Trattamento degli aneurismi aortici con endoprotesi e qualit

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Trattamento degli aneurismi aortici con
endoprotesi e qualità della vita

• Sergio Berti
• Istituto di Fisiologia Clinica del CNR
• Ospedale G. Pasquinucci, Massa

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Aortic Aneurysm
The natural history of aneurysms is to enlarge
and rupture
The primary objective of aneurysm repair is to
prevent rupture, while minimizing treatment
related risks and preserving functional outcome
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TAA - AAA natural history rupture risk
Group Rupture risk / year ()
Diameter 5 cm 4,1
Diameter 5-7 cm 6,6
Diameter gt 7 cm 19,0
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TAA-AAA indication to endovascular treatment
Max diameter
Fusiform
TAA gt 5,0 cm ( 5,5)
Saccular Penetrating ulcer
TAA lt 5,0 cm
TAA 5,0 cm
Expansion rate gt 1 cm/year
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New therapeutic concept
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EVAR vs Open surgery
AAA
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Preoperative evaluationImaging Techniques
CT
MR
TEE
ANGIOGRAPHY
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Preoperative management
Aneurysm morphology
Endograft selection
Procedure strategy
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Rupture of Thoracic Aneurysm

• Surgical mortality 50 - 67

Johansson G. J. Thorac Card. Surg. 1995 21958

• EVAR mortality 3.8 - 38

Doss M. Ann. Thorac Surg 2003 761465
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Rupture of Thoracic Aneurysm
Surg. EVAR
Mortality 17,8 3,8
Paraplegia 1,9 0
Doss. M. Ann. Thorac Surg 2003 761465
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Penetrating ulcer
3 of acute aortic syndromes
EVOLUTION
rupture 40
INTRAMURAL HEMATOMA
FALSE ANEURYSM
WALL RUPTURE
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Penetrating ulcer

• Surgical mortality 16-18
• EVAR mortality 6-7

Dake MD J. Thorac Cardiovasc 1998
116689 Ehrlich M. Ann. Thorac Surg 1998 6619
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RM Aortic rupture
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Aortic rupture
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Aortic rupture
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Combined approach (Hybrid)

• Endovascular aortic arch Reconstruction combined
  with supra-aortic vessel transposition

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Penetrating ulcer
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PRE
POST
Talent StentGraft
Penetrating Ulcer
Carotid-Carotid By-Pass
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TAA early postoperative outcomes
J Thorac Cardiovasc Surg 2007 133369-377
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Abdominal Aneurysm Endograft
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AAA indication for endovascular treatment
Type I
Type II
Type III
A
B
C
51,7
Schumacher, J. Endovasc Surg 1997
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Branched Endograft
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Preoperative evaluation and management
Aortic neck diameter
Aortic neck lenth
Aneurysm diameter
Iliac arteries diameter
Aortic neck angle
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Preoperative evaluation
J. Endovasc Surg 1997 4 107
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EVAR Trial 1 Operative mortality
Intention to treat analyses using logistic
regression
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EVAR Trial 1 Aneurysm-related mortality
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Early Primary Procedure Major Morbidity
RateStanford Patients
Arko et al. J Endovasc Ther 20029711-718
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Aneurysm Related DeathPrimary Treatment at
Stanford
417 pts
Arko et al. JVS
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Cumulative Hospital Utilization
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Early Functional OutcomePatient Questionnaire
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Late Functional Outcome
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Clinical Utility Recovery
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SF-36 Quality of LifeQuestionnaire
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MEN Choose Endograft Repair Because

• An Endograft Repair will almost always preserve
  A Mans function

Impotence 10-40 with open AAA Surgery
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Follow-up goals
To assess
Endograft
Aneurysmatic sack
Anchoring zone
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AAA Follow up Timing
Echo color Doppler
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12
18
30
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1
1
12
24
36
48
TC / MR scan
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TAA Follow up Timing
1
12

6
24
36
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TC / MR scan
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Wire-less pressure sensor
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The CardioMEMS EndoSensor
Implantable Sensor
14 Fr Delivery System
Measurement System
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Post operative Follow UPdo it yourself
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Conclusion
Higher risk of Aneurysm related death with open
surgery
Significant increase in late Morbility with open
surgery
Early functional outcomes better with
endovascular repair
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Conclusion

• EVAR represents a viable alternative with a low
  risk if compared to open surgery

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Open questions
New device technology
Long term Follow up
New follow up technology
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Trattamento degli aneurismi aortici con
endoprotesi e qualità della vita

• Sergio Berti
• Istituto di Fisiologia Clinica del CNR
• Ospedale G. Pasquinucci, Massa

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Descending aortic rupture / perforation(69 pts)
Stent graft emergency repair

• Mortality (34 months F.U.) 12,5
• Paraplegia (34 months F.U.) 4

Melnitchouk S. Eur. J. Cardiothorac Surg. 2004
25 1032
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Primary Procedure MortalityStanford patients
(500 pts)

• Open surgery 9/24 33.7
• Endovascular 1/17 40.6

p lt 0.05
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EVAR Trial 1 Time to first re-intervention
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Survival curves for the endograft group vs the
open surgical control

• J Thorac Cardiovasc Surg 2007 133369-377

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