Caso ClÃÂnico
Successful evolution of endovascular treatment in a complex case of ruptured abdominal aortic aneurysm
Lisandro José Tesoro, MatÃÂas RodrÃÂguez-Granillo, Carlos Fernández-Pereira, Juan Mieres
Revista Argentina de CardioangiologÃÂa Intervencionista 2023;(2): 0077-0082 | Doi: 10.30567/RACI/20232/0077-0082
This is the case of a large diameter ruptured abdominal aortic aneurysm that was promptly resolved through endovascular therapy. After meticulous stent-graftimplantation, the initial evolution of the case was satisfactory. As it often happens in cases of high cardiovascular complexity, even when the major conditions has been overcome, certain complication may arise requiring care for the patient’s complete and favorable final outcome. This report reflects the comprehensive cardiac interventional, anesthesiological, and clinical work conducted on this regard.
Palabras clave: abdominal aneurism, EVAR, endoprosthesis, aneurism rupture.
El caso que comunicamos hace referencia a un aneurisma aórtico abdominal roto de gran diámetro el cual recibió pronta resolución por vía endovascular. Luego de un laborioso implante de endoprótesis, la evolución inicial del caso fue satisfactoria. Como habitualmente ocurre en casos de alta complejidad cardiovascular, aun cuando la gran patología principal queda superada, determinadas intercurrencias pueden suscitarse y requerirán su atención para lograr un completo buen resultado final en el paciente. El presente reporte refleja la integralidad del trabajo cardiointervencionista, anestesiológico y clínico realizado a tales fines.
Keywords: aneurisma de aorta abdominal, endoprótesis, EVAR, aneurisma roto.
Los autores declaran no poseer conflictos de intereses.
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Recibido 2023-04-05 | Aceptado 2023-06-13 | Publicado
Esta obra está bajo una Licencia Creative Commons Atribución-NoComercial-SinDerivar 4.0 Internacional.
INTRODUCTION
Abdominal aortic aneurysm (AAA) has an incidence rate of up to 7.6% in patients older than 50 years. Risk of rupture varies depending on its diameter, ranging from approximately 10% to 20% annually for cases > 60 mm. Ideally, treatment should be performed electively during intermediate stages of its progression to prevent he acute event associated with the aneurysm (contained or free rupture), a catastrophic event with a very grim prognostic. Overall, we estimated that 80% of the patients with a ruptured aneurysm do not survive. This high mortality rate includes both the pre-hospital stage and in-hospital mortality, including adverse events of surgical treatments with mortality rates up to 50%. Therefore, aortic aneurysm ruptures can account for up to 2% of the causes of death in men older than 65 years.
Currently, there are 2 treatment options available: a) open surgery repair (OSR) and b) endovascular aneurysm repair (EVAR) through endoprosthesis implantation. In this report we will be describing a case of EVAR to treat a ruptured abdominal aneurysm (its EVRAR variant) as an example of a growing trend supported by the medical literature available over the past 10 years towards the interventional resolution of complicated aneurysms, as we will describe below.
DESCRIPTION OF CASE REPORT
This is the case of a 75-year-old man who initially presented to the ER with abdominal pain. His personal medical history includes a) hypertension, b) dyslipidemia, c) obesity, d) severe coronary artery disease requiring coronary artery bypass surgery 4 years ago at a different center (without anatomical details of the referred treatment), e) idiopathic pulmonary fibrosis diagnosed 2 years ago, f) maculopathy in the left eye with near-total loss of visual acuity in that eye.
The patient’s current drug treatment includes a) bisoprolol 5 mg/day, b) esomeprazole 40 mg/day, c) atorvastatin 40 mg/day, d) perindopril 10 mg/day, e) amlodipine 5 mg/day, f) deltisona 10 mg/day, g) spironolactone 25 mg/day.
The initial reason for consultation was right sacro-lumbar and abdominal pain, asthenia, adynamia, nausea, dizziness, and symptoms consistent with orthostatic phenomenon.
An abdominal computed tomography scan was requested to study the abdominal condition of this patient with risk factors and cardiovascular history. The report reads: “Infrarenal aneurysm with eccentric mural thrombus of heterogeneous density and disorganized parietal calcification. Hyperdense periaortic and retroperitoneal fat planes with signs of blood content, attributed to aneurysmal rupture with retroperitoneal hematoma. No active contrast substance extravasation is observed. The maximum diameter of the aneurysmal sac measures 85 mm,; he proximal neck, 29 mm; and is located approximately 35 mm from the left renal artery. Presence of severe aortic and iliac parietal calcification.”
Regarding the cardiovascular system, the ECG report indicates: sinus rhythm; HR, 100/min; axis -30°; PR, 150 ms; QRS, 100 ms; QS wave in leads DIII and aVF, isoelectric ST-segment and T-wave, regular progression of R in precordial leads. This was the report from the transthoracic echocardiogram requested for perioperative assessment: “Left ventricular hypertrophy, normal-sized cardiac chambers, preserved left ventricular global systolic function. Normal-sized aortic root. Aortic valve calcification with moderate aortic stenosis. Mitral filling pattern consistent with prolonged relaxation.”
The patient’s clinical condition was complex but remained stable. During the preoperative period, the patient had a tendency towards hypertension of diastolic predominance (blood pressure values between 135/90 and 160/110). The initial heart rate was 90 bpm up to nearly 110. The patient remained lucid, cooperative, in a mandatory dorsal decubitus position, with an initial arterial oxygen saturation (SatO2) of 92% in breathing room air up to 94%-95% with a nasal cannula delivering 3 L/m of O2. Some noticeable cutaneous-mucosal paleness was seen. The standard drug treatment to prepare for surgery (labetalol + NTG infusion pump) partially controlled the vasoconstrictive and tachycardic tendencies associated with the acute vascular event.
Within a few hours, during which the management of supplies and participating personnel was arranged, the patient was transferred to the cath lab for emergency aorto-bi-iliac stent-graft implantation. Technically, a hybrid surgical and interventional approach was performed. The vascular surgery team initially performed open dissection of the common femoral arteries bilaterally. Following the placement of introducer sheaths in both arteries an aortography was performed with a pigtail catheter. The aortogram revealed the presence of iliac trajectories with pronounced curves as seen during imaging planning. After meticulous instrumentation with increasing rigidity wires, the suitable juxtarenal level of the aorta was reached to start implantation. A 26 mm x 100 mm Endovascular Minos device was ascended via left femoral access of the main branch using an extra-rigid wire, and the upper limit was positioned just below the lower edge of the renal arteries. Subsequently, a 16 mm x 120 mm Amplatz catheter and the right extension were introduced from the right side. Afterwards, the 16 mm x 120 mm left extension was placed through a sheath via left femoral artery. At the end, a control aortography was obtained with no evidence of leaks and preserved patency of all branches. As the final surgical act, both femoral branches were closed using endarterectomy and arteriorrhaphy. Preserved pulse in the vessels distal portion and palpable posterior tibial pulse in both limbs were reported without changes compared to baseline.
In terms of clinical management, this procedure was performed under general anesthesia. The anesthetic procedure began with a peripheral 16G IV line in the upper limb followed by the IV induction of general anesthesia (midazolam 15 mg, propofol 180 mg, fentanyl 200 mcg, rocuronium 30mg). Induction was followed by hemodynamic stability without need for vasopressor support until that point. After preoxygenation and assisted ventilation with a mask without difficulties, orotracheal intubation was performed using a video laryngoscope. No airway complications were reported, achieving satisfactory glottic view and successful orotracheal intubation in a single attempt. Anatomically, our patient presented parameters indicative of a difficult airway, which is a common finding in cardiointerventional anesthesiology, such as a) obesity, b) short and thick neck, c) limited cervical extension, d) age, e) male gender, f) soft tissue proliferation in the pharyngeal area, and g) presence of coronary artery disease and lung pathology. Therefore, using the video laryngoscope as a valuable tool, our patient’s airway was both rapidly and effectively secured, and mechanical ventilation was initiated using the lung-protective setting. Additionally, a 20G arterial line was placed in the left radial artery for invasive monitoring and sampling. Afterwards, a dual-lumen 7-Fr central venous catheter was inserted under ultrasound guidance via right internal jugular vein, with strict asepsis in both vascular procedures. The maintenance phase of anesthesia was conducted with 0.8% sevoflurane, propofol infusion at 50 mcg/kg/min, and remifentanil at 0.1 mcg/kg/min. Ten minutes into the procedure, a mild trend towards hypotension was noticed, and noradrenaline was started via a central line. The slightly decreased blood pressure progressed into moderate hypotension when aortic instrumentation started, requiring increased noradrenaline up to 0.4mcg/kg/min, along with intravascular expansion using Ringer’s lactate solution at a rate of 2000 mL intraoperatively. Additionally, 1 unit of packed red blood cells was transfused during this period due to the presene of significant retroperitoneal hematoma, limited surgical bleeding, and hypotension.
Intraoperatively, close metabolic monitoring was performed using arterial samples to assess the internal milieu throughout the 3.5-hour procedure. We saw lactate levels dropping, with intraoperative values of 4.9 mmol/L compared with 6.76 mmol/L before surgery. This favorable metabolic evolution was reinforced by the clinical correlation of hemodynamic normalization in the later surgical phases and complete cessation of vasopressor drug requirements. A unanimous decision was made to extubate the patient immediately after surgery in the cath lab. The patient regained consciousness rapidly and effectively, without periods of disorientation being cooperative and responsive to commands, with good ventilatory mechanics, and bilateral air entry. SatO2 was 97% with a nasal cannula, with spontaneously preserved circulatory parameters without adjuvant drugs. Afterwards, the patient was transferred to the ICU for postoperative recovery. At follow-up, the postoperative situation remained the same, with blood pressure and HR levels of 140/90 and 90 bpm, respectively.
During the immediate postoperative period, the patient recovered moderately well, although not uneventfully. Within the first 36 hours, in a context of arterial hypertension according to the baseline records, the patient experienced symptoms described as blurry vision. The brain CT scan, ophthalmology and neurology assessments performed revealed: “Presence of cortico-subcortical hypodensity in the occipital region causing effacement of the cortical sulci at convexity level, which is consistent with acute-to-subacute ischemic injury. Some focal hypodensities can also be seen at periventricular white matter level associated with microangiopathic vascular sequelae.” In other words, the finding of an ischemic region at right occipital lobe level was later interpreted as “cardioembolic stroke of limited territory due to to recent surgery.” Additionally, the CCTA of neck and intracranial vessels described: “Both common carotid arteries, carotid bulb, and internal carotid arteries show atherosclerotic calcifications sparing their caliber without significant obstruction. The vertebral arteries have adequate flow, the right one looking hypoplastic. There are also atherosclerotic calcifications in the intracranial portions of the carotid and vertebral arteries.” The central embolic finding was pharmacologically treated with concomitant administration of acetylsalicylic acid and clopidogrel, as indicated for the recently placed aortic device.
Over the following days of recovery, visual symptoms improved favorably, with acceptable recovery of the right eye visual acuity and visual field. On the hematology level, 2 additional units of red blood cells were required during the postoperative period to compensate for initial losses during the aortic event, along with subsequent fluid redistributions. The patient’s renal function remained within the normal range, with adequate creatinine and urea levels, and proper diuresis via a urinary catheter. The metabolic prognosis remained favorable, with good alkaline availability in plasma throughout the intraoperative period: bicarbonate levels at around 20 mmol/L, normal base excess, and a decreasing lactate curve. Seventy-two hours into the postoperative period, there was a tendency towards feverish recordings. Serial blood cultures were obtained, all yielding negative results. The gram-negative bacterium Klebsiella oxytoca isolated in a urine sample exhibited low antibiotic resistance. A 1-week IV course of antibiotics with a combination of imipenem and vancomycin was used to treat this complication. The febrile syndrome resolved few days after starting antibiotic therapy. The patient’s recovery continued with a 6-day stay in the coronary care unit and 8 days in a general ward to rehabilitate the motor function. Having completed this intense but successful clinical course and being in a very good condition, both objectively and subjectively, the patient was successfully discharged.
CONCLUSIONS AND DISCUSSION
As multiple studies reveal throughout the world, the mortality rate of ruptured aortic aneurysms has traditionally been high, reaching overall values of 80%1. Being a critical condition with a grim prognosis. The innovative endovascular repair (EVAR) that has been using aortic stent-graft implantation over the past 20 years is a feasible solution to this problem. The use of this technique has been on the rise since it was first introduced2 because it offers multiple device variations and novel designs. The endovascular approach for the management of aortic pathology offers advantages associated with less tissue invasiveness and fewer repercussions on systemic physiology compared with surgery.
Since this technique was introduced in 199111, it was initially adopted for the elective resolution of aneurysms the best approach for ruptured aneurysms was still controversial. At that time, all aneurysms ended up on the operating room. However, since 2010, articles with solid evidence recommending EVAR have been published, and we now have important meta-analyses3 that suggest significant differences favorable to EVAR over OSR in complicated aneurysms.
The proven advantage of the interventional approach compared to open surgery is in the lower in-hospital mortality rate of EVAR cases (7), with an odds ratio (OR) for this outcome of 0.53. In addition to this crucial difference, there are other evidence-based interventional advantages. EVAR has a lower relative rate of pulmonary (OR, 0.53), complications (OR, 0.53), cardiac (OR, 0.65), and mesenteric complications (OR, 0.42). In other words, its impact on multiple target organs is not as strong P values < .01 in all cases. The rate of transfusions is also lower with EVAR, there is less variability in results among operators with different case volumes, and it is the preferred approach in multimorbid patients older than 80 years (2).
Stent-grafts have become the treatment of choice of ruptured aneurysms. In the United States, the rate of complicated aortas treated with endovascular techniques went up from 39% in 2009 up to 59% in 20153. The Society of Vascular Surgery guidelines from January 2018 recommended EVAR for cases of ruptured aneurysms whenever anatomically feasible, with a level 1 recommendation (strong evidence)4. Obviously, the option of open repair will always have its place and is currently evidence-based in cases deemed anatomically unsuitable for stent-graft implantation or cases of ruptured aneurysms with very complicated clinical situations. Also, it may be preferred in cases where there is limited availability of endovascular resources in a short timeframe, predominantly in peripheral centers, or guided by rational preferences or the skills of the personnel involved.
EVAR also has its own complications, especially in cases of ruptured aneurysms. The most common ones are endoleaks in their various subtypes, arterial occlusions of lower extremities, bleeding, and refractory shock leading to the death of the patient. Ruptured aneurysm is an event with a high physiological impact, and the expansion of endovascular techniques has improved many survival rates. However, we are still facing a problem with a high overall mortality rate3. The vascular surgical team will always act as an essential safety support when performing complex interventional procedures.
There is a long list of rare complications whose chances of happening run parallel to EVAR technical complexity10. Thus, the more complex cases of stent-grafts have a higher rate of these adverse events: a) myocardial infarction (OR, 18.7), b) acute kidney failure, c) major cardiovascular events (OR, 11.1), and d) stroke (OR, 7.3). In case described in this study, the severe complications mentioned earlier did not occur. However, we saw a lateral event less frequently, the aforementioned cerebral embolism at occipital level, which showed a favorable progression.
Although our case did not require fenestrated vascular branches or angioplasties using the chimney-stent technique, it did require a high level of technical complexity for anatomical reasons related to sharp curves in the iliac and aortic paths that required instrumentation to higher levels. The sources of embolism towards the posterior cerebral circulation were undoubtedly related to the plethora of atheromatous calcifications in aortic and carotid circulations, which is consistent with the presence of a hypoplastic right vertebral artery shown by imaging. In addition, aortic instrumentation, which was proposed as the cardioembolic source, and postoperative hypertensive events were other factors in the etiology of the event.
The great positive aspect of this case is that the most notable and adverse complications that lurk in these complex clinical contexts were avoided, and the patient underwent successful stent-graft implantation, remaining within the 20% overall survival rate after ruptured aortic aneurysm.
1. D.W. Harkin, M. Dillon et al. Endovascular Ruptured Abdominal Aortic Aneurysm Repair (EVRAR): A Systematic Review Eur J Vasc Endovasc Surg 34, 673-681 (2007).
James McPhee, Mohammad H Eslami et al. Endovascular treatment of ruptured abdominal aortic aneurysms in the United States (2001-2006): a significant survival benefit over open repair is independently associated with increased institutional volume J Vasc Surg. 2009 Apr;49(4):817-26.
George A Antoniou, George S Georgiadis et al . Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over open repaira J Vasc Surg 2013 Oct;58(4):1091-105.
Elliot L. Chaikof et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm Society for vascular surgery Document Vol 67, issue 1, p2-77, Jan 2018
Hiroyuki Ito. Postoperative Ruptured Abdominal Aortic Aneurysms and Management of Complications Ann Vasc Dis Vol. 12, No. 3; 2019; pp 323–328.
IMPROVE trial investigators Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. BMJ 2014;348:f7661
Real-world evidence of superiority of endovascular repair in treating ruptured abdominal aortic aneurysm, J Vasc Surg VOLUME 68, ISSUE 1, P74-81, JULY 2018
Nicholas J. Swerdlow et al. Rate of Stroke Following Endovascular Aortic Interventions in the Society for Vascular Surgery Vascular Quality Initiative.
Koji Sato et al. Treatment Strategy of Endovascular versus Open Repair for Ruptured Abdominal Aortic Aneurysm Based on the Fitzgerald Classification. Ann Vasc Surg 2020 Nov;69:324-331.
Thomas F X O’Donnell et al. The state of complex endovascular abdominal aortic aneurysm repairs in the Vascular Quality Initiative . J Vasc Surg 2019 Aug;70(2):369-38.
J. C. Parodi, J. C. Palmaz, H. D. Barone Transfemoral Intraluminal Graft Implantation for Abdominal Aortic Aneurysms. Annals of Vascular Surgery. Vol 5, Issue 6, Nov 1991, Pages 491-499.
Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management. Cardiovascular Diagnosis and Therapy. Vol 8, Supplement 1 (April 13,2018).
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Successful evolution of endovascular treatment in a complex case of ruptured abdominal aortic aneurysm
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Etiquetas
abdominal aneurism, EVAR, endoprosthesis, aneurism rupture
Tags
aneurisma de aorta abdominal, endoprótesis, EVAR, aneurisma roto
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