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Benjamin W. Starnes MD, FACS
The Alexander Whitehill Clowes Endowed Chair of Vascular Surgery
Professor and Chief;
Division of Vascular Surgery
University of Washington
Seattle, WA
Ruptured Aneurysm Protocol:
Lessons From a Busy Aortic Center
Disclosures
• Co-Founder: AORTICA Corporation
1993- 25 years ago
• SOD Walter Reed
• 71 yo male admitted to Neurology service with
four days of low back pain
• Found down in his room- Code Blue
• Suspected MI- transferred to MICU
• Multiple codes- abdomen becoming distended
• Discussed with VS Attending- CT Scan “STAT”
• 45 minutes later in scanner, Arrested and Died
Hughes. Surg. 1954; 36: 65-8
Clamp Before You Cut:Proximal Aortic Control with Balloon Occlusion
CPT Zachary Arthurs MD, CPT Craig See MD,
COL(R) Charles Anderson MD, and LTC Benjamin Starnes MD
Vascular and Endovascular Surgery Service
Madigan Army Medical Center
Tacoma, Washington2002
Harborview Medical Center
Methods
• Data on all rAAA between January 1, 2004
and October 31, 2014
• Six Data Abstractors
• Pre-hospital, Hospital, Op reports, Laboratory
• Over 37,000 variables
• 95,751 images reviewed from 215 evaluable
CT scans
• 30-day and long-term outcome data
16 Lessons Learned
Lesson #1
• Systems and Protocols Make a Difference
• Algorithms serve as surrogates for an
organized approach to rAAA’s and can be an
overall marker for good quality care
July 2007
IRB-approved protocol
2010
0
10
20
30
40
50
60
70
80
2003 2004 2005 2006 2007 2008 2012
Overall
REVAR
REVAR protocol
P<0.001
57.8%
25.3%
16.3%
Mortality 2012
Lesson #2
• Local or No anesthesia makes a difference
• 90 REVARS
– GETA- 30 day mortality= 25.5%
– Local- 30 day mortality= 16.3%} p=0.2
Br J Surg. 2014 Feb;101(3):216-24 Observations from the IMPROVE trial
concerning the clinical care of patients with ruptured abdominal aortic aneurysm.
Lesson #3
• Aortic Occlusion Balloons make a difference
…and Bide Time
– 12 Fr 55cm Sheath
– CODA (Cook, Inc)
– Placed from straightest iliac
Lesson #4
• 73% Qualify for EVAR
– 95,751 images
– 215 rAAA CTs
– Aortic Neck determines candidacy most often
– Iliac Access rarely an exclusion criteria with newer
devices
PMEG Subject 049
Lesson #5
Harborview Risk Score for rAAA
pH < 7.2
Age > 76
Creat > 2.0
Pre-op SBP < 70mmHg
AUC 0.81*
Compared with 0.64 for
Robinson
Glasgow
and Edinburg Scores
* Based on Linear Discriminant Analysis
Lesson #6
• Permissive Hypotension Works!
Lesson #7
• Mean neck Diam is 26.7mm and Length 17.2mm
– 95,751 images
– 215 rAAA CTs
– Standard Grafts
• 28 – 32 mm
• Inventory helps
• Average size is large at 82.4mm (r:37 to 182mm)
Lesson #8
–Pulse Pressure Variation (PPV) is THE BEST
method of resuscitating these patients in OR!
• Goal < 11% PPV
– The REVAR patients are JUST AS SICK as those
undergoing open repair
– Aggressive resuscitation
– Low Index of Suspicion for:
• Abdominal Compartment Syndrome
• Ischemic Colitis
Lesson #9
Lesson #10
• The incidence of Ischemic Colitis has essentially
evaporated for rAAA’s in the Endovascular Era
Results:303 rAAA
23 died in EDor en route
190 Open Repair 90 REVAR
Ischemic ColitisN=40 (21%)
Ischemic ColitisN=6 (6.7%)
P= 0.03
Lesson #11
• Imaging and Image Transfer Technology has
Revolutionized Systems of Care
Lesson #12
• Bifurcated Endografts are more durable than an
AUI/ Fem-Fem Strategy
Lesson #13
• Type 2 Endoleaks don’t matter after REVAR
Lesson #14
• Type 1 Endoleaks after REVAR do matter, are
rapidly fatal and must be ruled out with any
challenging aortic neck anatomy.
Lesson #15
• Patients who are not EVAR candidates and
undergo an attempt at EVAR die.
rAAA who were candidates for EVAR
Procedure Number (%) 30-day mortality
EVAR 85 (54%) 22.4%
Open 71 (46%) 49.2%
156 P=0.0007
rAAA who were NOT candidates for EVAR
Procedure Number (%) 30-day mortality
EVAR 5 (9%) 100%
Open 49 (91%) 46.9%
54 p=0.024
rAAA who were candidates for EVARrAAA who were NOT candidates for EVAR
Lesson #16
• The More You Do, The Better Your Results!
rAAA who were candidates for EVARrAAA who were NOT candidates for EVAR
Acknowledgements
@benstarnesmd
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