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Wave 2: Module 3: Aortic Week 3 – Case 2
55 yrs old female with no significant past medical history presented to the emergency department with sudden collapse and drop in the Hb to 5 g/dl. She is an active smoker. Bedside ultrasound showed pulsatile mass and CTA showered infrarenal AAA 5cm with retroperitoneal hematoma. The aneurysm neck is 18 mm in diameter 15 mm in length, parallel neck. The AAA does not extend to the iliac arteries. The CIA on the Rt side is 10 mm and on the Lt is 9 mm.
Q1: How will you approach the patient? What risks would like to discuss with the patient or her family?
Q2: What is your definitive management? If you are offering an intervention, please mention the type of intervention and support your answer with an evidence.
Q3: if the length of the aneurysm neck is 8 mm, will that change anything in your management, please justify your answer.
Q4: Please mention 2 causes/complications that can lead to kidney failure? Discuss how to diagnose and how to manage them.
Q1 resuscitation then plan urgent EVAR, tge risks include high mortality, renal failure, bowel ischemia, paralysis
Q2 EVAR as the anatomy is favourable
Q3 i can’t do complex EVAR in such case, so it will be OSR as the neck length 8 is outside IFU for standard EVAR
Q4 CIN by rising creatinine 24 to 72 hrs post procedure with oliguria, supportive care with iv fluids sodium bicarbonate and nephrology consultation
2 abdominal compartment syndrome with pressure more tgan 20 mmHg proceed to urgent laparotomy
A1 first start with ABCD
and put 2 large bore cannula and start massive blood protocol
and monitor patient vitals and urine output
then start with brief history and examination to abdomen and periphery
I will discuss with relatives the rate of mortality in ruptured AAA
and discuss with them the possible complications like stroke -MI -KIDNEY INJURY-bowel ischemia
A2 as it is female with ruptured AAA
so it is better go with EVAR
A3 open repair will be the solution as neck is less than 1.5cm
A4 pre renal
like hypovolemia TT with blood transfusion
clamping or injury of renal artery for longer time
coverage of renal artery TT with fenestrated evar
contrast induced TT with fluids and NaHCO3 and may need dialysis
Q1 This is a presenetation of likely ruptured AAA!! so the management will be Frist aid (ABCD together with Detailed Hx taking and examination)
and I will clearly inform the patient or her family with the risk of possible rupture aorta and obtain high risk consent up to death before intervention
q2 sure I will offer intervention and it depends on the availble materials ( the gold standard will be OSR)
Q3 With this diameter the EVAR opition will not be suitable for emergent intervetion
Q1
Air way secured, breathing , circulation
maintain SBP between 70 : 80 mmhg
Cross matching for blood , plazma
Family history
Personal H
Present H
Past H of DM , htn , dyslipedemia
General exam pulse- bp- RR temp-colours
Local ezam: abdomen- chest- heart
Peripheral exam for other aneurysm
Investigation
Cta if pt stable
Ecg- echo
Full lap
If pt is not stable rapid transfer into operation room
Q2
OSR and EVAR have the same perioperative morbidity snd mortality through 30 days
So if sets are available proceed into EVAR
Is sets not available proceed into OSR
Q3
8 mm neck is not appropriate for landing graft
So OSR is preferred
Q4
Aki can occur pre , in , post op
Pre : decrease renal flow , shock
Managed by maintaining intravascular fluid
Intra :
Graft closure opening of renal A
At EVAR
Ttt by using branched EVAR
At OSR by injury of renal A or prolonged clamping
Managed by accurately timing of clamping , secure disection
Post op 2ndry to compartmental syndrome
Ttt by open laparotomy
A1
Approach abcd
Consider hemorrhage resuscitation
2 wide pore cannula
Blood group
Iv packed rbcs : ffp : platelet 1 :1:1
Ask for cbc pt ptt inr Urea creat alt
Ask for urgent ct
Prepare for urgent intervention
Ask for high risk consent
Speak with relatives about the situation and clarify all risks
………….
A2
Rupture aaa is equal urgent repair
We have 2 options open or evar
Open is glod standard
And evar is also suitable according to mentioned diameters as available graft is suitable
………..
A3
evar neck length accepted minimum length 10 up to 15 mm
So it will affect
………
A4
Fisrt one
Hypoperfusion Dt supra renal clamping or hypotension cause aki
Dx by urine out put and increase creat
Tt by fluids
2nd
Compartment s
Decompression lalarotomy
• I would activate the vascular emergency pathway, start resuscitation (fluids, blood), control BP carefully, and arrange for urgent intervention.
I would explain to the family that the patient has a ruptured AAA, which is life-threatening and needs immediate surgery.
Risks: death, bleeding, kidney failure, bowel ischemia, graft infection, prolonged ICU stay.
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• I would offer emergency EVAR if anatomy allows — neck is 15 mm, diameter 18 mm, parallel walls = suitable.
Evidence: IMPROVE trial showed EVAR in rupture has lower early mortality and quicker recovery in anatomically suitable patients.
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• Yes, if the neck is only 8 mm, that makes standard EVAR unsuitable (short neck = risk of type I endoleak).
Options:
• Chimney EVAR if available and team is experienced
• Otherwise, go for open surgical repair (OSR)
Justification: EVAR needs at least 10–15 mm neck for proper sealing.
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• Two main causes of kidney failure in ruptured AAA:
1. Hypoperfusion (shock-related AKI)
• Diagnosis: low urine output, rising creatinine
• Management: optimize perfusion, fluids, inotropes if needed
2. Ischemic injury from suprarenal clamping or embolism
• Diagnosis: bloods, imaging, delayed recovery of renal function
• Management: minimize clamp time, consider dialysis if needed post-op
Q1: approach and risks
This presentation is highly suggestive of a ruptured or leaking AAAApproach:Immediate stabilization: airway, breathing, circulation (ABC).Resuscitation with IV fluids and blood transfusion to manage hemorrhagic shock.Urgent imaging (CT angiography) to confirm rupture and anatomy.Prepare for emergency intervention.Risks to discuss with patient/family:High risk of mortality and morbidity due to rupture.Risks of surgery or intervention including bleeding, organ failure, infection.Possibility of needing blood transfusions and ICU care.Potential complications like kidney injury, bowel ischemia.Prognosis depends on time to intervention and patient’s baseline status.⸻
Q2: definitive management and the type of intervention and support with evidence.
• Definitive management of ruptured AAA is emergency repair:
• Two main options:
1. Open surgical repair: Gold standard with direct control of bleeding but associated with higher perioperative mortality.
2. Endovascular aneurysm repair (EVAR): Increasingly used if anatomy is suitable, associated with lower early mortality and quicker recovery.
• For this patient: Neck diameter 18 mm, length 15 mm, parallel neck – these features may be borderline for EVAR but can be considered.
If anatomy permits, emergency EVAR is preferred because of less invasiveness and improved short-term outcomes (supported by trials like IMPROVE).If anatomy unsuitable or EVAR unavailable, proceed to open repair.• Support from evidence: IMPROVE trial showed EVAR in ruptured AAA reduces 30-day mortality compared to open repair.
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Q3: the aneurysm neck is 8 mm and management.
• Yes, the neck length is a critical factor for EVAR suitability and considered short, which increases risk of endograft migration and type I endoleak (poor seal).
• For short necks:Open repair may be preferred / advanced endovascular techniques like fenestrated EVAR (FEVAR) or chimney grafts may be considered.
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Q4: 2 causes/complications of kidney failure / diagnose and manage .
1. Ischemic acute kidney injury (AKI) :
• Cause:hypoperfusion > Shock and hypotension from hemorrhage or aortic clamping during surgery.
• Diagnosis: Rise in serum creatinine, decreased urine output.
• Management:
Optimize hemodynamics with fluids vasopressors avoid nephrotoxic drugs renal replacement therapy if severe.
2. abdominal compartment syndrome (ACS):
• Causes :
Massive retroperitoneal hematoma.Large volume resuscitation with fluids and blood products.Abdominal wall edema or tight abdominal closure after surgery. • Diagnosis:
Clinical signs: tense, distended abdomen; oliguria or anuria despite fluids.Measurement of bladder pressure as a surrogate for IAP (gold standard).Imaging may show organ compression but diagnosis is clinical plus pressure measurements. • Management:
Decompressive laparotomy (surgical opening of the abdomen) to reduce pressure.Supportive care: optimize hemodynamics and renal perfusion.Avoid fluid overload; careful fluid management.Monitor urine output closely.
Well done Dr Bedeer, clear and systematic answer. You need to revise the results of IMPROVE trial, your statement regarding the results of EVAR is not accurate. No significant difference between EVAR and OSR regarding 30-day mortality. EVAR is better in other aspects I highlighted in my other comments on your colleagues’ answers.
A1: Patient counseling about ruptured AAA treatment options and massive hemmorhage protocol and discuss the risks with the patient.
A2: EVAR according to NICE guidelines as suitable aortic anatomy in female patient
A3: Will have to do open surgical AAA repair as current available EVAR grafts have a 10mm minimum aneurysm neck
A4: Profound hypotension due to blood loss
Renal artery blockage by stent if deployed incorrectly by EVAR would cause kidney ischemia and failure
Thank you for the focused answer, any idea how to mange un-intentional coverage of the renal artery by the EVAR device?
A1.. for a patient with ruptured AAA urgency in decision making and intervention could be life saving ..
For this patient insertion of Two large bore IV accesses with obtaining blood samples for cross matching and beginning of resuscitation protocol in a permissive hypotension technique to target systolic blood pressure of 70_80 mmHg
Then if patient is quite stable CTA repidly should be done for proper planning for intervention and if patient is unstable emergent trensafer to operating rome
With her family I will discuss the risk of death which is high with over all ratio of 80% or ruptured AAA patients. Other risks include ischemic colitis , renal failure , ll ischemia, compartment syndrome and multi organ failure
A2..
I will offer EVAR as the anatomy of aorta is suitable with good landing zones and access vessels
Also as REVAR decrease the death rate by 10-30 percent compared with OSR
A3..
Yes it will change my plan sa all commercially available devices require neck length at least 10 mm so with neck length 8 mm OSR WILL BE THE CHOICE
A4..
Profound hypotension cal lead to pre renal AKI if not promptly treated
Can be managed by resuscitation
Intra operative coverage of renal artery by graft
Will lead to renal ischemia
Can be managed by graft fenestration and stenting the renal vessels however it is not advised to perform complex EVAR in the setting of rupture so if there is no enough landing zones at the neck sufficient to perverse renal vessels
OSR is preferred
Post operative abdominal compartmental syndrome can lead renal failure
And manged by abdominal decompression laparotomy
Well done Dr Mahdy for the systematic answer, I disagree only with percentage you mentioned in A1 and the statement in A2 that EVAR decrease the mortality 20-30% compared to OSR. Please revise the results of IMPROVE trial, there is no significant difference in the 30 day mortality between OSR and EVAR for rAAA, both around 35-37% (NOT 80%). EVAR had less peri-operative death and more EVAR patients discharged alive but the 30-day mortality remained similar to the OSR.
Q1:
resuscitation with permissive hypotension and blood transfusion to correct anemia and hemorrhage
a case of rAAA with high risk of death, renal failure, ischemic colitis, post operative ICU admission
Q2:
according to NICE guidelines and the data pooled from many RCT the largest was IMPROVE 2014 in case of rAAA in women it is better to go for EVAR especially if the anatomy is evarable
Q3:
yes will go for OSR as the proximal neck length is 8 mm and the available stent grafts IFU minimum proximal neck length from 10-15 mm
Q4:
Major bleeding and hypo-perfusion of the kidney with no urine out put which needs major blood transfusion protocol and permissive hypotension
accidental covering of the renal artery during deployment so good planning and accurate deployment is mandatory
Abdominal compartmental syndrome with organ failure with rise of the IAP above 25 mmHg which needs urgent abdominal decompression
Thank you for your answer Dr Malek, I agree with your answer except for the pre-op correction of anemia by blood transfusion, we should aim for permissive hypotension, any transfusion may disturb the tamponading effect of the hematoma and leads to free rupture. Ideally, we should activate major haemorrahge protocol and start the transfusion intra-operative once the bleeding is under control.
A1:
Regarding the ptn condition it is an emergency ruptured AAA for resuscitation permissive hypotesion activate major hge protocol prepare for repair and risks to be discussed to the family clearly includind death renal failure mesenteric ischemia icu admission SSI MI
A2:
Female ptn ruptured aaa suitable anatomy EVAR would be recommended by the ESVS and NICE guidelines
A3:
the guidelines according to the IFU recommend neck length of 10 through 15 mm according to angulations so in this ptn with neck length of 8 mm EVAR is not option and OSR is the tt of choice as far she is young with no comorbidities
A4:
In this ptn
Pre renal cause due to collapse and int bleeding ttt with support and bl transfusion correct the cause of bleeding control of hypotension
Renal cause if the stent deployed and cover the renal artery ttt through accurate deployment of the device or cheminy EVAR to revascularize the renals
Post renal due to hematoma or abd compartmental syndrome compressing the ureters with pelvic backpressure ttt through decompression and hematoma evacuation
Thank you Dr Mansy for the focused clear answer, I agree with all answers. For A2, in high volume centre, EVAR with adjunct procedure or temporary EVAR before and 2nd stage FEVAR can also be an option if patient is old and frail to have open, however this is outside the scope of this module to discuss here.