Leaking Aneurysm Minimizing Mortality with open surgery Joel Arudchelvam SLSVS aneurysm.pptx

Leaking Aneurysm Minimizing Mortality with open surgery Joel Arudchelvam

1. Leaking Aneurysm Minimizing Mortality with open surgery Joel Arudchelvam MBBS, MD ( SUR ), MRCS (ENG), FCSSL Consultant Vascular and Transplant Surgeon

2. Leaking Aortic aneurysms The classical triad - abdominal pain ,  hypotension , and pulsatile abdominal mass - only seen in less than 50 % of patients.  M ajority of patients (70%-80%) with ruptured abdominal aortic aneurysm do not reach a hospital For operated patients mortality - 40% to 50% Acosta SOgren MBengtsson HBergqvist DLindblad BZdanowski Z Increasing incidence of ruptured abdominal aortic aneurysm: a population-based study. J Vasc Surg 2006;44 (2) 237- 243PubMedGoogle ScholarCrossref 2. Ingoldby CJWujanto RMitchell JE Impact of vascular surgery on community mortality from ruptured aortic aneurysms. Br J Surg 1986;73 (7) 551- 553PubMedGoogle ScholarCrossref

3. Leaking Aortic aneurysms Presentation Abdominal pain and backache - 88.8% Hypotension / Dizziness - 38.9% Paraplegia * - 02.8% Long-term outcome of ruptured Abdominal Aortic Aneurysm:Acase series by single vascular surgical unit. Sanjaya Iddamalgoda , Gurusamy Kapilan , Joel Arudchelvam : s.n., 2021. 50 Annual Academic Sessions - 2021 of The College Of Surgeons of Sri Lanka. p.64. * Gurusamy Kapilan , Sanjaya Iddamalgoda , Joel Arudchelvam. Ruptured mycotic abdominal aortic aneurysm presenting with spinal cord ischaemia: A very rare presentation. Int J Case Rep Surg 2020;2(1):09-11

4. Sites of bleeding Intraoperative findings 9 patients (documented) Retroperitoneal leak - 6 (66.7%) Aorto-enteric fistula (AEF) - 2 (22.2%) Intra-peritoneal rupture - 1 (11.1%) Long-term outcome of ruptured Abdominal Aortic Aneurysm:Acase series by single vascular surgical unit. Sanjaya Iddamalgoda , Gurusamy Kapilan , Joel Arudchelvam : s.n., 2021. 50 Annual Academic Sessions - 2021 of The College Of Surgeons of Sri Lanka. p.64. .

5. Investigations Ultrasound Sharply demarcated aortic wall defect Hypoechoic - heterogeneous collection within retroperitoneal space Free intra-peritoneal fluid

6. Investigations CT Scan Periaortic , pararenal or the psoas muscle haematoma Draped aorta sign – no space posterior to the aorta and the vertebra

7. Investigations CT Scan Active extravasation Focal outward displacement of calcified intimal plaque

8. Aortic aneurysms NHSL - 2004 – 2010 Total - 141 Male - 80% Mean age – 68 years (35–86) Gunawansa N, Goonerathne T, Cassim R, Wijeyaratne M. Open repair of infra renal abdominal aortic aneurysms: a single center experience from the developing world. Ann Vasc Dis. 2011;4(4):313-8. NHSL – unpublished data

9. Leaking AAA repair NHSL - 2004 – 2010 Total AAA - 141 Leaking aneurysms – 33 (23.4%) Gunawansa N, Goonerathne T, Cassim R, Wijeyaratne M. Open repair of infra renal abdominal aortic aneurysms: a single center experience from the developing world. Ann Vasc Dis. 2011;4(4):313-8.

10. Leaking AAA repair NHSL - 2004 – 2010 Repaired aneurysm Elective – 45 (62.5%) Emergency – 27 (37.5%) All open repairs Gunawansa N, Goonerathne T, Cassim R, Wijeyaratne M. Open repair of infra renal abdominal aortic aneurysms: a single center experience from the developing world. Ann Vasc Dis. 2011;4(4):313-8.

11. Leaking AAA repair NHSL Total - 36 Mean age - 63.7 years (42-73) Males. - 88.9% . Long-term outcome of ruptured Abdominal Aortic Aneurysm:Acase series by single vascular surgical unit. Sanjaya Iddamalgoda , Gurusamy Kapilan , Joel Arudchelvam : s.n ., 2021. 50 Annual Academic Sessions - 2021 of The College Of Surgeons of Sri Lanka. p.64. * Gurusamy Kapilan , Sanjaya Iddamalgoda , Joel Arudchelvam. Ruptured mycotic abdominal aortic aneurysm presenting with spinal cord ischaemia: A very rare presentation. Int J Case Rep Surg 2020;2(1):09-11

12. Open AAA repair

13. Causes of mortality Effects of bleeding Myocardial ischemia Respiratory complications Bowel ischemia Limb ischemia Neurological

14. How to improve the outcome Future directions Patient selection Preparedness Improve diagnostic skills (Giles KA, Hamdan AD, Pomposelli FB, Wyers MC, Dahlberg SE, Schermerhorn ML. Population-based outcomes following endovascular and open repair of ruptured abdominal aortic aneurysms. J Endovasc Ther . 2009 Oct;16(5):554-64. doi : 10.1583/09-2743.1. PMID: 19842719; PMCID: PMC2793420.)

15. Sri Lanka - Vascular units 15 (18) Vascular and transplant units (2022) 70 - 80 AA repairs / year Concentration of cases - Mortality decreased with increased AAA repair numbers ( low 44%, high 38%; p<0.001).

16. Post operative care Haniffa , R., De Silva, A. P., Iddagoda , S., Batawalage , H., De Silva, S. T. G. R., Mahipala , P. G., … Jayasinghe , S. (2014).  A cross-sectional survey of critical care services in Sri Lanka: A lower middle-income country. Journal of Critical Care, 29(5), 764–768

17. Thank You