Ruptured Abdominal Aortic

Aneurysms

Eliza Long
 Treatment of the Ruptured
Abdominal Aortic Aneurysm
• Diagnosis
– Clinical
– Imaging
• Resuscitation
• Surgery
– Different options
• Complications
 Diagnosis
Clinical Presentation
• “Classic triad:”
– Severe abdominal pain
– Hypotention
• An episode of syncope may be a hint
– Pulsatile mass
• Large girth may obscure
• Less common symptoms:
– Groin/flank pain, hematuria, groin hernia all secondary to
increased intra-abdominal pressure
– Congestive Heart Failure with JVD and abdominal bruit if
patient has ruptured into the Vena Cava
14 x 8 cm abdominal aortic aneurysm arising from the supraceliac aorta and
extending to just above the take off of the left renal artery is visualized with
extensive thrombus but also extensive flow
 Diagnosis
Clinical Presentation
– RAAA is misdiagnosed 16% - 30% of the time
• Common misdiagnosis:
– Renal colic, perforated viscous, diverticulitis,
gastrointestinal hemorrhage and ischemic bowel
– Mortality rates for correctly diagnosed was
58%, and 44% for misdiagnosed
• Likely due to fact that less severe ruptures have a
more subtle presentation and can survive longer
before going to OR
 Diagnosis
Imaging
• Plain Films
– Enlarged outline of calcified aortic wall
• A retrospective review showed that 65% of x-rays form RAAA had
calcified aortic wall
– Loss of psoas shadow
• Abdominal U/S
– Sensitive in detecting aneurysm but not in detecting rupture
• Abdominal CT
– Most accurate method
– See presence of retroperitoneal blood (77% sensitive and
100% specific)
Loss of psoas Enlarged outline of
shadow calcified aortic wall
Sensitive in detecting aneurysm but not in
detecting rupture
 See presence of retroperitoneal blood. Here there is not a large
retroperitoneal hematoma, but stranding of blood into surrounding tissues
 Resuscitation
• If suspecting rAAA:
– 2 Large bore IVs
– Type and Cross for at least 6 Units of pRBCs
• Confirmed rAAA:
– Transfer to Operating room (transfer to center with
experienced surgeons prepared for rAAA)
– Establish art line and foley
– Prep and drape before and during anesthetic induction
 Resuscitation
• Actual Pre-Op resuscitation
– Controversial
• Aggressive crystalloid can elevate BP and cause rupture of
temporary aortic seal that forms after initial rupture
• Minimally resuscitate to “maintain conconsciousness” (~80
systolic) and use blood
• No randomized trials testing the different degrees of
resuscitation with rAAA
– Animal studies show increased mortality when resuscitation
occurs before control of hemorrhage
 Surgery
• OPEN TRANSPERITONEAL

• OPEN RETROPERITONEAL

• ENDOVASCULAR
 Surgery
Open Repair

Hypotension No Hypotension

Inspect Retroperitoneum
Supraceliac Clamp Reflect bowel and duodenum

Pararenal Extensive No Hematoma

Hematoma

Careful Dissection for

Infrarenal Control

Uncontrolled Bleeding
Develops
 Surgery
Open Repair  TRANSPERITONEAL

• Transperitoneal allows the fastest and easiest approach for

Supraceliac clamp
• Retract the left lobe of the liver to right to show supraceliac
aorta at diaphragm
• NG tube identifies esophagus and proximal stomach and
retracts to the left
• Enter lesser sac by opening gastrohepatic omentum
• Aorta is found between crura of diaphragm and is clamped
– Can reposition clamp to infrarenal neck of aneurysm once
aneurysm is opened
– or can make first anastamosis in aneurysm sac and then transfer
clamp to graft to reperfuse kidneys and viscera.
Retract the left lobe of the liver to
right to show supraceliac aorta at
diaphragm
NG tube identifies esophagus
and proximal stomach and
retracts to the left

Enter lesser sac by opening

gastrohepatic omentum
Sometimes crura may need to
be split with electrocautery for
appropriate visualization
 Aorta is found between
crura of diaphragm and is
clamped
 Surgery
Open Repair  TRANSPERITONEAL
Supraceliac Clamp
– Coordinate with anesthesia
• after clamp “crank up” the resuscitation
• before releasing supraceliac clamp prepare for hypotension
– Advantages
• quick solution to severe hypotension from intraperitioneal
rupture.
• avoids injury to renal and gonadal vein injury from blind
dissection of infrarenal neck
– Disadvantage
• ischemic injury injury to liver, bowel, and kidneys
 Surgery
Open Repair  RETROPERITONEAL
• ESPECIALLY for pararenal or suprarenal RAAA
• 10th interspace incision
– 1) Left colon mobilized to incise lateral peritoneal attachments.
– 2) Colon, pancreas, spleen, and kidney are elevated  access
diaphragmatic crura.
– 3) Divide crura  access entire intra-abdominal aorta and visceral
and renal vessels
– 4) May need a thoracoabdominal incision, or extra thoracic
incision for the larger people, or the hostile abdomen
 Surgery
Open Repair  Extras

• Brachial/femoral cut-down for occlusive balloon into aorta

• Aortic compressor to supraceliac aorta if rapid control
needed before establishing exposure for clamp
• Aortocaval fistula  direct digital pressure above and
below the fistula and suture of the fistula from within the
sac
• If iliac aneurysms are present leave alone unless ruptured,
if so repair easiest first (allow for pelvic reperfusion)
• Use cellsaver, its use is justified if anticipate large blood
loss
Aortic compressor to supraceliac
aorta if rapid control needed
before establishing exposure for
clamp
 Surgery
Open Repair  Anatomic abnormalities
• Venous anomalies that can cause bleeeding during
clamping:
– Retroaortic renal vein
– Circumaortic renal vein
– Left-sided vena cava
– Duplicate inferior vena cava
• Horseshoe kidney
– If at neck of aneurysm it prevents adequate exposure (another
reason to perform supraceliac clamping)
– Isthmus often contains renal tissue, collecting system and blood
supply
• If known before surgery, retroperitoneal approach
 Surgery
Open Repair

• Closing
– 25%-30% cases, the abdomen cannot be closed without significant
tension from swollen bowel or retroperitoneal hematoma
• Abdominal compartment syndrome (ACS) is bladder presser > 30cm
H2O or 25mm Hg
• Use early mesh to reduce incidence of multi organ failure from ACS
– Especially with pre-op anemia, prolonged shock, pre-op cardiac shock,
pre-op cardiac arrest, massive resuscitation, profound hypothermia, or
severe acidosis
• Use nonabsorbable mesh covered with plolyurethane
• Early mesh closure vs takeback mesh resulted in 6% and 40% colon
ischemia respectively
 Surgery
Endovascular Repair

• Institution requirements:
– 1) Rapid CT scanning
• For neck diameter, angulation, and iliac size
• Only about 20-46% of rAAA are suitable for EVAR
– 2) Training
– 3) Devices
– 4) Suite for Endovascular procedure
 Surgery
Endovascular Repair

• Stratagies for Repair:

– Aorto-unifemoral graft  ipisalateral internal
iliac exclusion and a femorofemoral crossover
graft (Montefiore group)
– Modular aortouniiliac and aortobiiliac
• Now rupture kits for repair
 Aorto-unifemoral graft
Endovascular Grafts and Other Image-Guided Catheter-Based Adjuncts to Improve the Treatment of
Ruptured Aortoiliac AneurysmsTakao Ohki and Frank J. VeithAnn Surg. 2000 October; 232(4): 466–479.
 Modular aortouniiliac and aortobiiliac
Early Experience with the Talent™ Stent-Graft System for
Endoluminal Repair of Abdominal Aortic AneurysmsFrank J.
Criado, MD, Eric P. Wilson, MD, Eric Wellons, MD, Omran Abul-
Khoudoud, MD, and Hari Gnanasekeram, MD Tex Heart Inst J. 2000;
27(2): 128–135.
 Surgery
Endovascular Repair

• Anesthesia
– Can use local (unless patients are squirming)
• Don’t loose the sympathetic tone that can maintain
pressure
• Some start under local and convert to general for
positioning and release of graft
 Surgery
Endovascular Repair

• Mortality Rates  10% to 45%, but limited

numbers of patients
• Causes 
– Colon ischemia
– MOF
– Continued hemorrage
• Endoleaks are a much bigger problem in this setting
as hemorrhage isn’t controlled
 Table 102-1. Reported Data on Ruptured Abdominal Aortic
Aneurysms (RAAA) Treated by Endovascular Aneurysm Repair

RAAA RE- EVAR EVAR CONVERSION

FIRST AUTHOR EVALUATED (no.) COMPLETED (%) MORTALITY (%) RATE (%)
Ohki, 200154 25 100 10 20

Hinchliffe, 20019 20 85 45 15

Lachat, 200255 57 37 9.5 0

Orend, 200239 21 71 14 29

Resch, 200394 21 100 19 0

Scharrer-Pamler, 24 100 12.5 4

200395
Peppelenbosch, 40 65 15 0
200352
Reichart, 200323 25 23 17 0

Totals 219 71 18 8.5

 
 Complications
Local
• Postoperative bleeding related to coagulapathy from hypothermia
(12%-14%)
• Limb ischemia  embolization from aortic debris, or clot formed in
illiacs if retrograde flushing is not performed
• Colonic ischemia (3%-13%) leads to mortality in 73%-100% of time
– Degree and duration of hypotension
– Patency of IMA
– Collateral supply
– Site of hematoma
• Spinal Cord Injury: incidence 2.3%.
– Interuption of pelvic blood supply, prolonged aortic cross-clamping,
introperative hypotension, aortic embolization, internal iliac interuption
 Complications
Systemic
• Respiratory Failure 
– 26-47% (mortality up to 68%)
– High O2 requirements, increased lung permeability, decrease in
lung compliance
– Factors that predispose
• Large shifts in fluid and blood
• Pre-existing pulmonary dysfunction
• Long cross-clamp time
• Renal Dysfunction 
– Incidence is 26-42% in patients in symptomatic aneurysms or
rAAA
– Higher with suprarenal cross-clamp, longer duration of cross-
clamp, pre-existing renal dysfunction, shock, old age
 Complications
Systemic
• Irreversible Shock 
– 10-15% of rAAA mortality
– Irreversible state in which aortic clamping, aggressive fluid
resuscitation, and inotropic support can fail to reverse hypotension
• Cardiac Complications 
– MI – mortality of 19-66%
– Arrhythmias – mortality 46%
– Cardiac arrest – mortality 81-100%
– CHF – mortality of 41%
– Common as patients usually have simultaneous cardiac dz
 Complications
Systemic
• Liver Failure 
– Due to hypoxic injury
• Although the liver is robust; can deal with a large degree of
hypoxic injury it still must reabsorb hematoma and the
increase in metabolism that is required to do this
– Patients usually develop jaundice on day 7
• Multisystem Organ Failure 
– Incidence of 64%
– Most common cause of death after 48 hrs
– Also referred to as a systemic inflammatory syndrome
 Complications
Systemic
• Multisystem Organ Failure 
– “Two hit” hypothesis
• 1) Hemorrhagic shock – first ischemic insult primes the
inflammatory response
• 2) Aortic Clamping – second ischemic insult
• 3) Resuscitation – first reperfusion insult
• 4) Aortic unClamping – second reperfusion insult
– Animal models support
• PMNs primed by pre-op hemorrhage, and after operative repair
there was further activation with elevations of oxidative burst.
– These patients are walking into the hospital with
oxidative injury
 Mortality
• Between 43% to 70% depending on the study
• Predictors 
– Scoring systems
• POSSUM – 12 physiologic variables and 6 operative variables
for calculated risk
• Hardman index – Based on age, creatinine, hemoglobin, EKG
evidence of ischemia, h/o loss of consciousness
• Multiple Organ dysfunction score (based on respiratory, renal,
hepatic, hematologic, neurologic, and cardiac)
– Deaths bimodal
» Those that died 48 after repair had sig increases in MODS
» Renal failure followed by hepatic failure at Day 10 are at
highest risk for mortality
 Table 102-2. Logistic Regression Model Showing the Interaction of Significant
Preoperative and Intraoperative Variables That Predicted Early Survival After
Ruptured Abdominal Aortic Aneurysm Repair

CREATININE (mg/dL) CLAMP SITE URINE OUTPUT (mL) PROBABILITY OF SURVIVAL (%)
≤1.3 Infrarenal ≥200 90
≤1.3 Infrarenal 1-199 76

>1.3 Infrarenal ≥200 71

≤1.3 Suprarenal ≥200 65

≤1.3 Infrarenal 0 52

>1.3 Infrarenal 1-199 46

≤1.3 Suprarenal 1-199 39

>1.3 Suprarenal ≥200 33

>1.3 Infrarenal 0 23

≤1.3 Suprarenal 0 18

>1.3 Suprarenal 1-199 15

>1.3 Suprarenal 0 6
 Logistic Regression Model Showing the Interaction of Significant Postoperative
Complications That Predicted Early Survival After Ruptured Abdominal Aortic Aneurysm

MYOCARDIAL INFARCTION RESPIRATORY FAILURE COAGULOPATHY RENAL DYSFUNCTION PROBABILITY OF SURVIVAL (%)
No No No No 96
No No Yes No 91
No Yes No No 74
Yes No No No 66
No No No ↑Cr 66
No Yes Yes No 58
Yes No Yes No 49
No No Yes ↑Cr 48
Yes Yes No No 21
No Yes No ↑Cr 20
Yes No No ↑Cr 15
No No No Dialysis 15
Yes Yes Yes No 11
No Yes Yes ↑Cr 11
Yes No Yes ↑Cr 8
No No Yes Dialysis 8
Yes Yes No ↑Cr 2
No Yes No Dialysis 2
Yes No No Dialysis 2
Yes Yes Yes ↑Cr 1
No Yes Yes Dialysis 1
Yes No Yes Dialysis 1
Yes Yes No Dialysis 0
Yes Yes Yes Dialysis 0
 Conclusions
• Diagnosis – Have RAAA on the
differential, don’t miss the diagnosis
• Resuscitation – Less is more until aorta is
clamped
• Surgery – Quick, safe exposure. Use a
method that you are experienced with.
• Complications – Expect them
I would like to end with
one more aorta…

mine