CASE 1

The patient was brought to theatre for emergency endovascular repair of a ruptured AAA. This was performed under local anaesthetic with titrated sedation. General anaesthesia was induced towards the end of procedure to allow surgical cut down in groin to close the femoral artery and because the patient was becoming agitated. Following surgery, the patient became increasingly unstable with difficult to manage hypotension. A central line was inserted and noradrenaline infused. The patient continued to deteriorate with worsening acidosis.

CASE 2

Patient passed away following elective repair of an AAA

CASE 3

During repair of an AAA the patient suffered myocardial infarction and developed pulmonary oedema. Oxygen saturations dropped to 70% and arterial blood gas analysis showed profound acidaemia and hypoxaemia. The patient was unresponsive to resuscitation, and a decision was made to withdraw treatment.

CASE 4

During emergency repair of a ruptured abdominal aortic aneurysm, the patient arrested, and CPR commenced. Resuscitation was unsuccessful and the patient died in theatre.

CASE 5

A Patient requiring emergency open AAA repair was unstable during transfer from ED to theatre. Relative stability was achieved during induction up to the point of cross clamping. 8 minutes after the X-clamp was applied, the patient deteriorated and suffered a cardiac arrest. CPR was attempted for 40 minutes but was unsuccessful.

Commentary

Although 30-day mortality rates following AAA surgery have fallen, both elective and emergency repair of ruptured AAAs remain high risk procedures. Mortality rates of up to 50% following emergency repairs are reported, with deaths accounting for a major proportion of in-hospital deaths in the surgical population. Although surgical techniques, peri-operative care and anaesthetic protocols have been refined, the patient population is increasingly old and frail. Although deaths immediately after surgery are largely due to haemorrhage, deaths after this are mainly due to patients’ comorbidities.¹ Several models are available to predict mortality and should be used for any patient undergoing this type of surgery.² Anaesthetists should be involved as early as possible in pre-operative discussion with patients. In the UK this type of surgery is restricted to designated centres. Anaesthetic care should be consultant-delivered by anaesthetists who regularly undertake such cases.

1. Reitz KM, Phillips AR, Tzeng E et al. Characterization of immediate and early mortality after repair of ruptured abdominal aortic aneurysm. J Vasc Surg 2022; 76(6): 1578-87
2. Won Lee C, Bae M, Han C et al. Review of scoring systems for predicting 30-day mortality in ruptured aortic aneurysm. Ann Vasc Surg 2024; 109: 77-82