Endovascular repair of ruptured abdominal aortic aneurysm

Momir Šarac; Ivan Marjanović; Aleksandar Tomić; Sanja Šarac; Mihailo Bezmarević

doi:10.2298/1616

Momir Šarac Clinic for Vascular and Endovascular Surgery, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
Ivan Marjanović Clinic for Vascular and Endovascular Surgery, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
Aleksandar Tomić Clinic for Vascular and Endovascular Surgery, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
Sanja Šarac Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia; Clinic of Pulmology, Military Medical Academy, Belgrade, Serbia
Mihailo Bezmarević Clinic of General Surgery, Military Medical Academy, Belgrade, Serbia

DOI: https://doi.org/10.2298/1616

Keywords: aortic aneurysm, abdominal, aortic rupture, comorbidity, diagnosis, vascular surgical procedures, blood vessel prosthesis, treatment outcome,

Abstract

Introduction. Rupture of an abdominal aortic aneurysm (AAA) is a potentially lethal state. Only half of patients with ruptured AAA reach the hospital alive. The alternative for open reconstruction of this condition is endovascular repair (EVAR). We presented a successful endovascular reapir of ruptured AAA in a patient with a number of comorbidities. Case report. A 60-year-old man was admitted to our institution due to diffuse abdominal pain with flatulence and belching. Initial abdominal ultrasonography showed an AAA that was confirmed on multislice computed tomography scan angiography which revealed a large retroperitoneal haematoma. Because of patient’s comorbidites (previous surgery of laryngeal carcinoma and one-third laryngeal stenosis, arterial hypertension and cardiomyopathy with left ventricle ejection fraction of 30%, stenosis of the right internal carotid artery of 80%) it was decided that endovascular repair of ruptured AAA in local anaesthesia and analgosedation would be treatment of choice. Endovascular grafting was achieved with aorto-bi-iliac bifurcated excluder endoprosthesis with complete exclusion of the aneurysmal sac, without further enlargment of haemathoma and no contrast leakage. The postoperative course of the patient was eventless, without complications. On recall examination 3 months after, the state of the patient was well. Conclusion. The alternative for open reconstruction of ruptured AAA in haemodynamically stable patients with suitable anatomy and comorbidities could be emergency EVAR in local anesthesia. This technique could provide greater chances for survival with lower intraoperative and postoperative morbidity and mortality, as shown in the presented patient.

References

Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC. Suggested standards for reporting on arterial aneu-rysms. Subcommittee on Reporting Standards for Arterial An-eurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, Interna-tional Society for Cardiovascular Surgery. J Vasc Surg 1991; 13(3): 452−8.

Thompson SG, Ashton HA, Gao L, Scott RA. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effec-tiveness results from the randomised Multicentre Aneurysm Screening Study. Br Med J 2009; 338: b2307.

Ashton HA, Buxton MJ, Day NE, Kim LG, Marteau TM, Scott RA, et al. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet 2002; 360(9345): 1531−9.

Kniemeyer HW, Kessler T, Reber PU, Ris HB, Hakki H, Widmer MK. Treatment of ruptured abdominal aortic aneurysm, a permanent challenge or a waste of resources? Prediction of outcome using a multi-organ-dysfunction score. Eur J Vasc Endovasc Surg 2000; 19(2): 190−6.

Wilmink TB, Quick CR, Hubbard CS, Day NE. The influence of screening on the incidence of ruptured abdominal aortic aneu-rysms. J Vasc Surg 1999; 30(2): 203−8.

EVAR trial participants. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2): randomised controlled trial. Lancet 2005; 365(9478): 2187−92.

Blankensteijn JD, de Jong SE, Prinssen M, van der Ham AC, Buth J, van Sterkenburg SM, et al. Two-year outcomes after conven-tional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 2005; 352(23): 2398−405.

Johnston KW. Ruptured abdominal aortic aneurysm: six-year follow-up results of a multicenter prospective study. Canadian Society for Vascular Surgery Aneurysm Study Group. J Vasc Surg 1994; 19(5): 888−900.

MacSweeney ST, O'Meara M, Alexander C, O'Malley MK, Powell JT, Greenhalgh RM. High prevalence of unsuspected abdominal aortic aneurysm in patients with confirmed symptomatic pe-ripheral or cerebral arterial disease. Br J Surg 1993; 80(5): 582−4.

Bradbury AW, Makhdoomi KR, Adam DJ, Murie JA, Jenkins AM, Ruckley CV. Twelve-year experience of the management of ruptured abdominal aortic aneurysm.Br J Surg 1997; 84(12): 1705−7.

Jones A, Cahill D, Gardham R. Outcome in patients with a large abdominal aortic aneurysm considered unfit for surgery. Br J Surg 1998; 85(10):1382−4.

Laheij RJ, van Marrewijk CJ. Endovascular stenting of abdomi-nal aortic aneurysm in patients unfit for elective open surgery. Eurostar group. EUROpean collaborators registry on Stent-graft Techniques for abdominal aortic Aneurysm Repair. Lan-cet 2000; 356(9232): 832.

Thomas SM, Gaines PA, Beard JD. Short-term (30-day) outcome of endovascular treatment of abdominal aortic aneurism: re-sults from the prospective Registry of Endovascular Treat-ment of Abdominal Aortic Aneurism (RETA). Eur J Vasc En-dovasc Surg 2001; 21(1): 57−64.

Benedikt P, Lachat M, Pfammatter T, Stalder N, Schmidli J, von Smekal A,et al. Emergency surgery for abdominal aortic aneu-rysm-could an endovascular methods be considered?. Swiss Surg 1999; 5(5): 239−42. (German)

Bettex DA, Lachat M, Pfammatter T, Schmidlin D, Turina MI, Schmid ER. To compare general, epidural and local anaesthesia for endovascular aneurysm repair (EVAR). Eur J Vasc En-dovasc Surg 2001; 21(2): 179−84.

Ruiz CE, Zhang HP, Whittaker P. Non-surgical treatment of abdominal aortic aneurysms. Cardiologia 1997; 42(9): 903−12.

Lachat M, Pfammatter T, Bernard E, Jerggy C, Vogt P, Turina M. Successful endovascular repair of leaking abdominal aortic an-eurysm under local anaesthesia. Swiss Surg 2001; 7(2): 86–9.

Yusuf SW, Whitaker SC, Chuter TA, Wenham PW, Hopkinson BR. Emergency endovascular repair of leaking aortic aneurysm. Lancet 1994; 344(8937): 1645.

Veith FJ, Ohki T. Endovascular approaches to ruptured in-frarenal aorto-iliac aneurysms. J Cardiovasc Surg (Torino) 2002; 43(3): 369−78.

Hinchliffe RJ, Yusuf SW, Macierewicz JA, MacSweeney ST, Wenham PW, Hopkinson BR. Endovascular repair of ruptured abdominal aortic aneurysm-a challenge to open repair? Results of a single centre experience in 20 patients. Eur J Vasc Endovasc Surg 2001; 22(6): 528−34.’

Orend KH, Kotsis T, Scharrer-Pamler R, Kapfer X, Liewald F, Görich J, et al. Endovascular repair of aortic rupture due to trauma and aneurysm. Eur J Vasc Endovasc Surg 2002; 23(1): 61−7.

Lachat ML, Pfammatter T, Witzke HJ, Bettex D, Künzli A, Wolf-ensberger U, et al. Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms. Eur J VascEndovasc Surg 2002; 23(6): 528−36.

Yilmaz N, Peppelenbosch N, Cuypers PW, Tielbeek AV, Duijm LE, Buth J. Emergency treatment of symptomatic or ruptured ab-dominal aortic aneurysms: the role of endovascular repair. J Endovasc Ther 2002; 9(4): 449−57.

Davidović L, Čolić M, Končar I, Marković D, Kostić D, Činara I, et al.. Endovascular repair of aortic aneurysm-preliminary results. Srp Arh Celok Lek 2009; 137(1−2): 10−7. (Serbian)

Kranokpiraksa P, Kaufman JA. Follow-up of endovascular aneu-rysm repair: plain radiography, ultrasound, CT/CT angiogra-phy, MR imaging/MR angiography, or what? J Vasc Interv Radiol 2008; 19(6 Suppl): S27−36.

Gupta PK, Ramanan B, Lynch TG, Gupta H, Fang X, Balters M, et al. Endovascular Reapir of Abdominal Aortic Aneurysm does not Improve Early Survival versus Open Reapir in Patients Younger than 60 Years. Eur J Vasc Endovasc Surg 2012; 43(5): 506−12.

IMPROVE Trial applicants, Powell JT, Thompson SG, Thompson MM, Grieve R, Nicholson AA, et al. The Immediate Management of the Patient with Rupture: Open Versus Endovascular repair (IMPROVE) aneurysm trial. Acta Chir Belg 2009; 109(6): 678−80.

The IMPROVE trials. The Immediate Management of the Pa-tient with Ruptured Aneurysm: Open Versus Endovascular repair. Available from: http://www.improvetrial.org