Surgery After eEVAR of Ruptured AAA Analyzed
July 1, 2009—In a study published in the Journal of Vascular Surgery, Dieter Mayer, MD, et al retrospectively analyzed 102 patients with ruptured abdominal aortic aneurysms (rAAAs) that were treated with emergency endovascular aneurysm repair (eEVAR) from January 1998 to April 2008 (2009;50:1–7).
The investigators stated that the background of the study is that open abdomen treatment (OAT) is considered a lifesaving procedure in patients with abdominal compartment syndrome (ACS) after endovascular or open intervention for rAAA. Standardized treatment methods and algorithms for its use are still lacking. The published high mortality rates may reflect difficulties in detecting and treating ACS, especially in patients treated with eEVAR. This study presented standardized algorithms for OAT, including a new technique using a vacuum-assisted closure (VAC) system developed during 10 years of experience with eEVAR for rAAA.
In the study, abdominal decompression was performed when intravesical pressure was > 20 mm Hg or when abdominal perfusion pressure was < 50 to 60 mm Hg and concomitant organ deterioration occurred. OAT was initially done with a subcutaneously sutured plastic bag or with a nonsutured zipper drape combined with the VAC/Ethizip (KCI International Inc., Amstelveen, The Netherlands; Ethicon, Somerville, NJ). All patients were switched to VAC/Ethizip as soon as possible. Dressings were generally changed every 3 to 5 days. Intra-abdominal pressure was monitored until stability was observed after delayed direct abdominal closure.
The investigators reported that 30-day mortality for eEVAR was 13% (13 of 102) overall, 8% (7 of 82) for patients without ACS, and 30% (6 of 20) for those with ACS. Decompression for ACS was needed in 20 patients (20%) primarily during the intervention (n = 14) or secondarily in the intensive care unit (n = 6). Six of 20 (30%) patients requiring OAT died at ≤ 30 days (4 primary, 2 secondary). A mean of 3.6 (range, 1–12) planned second-look interventions were done per patient at an interval of 3 to 5 days. No bowel lesions were observed. Four patients required antibiotic therapy for abdominal infection, and all infections were resolved. Delayed abdominal wall closure (direct closure, 11; closure with polypropylene mesh, 3; bilateral anterior rectus abdominis sheath turnover flap, 1) was achieved after a median of 6 days (range, 1–47 days).
The investigators concluded that the use of standardized novel techniques and a treatment protocol and algorithm for OAT after eEVAR for rAAA were feasible and safe. It decreased the workload of the medical and nursing staff, enhanced patient comfort because the need for dressing changes was minimized, and likely contributed to lower overall mortality in rAAA patients. Delayed direct fascial closure was possible in most patients, added the investigators.