Lives 4/4/2019 UCSF Symposium Sukgu M Han, MD, MS Assistant - - PDF document

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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

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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

Gore & Associates: Consultant, Research

Educational Support paid to USC

Cook Medical: Consultant, Proctor for Zenith

Fenestrated

DISCLOSURES

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50% pre-hospital mortality
Challenging anatomy more frequent
Hostile neck
Larger Sac
Survival advantage of EVAR over OR in

retrospective pooled data1,2

No difference in survival in RCTs (by intension

to treat)3,4,5

EVAR suitability affects survival
Survival advantage of EVAR by treatment received5

Ruptured AAA

1. Veith et al. Ann Surg 2009 2. Gupta et al. JVS 2018 3. Reimerink (AJAX). Ann Surg 2013 4. Desgranger (ECAR). Eur J Vasc Endovasc Surg 2015 5.

IMPROVE. BMJ 2014

11 STEPs to Successful Ruptured EVAR

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1. BE PREPARED

Dedicated aortic team
Surgeon
Critical Care
OR staff
IR tech
Hybrid Room- ready for

EVAR and open conversion

1. BE PREPARED

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1. BE PREPARED

50 100 150 200 250 300 2012 2013 2014 2015 2016 2017 2018

Number of Aortic Rapid Transfers

Cloud based imaging transfer
Referring physician
2. OBTAIN / REVIEW IMAGING IN

ADVANCE

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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
3. HYPOTENSIVE HEMOSTASIS

Induction causes loss of compensatory

sympathetic tone

Local anesthesia for access
Awake EVAR
AVOID HEMODYNAMIC SWINGS
4. AVOID GENERAL ANESTHESIA

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Pre-close if patient is

stable

Unstable- still

percutaneous and cut down after rAAA seal

5. PERCUTANEOUS ACCESS

Perform ONLY in unstable

patients

AVOID HEMODYNAMIC

SWINGS

Place it well above the

planned endograft, from a straighter iliofemoral

SUPPORTED

WITH A SEATH

6. OCCLUSION BALLOON

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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

7. ANGIO AND DEPLOY MAINBODY
Position 2nd occlusion balloon from ipsilateral femoral
Deflate and retrieve the 1st occlusion, as 2nd balloon is

inflated

AVOID HEMODYNAMIC SWINGS

8. BALLOON EXCHANGE

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Large Sac
Crossing the limb
Up and Over Snare

T echnique

9. CONTRA GAIT CANNULATION
Don’t leave the

room with Type1, Type III endoleaks

Type II endoleaks

can be watched

10. CONTRA LIMB AND COMPLETION

ANGIO

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28% Overall rEVAR mortality
12% Incidence of abdominal compartment syndrome
Hypotension
Need for occlusion balloon
Transfusion of 3 units or more
Ongoing postop anemia

11. POSTOP ICU RESUSCITATION, ACS

WATCH

Be prepared

Review imaging ahead of time

Hypotensive hemostasis

Avoid general anesthesia

Percutaneous access

Sheath supported occlusion balloon-only when needed

Fully deploy mainbody to ipsilateral iliac

Balloon exchange

Contra gait cannulation

10.

Contralimb and completion angio

11.

Critical care- ACS watch

STEPS

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