An 80-year-old gentleman arrives at the Accident and Emergency department complaining of central abdominal and back pain for three days . A bedside ultrasound scan reveals a 7 cm abdominal aortic aneurysm. His medical history includes hypercholesterolemia, hypertension, a past myocardial infarction in 2017 with subsequent coronary angioplasty, moderate aortic valve stenosis, and a history of smoking cessation.
Questions
1- What are the key steps in the initial management of this patient’s acute presentation?
permissive hypotension (recommendation 66 class I level B)
full bloods with group and save
urgent CTA recommendation 64 class IIa level B)
It is most probably RAAA until proved otherwise
Full exam of pt with vital signs assessment with full labs
Ct with contrast on thoracic,abdominal aorta and L.L arteries 1mm cut to rule out rupture AAA and to assess if any thoracic aortic aneurysms
resuscitation at ICU with echo and cardiac assessment
If rupture ,he is for emergency EVAR or open repair if EVAR is not available or transfer to specialized EVAR center.
If no rupture , plan for EVAR on elective basis
For this patient I must to differentiate between symptomatic AAA and rAAA. However, I suspect rAAA until proven otherwise So,
suspected case of rAAA because of abdominal and back pain of 3days duration….i will do general assessment and vital signs monitoring
insertion of 2 large bore peripheral IV access, permissive hypotension(keep the systolic pressure 70-90mmHg and the patient is conscious)…if the patient is stable i will do CTA to confirm the diagnosis and plane the management
Initially, i woulld start with vital signs and examination to detect or exclude rupture and internal bleeding. After stabilization of the patient i will talk with the patient about details of the ansurysm and consult anesthesia for fittnes for surgery. If the patient is not stable (proved rupture) i would go for open surgery with high risk and mortality consent.
If not fit for open ,CTA for planning for EVAR
Initial management of this patient include Permissive hypotension
2 wide bore cannulas and urinary catheter
increase systolic blood pressure to 70-90 mmhg below normotension
Full lab including urgent CBC for suspected Hb drop
if the patient is hemodynamically stable an Urgent CTA of thoracic and abdominal aorta is a must.
if the patient is hemodynamically unstable ie systolic bl/p <80 or lost conscious level, then patient should be transfered to the ER for Urgent intervention
Thanks Remon for summarising the EVAR steps, so operation went successful we used Medtronic device , completion angiogram shows Type 1A endoleak despite landing at the level of the renal. Patient ACT was 300
What will be your next step?
What are the types of endoleak and which one need to be treated and why?
Q1 next step we should ttt before leaving the operation room table 3 attached ilustrated the options we can used
Q2
Type I sealing zone failure 1a from proximal seal 1b from distal seal 1c from iliac occluder
Type 2 retrograde flow from aorticside branches 2a one visible vessel 2b more than one vessel visible
Type 3 midgraft failure 3a separation or poor apposition of modular component 3b graft disruption
Type 4 graft porosity
Undetermined endoleak
Type 1 endoleak should immediately ttt has high risk of rupture
Q1: i think i may use aortic cuff.
Q2: five types of endoleak:
type 1 and type 3 endoleaks mandatory to intervene.
Q1
Initial type IA endoleak treatment is predicated on the position of the endograft to the lowest renal artery.
Q2
Type I: Leak at graft attachment site (Ia: proximal attachment site; Ib: distal attachment site and IC: iliac occluder).
Type II: Aneurysm sac filling retrogradely via single (IIa) or multiple branch vessels (IIb).
Type III: Leak through mechanical defect in graft, mechanical failure of the stent-graft by junctional separation of the modular components (IIIa), or fractures or holes in the endograft (IIIb).
Type IV: Leak through graft fabric as a result of graft porosity.
Type V: Continued expansion of aneurysm sac without demonstrable leak on imaging (endotension, controversial).
Any initial type I or type III endoleak should be treated before leaving the endovascular suite (High risk for sac expansion and rupture)
let me summarise the CTA finding till admin team
1- common femoral artery diameter is 9 mm
2- aortic neck length is 19 mm
3- Iliac artery diameter is 13.5 on left and 14 mm on the right.
4- Aortic bifurcation is 19mm in diameter
finally is
Patient has single left renal artery
Aortic infrarenal angle is 64 degree
Do you consider this anatomy favourable for EVAR procedure? if not what is the adverse features here and how can you prepare yourself to minimise the risk.
What are the steps of EVAR procedure and is there any difference between percutaneous and open access?
angle more than 60* is not a favourable criteria for classic EVAR. However, some new stent-grafts still can be used like (AORFIX) device which is approved for neck angulations up to 90*
excellent Remon, thanks for your comment, we used to use aortic in angulated neck however I think we have given so far and it has shown high incidence of endo leak hence we stop using it, however recently, there was a Spanish presentation about their experience with aorofix and they have excellent results.
As you mentioned in your comment later Gore comfortable is approved for angulated neck, is it for all neck length or they have a length limit?
yes, there is a length limit;
we can also use the new (Conformable Gore device), with ability of proximal adjustment according to the existing angulation.
i can summarize the steps of EVAR as following:
Q1.
We have hostile neck beta angle > 60 standred EVAR is assosciated with endoleak Type 1a so we can use new generation grafts like anaconda device Or C3 Gore excluder
Q2.
Even though procedural steps might be different according to the stent-graft systems and manufacturers, EVAR procedure can be summarized as follows:
1) common femoral artery access,
2) full digital subtraction aortogram for confirming the length of aneurysm with a calibrated catheter,
3) ancillary procedure such as branch vessel embolization, if indicated,
4) sheath insertion via delivery system over stiff guidewire,
5) confirming an orifice of bilateral renal arteries after insertion of main body delivery system into proximal neck,
6) main body stentgraft deployment,
7) gate cannulation from contralateral common femoral artery access site for contralateral limb stent-graft,
8) contralateral limb stent-graft deployment after confirming length of stent-graft,
9) ipsilateral limb extension after confirming IIA orifice,
10) ballooning with compliant balloon to expand and attach the stent-graft to the native vessel wall at both proximal and distal ends as well as at the point of graft overlap,
11) completion aortogram to find any large post-EVAR endoleak and to confirm the patency of all graft components
Q3.
Percutaneous access for EVAR is safe and effective when compared to Open-Cutdown access for aortic aneurysm patients. Percutaneous access was associated with decreased rates of in-hospital mortality, hematoma formation, graft infection, and respiratory failure
i see these criteria compatible for EVAR, as they are within the IFU
Acute onset of pain 3 days before with 7cm AAA confirmed by ultrasound scan is an indication for intervention for this symptomatic AAA according NICE, ESVS, SVS guidelines.
next step after initial assessment, Full labs (e.g. CBC, creatinine) and stabilize all patient vital signs is to obtain CTA for planning the appropriate intervention that should be offered urgently under optimal conditions ( brief period of assessment and optimization)
IF the AAA anatomy is favorable for EVAR, it is preferable than OSR regarding patient age and his cardiac condition.
excellent Ahmed , it is better to perform urgent repair for patient with symptomatic aneurysm but under optimal condition, As Abdullah mentioned, there is time for anaesthetic review and input from different specialist team and to organise tests like echocardiogram and that will reflect on the outcome of the procedure if you do it in a controlled environment ( for example during working time in the morning)
1. Key steps is to differentiate between RAAA and smptomatic AAA vital signs
BP HR
clinical examination presence of triad abd or back pain pulsatil mass and hypotension which presence on 50% of pt.
Full labs
Good hydration and if pt stable CTA to confirme RAAA and anatomoical futures if not pt shift to operative theater with facilities for hybrid
2. Next steps after confirmation of stability, ICU admission close monitoring pain and risk factors control.
prepare the pt for operative by assessement of functional capacity and risks of procedures pulmonary function anaesthia assessement
3. I have no evidence for my answer but as soon as possible after good prepration
4. Table 13 AAA managment ESVS 2024 attached
Q5. After consultation of cardiac, anesthesia,griatric medicine, pulmonary, departments and know the fitness and there opinione.
I will start to disscus with pt and family the possibility of EVAR as choice and possible complication and needs of survilance after that
Abdullah you highlight the need for CTA, as you mentioned you can differentiate between Rupture and symptomatic Clinical stability and more importantly CTA finding, having a CTA is essential and mandatory for for this urgent cases specially in the view of Improve trial result.
Can you please summarise for us Improve trial findings, that will be very helpful for our discussion?
IMPROVE is a multicentre trial that randomised patients with a clinical diagnosis of ruptured abdominal aortic aneurysm to either an endovascular strategy of immediate computed tomography and emergency EVAR, with open repair for patients anatomically unsuitable for EVAR (endovascular strategy group), or to the standard treatment of emergency open repair (open repair group).
1. no differences in the 30 day and the 90 day mortality rates between EVAR and OSR.
2. One year results of IMPROVE trial suggested that an endovascular first strategy for rAAA does not offer an early survival benefit, but is associated with faster discharge, better QoL, and is cost effective.
3. The three year results of the IMPROVE trial suggest that, compared with OSR, an endovascular strategy is associated with a survival advantage, a gain in quality adjusted life years, similar levels of re-intervention, and reduced costs, and that this strategy is cost effective.
ok lets get the discussion running, looking forward to more interaction
On examination : –
Tender aneurysm with palpable femoral pulses
Vital signs BP 110-60, HR 90, RR 18 and O2 sat 94%
eGFR 80, Hb 11, WCC 7, CRP 5
CTA shows 7.5 cm infrarenal AAA with no signs of rupture.
What is your next course of action in management?
How urgently does this patient need treatment?
Which anatomical characteristics do you consider when devising an EVAR plan?
What is the process for obtaining consent from a patient for an EVAR procedure?
CT Scan and planning images will be uploads later today for you to plan, please feel free to comment on adverse features and how to tackle it in this situation?
Q1: this aneurysm is symptomatic- but not yet rupture- and indicated for urgent intervention.
Q2: I will consider these characteristics in planning:
Q3: i will explain to patient the potential complications as endoleak, graft infection, bleeding and take a documented consent for this.
Carina 18-20 mm is the standard and that recommendation was mentioned to reduce the risk of limb compression and occlusion. was there any evidence to support that claim or it just a common sense?
I searched for that but really did not find an evidence for that. Even the evidence supports the opposite.
here a trial by Gustavo Oderish saying that EVAR was safe and effective in distal narrow bifurcation even less than 14.
https://pubmed.ncbi.nlm.nih.gov/26372194/
symptomatic AAA showed be treated Urgently by either OSR or EVAR
since the age of the patient and the previous cardiac history it’s more preferred to go for EVAR than OSR.
Aortic neck (proximal landing zone ) Lengh >15mm width 18-32mm
neck angulation alpha <45 beta <60
aneurysm diameter >5.5
distal landing zone Lenght >15mm width <20
EVAR is graded as intermediate risk intervention with cardiac risk 1-5%
Consent should include all possible complication Cardiac, Pulmonary, Renal, and also possibility of re intervention
Thanks Saeed of your post,
you mentioned that permissive hypotension refer to delay aggressive resuscitation until proximal control achieved, i totally agree with you but the team in resuscitation are not aware of that term and asking you what will your target BP, HR? and if it is lower that your target, how do you like your patient to be resuscitated ( bloods, crystalloids, colloids)?
The target systolic BP between 70 and 90 mmHg.
Blood products are preferred to treat hypotension.
JVS SVS 2018
https://www.jvascsurg.org/article/S0741-5214(17)32369-8/fulltext
Management options are determined by the hemodynamic stability of the patient (loss, or reduced level of consciousness or systolic BP < 80 mmHg)
Permissive hypotension resuscitation strategy refers to a policy of delaying aggressive fluid resuscitation until proximal aortic control is achieved
Aggressive resuscitation lead to increase bleeding and worsen coagulopathy
Resuscitation goals are aimed at maintaining cerebral and myocardial perfusion by monitoring consciousness and ST changes on cardiac monitoring
ESVS 2024
Good start Muhamed, you highlighted very important initial assessment and resuscitation steps. so before providing you with vital signs and lab results , few questions to answer.
1- what is permissive hypotension? and why it is important?
2- Resuscitation, is a general term, how do you resuscitate patient with suspected rupture aneurysm?
3- is there a prognostic classification or score for patient with rAAA? how relevant it is to you daily practice?
looking forward to hear from other candidates!
Thanks dr/ahmed
1- Permissive hypotension is to delay aggressive fluid resuscitation until proximal aortic control.(normotensive resuscitation) to avoid bleeding ,coagulopathy, acidosis and hypothermia.
2- my recommendation for resuscitation is to target BP between 70-90 with balanced transfusion
blood and blood products fresh frozen plasma/red blood cell ratio close to 1:1.
Eur J Vasc Endovasc Surg 2016.
And Avoid resuscitation with stable conscious patient and measure urine output.
3-i have searched and found
the Glasgow Aneurysm Score (GAS),the Hardman Index,the Vancouver Scoring System (VSS), the Edinburgh Ruptured Aneurysm Score (ERAS). But i never use them.
J vasc surg 2016
-Patient is suspected to be rAAA.general condition of the patient is important.
-Vital signs for hypotenstion and tachycardia is highly suspicious.
-Full lab (Hb / kidney function ).
-If patient is haemodynamically stable should go for thoracoabdominal CTA to confirm daignosis and planning for interventions. ESVS class 1.
– if unstable can start resuscitation with permissive hypotension protocol.
And can go for CTA .
-If he is un conscious or with sever hypotension transport him to OR can use aortic ballon for resuscitation.
Welcome to the third week of the aortic module, will be interesting to know your thoughts about our first patient, please try to engage earlier as the case is long with lots of learning points to be addressed this week, looking forward to hear back from all of you!