satoshi Taniguchi
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Wakako Fukuda
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kazuyuki Daitoku
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Ikuo Fukuda
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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27
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Uchino H, Tamura N, Echigoya R, Ikegami T, Fukuoka T. "REBOA" - Is it Really Safe? A Case with Massive Intracranial Hemorrhage Possibly due to Endovascular Balloon Occlusion of the Aorta (REBOA). AMERICAN JOURNAL OF CASE REPORTS 2016; 17:810-813. [PMID: 27799653 PMCID: PMC5091201 DOI: 10.12659/ajcr.900267] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Patient: Female, 86 Final Diagnosis: Polytrauma Symptoms: Shock Medication: — Clinical Procedure: Resuscitative endovascular balloon occlusion of the aorta Specialty: Orthopedics and Traumatology
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Affiliation(s)
- Hayaki Uchino
- Department of Emergency Medicine and Surgery, Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Japan
| | - Nobuichiro Tamura
- Department of Emergency Medicine and Surgery, Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Japan
| | - Ryosuke Echigoya
- Department of Emergency Medicine and Surgery, Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Japan
| | - Tetsunori Ikegami
- Department of Emergency Medicine and Surgery, Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toshio Fukuoka
- Department of Emergency Medicine and Surgery, Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Japan
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Guo B, Dong Z, Fu W, Guo D, Xu X, Chen B, Jiang J, Shi Z. Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysms in a Chinese Population. Ann Vasc Surg 2016; 36:74-84. [DOI: 10.1016/j.avsg.2016.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 02/26/2016] [Accepted: 03/06/2016] [Indexed: 11/27/2022]
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Chao CS, Tsai CS, Wang YH, Liu YH, Chen JM, Chang YP, Chin HK, Chien ST, Lee TM, Yang SC. Original Research: Porcine model for observing changes due to ischemia/reperfusion injury secondary to intra-abdominal endovascular balloon occlusion. Exp Biol Med (Maywood) 2016; 241:1834-43. [PMID: 27216599 DOI: 10.1177/1535370216648802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 04/09/2016] [Indexed: 12/13/2022] Open
Abstract
Compared with conventional aortic cross-clamping, endovascular balloon occlusion (EBO) is a valuable strategy in unstable ruptured abdominal aorta aneurysm patients; however, it is unclear how long the balloon may remain safely inflated. Using a porcine model, we evaluated the influence of different EBO time periods on intra-abdominal pressure (IAP) and the association between various pathophysiologic indicators and reperfusion time. Twelve healthy three-month-old domestic piglets were subjected to ischemia/reperfusion injury using EBO within the abdominal aorta. Animals were grouped as A, B, and C based on 30, 60, or 120 min of ischemic time, respectively. Changes in IAP, hemodynamic data, respiratory and renal function, and histology after reperfusion were compared with baseline measurements. All pigs gradually developed intra-abdominal hypertension after ischemia/reperfusion injury. IAP increased significantly after 4 h of reperfusion in all three groups (all P < 0.001) with maximal IAP reaching > 22 mmHg in 10 pigs. However, no significant intergroup differences were found. Cardiac output remained stable, but mixed venous oxygen saturation decreased significantly at 4 h after reperfusion (P < 0.05). The pH decreased significantly at 10 min in all three groups (all P < 0.001). Histological changes in the small intestine, lung, and kidney occurred secondary to aortic ischemia; however, no significant differences were noted between groups (P > 0.05). EBO within the abdominal aorta induced ischemia/reperfusion injury which led to intra-abdominal hypertension, pathological changes within multiple organs, and decreased mixed venous oxygen saturation after only 30 min of abdominal aortic ischemia.
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Affiliation(s)
- Chia-Sheng Chao
- Division of Cardiovascular Surgery, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung 80284, Taiwan, R.O.C. School of Pharmacy, College of Pharmacy, Kaohsiung Medical University, Kaohsiung 80708, Taiwan, R.O.C. Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan, R.O.C
| | - Chien-Sung Tsai
- Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan, R.O.C
| | - Yao-Horng Wang
- Department of Nursing, Yuanpei University, Hsinchu City 30015, Taiwan, R.O.C
| | - Yuan-Hao Liu
- Division of Cardiovascular Surgery, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung 80284, Taiwan, R.O.C
| | - Jian-Ming Chen
- Division of Cardiovascular Surgery, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung 80284, Taiwan, R.O.C
| | - Yee-Phoung Chang
- Division of Cardiovascular Surgery, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung 80284, Taiwan, R.O.C
| | - Hsien-Kuo Chin
- Division of Cardiovascular Surgery, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung 80284, Taiwan, R.O.C
| | - Shang-Tao Chien
- Department of Pathology, Kaohsiung Armed Forces General Hospital, Kaohsiung 80284, Taiwan, R.O.C
| | - Tai-Ming Lee
- Department of Pathology, Kaohsiung Armed Forces General Hospital, Kaohsiung 80284, Taiwan, R.O.C
| | - Shyh-Chyun Yang
- School of Pharmacy, College of Pharmacy, Kaohsiung Medical University, Kaohsiung 80708, Taiwan, R.O.C.
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Sever A, Rheinboldt M. Unstable abdominal aortic aneurysms: a review of MDCT imaging features. Emerg Radiol 2016; 23:187-96. [PMID: 26797025 DOI: 10.1007/s10140-015-1374-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/29/2015] [Indexed: 11/27/2022]
Abstract
Abdominal aortic aneurysms are commonly encountered during abdominal CT imaging, and size-based parameters for surgical or endovascular repair are well established. Aneurysms greater than 5 cm in diameter are recognized as representing an increased rupture risk and meriting intervention. Increasingly, additional interest has been generated in recognizing imaging features which may herald instability and portend a higher chance for potentially catastrophic rupture. This article will review and illustrate such signs, including hyperattenuation of mural thrombus, rapid expansion, low thrombus to lumen ratio, intimal calcification disruption, posterior mural draping, and saccular outpouching. Other features of complicated abdominal aneurysms including perianeurysmal inflammation, aortocaval and aortoenteric fistula formation will also be addressed. Heightened awareness of these features and their prognostic implications, as well as timely communication with the clinical service, is critical for the interpreting radiologist.
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Affiliation(s)
- Alysse Sever
- Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
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31
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Pereira BMT, Chiara O, Ramponi F, Weber DG, Cimbanassi S, De Simone B, Musicki K, Meirelles GV, Catena F, Ansaloni L, Coccolini F, Sartelli M, Di Saverio S, Bendinelli C, Fraga GP. WSES position paper on vascular emergency surgery. World J Emerg Surg 2015; 10:49. [PMID: 26500690 PMCID: PMC4618918 DOI: 10.1186/s13017-015-0037-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 02/24/2015] [Indexed: 12/18/2022] Open
Abstract
Trauma, both blunt and penetrating, is extremely common worldwide, as trauma to major vessels. The management of these patients requires specialized surgical skills and techniques of the trauma surgeon. Furthermore few other surgical emergencies require immediate diagnosis and treatment like a ruptured abdominal aortic aneurysm (rAAA). Mortality of patients with a rAAA reaches 85 %, with more than half dying before reaching the hospital. These are acute events demanding immediate intervention to save life and limb and precluding any attempt at transfer or referral. It is the purpose of this position paper to discuss neck, chest, extremities and abdominal trauma, bringing to light recent evidence based data as well as expert opinions; besides, in this paper we present a review of the recent literature on rAAA and we discuss the rationale for transfer to referral center, the role of preoperative imaging and the pros and cons of Endoluminal repair of rAAA (REVAR) versus Open Repair (OR).
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Affiliation(s)
- Bruno Monteiro T. Pereira
- />Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | | | - Fabio Ramponi
- />Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, NSW Australia
| | - Dieter G. Weber
- />Department of Traumatology, John Hunter Hospital, Newcastle, NSW Australia
| | | | - Belinda De Simone
- />Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy
| | - Korana Musicki
- />Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, NSW Australia
| | - Guilherme Vieira Meirelles
- />Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Fausto Catena
- />Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy
| | - Luca Ansaloni
- />Department of general and emergency surgery, Papa Giovanni XIII Hospital, Bergamo, Italy
| | - Federico Coccolini
- />Department of general and emergency surgery, Papa Giovanni XIII Hospital, Bergamo, Italy
| | | | | | - Cino Bendinelli
- />Department of Traumatology, John Hunter Hospital, Newcastle, NSW Australia
| | - Gustavo Pereira Fraga
- />Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
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Desgranges P, Kobeiter H, Katsahian S, Bouffi M, Gouny P, Favre JP, Alsac J, Sobocinski J, Julia P, Alimi Y, Steinmetz E, Haulon S, Alric P, Canaud L, Castier Y, Jean-Baptiste E, Hassen-Khodja R, Lermusiaux P, Feugier P, Destrieux-Garnier L, Charles-Nelson A, Marzelle J, Majewski M, Bourmaud A, Becquemin JP. Editor's Choice – ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus): A French Randomized Controlled Trial of Endovascular Versus Open Surgical Repair of Ruptured Aorto-iliac Aneurysms. Eur J Vasc Endovasc Surg 2015; 50:303-10. [DOI: 10.1016/j.ejvs.2015.03.028] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 03/12/2015] [Indexed: 12/15/2022]
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The Impact of Aortic Occlusion Balloon on Mortality After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: A Meta-analysis and Meta-regression Analysis. Cardiovasc Intervent Radiol 2015; 38:1425-37. [DOI: 10.1007/s00270-015-1132-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 04/15/2015] [Indexed: 12/11/2022]
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