4/4/2019 EVAR for Ruptured AAA: This Step-by-Step Approach Will Save Lives 4/4/2019 UCSF Symposium Sukgu M Han, MD, MS Assistant Professor of Clinical Surgery Division of Vascular Sugery and Endovascular Therapy Co-director, Comprehensive Aortic Center Keck Medical Center of USC Sukgu.han@med.usc.edu 1 DISCLOSURES • Gore & Associates: Consultant, Research Educational Support paid to USC • Cook Medical: Consultant, Proctor for Zenith Fenestrated 2 2 1
4/4/2019 Ruptured AAA • 50% pre-hospital mortality • Challenging anatomy more frequent • Hostile neck • Larger Sac • Survival advantage of EVAR over OR in retrospective pooled data 1,2 • No difference in survival in RCTs (by intension to treat) 3,4,5 • EVAR suitability affects survival • Survival advantage of EVAR by treatment received 5 1. Veith et al. Ann Surg 2009 2. Gupta et al. JVS 2018 3. Reimerink (AJAX). Ann Surg 2013 3 4. Desgranger (ECAR). Eur J Vasc Endovasc Surg 2015 5. IMPROVE. BMJ 2014 3 11 STEPs to Successful Ruptured EVAR 4 4 2
4/4/2019 1. BE PREPARED • Dedicated aortic team Surgeon • Critical Care • OR staff • IR tech • Hybrid Room- ready for • EVAR and open conversion 5 5 1. BE PREPARED 6 6 3
4/4/2019 1. BE PREPARED Number of Aortic Rapid Transfers 300 250 200 150 100 50 0 2012 2013 2014 2015 2016 2017 2018 7 7 2. OBTAIN / REVIEW IMAGING IN ADVANCE • Cloud based imaging transfer • Referring physician 8 8 4
4/4/2019 3. HYPOTENSIVE HEMOSTASIS • Limit resuscitation to maintain detectable BP • AVOID HEMODYNAMIC SWINGS • Starts in ER • Ask for a-line, IV/central line • Continues through OR until rupture is sealed 9 9 4. AVOID GENERAL ANESTHESIA • Induction causes loss of compensatory sympathetic tone • Local anesthesia for access • Awake EVAR • AVOID HEMODYNAMIC SWINGS 10 10 5
4/4/2019 5. PERCUTANEOUS ACCESS • Pre-close if patient is stable • Unstable- still percutaneous and cut down after rAAA seal 11 11 6. OCCLUSION BALLOON • Perform ONLY in unstable patients • AVOID HEMODYNAMIC SWINGS • Place it well above the planned endograft, from a straighter iliofemoral • SUPPORTED WITH A SEATH 12 12 6
4/4/2019 7. ANGIO AND DEPLOY MAINBODY • Completely deploy down to ipsilateral common iliac • Limb extension • Use the device you are most familiar with • Gore C3 Excluder • Infrarenal active fixation • Repositionable • Low profile 13 13 8. BALLOON EXCHANGE • Position 2 nd occlusion balloon from ipsilateral femoral • Deflate and retrieve the 1 st occlusion, as 2 nd balloon is inflated AVOID HEMODYNAMIC SWINGS • 14 14 7
4/4/2019 9. CONTRA GAIT CANNULATION • Large Sac • Crossing the limb • Up and Over Snare T echnique 15 15 10. CONTRA LIMB AND COMPLETION ANGIO • Don’t leave the room with Type1, Type III endoleaks • Type II endoleaks can be watched 16 16 8
4/4/2019 11. POSTOP ICU RESUSCITATION, ACS WATCH 28% Overall rEVAR mortality • 12% Incidence of abdominal compartment syndrome • Hypotension • Need for occlusion balloon • Transfusion of 3 units or more • Ongoing postop anemia • 17 17 STEPS Be prepared 1. Review imaging ahead of time 2. Hypotensive hemostasis 3. Avoid general anesthesia 4. Percutaneous access 5. Sheath supported occlusion balloon-only when needed 6. Fully deploy mainbody to ipsilateral iliac 7. Balloon exchange 8. Contra gait cannulation 9. Contralimb and completion angio 10. Critical care- ACS watch 11. 18 18 9
4/4/2019 EXPANDING ANATOMIC SUITABILITY FOR ENDOVASCULAR REPAIR OF RUPTURED AORTIC ANEURYSMS ? 19 19 Thank you!!! 20 20 10
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