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Abdominal Aortic Aneurysm

Abdominal Aortic Aneurysm . (Infrarenal) Management. Abdominal Aortic Aneurysm. End result of a multifactorial process - destruction of aortic wall connective tissue Surgery (aneurysmorrhaphy) Transperitoneal Retroperitoneal Endoaneurysmorrhaphy Exclusion technique. Management.

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Abdominal Aortic Aneurysm

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  1. Abdominal Aortic Aneurysm (Infrarenal) Management

  2. Abdominal Aortic Aneurysm • End result of a multifactorial process - destruction of aortic wall connective tissue • Surgery (aneurysmorrhaphy) • Transperitoneal • Retroperitoneal • Endoaneurysmorrhaphy • Exclusion technique

  3. Management • When to treat? • Balance risk of surgery Vs risk of wait & see • Rate of rupture ~ Aneurysm diameter • Annual rupture rate 0 – 1% for AAA <4cm 0 – 12% for AAA <4.99cm 25% for AAA >5cm

  4. Surgery (open) • Emergency • Preoperative mortality risk 55% • Perioperative & Post operative mortality risk 27-50% • Elective • Perioperative mortality 5-7% (1-5%)

  5. Surgery (open) • Cardiac complication >50% • 25% mortality • Renal 10% • Stroke 7% • Respiratory

  6. Cardiac optimization • Preoperative cardiac assessment • Preoperative coronary artery revascularization • Beta-blockers • Intensive intraoperative monitoring and stabilization • Pulmonary optimization • Preoperative lung function assessment • Chest physiotherapy • Bronchodilator • Cease smoking

  7. Evolution • Endovascular / Endoluminal Stenting • Minimally invasive technique • Molecular genetics

  8. Molecular defect of AAA • Elastin & Interstitial collagens • Increased enzymes – degrading the fibrillar extracellular matrix protein • Matrix metalloproteinases (MMP) • Plasminogen • Serine elastases • Cathepsins

  9. Molecular Genetics • Chronic inflammation prominent feature • Stimulating factors ? Antigen-driven ? • Autoimmune disease ? Montaz W, Timothy B, Rex L C, et al. Pathogenesis of abdominal aortic aneurysms: A multidisciplinary research program supported by the National Heart, Lung and Blood Institute. J of Vascular Surgery Oct 2001 Vol. 34 Number 4: 730-738

  10. Molecular Genetics • Anti inflammatory agents • Doxycycline (Non selective MMP inhibitors)

  11. High risk patients • Pulmonary disease (FEV1 < 1.0 L) • Cardiac disease (class IV angina, Ejection fraction <30%) • Chronic renal impairment (creatinine > 1.8mg/dL) • Cirrhosis (Child B or C) • Hostile abdomen • Obesity (body mass > 35kg/m2)

  12. Morbidity • Cardiovascular • Renal • Pulmonary • Vascular • GI tract • Wound

  13. Suitability for Endoluminal Stenting • Suitability diminished as AAA size increased ? • No correlation for AAA with < 7cm size • Lower proportion of AAA suitable with > 7cm size Armo MP, Yusuf SW, Whitaker SC, et al. Influence of AAA size on the feasibility of endovascular repair. J Endovasc Surg 1997;4:279-83

  14. Endovascular RepairMortality (elective repair) • 0% to 6% inconsistent • High risk patients • Endovascular Tech evolving • Learning curve • 0.7% • Blum U, Voshage G, Lammer J et al. Endoluminal stentgrafts for infrarenal AAA. N Engl J Med 1997; 336:13-20 • 1.1% • Goldstone J, Brewster DC, Chaikof EL, et al. Endoluminal repair versus standard open repair of AAA: early results of a prospective clinical comparison trial. Proceedings of the 46th Scientific Meeting of The International Society for Cardiovascular Surgery; 1998 Jun 7-8; San Diego, Calif. • 2% • Zarins CK, White RA, Schwarten DE, et al. Medtronic AneuRx Stent Graft System versus open surgical repair of AAA: Multicenter clinical trial. Proceeding of the 46th Scientific Meeting of the International Society for Cardiovascular Surgery; 1998 Jun 7-8; San Diego, Calif.

  15. Endoluminal Stenting • Short Term Failure • Need for open surgical repair within 1 month • Long Term Failure • Need for further endovascular intervention • Need for explantation • Need for open surgical repair • Increased perioperative / postoperative morbidity and mortality • Finlayson SR, Birkmeyer JD, Fillinger MF, et al: Should Endovascular surgery lower the threshold for repair of AAA. Journal of Vascular Surgery: Vol 29(6) June 1999; 973-985

  16. Long Term Failure Endoluminal Stenting • Endoleaks persistent • 4 Types • Graft Thrombosis • Graft Migration • Graft Dysfunction • Graft Rupture

  17. Endoluminal Stenting • Long Term Durability ? • Outcome ?

  18. Decrease threshold for Endoluminal Stenting? • High risk patients • Low risk patients • Long term durability? • Advisable for young patient with small AAA?

  19. Current Recommendation • Minimally Invasive Procedure Vs open • Clear advantage • Suitable anatomy • Higher immediate cost • Lower perioperative morbidity • Lower perioperative mortality William DJ, Jordan MD, Francisco MD et al. Abdominal Aortic Aneurysm in High Risk Surgical Patients, comparison of Open and Endovascular Repair. Annals of Surgery Vol. 237, No 5, 623-630, 2003

  20. Current Recommandation • Elderly high risk patient advantage • Patient preferences • Full consent • Indications • Endo Vs Open : same • Lack of long term outcomes data • Await for ongoing clinical trials results • Goldstone J, Brewster DC, Chaikof EL, et al. Endoluminal repair versus standard open repair of AAA: early results of a prospective clinical comparison trial. Proceedings of the 46th Scientific Meeting of The International Society for Cardiovascular Surgery; 1998 Jun 7-8; San Diego, Calif. • Zarins CK, White RA, Schwarten DE, et al. Medtronic AneuRx Stent Graft System versus open surgical repair of AAA: Multicenter clinical trial. Proceeding of the 46th Scientific Meeting of the International Society for Cardiovascular Surgery; 1998 Jun 7-8; San Diego, Calif.

  21. AAA Management • Multidisciplinary approach • Cardiologist • Surgeon • Anaesthesiologist • Intensivist • Advancement in surgical approach • Open • Endovascular • Basic Pathophysiology Investigation

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