Journal of Vascular Surgery
Volume 50, Issue 1 , Pages 1-7, July 2009

Open abdomen treatment following endovascular repair of ruptured abdominal aortic aneurysms

  • Dieter Mayer, MD

      Affiliations

    • Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland
    • Corresponding Author InformationCorrespondence: Dieter Mayer, Clinic for Cardiovascular Surgery, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, CH
    • ,
  • Zoran Rancic, MD, PhD

      Affiliations

    • Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland
    • ,
  • Christoph Meier, MD

      Affiliations

    • Clinic for Trauma Surgery, University Hospital of Zurich, Zurich, Switzerland
    • ,
  • Thomas Pfammatter, MD

      Affiliations

    • Clinic for Interventional Radiology, University Hospital of Zurich, Zurich, Switzerland
    • ,
  • Frank J. Veith, MD

      Affiliations

    • The Cleveland Clinic and New York University Medical Center, New York, and University Hospital of Zurich, Zurich, Switzerland
    • ,
  • Mario Lachat, MD

      Affiliations

    • Clinic for Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland

Received 19 October 2008; accepted 16 December 2008.

Article Outline

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 ≤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).

Conclusion

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.

 

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).1, 2, 3, 4, 5, 6, 7, 8, 9 Since its first description by Fietsam2 in this patient cohort, many technical reports have been published. Clear treatment algorithms are still lacking, however, and the high mortality rates published10 may reflect difficulties in detecting and treating ACS.5 This is especially true for patients treated by emergency endovascular aneurysm repair (eEVAR) who do not undergo a laparotomy as part of their primary procedure.11, 12, 13, 14

This study reports our 10-year experience with the management of patients requiring OAT after eEVAR for RAAA. A further objective is to provide an algorithm for the diagnosis of intra-abdominal hypertension and abdominal compartment syndrome (ACS) and to demonstrate a standardized method for performing OAT.

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Methods 

Patients 

From January 1998 to April 2008, 102 of 212 consecutive patients with RAAA were treated by eEVAR in our tertiary referral center. Patients were a mean age of 73 ± 9 years (range, 48-90 years). Aneurysm rupture, defined as blood outside the aortic wall, was confirmed by computed tomography angiography in all patients. Blood was present in the retroperitoneum in 64, in the peritoneal cavity in 33, and in the duodenum (aortoduodenal fistula) in five. Critical clinical data were prospectively collected and retrospectively analyzed. A systematic retrospective review of all patient medical records was initiated for details concerning ACS. The Institutional Review Board approved the study.

Patient monitoring 

For all patients with RAAA—but in particular for patients treated by eEVAR—a proactive approach to the detection and treatment of intra-abdominal hypertension (IAH) is critical. These patients are at high risk for development of ACS and therefore, close monitoring of intravesical pressure (IVP; corresponds to intra-abdominal pressure) and organ function is crucial to detect critical IAH. The IVP measurement was initiated during EVAR and repeated every hour after the procedure (see Open abdomen treatment).

Urinary output, respiratory function and indices for bowel ischemia (blood lactate and lactate dehydrogenase elevation) were closely monitored. Close surveillance of IVP and organ function was continued in all patients either with or without abdominal decompression for the duration of IAH. Importantly, this surveillance was continued during the whole course of stepwise approximation of the fascial borders and subsequent fascial closure after abdominal decompression.

Open abdomen treatment 

Abdominal decompression after eEVAR was done during the primary intervention or secondarily in the intensive care unit (ICU). Indication for surgical decompression was based on an IVP >20 mm Hg or abdominal perfusion pressure (systemic mean pressure minus intra-abdominal pressure) of <50 to 60 mm Hg and new development of organ dysfunction, or when patients fulfilled at least one of the criteria from the Table.9, 15, 16, 17

Table. Predisposing factors for abdominal compartment syndromea
•Deep shock
Systolic blood pressure < 70 mm Hg during 20 minutes
± Hemoglobin < 8 g/dL
± pH < 7.3

•Intraoperative fluid infusion > 5 L

•Transfusion > 6 U red blood cell concentrates

•Temperature grade < 35°C

•Vast retroperitoneal hematoma

•Massive bowel swelling

aModified from references 9, 15, 16, 17.

The general algorithm of OAT for all RAAA patients in our institution is illustrated in Fig 1. To avoid IAH, the abdomen is primarily left open in all open repairs for RAAA.

  • View full-size image.
  • Fig 1. 

    General algorithm for open abdomen treatment after emergency endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (RAAA). ACS, Abdominal compartment syndrome; ICU, intensive care unit. *For risks, see the Table.

Patients treated by eEVAR are at high risk for development of ACS; therefore, close monitoring of IVP and organ function is crucial to detect critical IAH. IVP measurement is initiated during EVAR and repeated every hour after the procedure. Intermittent IVP measurement3, 18 is accomplished with a standard Foley catheter and volume priming with 25 mL of normal saline in the supine position during end expiration. The midaxillary line serves as the zero reference point. Urinary output, respiratory function, and indices for bowel ischemia (lactate and lactose dehydrogenase elevation) are closely monitored.

Surgical decompression is initiated when critical IAH is present and new organ dysfunction develops or when patients fulfill at least one of the criteria presented in the Table. In stable patients, surveillance is continued as mentioned.

The algorithm to choose the optimal type of OAT is illustrated in Fig 2. Once the decision for OAT is made, decompressive laparotomy is performed urgently. Subject to the clinical findings in the abdomen, two different pathways are possible: temporary closure with (1) a plastic bag silo closure (Bogota bag)19 and conventional secondary dressing, or (2) a vacuum-assisted closure (VAC) system (V.A.C., KCI International Inc, Amstelveen, The Netherlands). Key indicators for this decision are the volume of the intra-abdominal organs protruding from the abdomen due to massive swelling (Fig 3) and suspicion of impending bowel necrosis due to prolonged ischemia from hypotension, compression, and elevated IVP. If these factors are present, the abdomen is temporarily closed with a simple, large, sterile plastic drape or bag, which makes direct visualization of the small bowel possible (Fig 3). A bag silo closure also provides a large reserve capacity allowing further intra-abdominal organ swelling without relevant IVP elevation, thus preventing recurrent increased intra-abdominal pressure in the initial phase after decompression of ACS compared with other temporary abdominal closure techniques.20

  • View full-size image.
  • Fig 2. 

    Algorithm to choose the optimal type of open abdomen treatment (OAT) after emergency endovascular aneurysm repair (eEVAR) for ruptured abdominal aortic aneurysm (RAAA). VAC, Vacuum assisted closure; VAC/ETHIZIP, VAC-over-ETHIZIP.

  • View full-size image.
  • Fig 3. 

    Temporary abdominal closure with a simple, large sterile plastic drape or bag allows direct visualization of the bowel and further swelling of the abdomen without pressure rise.

The technique recently has been modified to improve the management of excessive fluid loss from the bag silo, still keeping its large reserve capacity (Bogota-VAC, Fig 4).21 For minor bowel edema/distension, a VAC system is placed over a zipper drape (Fig 5; ETHIZIP, Ethicon Inc, Somerville, NJ). This technique, which we call VAC-over-ETHIZIP (VAC/ETHIZIP), is described in detail in the next section.

  • View full-size image.
  • Fig 4. 

    A ring shaped black polyurethane foam of the vacuum-assisted closure system is put near the border where the Bogota bag is sutured to the skin. The adhesive foils just cover the polyurethane foam, not the whole bag silo. The TRAC-PAD (KCI International Inc, Amstelveen, The Netherlands) of the vacuum-assisted closure system is positioned so that it doesn't interfere with the bag or skin.

When the bag silo is initially applied, a second-look intervention with inspection of the abdominal contents is always performed 1 to 2 days after abdominal decompression. Temporary abdominal closure is converted to the VAC/ETHIZIP technique when (1) the patient is stabilized, (2) IVP remains <15 mm Hg, or (3) organ function is improved. In the situation of continued or even deteriorated ACS, the bag silo is applied again.

Our algorithm specifies that stable patients with primary application of the VAC/ETHIZIP undergo second-look interventions every 3 to 5 days with stepwise approximation of the fascial borders. The underlying zipper drape and the VAC foam are narrowed accordingly. In the situation of recurrent ACS during the latter course, however, the abdomen is decompressed again with the bag silo closure. The technique is converted back to VAC/ETHIZIP with continued fascial approximation whenever suitable until definitive closure.

VAC/ETHIZIP Technique 

The abdomen is left open after laparotomy and the zipper drape is placed sutureless underneath the entire abdominal wall (Fig 5). The VAC (black polyurethane foam) is then applied over the ETHIZIP and a subatmospheric pressure of 50 mm Hg is initiated (Fig 6). The zipper drape is reused after second-look interventions if undamaged. Partial abdominal wound closure is considered when the abdominal wall can be partially or totally approximated without any increase of the IVP. For this purpose, the ETHIZIP is shaped so that the wound area covered will be smaller and smaller. Accordingly, the size of the VAC foam is also reduced to allow for a stepwise fascial approximation and then reapplied. Delayed direct fascial (running suture with size 0 Maxon loop, Tyco Healthcare, Mansfield, Mass) and skin closure is done when the abdomen is clinically tension free and the fascial borders can be completely approximated without any increase in bladder pressure. In case of prolonged OAT due to abdominal inflammation or infection, direct closure of the abdominal fascia may prove impossible. Permanent closure may then be achieved by the bilateral anterior rectus abdominis sheath turnover flap method described by Kushimoto et al.22 The skin is then mobilized from the fascia and primarily approximated.

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Results 

Overall 30-day mortality for eEVAR was 13% (13 of 102). Reasons for death were suicide in 1, multiorgan failure in 5, cardiac events in 3, bleeding in 3, and bowel ischemia in 1. The 30-day mortality was 8% (7 of 82) for patients without ACS and 30% (6 of 20) for those with ACS.

Decompression after eEVAR for ACS was required in 20 patients (20%), either during the intervention (n = 14) or later in the ICU (n = 6). Six of 20 (30%) patients requiring OAT died ≤30 days. The two groups had a similar mortality rate (OAT during intervention, 4 of 14 patients; OAT later in the ICU, 2 of 6). One patient died in the operating room due to uncontrollable intraoperative decompressive bleeding, 1 died of multiorgan failure after small bowel ischemia, 1 died of sepsis after ischemic cholecystitis, 2 died of cardiac events, and 1 died pneumonia 29 days after the intervention.

Five of the remaining 14 OAT patients needed a temporary abdominal closure with a plastic drape or bag due to massive volume increase of the abdominal contents or suspicion of imminent bowel necrosis. In the other nine patients, VAC/ETHIZIP was initiated primarily. A mean of 3.6 (range, 1-12) planned second-look interventions were done per patient with an interval of 3 to 5 days. No bowel lesions or fistulas were observed during OAT. Local bacterial contamination (positive swab) developed in five patients, and four patients required antibiotic therapy for abdominal infection. All infections resolved under antibiotic therapy.

Delayed closure of the abdominal wall was achieved after a median of 6 days (range 1-47 days). Direct fascial closure was possible in 11 patients. Of the remaining three patients, two received a polypropylene mesh and one underwent a bilateral anterior rectus abdominis sheath turnover flap and direct skin closure.

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Discussion 

ACS is a major cause of death after endovascular and open repair for RAAA.2, 7, 9, 23, 24, 25, 26, 27 ACS-related mortality rates published for open repair are generally >50% and up to 100%. In a 2005 article, Mehta et al6 report a 57% mortality rate for patients with ACS after eEVAR for RAAA. Detection and treatment of ACS are therefore considered lifesaving and mandatory.9, 24 Vigilant awareness for ACS and consequent treatment according to our standard protocol has resulted in a low 30-day mortality of 13% in our patient cohort of 102 RAAAs treated endovascularly during a 10-year period.

Prevalence of ACS was much higher in our study than reported in the current literature after eEVAR.11, 12, 13, 14 Despite this high prevalence of ACS, the mortality was considerably lower in our eEVAR patients. We speculate that the difference in the prevalence of ACS and the short-term mortality might in part reflect an underdiagnosis or undertreatment of ACS in many previous studies. Notwithstanding the early diagnosis and aggressive management of ACS, the OAT subgroup had a 30% mortality. However, there was no difference in mortality in our study between the two groups of primary (intraoperative) OAT and secondary (later in the ICU) OAT, because decompression laparotomy was done in all cases before organ failure occurred. This meticulous surveillance and aggressive management of IAH might explain the difference with the published data from Rasmussen et al9 that show a tendency of increased in-hospital mortality in patients with late decompression after development of ACS.9 However, the data are difficult to compare due to the different management of both groups (endovascular vs open repair). Furthermore, to date, the best timing of abdominal decompression is still unknown and should be investigated further.

A variety of therapeutic modalities for OAT have been published during the last 20 years.23, 24, 28, 29, 30, 31, 32, 33, 34, 35, 36 Although algorithms have been proposed for the management of IAH and abdominal compartment syndrome after open RAAA repair, none have been proposed in the setting of eEVAR. In this article, we provide simple, safe clinical decision trees for OAT after successful endovascular sealing of RAAA as well as for choosing the optimal type of OAT according to the clinical presentation during the initial intervention or a secondary procedure. Key indicators are provided to help to initiate the best treatment available.

Bowel ischemia can be easily and rapidly detected through the transparent plastic drape or bag fixed only loosely to the skin. Furthermore, room is provided for further volume increases in the abdominal contents.20 Our VAC/ETHIZIP technique represents a simple and clean dressing that has to be changed every 3 to 5 days, thus providing more comfort to the patient and less workload for the ICU or ward staffs. The abdominal fascia is not traumatized, because neither the zipper drape nor the foam is fixed by sutures. Delayed step-wise wound closure can be accomplished with clean and healthy fascial margins, enhancing the probability of uneventful closure without hernia formation.

Finally, topical negative-pressure VAC dressing techniques have several benefits. This method exerts antimicrobial activity37 and stimulates granulation tissue formation.38, 39 By its mechanical mode of action,40 the VAC probably stabilizes the abdominal wall and may prevent abdominal wall retraction. VAC/ETHIZIP has been preferred rather than the prefabricated abdominal VAC system for three reasons:

1.better protection of the intra-abdominal contents when using the ETHIZIP compared with the thin and porous plastic foil, potentially decreasing the risk of abdominal fistulae,

2.better and safer patient mobilization due to a thicker and therefore more stable standard polyurethane foam compared with the prefabricated abdominal VAC foam, possibly leading to fewer eventrations due to VAC failures, and

3.lower cost of VAC/ETHIZIP compared with the commercially available dressing.

This study has several limitations. The first is the absence of a control group (conservative treatment) that would allow proving and quantifying the effect of the OAT treatment in RAAA patients treated by EVAR. With the acquired knowledge about the negative effect of untreated ACS in RAAA patients managed by open repair in the past years, however, we believe it is unethical to randomize patients to an control group and then not treat them. Furthermore, the recent publication of Mehta et al6 supports the aggressive diagnostic approach and treatment of ACS by OAT in RAAA patients managed by eEVAR.

A second limitation is the lack of a comparative group with a different treatment modality or algorithm. Thus, our study cannot answer the question of whether there exists another possibly more effective approach to ACS in RAAA patients treated by eEVAR. We believe, however, that the 30-day mortality of 13% obtained in our study with 102 RAAA patients managed by eEVAR has proven the effectiveness of our algorithm. Furthermore, although relatively frequent, the total number of patients per year with ACS after eEVAR is relatively low, and the experience would have been diluted by following too many combinations of algorithms and treatment choices.

A third limitation is the lack of comparison of RAAA patients treated by eEVAR with open repair. Our algorithm precludes such a comparison because we primarily use OAT in all patients managed by open repair. We are not able, therefore, to provide evidence of the effectiveness of our general algorithm including all RAAA patients.

Finally, although there is growing evidence of the mechanism of action of wounds managed with VAC, our study cannot definitely prove the assumptions made about the beneficial action of such therapy. Further studies should, therefore, include and quantify parameters such as antimicrobial activity, granulation tissue formation, and mechanical stability of the abdominal wall treated by VAC/ETIZIP.

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Conclusion 

The use of standardized novel techniques along with a treatment protocol and algorithm for OAT after eEVAR for RAAA proved to be feasible and safe. The workload of the medical and nursing staff was decreased and patient comfort was enhanced because the need for dressing changes was minimized. We believe it also contributed to lower overall mortality in RAAA patients. Delayed direct fascial closure was possible in most patients. Widespread use of these systems, methods, and algorithms is recommended.

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Author contributions 


Conception and design: DM, ML

Analysis and interpretation: DM, ZR, CM, FV

Data collection: DM, ZR

Writing the article: DM, CM, FV, ML

Critical revision of the article: DM, ZR, CM, TP, FV, ML

Final approval of the article: DM, ZR, CM, TP, FV, ML

Statistical analysis: DM (descriptive statistics)

Obtained funding: Not applicable

Overall responsibility: DM

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 Competition of interest: none.

PII: S0741-5214(08)02267-2

doi:10.1016/j.jvs.2008.12.030

Journal of Vascular Surgery
Volume 50, Issue 1 , Pages 1-7, July 2009

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