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Aortic aneurysm management. Dr Frijo Jose A. TA Aneurysm. Essentials of Diagnosis Asc Ao diameter > 4 cm on imaging study Desc Ao diameter > 3.5 cm on imaging study. Asc Ao aneurysms – 3 common patterns. Crawford classification - aneurysm in desc Ao and thoracoabdominal Ao.

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ta aneurysm
TA Aneurysm
  • Essentials of Diagnosis
    • AscAodiameter > 4 cm on imaging study
    • DescAodiameter > 3.5 cm on imaging study
slide7
Types of aneurysms, classified according to the EUROSTAR study (classification according to Schumacher).
slide8

Marfandisease-fibrillin

  • 21% of aneurysm probands have a first-degree relative with known/likely Ao aneurysm
  • TAAD1 (Thoracic Aortic Aneurysm and Dissection 1) locus
slide12

In Vivo

Mechanical

Properties

Of Human

Ascending

Aorta

depiction of hingepoints for lifetime natural history complications at various sizes of the aorta
Depiction of “HingePoints” for Lifetime Natural History Complications at Various Sizes of the Aorta
slide16

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
size criteria for surgical intervention for asymptomatic thoracic aortic aneurysm
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
how fast does the thoracic aorta grow
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
symptoms and signs
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
slide27

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
slide28

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
slide30

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
endovascular repair of aaa
Endovascular Repair Of AAA
  • older
  • substantial comorbidities (renal, respiratory, & cardiac dysfunction)
  • Females & those with a smallerbodyhabitus -↑ EVAR abortion rate – smaller access arteries
anatomic requirements for endovascular repair of taa
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
evar complications
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
treatment of endoleaks
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
eurostar
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

evar trial 1
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

evar trial 2
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

slide50
Data From the EVAR-2 Trial Showing No Benefitof Stent Therapy of Abdominal Aneurysm OverMedical Therapy
dream
DREAM
  • Comparing conventional and endovascular repair of AAA
  • 345 patients-30 d
  • Combined- op mortality + severe compli- 9.8% (open) v/s 4.7% (EVAR)- risk ratio- 2.1
  • EVAR preferable to open AAA at least 5 cm

Two-year outcomes

  • Cum survival rates- 89.6% open v/s 89.7% EVAR
  • The perioperative survival adv with EVAR- not sustained aft 1st post-op year

N Engl J Med. 2004 Oct 14;351(16):1677-9

N Engl J Med. 2005 Jun 9;352(23):2398-405

caesar
CAESAR
  • Comparison of Surveillance Versus EVAR for Small Aneurysm Repair
  • AAA 4.1-5.4 cm - immEVAR v/s surveillance by USG &CT →repair aft defined threshold (D≥5.5 cm, enlargement >1 cm/y, sympts)
  • 360 pts (early EVAR = 182; surv = 178)
  • At 54/12- no significant difference
  • Mortality & rupture rates in AAA <5.5 cm are low and no clear adv shown betw early or delayed EVAR strategy
  • <36/12- 3/5 small aneuunder surveillance might grow to require repair

Eur J VascEndovasc Surg. 2010 Sep 23

slide53

The PIVOTAL study: a randomized comparison of endovascular repair versus surveillance in patients with smaller abdominal aortic aneurysms

  • The ACE trial: a randomized comparison of open versus endovascular repair in good risk patients with abdominal aortic aneurysm
slide56

Paraplegia

or

Pareparesis

for

TEVAR

v/s

Open Surgery

slide57
AAA

Class I

1. Pts with infrarenal/juxtarenalAAAs ≥5.5 cm should undergo repair to eliminate risk of rupture. ( B)

2. Pts with infrarenal/juxtarenalAAAs 4.0-5.4 cm should be monitored by USG/CT every 6 -12/12 to detect expansion. ( A)

Class IIa

1. Repair can be beneficial in infrarenal/juxtarenalAAAs 5.0-5.4 cm. (B)

2. Repair is probably indicated in pts with suprarenal/type IV thoracoabdominalAA 5.5 to 6.0 cm. (B)

3. In pts with AAAs <4.0 cm, monitoring by USG every 2-3 yrs is reasonable. (B)

ACC/AHA 2005 Practice Guidelines

slide58

Class I

1. In pts with the clinical triad of abd and/or back pain, a pulsatile abdominal mass, and hypotension, immsurgical evaluation is indicated. (B)

2. In pts with symptomatic AA, repair is indicated regardless of diameter. (C)

ACC/AHA 2005 Practice Guidelines

th aa
Th AA

Class I

1. Asymptdegenerative thoracic aneu , who are otherwise suitable candidates and for whom the asc aorta or aortic sinus diameter is ≥5.5 cm should be evaluated for surgical repair. (C)

2. Marfansyndrome or other genetically mediated disorders (vascular EDS,Turner , BAV, or familial thoracic AA) should undergo elective Sxat smaller diameters (4.0 to 5.0cm) (C)

3. Pts with a growth rate >0.5 cm/y in an aorta <5.5 cm should be considered for Sx. (C)

4. Pts undergoing AV repair/replacement and who have an ascaorta or aortic root >4.5 cm should be considered for concomitant repair of Aoroot or replacement of ascAo. (C)

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines

desc th ao and thoracoabd aa
DescThAoand Thoracoabd AA

Class I

1. DescthoAo >5.5cm, saccular aneurysms, or postoperative pseudoaneurysms, endovascular stent grafting should be strongly considered when feasible.(B)

2. Thoracoabd A, in whom EVAR options are limited and surgical morbidity is elevated, elective sx recommended if the Ao >6.0 cm, or less if Marfan(C)

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines

evaluation of family members
Evaluation of Family Members
  • A CT scan recommended for adult males & females beyond childbearing age
  • For children & females of childbearing age, echo of the ascAo & abdAorecommended