Open abdomen treatment following endovascular repair of ruptured abdominal aortic aneurysms.
BACKGROUND
Open abdomen treatment (OAT) is considered a lifesaving procedure in patients with abdominal compartment syndrome (ACS) after endovascular or open intervention for ruptured abdominal aortic aneurysms (RAAA). Standardized treatment methods and algorithms for its use are still lacking. The high, published mortality rates may reflect difficulties in detecting and treating ACS, especially in patients treated by emergency endovascular aneurysm repair (eEVAR). Presented are standardized algorithms for OAT, including a new technique using the vacuum-assisted closure (VAC) system developed during 10 years of experience with eEVAR for RAAA.


METHODS
We retrospectively analyzed 102 patients with RAAA treated by eEVAR from January 1998 to April 2008. Abdominal decompression was done when intravesical pressure >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 a VAC device (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.


RESULTS
Overall 30-day mortality for eEVAR was 13% (13 of 102); 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 <or=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 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).


CONCLUSIONS
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.
Mayer
Dieter
D
Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland. dieter.mayer@usz.ch
Rancic
Zoran
Z
Meier
Christoph
C
Pfammatter
Thomas
T
Veith
Frank J
FJ
Lachat
Mario
M
D000005:Abdomen; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001019:Aortic Rupture / Q000150:complications / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D003161:Compartment Syndromes / Q000209:etiology / Q000601:surgery; D019299:Decompression, Surgical; D006801:Humans; D008875:Middle Aged; D054843:Negative-Pressure Wound Therapy; D012189:Retrospective Studies