Damage Control Endografting for the Unstable or Unfit Patient

Abstract

In the elective setting, both open surgical and endovascular therapies may be reasonable treatment options for many vascular conditions. However, an unstable or unfit patient with a vascular emergency may be less able to tolerate a definitive open vascular operation. We now report the outcomes for "damage control" endografting for unstable or unfit patients with vascular emergencies as bridge therapy before definitive open therapy. A retrospective review of patients who underwent damage control endografting over a 9-year period (2005-2014) was performed. The primary inclusion criterion was the use of emergency damage control endografting as temporizing therapy to permit time for patient stabilization or optimization before definitive open repair. Patients who underwent endografting as planned definitive therapy were excluded. Indications for damage control endografting included arterial bleeding or expanding hematoma related to infected pseudoaneurysms (n=5), infected grafts (n=3), or cancer (n=1). Anatomic locations included the aorta (n=3), common iliac artery (n=2), common femoral artery (n=2), common carotid artery (n=1), and subclavian artery (n=1). The medianage was 56years (interquartile range [IQR] 51-70). Five of our patients were male and 4 patients were female. Median follow-up was 8months (IQR 3-11). Operative (30-day) mortality was 11%. A single patient died on postoperative day 12 after undergoing aortic and duodenal reconstruction related to an aortoenteric fistula. Using the damage control approach, clinical stabilization was achieved in 8 of the 9 patients (88%). One patient with a bleeding infected common femoral artery pseudoaneurysm continued to bleed and required emergent open surgical repair. Definitive open repair was completed in 8 of the 9 patients (88%) at a median time interval of 3days (IQR 1-10). Planned open repair was not performed in a patient with exsanguinating carotid hemorrhage after the associated cancer was deemed unresectable. Damage control endografting facilitates stabilization of the majority of unstable and unfit patients with vascular emergencies to allow definitive open repair under more favorable conditions. This technique should be employed rarely due to the expense, but it is a technique worthy of consideration in select patients.