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Aortic aneurysm management

Aortic aneurysm management

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Aortic aneurysm management

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  1. Aortic aneurysmmanagement Dr Frijo Jose A

  2. TA Aneurysm • Essentials of Diagnosis • AscAodiameter > 4 cm on imaging study • DescAodiameter > 3.5 cm on imaging study

  3. AscAoaneurysms – 3 common patterns

  4. Crawford classification - aneurysm in descAoand thoracoabdominalAo

  5. Types of aneurysms, classified according to the EUROSTAR study (classification according to Schumacher).

  6. Marfandisease-fibrillin • 21% of aneurysm probands have a first-degree relative with known/likely Ao aneurysm • TAAD1 (Thoracic Aortic Aneurysm and Dissection 1) locus

  7. AoManifestation of Connective Tissue Disease

  8. In Vivo Mechanical Properties Of Human Ascending Aorta

  9. Depiction of “HingePoints” for Lifetime Natural History Complications at Various Sizes of the Aorta

  10. Survival With Thoracic Aneurysms of Various Sizes

  11. Yearly Rates of Rupture, Dissection, or Death Related to Aortic Size

  12. Diameter 6 cm- very dangerous size threshold • At/above this • yearly risk for rupture ≈4% • yearly risk of dissection ≈ 4% • Yearly risk of death ≈ 11% • Chance of any one of these phenomena occurring— 14%/year

  13. Size Criteria for Surgical Intervention for Asymptomatic Thoracic Aortic Aneurysm • For pts with a positive family hx, but without Marfan disease, the same criteria is applied as for Marfandisease • BAV also have inherently deficient Ao- lower intervention dimensions are used • Size criteria apply only to asymptomatic aneurysms. • Symptomatic aneurysms should be resected regardless of size • If aneurysm increases in size by 1cm per year

  14. How Fast Does the Thoracic Aorta Grow? • Annual growth rate of an aneurysmal thoracic Ao- 0.12 cm on average • DescAogrows faster than ascao, at 0.19 cm/year compared with 0.07 cm/year • The larger the aorta becomes, the faster it grows

  15. Symptoms and Signs • Most asymptomatic - detected fortuitously • When symptomatic • deep visceral pain • not usually pptedby exertion nor relieved by rest/NTG • often constant-not influby body motion/position • Rupture of thoracic aneu - excruciating pain, profound dyspneaand quickly shock • A large ascAoaneu – occdysphagia/stridor/bone pain

  16. “SilverLining” in Ascending AneurysmDisease: Protection From Arteriosclerosis

  17. New pts, for whom only one size data point is available- imaging at short intervals until the behavior of aorta is understood (3-6/12) • Compare present scan with the pt's first scan, not with the last prior scan • Stable, asymptomatic pts- imaging every 2 yrs (aneuAogrows at ≈1 mm/yr) • New onset of sympts- imaging should be done promptly, regardless of the interval

  18. Once the aorta has dissected- prognosis is thereafter adversely affected • Pts who required emergency sx- higher rate of early mortality & survival curve poor • Even after sx replacement of portions of Ao, the remainder will forever remain dissected • Ao wall was deficient to start with, after dissection- more vulnerable to enlargement & rupture • Elective sx- survival rate very similar to N population

  19. Aneu evaluated using a 3-dimensional reconstruction from CTA/MRA or aortography with a calibrated catheter • Access arteries are measured- FA –retroperitoneal access to iliacs or aorta entertained • Iliac A assessed for tortuosity & calcification

  20. Endovascular Repair Of AAA • older • substantial comorbidities (renal, respiratory, & cardiac dysfunction) • Females & those with a smallerbodyhabitus -↑ EVAR abortion rate – smaller access arteries

  21. Anatomic requirements for endovascular repair of TAA • A proximal neck at least 15 to 25mm from the origin of the left subclavian artery • A distal neck at least 15 to 25mm proximal to the origin of the celiac artery • Adequate vascular access—absence of severe tortuosity,calcification,or atherosclerotic plaque burden involving the aortic or pelvic vasculature • The transverse diameter of the proximal and distal neck should be within the range that available devices can appropriately accommodate

  22. Endovascular repair of thoracic aneurysms

  23. Multilayered stents

  24. EVAR Complications • Access-related • Hematoma • Lymphocele • Infection • Embolization • Ischemic limb • Deployment-related • Failed deployment • Arterial rupture • Dissection • Device-related • Structural failure • Implant-related • Endoleaks • Limb occlusion • Stent graft kink • Sac enlargement • Proximal neck dilatation • Stent migration • AAA rupture • Infection • Buttock/leg claudication • Systemic • Cardiac • Pulmonary • Renal insufficiency • Cerebrovascular • Deep vein thrombosis • Pulmonary embolism • Coagulopathy • Bowel ischemia • Spinal cord ischemia • Erectile dysfunction

  25. Treatment of Endoleaks • Methods employed- coil embolization, placement of stent-graft cuffs and extensions, laparoscopic ligation of inferior mesenteric and lumbar arteries, open surgical repair, and EVAR redo procedures • Type I and III - urgent intervention- blood flow & sac pressure will continue to ↑→ rupture • Type IV - resolve on their own • Type II – controversial • Some of them will thrombose on their own while others will lead to sac enlargement • Challenge - when to intervene • One approach - monitor with a 6/12 post-procedure CT scan- If aneu has increased- plan intervention • 3 approaches : transarterial, translumbarembolization, laparoscopic ligation

  26. EUROSTAR • Secondary interventions following endovascular AAA repair using endografts • 2846 pts- In 8.7% 2⁰procedure at some time • Annual rate of 2⁰ intv- 4.6% • proximal type I endoleak evident on completion angio- predictive of later 2⁰ intv • Mortality rate 2⁰ intv -15% >peri-op mortality aft elect open repair • Aneurysm expansion -17%pts 2⁰ intv • Continuing need for surveillance for device-related compli- necessary J vascSurg 2006;43:896-902

  27. EVAR trial 1 • Comparison of endovascular aneu repair with open repair in AAA • 1082 elect- EVAR(n=543) /open repair(n=539) • 30-d mortality- EVAR (1·7%-9/531) v/s (4·7%-24/516) in open gp • 2⁰ intv more in EVAR (9·8% vs 5·8%, p=0·02) • In large AAAs, EVAR reduced 30-d operative mortality by two-thirds compared with open repair • Long term- EVAR 1 - 3% lower initial mortality for EVAR, with a persistent ↓ in aneu-related death at 4 ys- Improvement in overall late survival was not demonstrated Lancet 2004; 364: 843–48

  28. EVAR trial 2 • Endovascaneu repair and outcome in pts unfit for open repair of AAA • 338 pts- EVAR (n=166) /no intrv (n=172) • 30-day op mortality in EVAR- 9% (13/150) • No intrv rupture rate- 9·0/100 person years • overall mortality aft 4 yrs- 64% • No signi diff betw EVAR v/s no intrv for all-cause mortality (hazard ratio 1·21, p=0·25) • No diff in aneu-related mortality • EVAR did not improve survival over no intrv, asso with a need for continued surveillance & reintrv, at substantially ↑ cost Lancet 2005; 365: 2187–92

  29. Data From the EVAR-2 Trial Showing No Benefitof Stent Therapy of Abdominal Aneurysm OverMedical Therapy