Management of Abdominal Aortic Anuerysms:

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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. Lukes-Roosevelt
Hospital Assistant Professor of Surgery Columbia
University, New York, NY
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Epidemiology

• Age
• 5-7 of population 60yrs age
• US reported incidence of 5-7
• Mean age 70-75yrs
• Sex
• MF 1.6-4.51
• Race
• White M gt 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

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Pathophysiology Risk Factors

• Atherosclerosis
• Elastin
• Wall Structure
• Genetics
• Smoking
• Brady AR, Thompson SG, Greenhalgh RM, et al. Br
  J Surg 90492, 2003.
• 90 had smoking history
• Others HTN, infection, trauma, arteritis, cystic
  medial necrosis, Marfan Syndrome, Ehlers-Danlos
  Syndrome

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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 3461437, 2002.
• Ruptured AAA
• Triad (50)
• Sudden onset abdominal pain
• Pulsatile mass
• Hypotension

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Imaging

• Incidental, ultrasound, CT angiogram and angiogram

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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 gt 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

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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

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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

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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
• gt70,000 men screened between ages of 65-74
• Aneurysms gt5.5 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

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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 20022872968.

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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

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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 371106, 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 (lt5 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 (gt1 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.  

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• 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.

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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

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Anatomic Requirements for EVAR

• Anatomic Criteria
• Length, angulation, and diameter of infrarenal
  neck
• gt 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

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Standard Open Repair
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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

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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)

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Endovascular Aneurysm Repair (EVAR)
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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

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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
  19985189193.

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Open vs. EVAR
Study Patients Follow up (yrs) 30d Mortality Total Death
Mayo Clinic AAA (Open) 307 36 5 7.6
Canadian AAA (Open) 680 6 5.4 5.8
AneuRx IIII (EVAR) 1192 4 1.9 2.4
EUROSTAR (EVAR) 2955 4 1.7 2.5
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St Lukes- Roosevelt Last
Evaluated 124 case Endoleak and rate
and aneurysm follow up data
Time 0 1 mo. 6 mo. 1 year 2 years 3 years
Persistent endoleak rate 21 5.9 7.5 10.1 8.5 8.5
New endoleak rate - 5.9 4.3 2.5 2.8 2.8
Total endoleak rate 21 11.8 11.8 12.6 11.4 11.4
Migration rate - 4 1.0 1.2 1.4 0
Aortic size 5.4 cm 5.3 cm 5.1 cm 4.8 cm 4.5 cm 4.0 cm
Reintervention rates - .83 2.0 0 2.8 0
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Trials

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

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DREAM (Dutch Randomized Endovascular Aneurysm
Management)

• Prinssen M, Verhoeven EL, Buth J, et al. N Engl J
  Med 200435116071618.
• Open vs. EVAR
• Radomized controlled trial of 345 patients with
  AAA gt5cm
• EVAR operative mortality 1.2
• Open repair operative mortality 4.6
• Blankensteijn JD, de Jong SE, Prinssen M, et al.
  N Engl J Med 200535223982405.
• 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)

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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)

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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

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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

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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?

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Questions?