Establishing a protocol for endovascular treatment of ruptured abdominal aortic aneurysms: outcomes of a prospective analysis.

Purpose: In our transition from elective abdominal aortic aneurysm (AAA) to emergent ruptured AAA (r-AAA) repair with endovascular techniques, we recognized that the availability of endovascularly trained staff in the operating rooms and emergency departments, and adequate equipment were the limiting factors. To this end, we established a multidisciplinary protocol that facilitates endovascular repair (EVAR) of r-AAA.

Methods: In January 2002, we instituted a multidisciplinary approach that included the vascular surgeons, emergency department physicians, anesthesiologists, operating room staff, radiology technicians, and availability of a variety of stent-grafts to expedite EVAR of r-AAAs. Five patients with symptomatic, not ruptured AAAs suitable for EVAR underwent simulation of patients presenting to the emergency department with r-AAAs. Emergency department physicians alerted the on-call vascular surgery team (vascular surgeon, vascular resident or fellow) and the operating room staff, emergently performed an abdominal computed tomography (CT) scan in only hemodynamically stable patients with systolic blood pressures > or =80 mm Hg, and transported the patient to the operating room. The vascular surgeon informed the operating room staff to set up for EVAR and open surgical repair in an operating room equipped with interventional capabilities. The operating room setup was rehearsed with the anesthesiologists, operating room staff, and radiology technicians who were knowledgeable of the sequence of steps involved. Since then, 40 patients have undergone emergent EVAR for r-AAAs with general anesthesia.

Results: No complications developed in any of the symptomatic (simulation) patients, and 40 (95%) of 42 patients with r-AAAs had a successful EVAR with Excluder (n = 27, 68%), AneuRx (n = 9, 23%), or the Zenith (n = 4, 10%) stent-grafts. The mean age was 73 years (range, 54 to 88 years), and pre-existing comorbidities included coronary artery disease in 26 (65%), hypertension in 23 (58%), chronic obstructive pulmonary disease in 7 (18%), renal insufficiency not on dialysis in two (5%), and diabetes in nine (23%). Fourteen (38%) patients were diagnosed with r-AAAs at another hospital and subsequently were transferred to us, and 26 (62%) presented directly to the emergency department at our institution. At the initial presentation, 30 patients (75%) were hemodynamically stable and either had a CT scan at an outside hospital or in the emergency department, and 10 (25%) hemodynamically unstable patients with systolic blood pressures <80 mm Hg were rushed to the operating room for EVAR without a preoperative CT scan. The mean time from the presumptive diagnosis of a r-AAA in the emergency department to the operating room for EVAR was 20 minutes (range, 10 to 35 minutes), and the mean operative time from skin incision to closure was 80 minutes (range, 35 to 125 minutes). Seven patients (18%) needed supraceliac aortic occlusion balloon, and six (15%) needed aortouniiliac stent-grafts. The mean blood loss was 455 mL (range, 115 to 1100 mL). Two patients each (5%) developed myocardial infarction, renal failure, and ischemic colitis, seven (18%) developed abdominal compartment syndrome, and seven (18%) died. Over a mean follow-up of 17 months, three patients with endovascular r-AAA repair required four secondary procedures.

Conclusions: The early results show that emergent endovascular treatment of hemodynamically stable and unstable patients is associated with a limited mortality of 18% once a standardized protocol is established. There is an increased recognition of emerging complications with an endovascular approach, and a synchrony of disciplines must be developed to initiate a successful program for endovascular treatment of r-AAAs.