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M & M for bowel ischemia after EVAR

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Robert Chen
Robert Chen

A 72-year-old man underwent EVAR for an abdominal aortic aneurysm on November 7, 2015. He developed postoperative complications including pneumonia and renal failure. A CT scan on December 5th showed a rupture above the stent graft, so he underwent a chimney stent graft procedure to repair it on December 7th. However, he then developed diarrhea and signs of bowel ischemia. Another procedure on December 14th found kinking of the chimney graft to the superior mesenteric artery. Despite a rescue procedure, the patient went into shock and died, with the cause of death determined to be bowel ischemia.

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Morbidity & Mortality ConferenceMorbidity & Mortality Conference Bowel Ischemia after Abdominal Aortic Aneurysm Stent-grafting 伉K僮砿翌親 迭 t 岬臼竿t垪 02/24/2016
? Sex: MaleSex: Male ? Age: 72 yearsAge: 72 years ? Date of admission: 11/07/2015Date of admission: 11/07/2015 ? Dates of surgery/procedure:Dates of surgery/procedure: 11/07/2015, 12/07/2015, 12/14/201511/07/2015, 12/07/2015, 12/14/2015 ? Date of death: 12/14/2015Date of death: 12/14/2015 Patient data
? CC: Abd pain for 3 daysCC: Abd pain for 3 days ? PH: CRI=6+ but UO++; Gout; CAD s/p POBASPH: CRI=6+ but UO++; Gout; CAD s/p POBAS ? Course:Course: ? 11/07/2015: EVAR11/07/2015: EVAR ? 11/25/2015: HD11/25/2015: HD ? 12/02/2015: ICU-> Ward12/02/2015: ICU-> Ward ? 12/05/2015: CTA: supra-EVAR Ao rupture12/05/2015: CTA: supra-EVAR Ao rupture ? 12/07/2015: Chimney & TEVAR12/07/2015: Chimney & TEVAR ? 12/14/2015: Rescue Chimney (SMA); Mortality12/14/2015: Rescue Chimney (SMA); Mortality Brief summary
? Cons: alertCons: alert ? VS: BP=177/89, HR=70, BT=35.9C, RR=20VS: BP=177/89, HR=70, BT=35.9C, RR=20 ? Abdomen: soft, midline pulsatile massAbdomen: soft, midline pulsatile mass ? EKG: sinus, 74/min, no ST changeEKG: sinus, 74/min, no ST change ? Lab: Hb=9.6, WBC=10.3k, Cre=6.3 (no HD)Lab: Hb=9.6, WBC=10.3k, Cre=6.3 (no HD) ER (4am, 11/07/2015)
CTA (11/07/2015)
CTA (11/07/2015)
EVAREVAR ? Endovascular aortic repairEndovascular aortic repair
Operation: EVAR (11/07/2015)
Operation: EVAR (11/07/2015)
Postop CoursePostop Course ? PneumoniaPneumonia ? Progressive deliriumProgressive delirium ? Strong Abx useStrong Abx use ? Diuretic-responsive UO=2000 kcal/dayDiuretic-responsive UO=2000 kcal/day ? BUN/Cre =200/7BUN/Cre =200/7 ? NG pump feeding 1500 kcal/dayNG pump feeding 1500 kcal/day
CXR (11/16/2015)
Postop CoursePostop Course ? 11/07: EVAR11/07: EVAR ? 11/25: Hemodialysis; improving11/25: Hemodialysis; improving ? 12/01: MV extubation12/01: MV extubation ? 12/02: ICU -> ward; NG & oral12/02: ICU -> ward; NG & oral ? 12/05: Pre-MBD CTA12/05: Pre-MBD CTA !!! Supra-renal artery Ao rupture!!!! Supra-renal artery Ao rupture!
CXR (12/05/2015)
CTA (12/04/2015)
CTA (12/04/2015)
Chimney TechniqueChimney Technique
Op2: ChTEVAR (12/07/2015)
Postop2 CoursePostop2 Course ? 12/07: Chimney SMA & TEVAR, sacrificing bil12/07: Chimney SMA & TEVAR, sacrificing bil renal arteries; PermCathrenal arteries; PermCath ? 12/08: NG pump 800kcal/day, abd soft, bowel12/08: NG pump 800kcal/day, abd soft, bowel sounds activesounds active ? 12/09: HD; GCS: M6; MV extubation12/09: HD; GCS: M6; MV extubation ? 12/10: NG 1500 kcal/day, Abx: Tapi, Vanco,12/10: NG 1500 kcal/day, Abx: Tapi, Vanco, Diflucan; WBC=13k, CRP=27, CK=554,Diflucan; WBC=13k, CRP=27, CK=554, lipase=93, Lac=1.4lipase=93, Lac=1.4
CXR (12/11/2015)
Postop2 CoursePostop2 Course ? 12/11: Diarrhea 2335 g/day, WBC=8.4k,12/11: Diarrhea 2335 g/day, WBC=8.4k, ABG=7.32/157/34/19/-9, NIPPV useABG=7.32/157/34/19/-9, NIPPV use ? 12/12: NG 1500 kcal/day, abd soft & flat,12/12: NG 1500 kcal/day, abd soft & flat, diarrheadiarrhea ? 12/13: NG 1500 kcal/day, diarrhea stopped12/13: NG 1500 kcal/day, diarrhea stopped after Imodium, CRP=34, PCT=47, WBC=8.4kafter Imodium, CRP=34, PCT=47, WBC=8.4k
Postop2 CoursePostop2 Course ? 12/14: Shock, re-ETT, Lac=3.4, WBC=7.2,12/14: Shock, re-ETT, Lac=3.4, WBC=7.2, CK=21, CRP=18, lipase=137CK=21, CRP=18, lipase=137 ? CT workup: ischemia bowel! SMA chimneyCT workup: ischemia bowel! SMA chimney kinkingkinking ? Cath rescue: SMA re-chimneyCath rescue: SMA re-chimney ? 12/14: Treatment futility; support withdrawal;12/14: Treatment futility; support withdrawal; MortalityMortality
CXR (12/14/2015)
CTA (12/14/2015)
CTA (12/14/2015)
CTA (12/14/2015)
Rescue (12/14/2015)
Rescue (12/14/2015)
Rescue (12/14/2015)
Possible Causes of Mortality ?Shock ?Bowel ischemia ?Kinked chimney to SMA ?Delayed diagnosis & treatment ?Hesitated hemodialysis (Prolonged toxinemia)
M & M for bowel ischemia after EVAR
M & M for bowel ischemia after EVAR
?返gm屏 (2nd) 頁倦如 --> Yes ?返g念u浩頁倦頼屁 --> Yes ?返g嶄醍恪頁倦尿 --> Yes ?紗o押型岻孚o尿倦 --> Yes? ?棒蘭圻咀岻功云蛍裂 ? Bowel ischemia ?屁w遇冱 , 云宛箭辛參個M岻藝 ? Alertness; Technique ?云宛箭W欺焚N ? Timely management! How to do better?
Thank you!Thank you!
Other CasesOther Cases
Other CasesOther Cases
M & M for bowel ischemia after EVAR
M & M for bowel ischemia after EVAR

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M & M for bowel ischemia after EVAR

  • 1. Morbidity & Mortality ConferenceMorbidity & Mortality Conference Bowel Ischemia after Abdominal Aortic Aneurysm Stent-grafting 伉K僮砿翌親 迭 t 岬臼竿t垪 02/24/2016
  • 2. ? Sex: MaleSex: Male ? Age: 72 yearsAge: 72 years ? Date of admission: 11/07/2015Date of admission: 11/07/2015 ? Dates of surgery/procedure:Dates of surgery/procedure: 11/07/2015, 12/07/2015, 12/14/201511/07/2015, 12/07/2015, 12/14/2015 ? Date of death: 12/14/2015Date of death: 12/14/2015 Patient data
  • 3. ? CC: Abd pain for 3 daysCC: Abd pain for 3 days ? PH: CRI=6+ but UO++; Gout; CAD s/p POBASPH: CRI=6+ but UO++; Gout; CAD s/p POBAS ? Course:Course: ? 11/07/2015: EVAR11/07/2015: EVAR ? 11/25/2015: HD11/25/2015: HD ? 12/02/2015: ICU-> Ward12/02/2015: ICU-> Ward ? 12/05/2015: CTA: supra-EVAR Ao rupture12/05/2015: CTA: supra-EVAR Ao rupture ? 12/07/2015: Chimney & TEVAR12/07/2015: Chimney & TEVAR ? 12/14/2015: Rescue Chimney (SMA); Mortality12/14/2015: Rescue Chimney (SMA); Mortality Brief summary
  • 4. ? Cons: alertCons: alert ? VS: BP=177/89, HR=70, BT=35.9C, RR=20VS: BP=177/89, HR=70, BT=35.9C, RR=20 ? Abdomen: soft, midline pulsatile massAbdomen: soft, midline pulsatile mass ? EKG: sinus, 74/min, no ST changeEKG: sinus, 74/min, no ST change ? Lab: Hb=9.6, WBC=10.3k, Cre=6.3 (no HD)Lab: Hb=9.6, WBC=10.3k, Cre=6.3 (no HD) ER (4am, 11/07/2015)
  • 7. EVAREVAR ? Endovascular aortic repairEndovascular aortic repair
  • 10. Postop CoursePostop Course ? PneumoniaPneumonia ? Progressive deliriumProgressive delirium ? Strong Abx useStrong Abx use ? Diuretic-responsive UO=2000 kcal/dayDiuretic-responsive UO=2000 kcal/day ? BUN/Cre =200/7BUN/Cre =200/7 ? NG pump feeding 1500 kcal/dayNG pump feeding 1500 kcal/day
  • 12. Postop CoursePostop Course ? 11/07: EVAR11/07: EVAR ? 11/25: Hemodialysis; improving11/25: Hemodialysis; improving ? 12/01: MV extubation12/01: MV extubation ? 12/02: ICU -> ward; NG & oral12/02: ICU -> ward; NG & oral ? 12/05: Pre-MBD CTA12/05: Pre-MBD CTA !!! Supra-renal artery Ao rupture!!!! Supra-renal artery Ao rupture!
  • 18. Postop2 CoursePostop2 Course ? 12/07: Chimney SMA & TEVAR, sacrificing bil12/07: Chimney SMA & TEVAR, sacrificing bil renal arteries; PermCathrenal arteries; PermCath ? 12/08: NG pump 800kcal/day, abd soft, bowel12/08: NG pump 800kcal/day, abd soft, bowel sounds activesounds active ? 12/09: HD; GCS: M6; MV extubation12/09: HD; GCS: M6; MV extubation ? 12/10: NG 1500 kcal/day, Abx: Tapi, Vanco,12/10: NG 1500 kcal/day, Abx: Tapi, Vanco, Diflucan; WBC=13k, CRP=27, CK=554,Diflucan; WBC=13k, CRP=27, CK=554, lipase=93, Lac=1.4lipase=93, Lac=1.4
  • 20. Postop2 CoursePostop2 Course ? 12/11: Diarrhea 2335 g/day, WBC=8.4k,12/11: Diarrhea 2335 g/day, WBC=8.4k, ABG=7.32/157/34/19/-9, NIPPV useABG=7.32/157/34/19/-9, NIPPV use ? 12/12: NG 1500 kcal/day, abd soft & flat,12/12: NG 1500 kcal/day, abd soft & flat, diarrheadiarrhea ? 12/13: NG 1500 kcal/day, diarrhea stopped12/13: NG 1500 kcal/day, diarrhea stopped after Imodium, CRP=34, PCT=47, WBC=8.4kafter Imodium, CRP=34, PCT=47, WBC=8.4k
  • 21. Postop2 CoursePostop2 Course ? 12/14: Shock, re-ETT, Lac=3.4, WBC=7.2,12/14: Shock, re-ETT, Lac=3.4, WBC=7.2, CK=21, CRP=18, lipase=137CK=21, CRP=18, lipase=137 ? CT workup: ischemia bowel! SMA chimneyCT workup: ischemia bowel! SMA chimney kinkingkinking ? Cath rescue: SMA re-chimneyCath rescue: SMA re-chimney ? 12/14: Treatment futility; support withdrawal;12/14: Treatment futility; support withdrawal; MortalityMortality
  • 29. Possible Causes of Mortality ?Shock ?Bowel ischemia ?Kinked chimney to SMA ?Delayed diagnosis & treatment ?Hesitated hemodialysis (Prolonged toxinemia)
  • 32. ?返gm屏 (2nd) 頁倦如 --> Yes ?返g念u浩頁倦頼屁 --> Yes ?返g嶄醍恪頁倦尿 --> Yes ?紗o押型岻孚o尿倦 --> Yes? ?棒蘭圻咀岻功云蛍裂 ? Bowel ischemia ?屁w遇冱 , 云宛箭辛參個M岻藝 ? Alertness; Technique ?云宛箭W欺焚N ? Timely management! How to do better?

Editor's Notes

  • #2: N101473796