title: Tissue plasminogen activator-assisted hematoma evacuation to relieve abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysm.
abstract: OBJECTIVE
  To describe our experience with a novel technique to decompress abdominal compartment syndrome after endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA).
  
  
  METHODS
  From January 2003 to April 2010, 13 patients (12 men; mean age 75 years) treated for rAAA with EVAR underwent tissue plasminogen activator (tPA)-assisted decompression for intra-abdominal hypertension. All of the patients but one had intra-abdominal pressure >20 mmHg, with signs of multiple organ failure or abdominal perfusion pressure <60 mmHg. With computed tomography guidance, a drain was inserted into the retroperitoneal hematoma, and tPA solution was injected to facilitate evacuation of the coagulated hematoma and decrease the abdominal pressure.
  
  
  RESULTS
  In the 13 patients, the mean intra-abdominal pressure decreased from 23.5 mmHg (range 12-35) to 16 mmHg (range 10-28.5). A mean 1520 mL (range 170-2900) of blood was evacuated. Urine production (mean 130 mL/h, range 50-270) increased in 7 patients at 24 hours after tPA-assisted decompression; among the 5 patients in which urine output did not increase, 3 underwent hemodialysis by the 30-day follow-up. One patient did not respond with clinical improvement and required laparotomy. The 30-day, 90-day, and 1-year mortality was 38% (5/13 patients); none of the deaths was related to the decompression technique.
  
  
  CONCLUSIONS
  tPA-assisted decompression of abdominal compartment syndrome after EVAR can decrease the intra-abdominal pressure and could be useful in preventing multiple organ failure. It is a minimally invasive technique that can be used in selected cases but does not replace laparotomy or retroperitoneal surgical procedures as the gold standard treatments.
authors.affiliation: Department of Cardio-Vascular and Thoracic Surgery, Örebro University Hospital, Örebro, Sweden. tal.horer@orebroll.se
authors.forename: Tal
authors.initials: T
authors.lastname: Hörer
authors.forename: Per
authors.initials: P
authors.lastname: Skoog
authors.forename: Artai
authors.initials: A
authors.lastname: Pirouzram
authors.forename: Thomas
authors.initials: T
authors.lastname: Larzon
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001019:Aortic Rupture / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality; D003664:Decompression / Q000009:adverse effects / Q000379:methods*; D019299:Decompression, Surgical; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006406:Hematoma / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality; D006801:Humans; D015552:Injections, Intralesional; D059325:Intra-Abdominal Hypertension / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology; D011312:Pressure; D013548:Sweden; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator