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R9 > Chapter 74 - Ruptured AAA > Flashcards

Chapter 74 - Ruptured AAA Flashcards

1
Q

Causes of symptoms in non-ruptured AAA

A

1) Acute expansion
2) Intramural hemorrhage
3) Wall degeneration
4) bleeding into thrombus

Preludes rupture

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2
Q

Bahnson 1953

A

First successful RAAA repair with homograft

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3
Q

Cooley + DeBakey 1954

A

Treated 6 patients with 50% survival

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4
Q

Hopkinson 1994

A

First EVAR in rupture

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5
Q

Trend of death due to RAAA over time

A

decrease mortality

Male mortality decreased more than female

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6
Q

Causes of decline in RAAA mortality

A

1) decrease smoking
2) better cardiovascular risk factor control
3) increase EVAR and repair of elders at risk
4) screening programs

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7
Q

Mortality post-rupture surgery

A

31.6%

US 41.6%
UK 41.8%

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8
Q

Percent of ruptures offered repair in US vs UK

A

80% US

58% UK

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9
Q

Post-op mortality causes

A

1) hemorrhagic shock

2) reperfusion injury

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10
Q

Wall strength in pressure measurements

A 
Normal = 121 N/cm2
AAA = 65 N/cm2
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11
Q

Laplace’s Law

A

Tension proportional to radius and pressure

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12
Q

Hot spots in wall weakness

A

localized MMP activity with local weakening

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13
Q

Typical weakest spot in aortic aneurysm

A

Posterior wall

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14
Q

Martin 1965 on theory of wall thrombus

A

Wall thrombus prevent nutrition transfer therefore weaker wall

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15
Q

Schurink on wall thrombus and pressure

A

Thrombus does not decrease pressure

Tested using transducers during OAAA

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16
Q

Vorp on wall thrombus

A

Causes local hypoxia resulting in

1) neovascularization
2) inflammation
3) wall thinning
4) increase collagenase –> less elastin and collagen

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17
Q

% of ruptures that occur at site of mural thrombus

A

80%

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18
Q

Classic triad of RAAA

A

1) pulsatile mass
2) hypotension
3) abdominal/back pain

9% in mis diagnosed group
34% in correctly diagnosed group

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19
Q

Rate of accurate diagnosis of RAAA upon first physician

A

23%

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20
Q

Rate of incorrect diagnosis of RAAA

A

16-60%

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21
Q

Common mis diagnosis of RAAA

A

1) renal colic
2) perforated viscus
3) diverticulitis
4) GI hemorrhage
5) ischemic bowel

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22
Q

US accuracy to identify RAAA

A

51%

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23
Q

Aortocaval fistula sign

A

1) new onset CHF
2) increase IJ pressure
3) loud new bruit/thrill
4) pulsatile mass

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24
Q

RAAA sign on plain X-RAY

A

1) large calcified wall 65%

2) loss of psoas shadow 75%

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25
Q

CT scan for RAAA in terms of sen/spe, ppv/npv

A

77% SEN
100% SPE
100% PPV
89% NPV

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26
Q

Time to death from onset of symptomsin ruptures natural course

A

16 hours median

13% died within first 2 hours of hospital admission

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27
Q

Does getting a CT affect mortality of RAAA

A

no

shown by IMPROVE

28
Q

Does transfer to centre with vascular improve outcome

A

yes

shown by US NIS

29
Q

Problem with aggressive resuscitation in RAAA

A

1) increase BP
2) increase hemorrhage
3) hemodilution
4) coagulopathy
5) hypothermia
6) acidosis

30
Q

Permissive hypotension goals

A

1) maintain consciousness
2) minimize organ ischemia
3) prevent ST depression
4) SBP 70-80 (IMPROVE showed better survival when it’s at least 70)

31
Q

Proportion of RAAA suitable for EVAR

A

47-67%

32
Q

Neck length relationship to RAAA mortality

A

inversely proportional

15mm increase neck will drop mortality by 20% (IMPROVE)

33
Q

Balloon occlusion technique

A

Insert 12-16Fr sheath that’s 45cm length with a compliant balloon

34
Q

Balloon vs clamp for proximal control on intraop mortality

A

19% vs 34%

in hospital mortality is however the same

35
Q

Anesthetic type in mortality

A

Local better than general (IMPROVE)

36
Q

ABI vs AUI in RAAA mortality

A

similar outcome

37
Q

Cell save: pRBC ratio that’s been shown to reduce mortality

A

Ratio > 1

more cell saver better

38
Q

Venous anomaly in OAAA encountered

A

1) Retroaortic renal vein 1-3%
2) Circum aortic renal vein 0.5-1.5%
3) left sided IVC 0.15-0.5%
4) Duplicate IVC 0.4-3%

39
Q

Mannitol dose

A

3-5 ml/kg

40
Q

Rate of unclosable abd after RAAA

A

25-30%

41
Q

Local complications after RAAA treatment

A

1) Coagulopathy and bleed 12-14%
2) access bleed/thrombosis 7-10%
3) colon ischemia 26% Gr 1-2; 10% Gr3
4) Abdominal compartment syndrome 8% total; 21% in EVAR
5) Spinal ischemia: 1.2% OSR, 0.5-11.5 EVAR

42
Q

Risk of ischemic colitis in different types of open repair and EVAR

A

OSR 38%
Tube 4%
ABI 2.7%
ABF 22%

EVAR 23%

43
Q

Abdominal compartment syndrome definition and when to treat

A

> 20 mmhg with organ failure

Decompress if > 25 mmHg

44
Q

How to measure abdominal compartment pressure

A

Instill 50-100 ml fluid then zero at pubic symphysis

45
Q

Systemic complication

A

1) Cardiac arrest 20%; mortality 81-100%
2) MI 15-20%; mortality 17-66%
3) CHF 20%; mortality 40%
4) troponitis 55%; mortality 40.3%
5) respiratory: 35.9% OSR, 28.5% EVAR
6) trach 9.9% OSR; 4.6% EVAR
7) renal complication 26-45%; dialysis 11-40%; mortality 76-89%
8) liver complication mortality 83%

46
Q

Renal failure post RAAA repair for OSR vs EVAR in NIS and medicare

A

NIS: 19.6% OSR vs 12.1% EVAR
MEDICARE: 45.4% OSR vs 33.4% EVAR

47
Q

Multiorgan failure rate in OSR for elective, urgent and rupture

A

3.8% elective
38% urgent
64% rupture

48
Q

Mortality after multiorgan failure in ruptures

A

64-93%

49
Q

Theory of multiorgan failure in ruptures

A

Two-hit hypothesis

Neutrophil oxidative bursts

50
Q

US National discharge database, NIS and MEDICARE on EVAR vs OSR for ruptures

A

30d mortality benefit 13-14% better in EVAR

51
Q

MEDICARE study 2001-2008 key findings

A

1) mortality 33.8% EVAR vs 47.7% OSR
2) decrease complication EVAR except MI, HD, DVT
3) LOS 7 vs 14 days
4) dC home 22% higher in EVAR
5) longer term benefit of EVAR present up to 4 years

52
Q

Trends in MEDICARE data from 2001 to 2008

A

1) increase EVAR use 6-31%
2) EVAR mortality 46% to 27%
3) OSR mortality 44.7% to 40%
4) % of RAAA unrepaired dropped

53
Q

NIS data 2005-2009 on 21206 patients

A

1) EVAR more common at teaching hospitals
2) non-operative management higher in rural hospitals
3) > age 80 increase non-operation and less OSR
4) EVAR pt have more CHF, CAD, DM, CKD
5) EVAR has reduced mortality and complications

54
Q

NIS and UK hospital episode statistics comparison

A

1) Higher rates of repair in US 80.4% than UK 58.4%
2) OSR more in UK 91.5% than US 79.1%
3) UK OSR have less mortality
4) US EVAR have less mortality
5) UK dc home more; US dc to nursing facility
6) predictor of mortality: weekend admit, interhospital transfer, not at teaching hospital

55
Q

Pilot study in 2002-2004 of 32 ruptures

A

feasibility study to determine if RCT can be done

56
Q

AJAX key points

A

1) Amsterdam study
2) randomize after CTA for suitable for both groups
3) 2004-2011
4) 520 pt evaluated; 116 enrolled (22%)
5) mortality 21% EVAR; 25% OSR
6) death and severe complication at 30d: 42% EVAR; 47% OSR

57
Q

IMPROVE key points

A

1) Clinical diagnosis and randomize before CT
2) mortality 35.4% EVAR vs 37.4% OSR
3) women mortality benefit from EVAR 37 vs 57%
4) patients who ultimately had EVAR has less mortality at 30d 25 vs 38%
5) evar had less ICU, increase DC home
6) cost the same

58
Q

ECAR key points

A

1) french study
2) stable RAAA
3) 30d and 1 yr mortality same 30 vs 35 at 1 yr
4) EVAR benefit = less resp comp, blood transfusion and ICU

59
Q

Metaanalysis of 3 RCT on ruptures

A

1) no mortality benefit at 1 year
2) EVAR has less LOC, pulm, renal and cost
3) mortality benefit in women

60
Q

IMPROVE 3 YEAR key points

A

1) EVAR decrease mortality 42 vs 54%
2) decrease LOC 14.4 vs 20.5
3) increase DC to home
4) cost effective
5) every 10 mmhg increase in BP upon presentation improves 13% survival
6) local anes improve survival 4x
7) 28% reintervention at 3 year in each group and most within 3 months

61
Q

Predictor of mortality

A

1) LOC on presentation
2) pre-op MI
3) CHF history
4) CKD history
5) advanced age
6) female
7) non-white
8) high APACHE II score

62
Q

VSGNE RAAA independent predictors of death

A

1) Age > 76
2) preop MI
3) LOC
4) suprarenal clamp

63
Q

Post-op outcome factors

A

1) pre-induction SBP
2) pre-op Cr
3) intraop urine output
4) site of cross clamp
5) duration of cross clamp
6) intraop MI, resp, renal coagulopathy
7) dialysis post-op
8) volume of blood needed

64
Q

Studies that looked at late survival 5 year elective vs rupture

A

Canadian aneurysm study: RAAA 53% vs 71% elective
US VA data: 54 vs 69%
Mayo: 64 vs 74%

65
Q

VQI on in hospital mortality and 1-5 year mortality

A

In hospital 23% EVAR vs 35% OSR

1-5 year no difference

66
Q

Post-EVAR rupture risk

A

1.4% at 28 months
mostly due to Type 1 endoleak

46.8% had attempted repair of endoleak

R9 (200 decks)

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