Final draft AAA podcast 1_Brookdale

Hello everyone, and welcome back to another episode of Behind the Knife the Surgery Podcast. My name is Christian Hadid, a fourth year general surgery resident from Brookdale in Brooklyn, New York, and I'm excited to be bringing in new segment of this podcast where we'll be discussing challenging cases and some of the hottest topics in vascular surgery.

I'll now introduce my co-host, Dr. Paul Heer, who's the chief of the Division of Vascular Surgery at Brookdale. Dr. Hazer has been in practice for over 25 years and was part of the team that brought endovascular to the forefront, helping to perform the first aortic endograft in New Jersey. Next, Dr. Andrew Harrington, who has been in the practice for about five years, finishing his general surgery training at St.

Luke's Roosevelt, and then going on to vascular surgery at Stony Brook. Finally, Dr. Lucio Flores, who's our most experienced attending and is essentially the godfather of vascular surgery at our institution. He has been in practice for almost 50 years and has been board certified in both general and vascular surgery.

It's great to have you guys here. We have a

really great case for our listeners at home today, so let's get into it. Dr. Harrington, you get a call from your second year resident around 2:00 AM with a shaky voice. He begins telling you of a 65-year-old male presenting to the ED with abdominal pain distension, and a single episode of non-blood, non-bill emesis.

The ED got a CTA and it's showing a massive 18 centimeter AAA with a type one endo leak. On the right, there's fluid in the belly and the radiologist can't rule out a ruptured aneurysm. The ED thinks we need to take this patient to the OR emergently, and you need to come in right now. What's your first move?

Oh wow. Well, probably the first thing I'm gonna do is try to get Dr. Hazer on the phone, but seriously though there's a little bit more information that I probably would want to get from the resident first. So when I get a call in the middle of the night, the first thing I really want to hear is the headline statement.

What the patient is presenting with, right? So in this case, the resident might say something such

as, we have a 65-year-old male with an 18 centimeter AAA and a type one B end ale. That's the headline sentence. Then they can add things like whether it's free or contained rupture. It's important for the residents to try to present in a.

Succinct, clear manner that can tell me what the case is all about without adding a lot of extra distractors. In this case, abdominal pain, dissension, vomiting are not really what I need to hear. I need to know how much I have to turn my brain on and whether I need to actually come in. The other thing is when we have something this serious, I probably wanna hear about it from the most senior resident on call.

Fair enough. Dr. Harrington. So the chief resident who has been listening in, picks up the phone and goes on to say, Dr. Harrington, this is a pretty complex case. So let me tell you about his medical history before talking about the scan. He has an extensive cardiac history with multiple previous cardiac arrests.

He has a previously infected left sided

defibrillator and a current right sided defibrillator. His last EF is less than 35%. In terms of his surgical history, he initially had an EVAR 10 years ago for aaa that was 6.4 centimeters. Five years later, he presented with a type one B endoleak and his aneurysm was measuring 13 centimeters.

At that time, he left against medical advice before any intervention was performed. He's now back with a sac measuring 18 centimeters, still with a type one B endoleak on the right. It looks like his right common iliac arteries aneurysmal causing a be bottom of the graft leading to that endoleak. There also appears to be a pseudo aneurysm of the left common femoral artery.

He wants you to look at the scan, but he says that he thinks this is a contained and not a free rupture. He says that the patient is currently hemodynamically stable with low-grade tachycardia. So with this extra information, Dr. Harrington, what are you thinking? Okay, so, you know, I would pull up the scan, and so in this case, I'm looking at that scan.

The first thing I notice is

that there's gas in the aneurysm. This is highly concerning finding of that the grafts not just, you know, a contained rupture, it's actually an infected graft and maybe even an aortic enteric fistula. The aortas really pressed up against the eda given his relative.

Hemodynamic stability and these findings on the scan. I definitely wanna get him optimized while we plan out what his intervention will be. I would admit him to the ICU and get him lined up. We would start with light fluids, resuscitation and antibiotics. We would also get blood cultures assuming he remains stable.

I also want him to be evaluated by electrophysiology and cardiology. Even though I was joking before with this kind of case, I definitely am gonna get Dr. Hazer on the phone and also discuss it with our other senior colleagues. Okay, so we get him to the ICU, blood cultures start antibiotics, light fluid

resuscitation.

Dr. Hazer, what are your surgical plans at this point? This is definitely an extremely complex case, and I agree with Dr. Harrington. With the plan he's put forth so far, including central and Aline access a folate to make, make sure we can monitor his urine output and hemodynamics with this presentation.

He clearly needs some kind of intervention. Hopefully he doesn't a MA this time when, when looking at the scan, it looks to me like he has ruptured into his intestines or from his intestines. The entire sac, including the graft, is likely infected, unfortunately. When thinking about the surgical plan, although he may eventually require an open approach given his extensive cardiac history, starting with an open will put a very high stress on him and likely he wouldn't survive the index operation.

There's other approaches to consider besides the open that we could potentially temporize him, including an extra anatomic bypass versus endovascular. This is the kind of patient we usually present to our entire vascular group before proceeding.

Dr. Flores, you've seen the evolution of how we manage these cases over the past few decades.

When you hear about a patient like this huge aneurysm prior EVAR, possible graft infection, how do you start thinking through the options? Well, the thing about dealing with patient with abdominal aortic aneurysm is that you must tailor your approach based upon the case that's in front of you. For example, dealing with bleeding infections, pseudo AEUs.

Like this patient, a combination of of those findings, some fluid in the abdomen is concerning about possible rupture. Assessing his condition. He will benefit from any stage approach endovascular to correct the type one B endo leak, and subsequently an open intervention for the aortic, the fistula, and through it in the abdomen.

The initial

endovascular management will help to facilitate and minimize bleeding from the open approach. Thank you for that insight, Dr. Flores. On that note, the over trial or open versus endovascular repair trial, which is a randomized control trial from 2008, showed that the endovascular approach for aortic aneurysms had a 0.5% 30 day perioperative mortality versus 5% in patients who underwent initial open repairs.

And that complication rate was even higher in patients when you considered comorbidities like CHF, coronary artery disease, COPD, you know, which this patient actually had. And the study didn't even include infected aneurysms. So we know this patient is at a high perioperative mortality risk, and we want to choose an operation that minimizes this risk.

Okay, back to the patient in the ICU arterial line, central Line Foley and G-tube. Stress does done and EF confirmed 25%. The decision was made to start with an

endovascular approach. An angiogram should a right common iliac artery aneurysm with a type one B endoleak. Therefore, we coiled the right hypogastric and extended the iliac limb all the way from the original main body to the external iliac to exclude the bebo.

A left femoral pseudo aneurysm, which was thought to be a chronic pseudo aneurysm and less likely to be infected, was also stented. The patient had large arteries, so using a pre-close device, we approached through the ips C lateral SFA, and deployed a covered stent from the external iliac to the common femoral to exclude the pseudo aneurysm.

Post angiogram showed that both issues had resolved. Now what can we just watch this with antibiotics? The gold standard for these procedures is usually graft excision with an extra anatomic bypass, but this was not the initial approach for this patient. Dr. Harrington, can you shed some light on why we decided to proceed with an endovascular approach despite high suspicion of graft infection?

Christian,

before I let Dr. Harring to answer, you mentioned that graft excision and extra anatomical bypass at the gold standard, that is not completely accurate. In this cases, there are no really no gold standard. And each case should be approached individually. This patient following the correction of the endo leak still has a large aneurysm, intestinal obstruction, sepsis, anemia, and fluid in the oven, which will eventually require an open exploration.

The ideal procedure will depend upon the general condition of the patient. Yeah, I, I completely agree with Dr. Flores. This patient is a very complex presentation. We discussed as a group among our vascular team what to do. We also actually had a multidisciplinary discussion with general surgery, the ICU, cardiology and even

ep.

Together, we decided that the safest thing, given how critically ill he was, would be to at least temporize him with an endovascular solution. This would at least in theory, contain his rupture and allow us time to resuscitate and optimize him for the bigger, you know, more life-threatening procedure. But once stable, we plan to review the definitive options.

But just to review those. Traditionally when dealing with infected aneurysm, broadly speaking, we have two options. So syphilis would be extra anatomic repair. Usually an ax by femme, followed by ligation of the aorta in this patient who had a previously infected left side defibrillator and potentially infected left femoral pseudo aneurysm.

It might be difficult to perform an ax by fem from the left side. The right side also had some limitations given the current location of its defibrillator on the right chest, although not, not necessarily impossible. Another

approach would be inline reconstruction. So, that, that type of approach has three different ways to do it.

You can either use a Rifampin soak graft. Cryo graft, which is like a frozen graft, or you can create a neo aortic iliac system using femoral veins harvested from the patient. All of these are possible options. There are benefits to doing each one, depending on the specific circumstances, including what we think the organism is that's infecting the graft.

I think the biggest thing for this specific patient was that we would consider it a win if we could buy him even a few more months of decent quality life. So the procedure we chose, we thought gave him the highest chance of that outcome. Thanks for clarifying that. Dr. Flores and Dr. Harrington in line with that thinking, there was a retrospective study performed in 2016 in Sweden by Sirius and Al, who compared EVAR to open repair.

For selected

infected triple A specifically and found that EVAR was associated with improved short-term survival in comparison with open repair without higher associated incidents of serious infection related complications or re-operation. That basically goes along with the decision that we made.

Okay, back to the case post-op. The patient continued to have high NG tube outputs and was unable to tolerate an oral diet. Repeat CT scan showed dilated loops of bowel and free fluid in the abdomen. At this point, we're thinking that the 18 centimeter sac is causing a partial SBO. Furthermore, his hemoglobin was trending down and he began having melanin.

All this was highly suspicious for an aorta enteric fistula. Dr. Hazer, with these findings, are we obligated to perform an open exploration? What are your options when taking this patient back to the or? Well, Christian, from the beginning we anticipated. That he would eventually need an exploration of his abdomen and

that the timing should be as soon as feasible.

The initial sac raised concerns for aorta, enteric fistula, which is now essentially a very large contained infected hematoma. So the question isn't if he needs to be explored, it's when. Standard SBO Management with IV fluids and NG tube compression really doesn't apply in here. In this case, the sac isn't just causing obstruction.

It's exerting pressure leading to a necrosis and erosion into the bowel. As Dr. Harrington discussed, weighing the options is critical, but more urgently, we need to address the bowel first. After he's stabilized, we can later return to deal with the infected aortic endograft. Dr. Flores, I imagine that back in the day, all of these patients were managed initially with an open approach.

Do you think that we were right to start with an endovascular procedure in this patient? Why or why not? In the early days of vascular surgery, there was no endograft, and the open intervention was the only approach. But

dealing with a. Critical yield patient with a endo, type one B from the right iar, intestinal obstruction, bleeding.

The endovascular intervention will facilitate the open approach minimizing the blood loss, starting with endovascular. What you have done is taking care of the endo leaks first. Otherwise, you'll be dealing with massive intraoperative bleeding during the open portion. Your chances ornate, this critically patient is very high.

The presence of intestinal obstruction and infected endograft mandate an open approach, and the operative procedure should be tailored to the general condition of the patient. Axial femoral bypass is also an option, but without aortic ation, this does not effectively decrease pre corruption.

Aortic ligation and axial femoral bypass in a patient with such poor general condition is associated with high morbidity and mortality.

All these factors led to the team to initially select the endovascular approach. Thank you for that reasoning, Dr. Flores. So we take him back to the OR for an X lab on entry into the abdomen. Two liters of sero purulent fluid was found. Two connections of the aneurysm sac to the bowel were also noted, one at 35 centimeters and one at 70 centimeters from the ligament of trites.

The bowel encompassing the fistulas was then excised, and a primary anastomosis was performed. The aneurysm sac was opened and found to have two liters of speral fluid. The entire area was irrigated with six liters of fluid. The underlying endograft appeared. Rifampin beads and antibiotic irrigation were then instilled and the aneurysm sac was closed primarily Dr.

Harrington, we made the decision to leave

the endograft in place and manage with local control given the obvious infection. Are you thinking that this is something temporizing with a later plan for definitive management? You know, that's an excellent question. Christian. Obviously, the ideal situation for this patient would've been to remove the graft entirely, and it's worrisome that it's still in place.

However, at the time we were making our decisions based on the patient we had in front of us not the textbook patient, so a different patient with the same presentation, but less comorbidities and healthier. We probably would've done something that is quote unquote more definitive. This patient's life expectancy was already so low that we were concerned about accelerating his demise.

The successful operation, or at least what, what we kind of classified in our heads is the successful operation would be one that could prolong his life a few months while still giving him a decent quality of life. You know,

in my mind when he presented, really, this was already a terminal illness, it's easy to second guess the decisions we made in hindsight, but we were making those decisions in real time based off the condition of the patient in front of us.

Would it change anything in your management plan if I told you that the intraoperative cultures came back growing Candida albicans and bacter for gilis? I don't think it does. I would say the bacter not too surprising given that the, it's a GI bug. The Canada is highly ent. Technically, they're both very, you know, highly virulent organisms.

Unfortunately, I don't think there is much we could have done differently. As we discussed, our goal wasn't to provide something definitive, but more of a temporizing solution to keep 'em alive for a few good quality months. The way we were thinking is that the graft is still infected. The only way to get rid of the infection is to definitively remove the graft.

But if we do that now, the patient was not

expected to survive. With Candida, even in a healthy patient, a Rifampin soaked Dacron graft is not a particularly great option. Again, in hindsight, it is easy to judge what we did. At the time we were thinking that we may be able to prolong his life if we just put some Rifampin beans in almost like a Rifampin soak graft.

Even though it's PTFE and not Dacron, it's not exactly a one-to-one thing. I think he had really virulent organisms. In hindsight, this probably was not going to be particularly durable solution, but again, that wasn't our intention anyway. Yeah, that definitely makes sense. Dr. Harton prolonged his life with some quality versus the risks of a definitive repair that could kill him.

The patient initially did well post-op and was weaned off pressors. However, on post-op day four, he required massive transfusion protocol after sudden decompensation with a sudden decompensation like that. Dr. Hazer, what is on

your differential diagnosis? Well, I'm worried that the graft is likely broken down and ruptured into the sac, making the patient suddenly spin into a hemorrhagic shock.

The other possibilities could include bleeding that was missed during the initial procedure, or even worsening of his septic or cardiogenic shock. But with that kind of presentation, my money would be on the graph blowout. I, I think you don't have any choice but to take him emergently back to the, or.

Yeah, definitely a scary situation to be in and you're spot on. Dr. Hazer, the patient was emergently taken back to the OR due to concern for continued intraabdominal bleeding. He was found to have fresh blood clots in the abdomen. A right sub hepatic hematoma was found and evacuated. There was also a pumper from the mesentery at his staple line that was found.

The bowel anastomosis itself was intact. After washing out again, the patient was brought to the ICU and initially did well. About two weeks later, he started developing progressively worsening liver and renal function requiring continuous renal

replacement therapy. A couple days after that, the patient had a large volume coffee ground emesis, and was taken for simultaneous X lap and endoscopy where there was bleeding from a small bowel enterotomy, which was repaired.

Endoscopy revealed a de la foil lesion, which was over sewn through an open gastro. The patient continued to become progressively coagulopathic with worsening liver, kidney, and heart failure. He eventually required tracheostomy creation and perma cat placement for dialysis. Despite multiple procedures, the patient became progressively more acidotic, hypothermic, and coagulopathic, and eventually succumbed.

Dr. Flores, in retrospect, could there be anything we could have done differently? Even in retrospect dealing with a critical ill patients with significant comorbidities. Presented with bleeding endo leak, type one from the right electro intestinal obstruction. The stage proce endovascular procedure follow when open

was appropriate.

One decision that could analyze was the intestinal anastomosis performed by general surgery at the first operation. The performance of intestinal anastomosis in a very ill patient will depend. Many factor, but the most important are hemodynamic status of the patient and location of the fistula. There is always the option of damage control, which may have been a better option for this patient given that he was on and off presence.

Another important consideration is that dealing with critical I patient. In meat of intervention, a multidisciplinary assessment is mandatory. Dr. Hazer, Dr. Harrington, any last points? Well, it's always hard to go off the usual roadmap. Infected aortas

have a, a general roadmap, which we, we talked about earlier with this patient's comorbidities and previous procedures, we decide to go another route.

In the end, he still died. Maybe if it wasn't due to these other complications like mesentary bleeding or the GI bleed, he, he might have survived a few months. We'll never know for sure. I guess what I would take from this is that every patient is unique and you should tailor your approach as such.

Also that you're never alone. You should always feel comfortable to consult your colleagues for advice, including your non-surgical ones, even if you're the smartest person in the room and never hurts to have other smart people's advice too. Yeah, I agree. I'd add to what Dr. Flores said as well, and perhaps consider the addition of a feeding tube at the first open surgical case while the EF of 20%, along with all of his other morbidities, including previously infected, left-sided, A

ICD and the right-sided active.

A ICD made the idea of an ax, fem femme with graft excision, very treacherous. He did eventually undergo open surgical procedures. Granted, no aortic cross clamping or over sewing was required. Perhaps the most important take home address is the clear demonstration that endograft therapy for aortic aneurysms is not a one-time fix.

It requires at least annual, if not biannual observation. The highest risk for post implant significant problems is somewhere beyond the seven years post-op, especially with the older devices. There may be some advancing imaging now available and. Generative AI algorithms that will move this to every two years surveillance or, or guide us to operate earlier, so we can stay tuned for that.

Okay, everyone. That brings us to the end of our first session. We hope you all enjoyed it and we'll be able to take something from this to add to your own practice. Before we get on our way, we'll leave you with some quick hits.

In complex cases, there is not necessarily any gold standard approach, and each case should be approached individually.

Looking at the prognosis from the beginning is very important, and establishing clear goals of care is essential. A successful surgery may be the one that prolongs the patient's life by only a few months. Endograft explanation is not always feasible. Leaving graft components behind may be acceptable in certain high-risk patients with long-term suppressive antibiotics.

In fact, many studies show that the mortality of these patients with infected triple A is usually not due to surgical complications. But due to complications of sepsis and multi-organ system failure, like what we saw in this patient. Another big point is that surveillance for patients with EVAR is extremely important as this is not a one-time fix, as Dr.

Hazer already mentioned. Finally, critically ill patients requiring multidisciplinary team with more experienced colleagues to come up with a safe and

effective approach. Thanks to everyone for tuning in today. From all of us here at Behind The Knife. Dominate the day. Dominate the day.