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SIR 2009. Less Invasive Interventional treatment can be recommended as 1 st line treatment for “Silent Killer”, AAA. Guy’s & St. Thomas’ Hospital, London, UK TARUN SABHARWAL MD FSIR FCIRSE

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SIR 2009

Less Invasive Interventional treatment can be recommended as 1st line treatment for “Silent Killer”, AAA

Guy’s & St. Thomas’ Hospital, London, UK

TARUN SABHARWAL

MD FSIR FCIRSE

K Konstantinos, S.Black, S.Thomas, R.Salter, J.Reidy, C.Sandhu, R.Bell, M.Waltham, T.Carrel, P.Taylor

abdominal aortic aneurysm
Abdominal Aortic Aneurysm
  • Weakened area in the aorta
  • Natural history of AAA is of slow expansion and rupture with catastrophic consequence
role of ir in aaa
Role of IR in AAA
  • The goal is to prevent aneurysms from rupturing
aaa silent killer
AAA Silent Killer
  • AAA occurs in 5-7% population older than 60yrs
  • Affects 2.7m Americans and is the 13th death
  • Risk factors : age, smoking, male sex and family history
  • Asymptomatic in majority
  • Back pain, abdominal pain
rupture
Rupture
  • Manifest with unheralded rupture and death
  • Prognosis after rupture is grim with community based mortality as high as 79%
  • 59-83% AAA die before reaching hospital
  • Operative mortality rates are 40%
  • Leaving at best 10-25% discharge
evar compared with open repair
EVAR compared with Open Repair
  • Mortality rate for elective surgical repair of nonruptured AAAs is 5%
  • EVAR is associated with periprocedural mortality benefit compared with open repair (relative risk reduction 3.1)
  • ↓ periprocedural complications
  • Benefit of reduced aneurysm related mortality at 4yrs (4% vrs 7%)

DREAM and EVAR 1 trials

benefits of evar over open repair in raaa
Benefits of EVAR over Open repair in rAAA
  • Local anesthesia
  • Maintenance of abdominal wall and muscle tone
  • Decreased aortic occlusion time
  • Diminished blood loss
  • Better thermoregulation
common perceptions of evar
Common perceptions of EVAR
  • High late complication rate
  • High rate of secondary interventions
  • Long term surveillance required: more expensive and risk of radiation cancers
secondary intervention rates
Secondary Intervention rates

Endoluminal repair

  • RETA (Thomas EJVES 2005 n=1823) 38% at 5 y
  • EUROSTAR (Laheij BJS 2000 n=1023) 38% at 4y
  • EVAR 1 (Lancet 2005 n=543 EVAR) 20% at 4 y
  • EVAR 2 (Lancet 2005 n=166 EVAR) 26% at 4 y
  • Greenberg (JVS 2008 n=739) 20% at 5 y
  • Sampram (JVS 2002 n=703) 35% at 3 y

EVAR 1 Open repair cohort: 6% at 4 y

aim of our study
Aim of our Study
  • Analyze the treatment of patients with AAA with EVAR
  • Assess rate of secondary interventions
  • Assess need for intense CT surveillance
method
Method
  • Prospective database
  • 453 patients
  • 2000 – 2008
  • Male/female = 11/1
  • Follow up 30 months (2-90)
  • Age 76 (40 – 93)
  • Aneurysm diameter 6.1 (5.3 – 11)
  • Elective 406 (89.8%)
  • Urgent 17 (3.6%)
  • Emergency 30 (6.6%)
results
Results
  • 30-day mortality: 15/453 (3.3%)
  • Technical Success: 451/453 (99.6%)
  • Open conversion: 1 urgent : 1 emergent
  • Secondary Interventions: 33/453 (7.2%)

of which 6/453 (1.3%) from surveillance

conclusion
Conclusion
  • Low secondary intervention rate for EVAR
  • Secondary interventions are effective
  • Surveillance with intensive CT scanning identifies few complications
  • Questionable benefit of intensive CT surveillance protocols
  • Suggested current protocol: 3/12 CT and yearly duplex thereafter
conclusions
Conclusions
  •  durability and effectiveness of EVAR
  • EVAR ↓ risks of surgery, amount of pain, large incisions, hospital stay and much shorter recovery time