AAA EVAR open aneurysm surgery

Abdominal Aortic Aneurysm in Remission

Look again, it is a doodle of a CT scan of a patient with an Ancure stent graft with sac shrinkage

I remember in the mid-2000’s, driving very fast to Lutheran Hospital in Des Moines on a Saturday night to fix an aneurysm that had ruptured. He was a man over 70 years of age with a type III endoleak from a component separation. The endografts had been placed by a cardiac surgeon who had taken some courses. I rescued him by open replacement of the aneurysm with a tube graft after I pulled out the endografts. Later, as the patient recovered, I asked him why he never followed up as required on his stent graft. His answer was, in typical Iowa farmer fashion, “Welp. If it was fixed, why should I?”

Indeed, why should he? Looking at his chart from the time of his EVAR, he was determined to be a “high risk” patient, necessitating the new minimally invasive procedure EVAR in 2003. Seeing that he survived the stress test of a ruptured aneurysm, it was clear he was not all that “high risk.” I did reassure him that with the open repair, he was basically cured. Despite scheduling a followup appointment, he never showed up. And that was okay.

EVAR is a treatment for AAA, but currently not a cure. All of the devices instructions for use stipulate the need for lifelong followup with CT scans with contrast and visits with qualified specialists. As I have mentioned in the past, what other condition requires surveillance CT scans with contrast and followup with a specialist? Cancer in remission. For those with good cardiac risk and functional status, placing an endograft rather than open repair creates “Aortic Aneurysm in Remission.” If they are in the majority of patients with a stable aneurysm sac, their endografts are sitting in a bag of static, aging blood. If there are type II endoleaks, and it is my belief that the majority of stable aneurysm sacs have some type II endoleaks that blinker on and off depending on the hemodynamics, particularly through needle holes, they are circulating the products of breakdown of that bag of old blood and exposing a perfect culture medium to potential inoculation. These type II and IV endoleaks can inflate the aortic sac over time. Occasionally, the residual AAA sacs rupture, erasing any of the early advantage conferred by the minimally invasive index procedure in long term followup EVAR v OPEN repair.

What is a cure? A cure is when you quell an infection with an antibiotic. A cure is when you’ve taken out an inflamed appendix. It’s when you’ve eradicated early stage cancer. It’s when you perform an open aortic graft and the patient can disappear after you remove the dressings and never followup, sure in the knowledge that the aneurysm in that spot will never bother them again. With EVAR, only a minority get to the state (figure at top) a sac shrunk intimately around the endograft. Most are not cured but enrolled in a regime of lifelong surveillance and maintenance.

EVAR does allow people to leave the hospital with less scarring and pain, but the consequences of its popularity are:   

1. Letting more practitioners, not all of them vascular surgeons, treat aortic aneurysm disease with less training and with less or no ability to manage the inevitable failures surgically. 

2. Creating the business model for “Advanced, Minimally Invasive, Super-Fantastic Aortic Centers of Excellence” which is predicated on the business of surveillance and maintenance of aortic endografts. It is a busy-ness that generates revenue, but burdens the country with more healthcare costs. It ultimately siphons business away from true centers of excellence involved in training the next generation of vascular surgeons.

3. Skewing the training curriculum of trainees to endovascular so much that I have met vascular surgeons who have done no aortic operations. That was the case when I sat in on an open aortic surgery class at the 2017 ESVS meeting in Lyons, France. All the attendees were very eager to try sewing anastomoses, but felt they needed proctoring which isn’t available.

4. Establishing the expectation that open aortic surgery is a failed, antiquarian, obsolete technique to be relegated to the history books. This last one is infuriating and not true but it is out there in the claims of the aorticians.

5. Resulting in palliation when the aortic aneurysm in remission ruptures and there are no readily available open-capable surgeons experienced in rescuing these patients. This happens. Don’t let it happen to you.

Various solutions have been broached including regionalization of aortic aneurysm care, superfellowships in exovascular surgery to complement the widespread endovascular training, and going back to open aortic surgery as the norm as had been proposed controversially in the UK. There is no turning back the clock. The moment that Dr. Parodi combined an aortic graft with Dr. Palmaz’s stent, a quantum leap occurred. The operation of aortic aneurysm surgery was changed from a challenging operation mastered by a few to a straightforward procedure performed by many.

Interesting to me is that illustration at the top of the post is of a common observation – the obliteration of the aortic aneurysm sac around a Guidant Ancure stent graft. When the sac disappears, it is as close to a cure that you can get. For some reason, I see this more frequently with Ancure than with other grafts over the past twenty years.

Odd fact -I may have been the last surgeon to implant an Ancure in the world. In 2003, I was treating a AAA with an Ancure graft when the delivery system froze in mid deployment. I called Dr. Dan Clair away from some meeting, and he called for pliers, screw drivers, and a saw, and after deconstructing the delivery system, deployed the graft and returned to his meeting with nary a word. The Guidant rep, who had been on the phone, looked up with saucer eyes, and said, “Wow. They’ve pulled Ancure off the market.”

I think it is because of the design, which is now off the market. When stents are sewn to cloth, the needle holes leak, and leak particularly where the stent graft makes a turn, stretching the suture hole. Junctions and seams leak. The Ancure, aside from the stents at top and bottom in the seal zone, has no such holes as it is unsupported and manufactured as a single piece with no junctions or seams. It is the closest you get to sewing in a graft by open surgery. If it weren’t for its overly complicated delivery system which was its downfall, I think it would be in its third generation with visceral branches that are created off the textile machines rather than joined inside the patient. There are lessons to be learned from this abandoned tech.

I believe a treat once and walk-away cure is achievable in EVAR. The idea is not to be satisfied with anything less than a cure, anything that ends with aortic aneurysm in remission. We have to understand we have chosen a path of iteration and continuous but slow improvement in the EVAR space. The front end benefits of EVAR are clear but it is in the long term we have to focus. Until then, warranties would be great.

AAA EVAR hybrid technique mycotic aneurysm ruptured AAA skunk works techniques training

The Hands of a Surgeon

My partner, Lee Kirksey, Vice-Chair of Vascular Surgery, just got a paper on-line (link) about the curiously increasing volume of open surgical repairs we were experiencing from 2010-2014 at the Cleveland campus of the Cleveland Clinic. When I joined in 2012, my impressions at that time were mostly the paucity of straightforward EVAR cases that I had seen in private practice, and the high prevalence of stent graft explantation, infected aortic grafts, and open aortic aneurysm repairs (OAR) for juxtarenal and thoracoabdominal aortic aneurysms for nominally high risk patients. My TAAA muscles had atrophied during my years out of fellowship and I eagerly took the opportunity to recruit the help of my partners and scrub in on these cases with Pat O’Hara, Jean Kang, Dan Clair, Ezequiel Parodi, and Lee Kirksey. It is without any shame that I sought out not just extra expert hands, but interrogated these experts for different ideas and approaches, and absorbed feedback. At the time, I was ten years removed from graduation, a full-fledged vascular surgeon who thought he could do any operation put before him. I cannot imagine the thoughts churning through the head of a recent graduate faced with the choice of taking on an open aortic operation with only 5 cases under their belt, referring the case on to the regional tertiary center, or trying to McGyver an endovascular solution. I contributed probably about 35-50 cases to this paper, but the outcomes were a collective effort. Even today, I will run cases by Sean Lyden, Christopher Smolock, or Lee, if only for the company and gossip.

“We explain this distribution of cases as a function of several factors: a unique, broad regional quaternary referral practice whereby patients with complex aneurysmal disease are referred to our institution; an institutional practice evolution resulting from a critical analysis and understanding of EVAR failure modes that lead to explantation, thus generating a different perspective in the EVAR vs open decision-making process; a parallel high-risk IDE fenestrated graft study; a historical willingness to accept all physician and self-directed patient referrals (ie, a willingness to manage more complex cases); and a published expertise in the area of EVAR device explantation with an annually growing volume of commercial device removals” -from El-Arousy et al.

Reading through that paper, I have come to the conclusion that the increasing open aortic volumes at the Cleveland campus has as much to do with the ongoing retirement of experienced surgeons regionally as it does with the ability to attract these cases. Loss of these surgeons has a cascade effect like losing a species in an ecosystem. The operating rooms forget where the OMNI retractor is because nobody asks for it anymore. The ICU’s are no longer familiar with the ebb and flow of the postoperative open aortic operation. The floors lose institutional memory of the care of these vascular patients as the stent grafts and interventions go home within 48 hours, sometimes the same day.

If you were a vascular surgeon born before 1970, your approach to the scenario of the ruptured abdominal aortic aneurysm may differ substantially from that of surgeons born after the Carter administration. Most of my cohort, Gen-X and older, feel comfortable applying some betadine, opening the belly and placing a clamp. Those younger than us have told me they feel more comfortable putting up a large balloon and deploying a stent graft. In this generation, it is normal to call a general surgeon to decompress the abdominal compartment syndrome and manage the abdominal vacuum dressing. For our generation, the giant industrial robot arms and 80 inch monitors creates a barrier to the problem at hand, and gathering all the extra staff after hours and on weekends requires the logistical skills of a wedding planner.

We prefer an operating table, a willing anesthesiologist, a cooler full of O-neg blood, Prolene and a graft, strong suction, and an extra set of hands. The data suggests either method is equivalent in outcome, but I would argue that depending on the circumstance, there is an optimal method for that patient and you have to have the ability to do either open or endovascular or some hybrid combination. Unfortunately, it is clear that open vascular surgery is year over year diminishing, and and it might not be so great when we start rupturing our aneurysms.

The open approach is preferred because we got good at it by doing a lot of these cases. Your hands -it becomes natural to change the course of the disease and the fate of the patient with your hands. One of the things you lose with a wire based approach is the tactile feedback from the organ that you are treating. Yes, there is a subtle feedback from the flexible tip of a Glidewire, but that’s missing the point. The thing that is rarely considered with open surgery is the tactile aspects of operating.

Your fingers are your point of care ultrasound. As an intern, one of my earliest tasks was reaching in through a 2cm incision with my index finger, feeling for what I would describe as a rotten shrimp, and delivering it out by hooking my distal phalanx around its base. Adhesions were rubbed like money between finger and thumb to judge if you could bovie through it. If you felt a sliding sensation, it was mucosa to mucosa and you looked for another spot to cut. Into my fellowship which could be called the triple-redo, no-one else wants to do-, difficult vascular operations fellowship, the pulse or the plaque felt under the finger would guide me to carve away scar tissue from blood vessel, visualizing the feedback from the fingers. In a rupture, with the belly under a dark mire of blood, there is no seeing, only feeling. Your hands reach into the lesser sac or transverse mesocolon and strangle the aorta -your fingers while clamping, feel and avoid the caudate lobe, the NG tube in the esophagus, and split the crura of the diaphragm like a pick pocket. Once the pulse returns as anesthesia refills the tank, you scratch free the aorta with your thumb and forefinger, then slide the jaws of the aortic cross clamp over your fingers and against the spine and clamp. This takes about 60 to 90 seconds (link).

When a patient is bleeding out, this is the way to control the bleeding. In practice, no amount of rehearsing for getting a patient into a endovascular suite, getting airway and access, swinging in the industrial robot arm, and getting everyone into lead aprons, sending up wire, placing a 12F sheath and an aortic occlusion balloon, will be satisfactorily smoothly and efficiently as a STEMI or STROKE alert. The rAAA is for most hospitals, unless you are in Seattle, a once in a while occurence. Many more people can find a scalpel and an aortic clamp than they can find a 32 inch aortic balloon, a stiff exchange length wire, and a 12F sheath.

When a patient presents with a slowly bleeding, contained rupture, there is time to assemble the teams required for an endovascular repair, and for opening and decompressing the abdomen, for anesthesia to get IV’s, central lines, arterial lines, and order crossmatched blood. One has the time to get and review CT scans and choose grafts. One can even do things backwards, debranching after securing the leak (link) with a stent graft. The luxury of time should signal to you that the endovascular option is the preferable route, as all the advantages of minimally invasive repair are possible. Rural hospitals sending patients two hours by ambulance or arranging for a helicopter -this is the great filter through which those likely to survive make it into the endovascular suite. These patients do great with EVAR, because everything moves more or less like a routine elective EVAR.

The setting up the operating room for tackling rAAA is quite simple. Keep everything nearby. Nothing should ever be stored out of sight, retrievable only by arcane codes whispered in the ears of people down in the basement or across the street. Amazon gives itself a day to get that gadget to you, but the rupturing patient does not have the time to have a 28mm stent graft ordered by looking up a Lawson number, finding the materials person in the faraway room to find it, running it over a city block. The stuff has to be next to the OR. Every scenario is unique, and the best planning is assuming no one person knows where everything is but everything is close at hand -major vascular sets, retractors, C-arm, cell saver, stent grafts, open grafts, balloons, cardiopulmonary bypass -every gewgaw is few steps away. The inventory is what you see, because if you can’t grab it, it does not help the hemorrhaging patient.

If you are a vascular surgeon born after 1980, it is likely that you may have trained in a 0-5 residency and all the old people harumphing about the old ways seem biased. Rather than being rational about their awful upbringing, the old people seem to suffer from Stockholm Syndrome, turning from victims of a harsh and brutal system inherited from the original, Halsted, a cocaine addict, to willing collaborators now mooning about the good old days of every other day call and 120 hour work weeks.

There might be a growing suspicion about advocating for open surgery when fewer people can perform it. One of the truisms of surgery is if only one surgeon claims to be able to do a rare operation with great results when everyone else abandons it, like venous valve surgery or robot assisted mastectomies, it can mean that surgeon might be uniquely talented or shamelessly selling something. It is a shame that open vascular surgery is devolving into that category of arcana, like the Jedi. I have no doubt that the last open vascular surgeon will be a reclusive, bitter, wild eyed hermit like Luke Skywalker was in episode VIII, if we let it get that far.

Bald eagles were saved from extinction. The methods of species reclamation may be what is needed to save open vascular surgery. Financial metabolism drives behavior, and there must be recognition of the time and dedication required to perform good open vascular surgery in the form of increased RVUs and reimbursement. The surgeons retiring in their mid 60’s with straight backs and steady hands need to be incentivized to stay around and coach the next generation in the ways of the Jedi. Call it the master surgeon designation. Every 0-5 graduate needs to focus on getting 100 leg bypasses, 50 carotid emdarterectomy, and 25 open aortas within the first five years of practice with a master surgeon if they did not get this experience during training. Like dead Jedi, it would help even if they were just virtually present, shimmering on Facetime in their (bath)robes to go over planning and approaches, but being physically present and reimbursed for it would make the most sense.

There is always self service in any human activity. One mildly prominent vascular surgeon that I have come across is famous for saying he did not have a vascular fellowship because he did not want to train his competition. It is easy for the fifty somethings to sit and proffer their open skills and profit from its scarcity but it goes against decency to not pass on this collective body of hard won knowledge and skills. There must be stewardship of this great thing we do, this honorable and treasured endowment.

Of the concrete ways we are trying is creating a network of advanced open surgery capable surgeons regionally organized by Martin Maresch, capitalizing on social media and electronic communications. Here at CCAD we are in the organizing phase of a vascular residency, and I very fortunate to have Houssam Younes join us as he shares my interest in surgical education and open vascular surgery. We are contemplating a non-accredited fellowship. We have general surgery residents coming through our service as well as medical students.

One of my mentors told me, “I can train a monkey to do cardiac surgery,” as he was training me to do cardiac surgery. And he was right. The final comment I have is you have to demystify surgery, take away the Instagram perfection, the romance, and list in practical terms the toolkit of maneuvers that form the component parts of all operations and propagate it. Let us not kid ourselves. The technical skills of surgery can be taught to anyone. The Mayo brothers were performing surgery as teenagers before medical school. The knowledge and experience and judgement -that varies as much as people vary and we have a curriculum for that, but the physical acts of surgery need to be taught starting at the medical school level. Standardized drills and exercises need to be created so that proficiency can be metered.

“The individual per trainee OAR volume did not decrease during this period. In the training program, the use of “component separation” (separation of each
operation into discrete, instructionable steps that facilitates trainee mastery) is integral to instruction of open aortic aneurysm repair techniques and permits the
trainee to master all of the technical exposure and repair skills necessary to address and to manage both straightforward and complex aneurysm anatomy. Component
separation is essential to maximize trainee experience across all levels” –from reference 1

Here is my list of things a trainee must accomplish by the time they graduate from a vascular residency or fellowship.
1. Tying knots with gloves on with 6-0 Prolene inside a pickle jar without lifting or moving a 12 ounce lead fishing weight to which the suture is being tied, fast, one handed, two handed, left and right handed.
2. Holding forceps, needle holders, and clamps
3. Correct operation of the OMNI retractor, Weitlander retractor, Balfour retractor, Thompson retractor
4. Incise skin through dermis through correct depth and length with both #15 and #10 blade
5. Open the abdomen through midline and flank incisions and close these incisions
6. Harvest saphenous vein
7. Vascular anastomosis on a table, inside a pickle jar, inside a short Pringle’s can
8. Dissection of adhesions and scar tissue around blood vessels and organs
9. Dissect and expose the common femoral artery via vertical and oblique incisions and close these incisions
10. Dissect and expose the carotid bifurcation, left and right side, and close these incisions
11. Dissect and expose the tibial vessels in various parts of the leg and foot
12. Dissect out the brachial artery at the elbow
13. Dissect out the axillary artery and vein below the clavicle
14. Dissect out the axillary artery and vein from the axilla
15. Dissect out the subclavian artery, vein, and brachial plexus above the clavicle
16. Dissect out the arm veins
17. Dissect out the iliac artery via a lower quadrant pelvic retroperitoneal exposure
18. Dissect out the abdominal aorta via midline laparotomy
19. Dissect out the abdominal aorta via retroperitoneal approach
20. Dissect out the thoracoabdominal aorta via a thoracoabdominal exposure
21. Dissect out the popliteal artery via suprageniculate, infrageniculate incisions and prone position
22. Dissect out the inferior vena cava
23. Dissect out the iliac veins
24. Harvest deep femoral vein
25. Temporal artery biopsy
26. Endarterectomy of carotid, femoral artery, any artery with patch angioplasty
27. Exposure and control of supraceliac aorta, suprarenal aorta for clamping
28. Exposure and control of thoracic aorta
29. Exposure and control of the great vessels via sternotomy and supraclavicular incisions
30. Exposure and control of the vertebral artery
31. Safe removal of vascularized tumors
32. Amputations of digits, legs and arms up to pelvis and shoulder
33. Exposure and control of radial and ulnar arteries
34. Hand surgical techniques of exposing arteries, tendons, and nerves in forearm and hand
35. Plastic surgical techniques of skin grafting and basic rotational flaps
36. Fasciotomy of arms and legs, hands and feet.
37. Exposure and control of celiac axis
38. Exposure and control of superior mesenteric artery
39. Exposure and control of left renal vein
40. Exposure and control of hepatic veins, portal vein
41. Exposure and control of renal arteries
42. Exposure and control of profunda femoral arteries
43. Safe removal of spleen
44. Transabdominal retroperitoneal exposures of the abdominal aorta and inferior vena cava
45. All of the above in a reoperative field
46. All of the above with limited visualization and by sense of feel only
47. Laparoscopic and thoracoscopic techniques
48. Orthopaedic surgical techniques of myodesis, bone grafting, precision osteotomies, infection control, external fixation, spinal exposure
49. Safe resection and anastomosis of bowel
50. Drainage of infection
51. Intensive care of SIRS, MOFS, CHF, Septic shock, postoperative fluid shifts
52. Nonsurgical and surgical management of lymphedema, seromas, and edema
53. First rib resection
54. Spinal exposure
55. Organ harvest and transplantation
56. Planning of complex open, hybrid, and endovascular procedures

Every year, it is apparent that endovascular options suffer from some flaw when outcomes are studied beyond 2 years, but progress will march on in that sphere. It has to. The loss of open capable surgeons to early retirement is accompanied by overapplication of endovascular techniques at least partly due to the lack of knowledge of these open surgical options and achievable good results and partly due to financial incentives. The solution lies in redistribution of reimbursement to open procedures and creation of open surgical fellowships and identifying and empowering mentors who still walk among us.

AAA Commentary common iliac artery aneurysm EVAR iliac artery aneurysm imaging open aneurysm surgery

When You Pay Your Own Way, You Chose Value

abd angio  11836788149..jpg

The patient is an active man in his 60’s with a history of hypertension who had known about a right common iliac artery aneurysm for several years and had come for an opinion. He was asymptomatic of pain. He had a prior splenic artery aneurysm embolization about a decade prior to presentation.. CT scan showed a large eccentric aneurysm arising from a retrograde chronic dissection dilating the right common iliac artery to over 4cm. This is typically iatrogenic, but impossible to know for sure. The left common iliac artery was ectatic to 2cm as was the aorta to 3 cm and all were “wavy.” This sort of tortuosity is the result of remodeling in the axis of flow resulting in lengthening of the artery and is found in those with the substrate for aneurysmal degeneration (footnote). He did not smoke and he could climb stairs without dyspnea or chest pain.

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On examination, he was a fit middle aged man with a slight paunch. His abdomen was soft and his peripheral pulses were present and normal. Laboratory results were normal, including creatinine. EKG and echocardiogram were also normal.Treatment options were discussed in detail. The patient was paying for the operation himself and wanted to understand in detail the possible options. These included

1. Open aortobi-iliac bypass with a jump bypass to the right internal iliac artery
2. Open aortobi-iliac bypass with ligation of right internal iliac artery
3. EVAR with right external iliac extension after embolization of right internal iliac artery
4. EVAR with parallel grafts to right external and internal iliac artery (off label)
5. EVAR with iliac branched graft to right internal and external iliac artery (off label)

People are known to react with emotions and to decide typically for near term gain over far term benefits. The offer of an operation involving laparotomy and a possible weeklong hospitalization with all the attendant risks of death, heart attack, stroke, ileus, wound infection, pneumonia, organ failure and so on provides a stark contrast to the appeal of endovascular repair which can be done percutaneously, with local anesthesia, and with a short hospital stay. The lifelong CT scans are in the murky future compared to the present which is sharply in focus. This is why few people save for retirement, why profligate grasshoppers far outnumber industrious ants. In the same vein, the offer of an “advanced minimally invasive” solution plays to several cognitive biases that exists in the mind of not only the patient but the health-care provider. These include this preference for short term gain over long term gain, but also viewing all innovation as being necessarily better than what was available.

After going over the operation in great detail, the patient cut me off when I mentioned the need for lifelong followup CT scanning. Because he lives in several countries, typically, he has to pay for his healthcare out of pocket and he balked at the notion of paying for an annual CT scan. He was also disdainful of the possibility of reintervention (quoted at 10%) and having to pay for it. Also, the stent grafts, which he would have to pay for, end up being as costly as a new luxury sedan based on local pricing.

We chose open surgical repair via a midline laparotomy. An aortobi-iliac bypass was performed from proximal aorta to right internal iliac artery and left common iliac artery bifurcation with a jump bypass from the right graft branch to the right external iliac artery. Technically, this sequence was chosen for ease of access to the internal iliac artery with the external clear of graft. Operative time was 3 hours. He was in the ICU for one night. He went home after 10 days after contracting a UTI. In followup three weeks after discharge, because he had fevers, a CT scan was performed (figure). He was treated for an upper respiratory infection which cleared, and he has been doing well since. We are both happy that he will never need a followup CT scan.

Before and After

The literature supports this stance. The long term followup of the EVAR-1 Trial (Reference 1) is an example. This was the late followup of the prospective randomized study looking at open surgery versus EVAR in 1252 patients. The initial EVAR 1 findings are well known and put into question the long term benefits of EVAR as the initial mortality benefit of EVAR is lost within a few years of treatment. At a mean of 12.7 years of followup, there were more deaths from aortic aneurysm rupture and aneurysm related death in the EVAR group compared OPEN surgery (adjusted HR 5.82, p=.0064), with 13 AAA ruptures. I have mentioned before that the failure of a handful of pacemakers drove the Guidant company to recall over 20,000 of their devices. Plus, the cost of annual CT scans in the treatment group and cost of devices and cost of reintervention have driven the UK’s NICE Guidelines recommending against EVAR in elective AAA repair. The meta-analysis of EVAR-1, DREAM, OVER, and ACE trials comprising 2783 patients is confirmatory, that aneurysm related mortality was significantly higher after the initial mortality benefit of EVAR fades away, and that patients of marginal fitness gain no advantage from EVAR, particularly those with heart or renal disease, and those with PAD had lower mortality in the period of 6 months to 4 years (reference 2).

I post this case, because despite a complications, in this case UTI and URI, the patient did fine. So why is open aortic surgery considered a dying art? Why is there such pushback against the UK NICE Guidelines?During my residency in the 1990’s, in the heyday of open surgery, I observed a lot of mediocre vascular surgeons and a very few great ones. The average vascular surgeon would take 6-8 hours to perform open aortic surgery, and the patient would come out with a typical picture of oliguria, third spacing, SIRS, that would generate a 1-2 week stay that would even be described as the normal and expected course for AAA repair in surgical and critical care textbooks. The best surgeons back in the day did these operations under 3 hours with 100mL blood loss and the patients would spend a day in the ICU (often not needing it), and 3-7 days in the hospital, but they were the exception.A higher percentage of surgeons today can do EVAR well than surgeons 25 years ago could perform competent open aortic surgery. Most surgeons graduating from training rarely see or do open aortic surgery compared to the multitude of interventions. Capable open surgery basically is not available outside of a few centers, and most surgeons admit to not having equipoise to start a new trial with modern devices. Open aortic surgery is a lost art, like growing your own vegetables, dressing your own game, reading cursive script, and dialing a rotary telephone.

It is not for a lack of desire. I have several younger colleagues I have met or interacted with via social media who have an intense interest in gaining open vascular skills. They have organized open skills courses at major European vascular meetings, but I believe that is not enough.The need for exovascular fellowship, the running topic of conversation of older surgeons through the 2000’s, is never as critical as it is now as we see milennia of surgeon-years of experience retiring to golf courses and cottages. The recommendation for preferring open surgery in the younger and fitter patients is sadly out of reach for most patients and surgeons. The same passion in disseminating endovascular knowledge needs to be applied to repair the damage to vascular education by over-relying on and over-prescribing endovascular approaches.

Finally, and sadly, this patient is the exception. When given clear options and outcomes and costs, this patient made a rational decision, choosing value over convenience.

1. Lancet 2016;388: 2366-2374.
2. BJS 2017;104:166-178


Pearls for finding AAA:
1. Tortuosity of the internal carotid arteries including loops and hairpin turns found in patients particularly smokers implies the present of a AAA until proved otherwise
2. Palpating bounding popliteal or pedal pulses in an older smoker implies the presence of a AAA until proved otherwise. Especially if the medical student can feel these pulses.
3. African-American Females with Diabetes almost never get AAA.
4. Palpate their abdomen

AAA common iliac artery aneurysm iliac artery aneurysm ruptured AAA training

If the odds are against the patient, who is for the patient?


The first patient, a man in his late 70’s, ruptured in the emergency room at around four in the afternoon on a weekday, which was fortuitous, as the hospital was fully staffed, fully armed. The patient had arrived only a bit earlier with the complaint of severe abdominal pain, and soon after getting his CT, arrested. CPR commenced as I arrived by Dr. Timothy Ryan, our chief resident at that time. 

Ruptured CIAA with CPR 1 -_1
a rupture
The patient was wheeled upstairs with ongoing chest compressions. The anesthesia and operating room staff started a bucket brigade of blood -there was enough staff to start a symposium. Within 5 minutes of hitting the operating, I poured betadine on the chest and belly and took a blade and cut open the abdomen. Blood poured out onto our scrubs and to the floor and our shoes. I pushed my hand into the retroperitoneum, gently sweeping aside the torn tissues and blood clot to feel the hill of the aneurysm. I walked over the slope of the aneurysm and tweedled my fingers around the aorta above the aneurysm. The cross clamp rode my fingers into position around the aorta. The patient, so very dead minutes before in the ED, came back as I began to feel a pulse above the clamp. The patient lived through the operation and the night where grim data -pH of 6.8, lactates in the double digits, four figure LFT’s, kidney failure all predicted a bad outcome. And yet he survived, and a few days later, a second operation to washout and close his belly which had been left opened and packed occurred, and he recovered. We still talk about that day now three years out, and while he thanks me, I thank the whole hospital because I don’t remember speaking very much -the right things just happened around me as we worked, the whole hospital and me.

More recently, while I was finishing up two urgent cases, I got a call that the patient with the leaking aneurysm had arrived from across town and was becoming hypotensive.

ruptured AAA -_1
another rupture
Gratefully, one of my partners, Dr. Christopher Smolock, was rounding that Saturday and stepped in to finish up the last of the two cases while I ran down to the patient, a man in his late sixties, who had arrived in our acute aortic syndrome unit.

IMG_7195 (1)
Dr. Christopher Smolock
We conversed, the patient and I, and he understood what laid ahead. We rolled him up to the OR, and while we were prepping and draping, my fellow, Dr. Francisco Vargas, looked to me gravely and said with certitude, “I think he’s dead.

Dr. Francisco Vargas
Chest compressions commenced and again, knife in hand, I cut him open from sterum to pubis and got the clamp on. It took 15 minutes of CPR to get a pulse back. I was very pessimistic as during the case, ridiculously bad lab data came back like a pH of 6.9, lactate above 10, no urine.

Graft Repair of Rupture
The blood bank sent down coolers like the kind you take to tailgates, only filled with blood and plasma. The aneurysm had grown like a rotten apple on a stick and the graft we needed to repair it was surprisingly short. He too made it to the ICU, and after a long recovery which included dialysis, a tracheostomy, and a reboot of the brain -the brain takes a while to recover from the anoxia, but his went “bonnnnng” like a waking Mac after days of spinning beach balls, and he started to follow commands. The morning before he transferred to rehab, we talked about what he could have done to prevent the rupture. Not knowing about it, not much, I replied. People traditionally lived to about 20-30 years of age, I said, before dying of disease, violence, or predation. Longevity has meant wear and tear on irreplaceable parts. We agreed it was good to be alive.

Ruptured aortic aneurysms are the sine qua non of vascular surgical practice. As a junior resident back in the antedeluvian 90’s, I remember one of my chiefs, Dr. Eric Toschlog, now a trauma surgeon out East, running a patient upstairs from the ER with a rupture, and before the attending arrived by taxi, had the graft in. When it became my turn, as a fellow working on a patient who had been helicoptered in from the frozen wastes of Minnesota, I remember playing a trick with my mind -that the patient was proportionally the same size as the rabbits I was working with in the research lab, that I was really big and the patient’s aneurysm very small. This works to calm the heart, steady the hand. Nowadays, my mind is blank, and my hands working reflexively.

There has been a series of papers that create scores that allow prediction of odds for survival, and both of these patients, particularly with their prolonged CPR, have greater than 90% predicted mortality on these measures. In this month’s JVS, Broos et al, in the aptly named paper, “A ruptured abdominal aortic aneurysm that requires preoperative cardiopulmonary resuscitation is not necessarily lethal” describe a 38.5% survival rate among their series of patients with rupture who had CPR (ref 1).

Practically speaking, no one I know would use these scores to decide to not operate. While many series show better survival for emergency EVAR compared to open repair, several randomized control trial failed to show better results when these methods were directly compared. A retroperitoneal approach is preferred by some in our group, but having tried both closed chest CPR with the patient in right lateral decubitus position and open cardiac massage -(both died), I prefer supine.

There is no survival if there is no attempt.


  1. J Vasc Surg 2016;63:49-54.