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Management of Abdominal Aortic Anuerysms : Endovascular vs Open Approaches 2009 a Review

Management of Abdominal Aortic Anuerysms : Endovascular vs Open Approaches 2009 a Review. John C. Lantis II, MD, FACS Chief of Vascular and Endovascular Surgery St. Luke’s-Roosevelt Hospital Assistant Professor of Surgery Columbia University, New York, NY. Epidemiology. Age:

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Management of Abdominal Aortic Anuerysms : Endovascular vs Open Approaches 2009 a Review

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  1. Management of Abdominal Aortic Anuerysms: Endovascular vs Open Approaches 2009 a Review John C. Lantis II, MD, FACS Chief of Vascular and Endovascular Surgery St. Luke’s-Roosevelt Hospital Assistant Professor of Surgery Columbia University, New York, NY

  2. Epidemiology • Age: • 5-7% of population 60+yrs age • US: reported incidence of 5-7% • Mean age 70-75yrs • Sex: • M:F = 1.6-4.5:1 • Race: • White M > Blacks M • White F = Black F • Mortality/Morbidity: • Grows ~0.4 cm/year • 75% mortality (upon rupture) • 13th leading cause of death in the US (~15,000 deaths per year) • Overall mortality 0.9%-5% after repair • Rupture is based on size

  3. Pathophysiology & Risk Factors • Atherosclerosis • Elastin • Wall Structure • Genetics • Smoking • Brady AR, Thompson SG, Greenhalgh RM, et al. Br J Surg 90:492, 2003. • 90% had smoking history • Others: HTN, infection, trauma, arteritis, cystic medial necrosis, Marfan Syndrome, Ehlers-Danlos Syndrome

  4. Symptoms and Signs • Asymptomatic • Inflammatory AAA may cause back pain • Pulsatile abdominal mass • Mid-abdomen just above and left of the umbilicus • Lederle FA, Wilson SE, Johnson GR, et al. N Engl J Med 346:1437, 2002. • Ruptured AAA • Triad (50%): • Sudden onset abdominal pain • Pulsatile mass • Hypotension

  5. Imaging Incidental, ultrasound, CT angiogram and angiogram

  6. Diagnosis • Physical exam • Firm, pulsatile abdominal mass • Overall sensitivity of 52% • Sensitivity increases with diameter • 29% for 3.0 to 3.9cm • 50% for 4.0-4.9 cm • 76% for > 5.0 cm • Extension into iliac arteries is not appreciated • X-ray • About 70% of cases • Characteristic eggshell pattern of calcification • Accurate determination of size difficult • Negative AXR does NOT rule out diagnosis • Ultrasound • Most widely used noninvasive test • Provides structural detail of vessel wall • Can accurately measure the size in longitudinal and cross sectional directions • Advantages • Noninvasive, low cost, wide availability • Good for initial evaluation or pts, screening and surveillance

  7. Diagnosis • CT • Most precise test for imaging AAA • Can identify • Proximal and distal extent of aneurysm, including thoracic portion • Occlusive aneurysmal disease • Presence of multiple and accessory renal arteries • Seize of aortic lumen, amount of thrombus, and presence of calcific disease • MRI • Imaging of choice for patients with renal insufficiency • High quality images of aorta • However, less sensitive in identifying accessory renal arteries or renal artery stenosis • Arteriography • Reliable information on size of aortic lumen and branch vessel disease • However, due to thrombus, aortic lumen is near normal in size so inaccurate assessment of size or aneurysm • Helpful for assessment of associated arterial disease in pre-op eval

  8. Screening • SVMB/SVS/AAVS (2004) • Kent KC, Zwolak RM et al: Screening for abdominal aortic aneurysm: a consensus statement. J Vasc Surg 39(1):267, 2004 • Men: Recommends for screening in all men age 60-85 years • Women: Recommends for screening in women age 60-85 years with a family history of AAA • USPSTF (2005) • Men: Recommends for screening in men age 65-75 years who have ever smoked. Recommends against screening in men age 65-75 years who have never smoked • Women: Recommends against screening in all women • ACC/AHA (2006) • Men: Recommends for screening in men age 65 years or older who have ever smoked. Recommends for screening in men age 60 or older with a family history of AAA • Women: None

  9. Screening for Aneurysms • 4 randomized trials of AAA screening have been performed • Reduction in AAA related mortality ranging from 21-68% • Reduction in AAA rupture ranging from 45-49% • Multicentre Aneurysm Screening Study • >70,000 men screened between ages of 65-74 • Aneurysms >5.5 cm referred for repair • After 4 years there was 42% reduction in AAA related deaths in the screened group • Society for Vascular Surgery screening recommendations • Baseline ultrasound screening for AAA in • Men 60-85 • Women 60-85 with cardiovascular risk factors • Men and women older than 50 with a family history of AAA • Yearly ultrasound for AAA 4.0-4.5cm • Ultrasound every 6 months for AAA larger than 4.5cm

  10. AAA Expansion and Rupture • Average growth rate: ~0.4cm per year • Factors: BP, size at detection, COPD • Size is the best determinant of rupture • 40% of untreated aneurysms 5.5-6cm or larger will rupture within 5 years • Average survival without treatment: 17 months • Lederle FA et al. JAMA 2002;287:2968.

  11. Rupture Repair – EVAR is superior • 30 day mortality • EVAR 19%, Open 47% • LOS • EVAR 6, Open 18.5 • D/C to home • EVAR 55%, open 20% • Major complication • EVAR 36%, Open 80% • OR time • EVAR 3 hours, Open 4.5 hours • Blood loss • EVAR 200 cc, Open 4 liters

  12. Treatment Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery (Brewster DC, Cronenwett JL, Hallett JW, et al. Vasc Surg 37:1106, 2003) 1.   The arbitrary setting of a single threshold diameter for elective AAA repair that is applicable to all patients is not appropriate, as the decision for repair must be individualized in each case.   2.   Randomized trials have shown that the risk of rupture of small (<5 cm) AAAs is quite low and that a policy of careful surveillance up to a diameter of 5.5 cm is safe, unless rapid expansion (>1 cm/y) or symptoms develop. However, early surgery is comparable to surveillance with later surgery, so patient preference is important, especially for AAAs 4.5 to 5.5 cm in diameter.   3.   Based upon the best available current evidence, a diameter of 5.5 cm appears to be an appropriate threshold for repair in an "average" patient. However, subsets of younger, low-risk patients with long projected life expectancy may prefer early repair. If the surgeon's personal documented operative mortality rate is low, repair may be indicated at smaller sizes (4.5 to 5.5 cm) if that is the patient's preference.  

  13. 4.   For women, or AAAs with greater-than-average rupture risk, 4.5 to 5.0 cm is an appropriate threshold for elective repair.   5.   For high-risk patients, delay in repair until larger diameter is warranted, especially if endovascular aortic repair (EVAR) is not possible. 6.   In view of its uncertain long-term durability and effectiveness, as well as the increased surveillance burden, EVAR is most appropriate for patients at increased risk for conventional open aneurysm repair.   7.   EVAR may be the preferred treatment method if anatomy is appropriate for older, high-risk patients, those with "hostile" abdomens, or other clinical circumstances likely to increase the risk of conventional open repair.   8.   Use of EVAR in patients with unsuitable anatomy markedly increases the risk of adverse outcomes, the need for conversion to open repair, or AAA rupture.  9.   At present, there does not appear to be any justification that EVAR should change the accepted size thresholds for intervention in most patients.   10.  In choosing between open repair and EVAR, patient preference is of great importance. It is essential that the patients be well informed to make such choices.

  14. Surgery • Open repair with synthetic graft • 35% of current cases • Primarily for poor anatomy • Ocassionally young age • Endovascular aneurysm repair (EVAR) • 65% of current cases

  15. AnatomicRequirements for EVAR • Anatomic Criteria • Length, angulation, and diameter of infrarenal neck • > 60° neck angulation – 70% complication rate • Minimum adequate length is 8 mm • Desireable length is 1.5 cm • Iliac artery diameter • Large enough to accommodate device (7 mm) • Small enough to allow device to seal (1.5 cm) • Concurrent common or internal iliac artery aneurysm • Can be difficult to manage • Absence of thrombus at aortic neck • Thrombus does not allow for a good neck seal

  16. Standard Open Repair

  17. Complications of Open Repair • Mortality rate less than 5% in good risk pts • Most frequent cause of death is ischemic myocardial injury • Complications following elective open repair occur in 10-30% of cases • Most frequent complication is nonfatal MI (avg. 6.9%) usually within first 48 hours post-op • Renal failure (6%) • Pneumonia (5%) • Bleeding • Ileus • Ischemia of left colon and rectum • Lower extremity ischemia from embolization of thrombus or atherosclerotic plaque • Ischemic injury to lumbosacral plexus or to the spinal cord • Post-op sexual dysfunction from injury to autonomic nerves during dissection (up to 25% of patients) • DVT in as many as 18% of patients

  18. Complications of Open Repair • Late complications after successful repair are rare • Only occurs in about 7% of patients, but Late complications more common in repair of rupture (17%) • Complications include: • Anastomic pseudoaneurysm (3%) • Graft thrombosis (2%) • Graft-enteric erosion or fistula (1.6%) • Graft infection (1.3%) • Anastomotic hemorrhage (1.3%) • Colonic ischemia (0.7%) • Atheroembolism (0.3%)

  19. Endovascular Aneurysm Repair (EVAR)

  20. Potential Drawbacks of EVAR • Need for frequent CT scans/follow up • 1 month, 3 months, 6 months, one year and every year thereafter • 90 % efficacious at 6 year mark • Need for conversion • Late rupture rate • Up to 25% of patients need reintervention within the first year

  21. Complication of EVAR: Endoleaks • Type I: Lack of complete seal between stent graft and vessel wall at attachment sites • Type II: Back filling of the aneurysm sac via such branch vessels as the lumbar of inferior mesenteric arteries • Type III: Leaks at connections of modular components, device disruption, fabric tears • Type IV: Extravasation of contrast material through interstices in the grafted artery • White GH, May J, Waugh RC, et al. J Endovasc Surg 1998;5:189–193.

  22. Open vs. EVAR

  23. St Luke’s- Roosevelt Last Evaluated 124 case – Endoleak and rate and aneurysm follow up data

  24. Trials • EVAR (Greenlagh, R) • DREAM (Blankensteijn, J) • ACE (Becquemin, J) • OVER (Lederle, F)

  25. DREAM (Dutch Randomized Endovascular Aneurysm Management) • Prinssen M, Verhoeven EL, Buth J, et al. N Engl J Med 2004;351:1607–1618. • Open vs. EVAR • Radomized controlled trial of 345 patients with AAA >5cm • EVAR operative mortality 1.2% • Open repair operative mortality 4.6% • Blankensteijn JD, de Jong SE, Prinssen M, et al. N Engl J Med 2005;352:2398–2405. • Evaluation of perioperative period • Cumulative survival rate were similar (89.6% vs. 89.7%) • EVAR had lower aneurysm-related death (2.1% vs. 5.7%)

  26. Dutch Randomized Endovascular Management Trial (DREAM) • 30 day mortality was better in EVAR group (1.2% vs.. 4.6%) • EVAR group showed less operative mortality and post-op complications (4.7% vs.. 9.8%) • No overall survival difference at 2 years • Aneurysm related death less in EVAR group (2.1% vs.. 5.7%)

  27. Endovascular Aneurysm Repair Trial -1 (EVAR-1) • Short term survival benefit of EVAR • 30 day mortality rate 1.7% vs.. 4.7% • At 4 years, no difference in mortality • Aneurysm related death less in EVAR group (4% vs.. 7%) • Greater post-op complications over 4 year follow-up in the EVAR group (41% vs. 9%) • No difference in quality of life • Hospital costs higher in EVAR group

  28. EVAR-2 Trial • Looked at effectiveness of EVAR in high risk patients • Compared EVAR to observation • No benefit of EVAR over observation • 30 day mortality rate after EVAR was 9% • 4 year mortality rate in EVAR group 64% • No difference in late overall mortality • No difference in aneurysm related mortality • Higher hospital costs in EVAR group • No health-related quality of life benefit to EVAR

  29. Where are we going next? • Suprarenal fixation • Including renal stent grafts • Branched grafts • Including visceral artery stent graft • More skills? • Less access? • More cost? • More morbidity?

  30. Questions?

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