Successful Open Surgical Repair and Postoperative Complications for Ruptured Abdominal Aortic Aneurysm Transferred with Intra-aortic Balloon Occlusion Catheter / 日本心臓血管外科学会雑誌

A 74-year old man, presented with dyspnea following acute abdominal pain, was admitted to an initial hospital. The plain computed tomography (CT) scan revealed a ruptured abdominal aortic aneurysm (AAA). Emergency insertion of intra-aortic balloon occlusion (IABO) catheter was carried out due to his unstable hemodynamic condition. The patient was transferred to our hospital after surgical consultation. Open surgical repair was carried out, and massive retroperitoneal hematoma and excessive bowel edema made it difficult to close the abdomen primarily. Delayed closure following Open Abdomen Management (OAM) was effective.

A Case of Ruptured Abdominal Aortic Aneurysm Induced by a Hard Blow to the Abdomen / 日本心臓血管外科学会雑誌

A 77-year-old man was transferred to our hospital with a complaint of a sudden abdominal pain after receiving a hard blow to the abdomen. Contrast-enhanced CT revealed rupture of the abdominal aortic aneurysm with a massive retroperitoneal hematoma. Because of severe hemorrhagic shock, he underwent graft replacement with a woven bifurcated graft through a median laparotomy on an emergent basis. His postoperative course was uneventful and now he is doing well 3 years after surgery. Most blunt abdominal aortic injuries are caused by high-energy trauma, such as motor vehicle collisions and fall injuries. Although body blow is considered as a low-energy trauma, abdominal aortic injury could be caused in patients with an abdominal aortic aneurysm.

Early Abdominal Closure Achieved through Retroperitoneal Hematoma Evacuation after Endovascular Aneurysm Repair and Open Abdominal Management for a Ruptured Aortic Aneurysm / 日本心臓血管外科学会雑誌

Abdominal compartment syndrome (ACS) is an important postoperative complication of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (rAAA). Open abdominal management (OAM) has been reported to be effective in EVAR ; however, only a limited number of reports are available on when and how to close the abdomen. Here we report a case of early abdominal wall closure achieved through the combined use of retroperitoneal hematoma evacuation after EVAR and OAM for rAAA. The patient was a 79-year-old woman who underwent EVAR for rAAA on an emergency basis. She developed ACS after EVAR and underwent OAM. Four days after surgery, a decrease in intraabdominal pressure was confirmed, and subsequent contrast-enhanced computed tomography revealed the absence of an endoleak ; retroperitoneal hematoma evacuation was performed, during which the abdominal wall was closed. The postoperative course was good, and the patient was discharged. Early closure of the abdomen may be possible by concomitant retroperitoneal hematoma evacuation after EVAR and OAM for rAAA.

Late open conversion in ruptured abdominal aortic aneurysm after endovascular repair / Conversão tardia para cirurgia aberta em um aneurisma roto da aorta abdominal após reparo endovascular

Abstract Despite technological advances, the long-term outcomes of endovascular aortic aneurysm repair (EVAR) are still debatable. Although most endograft failures after EVAR can be corrected with endovascular techniques, open conversion may still be required. A 70-year-old male patient presented at the emergency unit with abdominal pain. Twice, in the third and fourth years after the first repair, a stent graft had been placed over a non-adhesive portion of the stent graft due to type Ia endoleaks. In the most recent admission, a CT scan showed type III endoleak and ruptured aneurysm sac. On this occasion the patient underwent late open conversion. The failure was repaired with total preservation of the main endovascular graft body and interposition of a bifurcated dacron graft. This case demonstrates that lifelong radiographic surveillance should be considered in this subset of patients. Late open conversion following EVAR of ruptured abdominal aortic aneurysms can be performed safely.

Resumo Apesar dos avanços tecnológicos, os desfechos de longo prazo do reparo endovascular de aneurismas da aorta abdominal (endovascular aortic aneurysm repair - EVAR) ainda são objeto de debate. Embora a maioria das falhas de endoenxerto após EVAR possam ser corrigidas com técnicas endovasculares, conversão para cirurgia aberta ainda pode ser necessária. Um paciente de 70 anos de idade, do sexo masculino, apresentou-se no serviço de emergência com dor abdominal. Duas vezes, dois e quatro anos após o primeiro reparo, um enxerto foi colocado sobre uma porção não adesiva do stent devido a endoleak tipo Ia. Na mais recente hospitalização, a tomografia computadorizada mostrou endoleak tipo III e ruptura de um saco aneurismático. Nesta ocasião, o paciente foi submetido a conversão tardia para cirurgia aberta. A falha foi tratada com preservação total do corpo principal do enxerto endovascular e interposição de um enxerto tipo Dacron bifurcado. Este caso demonstra que a vigilância radiográfica ao longo de toda a vida deveria ser considerada nesse subgrupo de pacientes. Conversão tardia para cirurgia aberta após EVAR de aneurismas rotos da aorta abdominal pode ser realizada com segurança.

Abdominal Vacuum-Assisted Closure for Secondary Abdominal Fascial Closure into Open Abdomen after Surgical Repair for Ruptured Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

Secondary abdominal fascial closure by abdominal vacuum-assisted closure (VAC) therapy is required for abdominal organ protection and prevention of infection due to abdominal compartment syndrome (ACS) developing after the surgery. In this paper, we present our experience with abdominal VAC therapy for two cases that required open abdominal management after surgical repair for ruptured abdominal aortic aneurysm, with favorable outcomes. Case 1 involved a 72-year-old man who underwent endovascular aortic repair for ruptured abdominal aortic aneurysm. Abdominal VAC therapy was started after decompression laparotomy because he developed ACS immediately after surgery. Secondary abdominal fascial closure was performed on day 4 postoperatively, and he had no complications. Case 2 involved a 71-year-old man who underwent emergency Y-graft replacement for ruptured abdominal aortic aneurysm. We considered secondary abdominal fascial closure necessary because of prominent intestinal edema and massive retroperitoneal hematoma, and performed abdominal VAC therapy. We changed the VAC system on day 4, postoperatively and performed secondary abdominal fascial closure on day 7, postoperatively. Abdominal VAC therapy is considered effective and safe for patients requiring secondary abdominal fascial closure after abdominal surgery.

A Case of Saved Transplanted Kidney by Axillo-Common Iliac Perfusion for Replacement of Ruptured Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 58-year-old man underwent renal transplantation 26 years previously and had been treated with immunosuppressive drugs. He presented at the local hospital with backache symptoms during the waiting period prior to repair of an abdominal aortic aneurysm. Computed tomography revealed a retroperitoneal hematoma around the abdominal aortic aneurysm. He was admitted to our hospital and emergency straight graft replacement was performed. After clamping of the aorta, we performed axillo-common iliac perfusion to protect the transplanted kidney. The patient recovered without transplanted kidney dysfunction.

Efficacy of the Amplatzer Vascular Plug in a Patient Undergoing EVAR for Ruptured Aortoiliac Aneurysm / 日本心臓血管外科学会雑誌

The purpose of this case report was to discuss the efficacy of The Amplatzer Vascular Plug (AVP) in endovascular aneurysm repair (EVAR) for ruptured aortoiliac aneurysm. A 73-year-old man was referred to our institution with a diagnosis of ruptured abdominal aortic aneurysm (rAAA) by CT scan. The CT scan showed an rAAA of 70 mm (Fitzgerald classification 3) and a right common iliac aneurysm of 30 mm. The patient was immediately transferred from the ER to the OR and treated with EVAR in combination with occlusion of the right internal iliac artery (IIA) using AVP. The total procedural time was 138 min. The patient recovered uneventfully after the operation with an ICU stay of 2 days and was discharged 9 days after the onset. EVAR has been recognized as a therapeutic option for rAAA in Japan. However, it is not yet been generally adopted as a first-line therapy for rAAA accompanied with iliac aneurysm because of the necessity to occlude IIA. The conventional method with coils to induce thrombosis of IIA is unsuitable for patients in a critical situation for the time required and the difficulty in precise placement. AVP is a nitinol-based self-expanding cylindrical device that is used for arterial embolization. AVP allows assured embolization of IIA in a shorter procedural time, which is essential in an urgent situation. Although AVP is still under post-market surveillance in Japan and only available in limited institutions, the usage of AVP should be considered as an adjunctive procedure in EVAR for rAAA and may expand the limits of endovascular treatment for rAAA.

Surgical treatment of ruptured abdominal aortic aneurysm / 国际外科学杂志

Objective To evaluate surgical management of ruptured abdominal aortic aneurysm (RAAA).Methods Clinical data of 36 RAAA patients undergoing emergent graft replacement or endovascular aortic repair (EVAR) from May 2002 to July 2013 were retrospectively analyzed.25 and 21 patients were associated with hypertension and chronic obstructive pulmonary disease respectively.33 patients were treated with graft replacement.3 patients received endovascular treatment and 1 patient converted to open surgery.Results Perioperative death occurred in 3 patients including severe hemorrhagic shock in 1 patient,cardiac arrest in 1 patient and multiple organ failure in 1 patient.During follow up for 3 to 61 months,no operation related complication,such as artificial graft infection happened.Conclusions Emergent operation including open surgery and EVAR is crucial for RAAA treatment.Early diagnosis,excellent operative techniques and effective perioperative management are measures conducive to lowering the mortality rate of RAAA.

Successful Management in the Case of Mesenteric Ischemia Following EVAR for Ruptured Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

We report a case of successfully treated mesenteric ischemia following emergency endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysm (r-AAA). A 79-year-old man, who had received hemodialysis for 5 years for diabetic nephropathy, presented with sudden onset abdominal pain. Contrast-enhanced computed tomography revealed an rAAA with a 60-mm diameter in the infrarenal abdominal aorta. Emergency EVAR was performed. After completion of stent graft placement, intraoperative angiogram revealed serious imaging delay of the superior mesenteric artery. An emergency saphenous vein bypass was performed from the right external iliac artery to the ileocolic artery. The postoperative course was uneventful, and there has been no evidence of endoleak or enlargement of aneurysm diameter during the follow-up period of 2 years.

Mejores resultados en ruptura de aneurismas de aorta abdominal manejados con reparación endovascular: Algoritmo sugerido / Improved outcome of ruptured abdominal aortic aneurysms managed with endovascular repair: A suggested algorithm

Antecedentes: El propósito de este estudio es comparar la morbilidad y la mortalidad tanto de la reparación abierta (RA) como endovascular de la ruptura del aneurisma aórtico abdominal(rAAAs); y de presentar un algoritmo para el tratamiento y evaluaciones de la tomografía computarizada (CT) para determinar el uso de un balón oclusivo supra-celíaco. Métodos: Una revisión gráfica retrospectiva se realizó de los rAAAs tratados ya sea con reaparicióna cielo abierto (RA), ya sea con reparación aórtica endovascular (EVAR) entre junio de 1998 y junio de 2009. Se informaron las co-morbilidades, los datos peri-procedimientos y tanto la morbosidad como la mortalidad. Las TC se revisaron desde el uso inicial del balón oclusivo (Marzo de 2001) a fin de evaluar el hematoma retroperitoneal. Se desarrolló un algoritmo para determinarcuándo el balón oclusivo se debería implementar. El test exacto de Fisher, el t-test, y el test log rank fueron los que se utilizaron para el análisis estadístico.Resultados: Entre junio de 1998 y junio de 2009, 105 pacientes, 75 (71.4%) hombres, edad promedio de 74 años (rango 47-93) presentaron un rAAA y a 69 (65.2%) se les realizó la reparación a cielo abierto. 87 pacientes (82.9%) fueron sintomáticos y 25 (23.8%) tenían un AAA conocido. El tiempo medio transcurrido entre el diagnóstico y el tratamiento fue de 5 a 6 horas, 4.5 horas para la RA y de 8 horas para EVAR. El test rank log mostró una mejoría en la supervivencia con EVARa pesar del tiempo promedio más prolongado desde el diagnóstico al tratamiento. (p=0.02). Se administraron casi tres veces más concentrados de hematíes en el cohorte de reparación a cielo abierto (RA), 6.3 unidades y en EVAR 2.2 unidades. Se utilizaron vasopresores perioperatorios en el 57.1% de los casos, dos veces más en la RA, 69.6%, que con EVAR 33.3%. Se utilizó el balón oclusivo aórtico en el 27,6% de los casos, dos veces más frecuente en RA que en EVAR (41,7% verus 20,3%)...

Antecedentes: O propósito deste estudo é comparar a morbilidade e a mortalidade tanto da reparação aberta (RA) quanto endovascular, utilizadas no tratamento da ruptura do aneurisma aórtico abdominal (rAAAs); e de apresentar um algorítmo para o tratamento e avaliações da tomografiacomputarizada (CT) para assim determinar o uso de um balão para oclusão supra-celíaca. Métodos: Realizou-se uma revisão gráfica retrospectiva das rAAAs tratadas, seja com reparação a céu aberto (RA), ou com reparação aórtica endovascualar (EVAR) entre os meses de junho de1998 e junho de 2009. Informaram-se as comorbilidades, os dados periprocedimentos , além da morbidade e mortalidade. As TC foram revisadas desde o uso inicial do balão oclusivo (março de 2001) com o objetivo de avaliar o hematoma retroperitoneal. Desenvolveu-se um algorítmo para determinar quando o balão oclusivo deveria ser implementado. Para esta análise estatística, utilizaram-se o teste exato de Fisher, o t-test, e o test log Rank. Resultados: Entre junho de 1998 ejunho de 2009, 105 pacientes, 75 (71.4%) homens, com média de idade de 74 anos (média 47-93) apresentaram uma rAAA e em 69 (65.2%) realizou-se uma reparação a céu aberto. 87 pacientes (82.9%) foram sintomáticos e 25 (23.8%) tinham um AAA conhecido. O tempo médio transcorrido entre o diagnóstico e o tratamento foi de 5 a 6 horas, 4.5 horas para a RA e de 8 horas para aEVAR. O test rank log mostrou uma melhoria na sobrevivência com a EVAR, apesar do tempo médio mais prolongado do diagnóstico ao tratamento. (p=0.02). Administraram-se quase três vezes mais concentrados de hematies no grupo de reparação a céu aberto (RA), 6.3 unidades e no grupo EVAR, 2.2 unidades. Utilizaram-se vasopressores perioperatórios em 57.1% dos casos: 33.3% com EVAR e 69.6% com a RA, ou seja, duas vezes a mais. Utilizou-se o balão oclusivo aórtico em 27.6 % dos casos, duas vezes mais frequente nos casos da RA do que nos de EVAR (41.7 % versus 20.3%)...

Background: The purpose of this study is to compare morbidity and mortality of open and endovascular repair of ruptured abdominal aortic aneurysms (rAAAs); and present a treatment algorithm and assessment of computer tomography (CT) to determine usage of a supra-celiac occlusive balloon.Methods: Restrospective chart review was done of rAAAs treated with open (OR) or endovascular aortic repair (EVAR) between June 1998 and June 2009. Comorbidities, periprocedural data, and postoperative morbidity and mortality were recorded. CTs were reviewed from the initial use of the occlusive balloon (March 2001) to assess the retroperitoneal hematoma. An algorithm was developed determining when the occlusive balloon should be implemented. Fisher’s exact test, and log rank test were used for statistical analysis. Results: Between June 1998 and June 2009, 105 patients, 75 (71.4%) males, mean age of 74.0 years (range 47-93), presented with a rAAA and 69 (65.2%) received open repair. Eighty-seven patients(82.9%) were symptomatic and 25 (23.8%) had a known AAA. Mean time elapsed between diagnosis to treatment was 5.6 hours, 4.5 hours for OR and 8.0 hours for EVAR. Log rank test showsimproved survivability with the EVAR despite higher mean time from diagnosis to intervention (p=0.02). Nearly three times as much packed red blood cells were given in open repair cohort, O,6.3 units and EVAR, 2.2 units. Perioperative vasopressors were used in 57.1% of total cases, more than 2 times as often for O, 69.6%, and EVAR, 33.3%. Aortic occlusive balloon was used in 27.6% of cases, twice as often in EVAR (41.7% versus 20.3%)...

Factors Affecting Mortality Rate of Ruptured Abdominal Aortic Aneurysm

PURPOSE: Ruptured abdominal aortic aneurysm (RAAA) still carries high operative mortality, despite improvements in anesthesia, intensive perioperative monitoring, surgical methods. The authors reported on the factors affecting mortality rate of the RAAA providing clues for successful operations. METHODS: Charts of the patients, who received operations for RAAAs at Asan Medical Center from July 1990 to July 1998 were reviewed to find out whether there is a difference between survival group and fatal group. RESULTS: Multivariate statistical analysis of factors between survival group (12 patients) and fatal group (7 patients) showed that preoperative loss of consciousness, cardiopulmonary resuscitation, and intraperitoneal free rupture were the factors affecting poor prognosis. Improvement in survival was also noted in patients who were treated in latter period (since January 1997) when autotransfusion using the cell saver and circulatory monitoring with Swan-Ganz cathter were introduced. Other risk factors were similar between the earlier group (8 patients) and latter group (11 patients). CONCLUSION: Rapid and accurate diagnosis of RAAA and timely transfer to the operating room for laparotomy is cleary paramount, and this can decrease the mortality of RAAA.

Factors Affecting Mortality Rate of Ruptured Abdominal Aortic Aneurysm

PURPOSE: Ruptured abdominal aortic aneurysm (RAAA) still carries high operative mortality, despite improvements in anesthesia, intensive perioperative monitoring, surgical methods. The authors reported on the factors affecting mortality rate of the RAAA providing clues for successful operations. METHODS: Charts of the patients, who received operations for RAAAs at Asan Medical Center from July 1990 to July 1998 were reviewed to find out whether there is a difference between survival group and fatal group. RESULTS: Multivariate statistical analysis of factors between survival group (12 patients) and fatal group (7 patients) showed that preoperative loss of consciousness, cardiopulmonary resuscitation, and intraperitoneal free rupture were the factors affecting poor prognosis. Improvement in survival was also noted in patients who were treated in latter period (since January 1997) when autotransfusion using the cell saver and circulatory monitoring with Swan-Ganz cathter were introduced. Other risk factors were similar between the earlier group (8 patients) and latter group (11 patients). CONCLUSION: Rapid and accurate diagnosis of RAAA and timely transfer to the operating room for laparotomy is cleary paramount, and this can decrease the mortality of RAAA.