Clinician-to-Clinician Update Clinician-to-Clinician Update

New Center Offers Innovative Care for Aortic Emergencies

May 2015 - Aortic Care

Acute aortic syndromes, including dissection, intramural hematoma, penetrating ulcer, and aneurysm, are life-threatening emergencies that necessitate prompt diagnosis and treatment.1 The risk of lethal aortic rupture rises with the increasing passage of time after the episode. Successful treatment depends on early diagnosis,2 early transfer to a specialized care facility,3 rapid initiation of medical therapy or endovascular or surgical intervention,4 availability of high-quality cardiovascular anesthesia,5 and care in a specialized, permanently staffed intensive care unit.6

HybridOR DSC 0773-974x649
— Surgeons attend to a patient at the hybrid operating theater at University of Minnesota Medical Center.

Acute aortic syndromes often require invasive treatments, either through an open surgery or a minimally invasive, endovascular aortic repair (EVAR) with stent placement. Both the open and endovascular strategies are associated with similar 30-day survival rates,7 although the median length of stay, in-hospital mortality rate, and complication rate are reported to be lower with EVAR.8 A very recent innovation in acute aortic syndrome treatment is percutaneous endovascular aortic aneurysm repair (pEVAR). While the traditional endovascular procedure uses a femoral cutdown, pEVAR does not require an incision. The percutaneous strategy, which can be performed under local anesthesia in some cases, has been associated with shorter mean operative time, shorter median length of stay, and fewer wound complications than EVAR with cutdown.9 Particularly in the case of ruptured abdominal aortic aneurysms (AAA), pEVAR allows for a shift in anesthetic modality from general to local anesthesia. An analysis of outcomes reported in a randomized study of repair methods for ruptured AAA identified a fourfold reduction in operative mortality when local anesthesia is used.10

The University of Minnesota Health Aortic Center, which launched earlier this year, brings together skilled vascular surgeons, cardiothoracic surgeons, interventional radiologists, cardiologists, and anesthesiologists, all dedicated to aortic disease care. At our specialized aortic care facility, physicians and surgeons perform complex aortic repairs in a state-of-the-art, hybrid operating theater at University of Minnesota Medical Center. The hybrid operating theater contains the latest radiologic equipment and can accommodate all types of interventions, including minimally invasive and robot-assisted procedures. For aortic emergencies, the multidisciplinary Aortic Center team offers open surgery, EVAR, and pEVAR strategies, as appropriate, along with medical management for less-severe aortic conditions. According to vascular surgeon Rumi Faizer, MD, the Aortic Center is one of the few to effectively utilize a local anesthesia first approach in conjunction with pEVAR for aortic ruptures. This program sets the standard in complete, comprehensive care for these conditions, providing early detection, immediate therapy, and surveillance.

References

1. Wells CM, Subramaniam K. Chapter 2: Acute aortic syndrome. In: Subramaniam K, Park KW, Subramaniam B, eds. Anesthesia and Perioperative Care for Aortic Surgery. New York, NY: Springer-Verlag New York; 2011:17-36.

2. Karthikesalingam A, Holt PJ, Hinchliffe RJ, et al. The diagnosis and management of aortic dissection. Vasc Endovascular Surg. 2010;44:165-169.

3. Davies MG, Younes HK, Harris PW, et al. Outcomes before and after initiation of an acute aortic treatment center. J Vasc Surg. 2010;52:1478-85.

4. Nienaber CA, Clough RE. Management of acute aortic dissection. Lancet. 2015;385:800-811.

5. Hassoun HT, White LE, Cheema F, Reardon MJ. Endovascular repair of ruptured abdominal and thoracic aortic aneurysms. Methodist Debakey Cardiovasc J. 2011;7:20-24.

6. Pronovost PJ, Jenckes MW, Dorman T, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 1999;281:1310-1317.

7. IMPROVE Trial Investigators, Powell JT, Sweeting MJ, et al. Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. BMJ. 2014;348:f7661.

8. Ali MM, Flahive J, Schanzer A, et al. In patients stratified by preoperative risk, endovascular repair of ruptured abdominal aortic aneurysms has a lower in-hospital mortality and morbidity than open repair. J Vasc Surg. 2015 Mar 6 epub.

9. Buck DB, Karthaus EG, Soden PA, et al. Percutaneous versus femoral cutdown access for endovascular aneurysm repair. J Vasc Surg. 2015 Mar 28 epub.

10. Powell JT, Hinchliffe RJ, Thompson MM, et al. Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm. Br J Surg. 2014;101(3):216-224

When to refer

Patients with acute aortic syndrome often present with one or more of the following:

• Severe pain in the chest, back, abdomen, or neck that may be experienced as a tearing, throbbing, or radiating sensation

• Syncope

• Shock

• Distal pulse differential

• Deterioration of hemodynamics

Because, in acute aortic syndrome, survival is closely tied to time to effective treatment, the multidisciplinary care team at the University of Minnesota Health Aortic Center has implemented the Aortic Center Emergency Triage Line. When a referring provider places a call to the triage line, the provider is connected within minutes to a vascular surgeon, a cardiovascular/thoracic surgeon, and an emergency department attending physician. After consultation, the team jointly decides on either a code red admission to the operating room or a code white admission to the intensive care unit. When the patient is 10 minutes away from arrival at University of Minnesota Medical Center, the Triage Coordinator pages 20 personnel, who respond immediately to be ready for the patient. These personnel include key players from cardiovascular surgery, interventional radiology, anesthesia, pharmacy, blood bank, nursing, and others.

The contact number for the University of Minnesota Health Aortic Center Emergency Triage Line is 612-672-7575.

Collaborative Care

At the University of Minnesota Health Aortic Center, we are committed to working closely with you to ensure the best possible care for your patient. After an Aortic Center Emergency Triage Line call, the decision to transfer and admit is always made in concert with the referring provider. Once the patient is transferred to our care, we communicate the ongoing management plan and the patient’s status to you, the referring provider, within 48 hours. Upon the patient’s discharge, we arrange a consultation call with the Aortic Center team so that you have all the information you need to continue follow-up care with your patient. Although most patients travel to the Aortic Center once a year for follow-up imaging, in some cases, we can work with you to obtain imaging studies locally, thereby sparing the patient time lost to travel.

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