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Abdominal Aortic Aneurysms

Aurelia Thibonnier-Calero PGY-2 Vascular Surgery

Types of Aneurysms

True vs. False (pseudoaneurysm)

True: involves all 3 layers of the arterial wall False: presence of blood flow outside of normal layers of arterial wall. Wall of false aneurysm is compose of the compressed, surrounding tissues.

Types of Aneurysms

Etiology

Degenerative- complex process that involves some degree of calcification, atherosclerotic pathology as well as degeneration by MMPs. Inflammatory- thick inflammatory wall with fibrotic process in retroperitoneum that can encase aorta as well as surrounding structures. Associated with other inflammatory conditions : Takayasus, Giant cell arteritis, Polyarteritis nodosa, Behcets, Cogans. Post-dissection- up to 20% of aneurysms are related to previous dissection. Overtime, develops into true aneurysm Traumatic- false aneurysms Developmental Anomalies- persistent sciatic arteries, aberrant right subclavian artery. Infectious- Can be primary or secondary infections. Congenital- Tuberous sclerosis, aortic coarctation, Marfans.

Crawford Aneurysm Type

Assessing the AAA patient


Normal - aorta 1-2.4cm & iliac 0.6-1.2cm Aneurysm - Aorta >3cm & iliac > 2cm RF for aneurysm

Older age, male gender, white race, positive family history, smoking, HTN, hypercholesterolemia, PVD, CAD. used to diagnose and monitor AAA until aneurysm approaches size at which repair considered. used in preop assessment of AAA.

Ultrasound

Computed Tomography

Ruptured AAA

No significant overall change in mortality with open repair from 1991-2006 Overall mortality for ruptured AAA = 90%

Mortality rate for patients who arrive at hosptial alive = 40-70%

High postop mortality rate due to MI, renal failure, and multi-organ failure

Ischemia-reperfusion injury, hemorrhagic shock, lower torso ischemia

rEVAR significantly reduces mortality of ruptured AAA patients (31 vs 50%)

Screening for AAA

US Preventive Services Task Force


Men 65-75 yo who have ever smoked No for or against men 65-75yo who have never smoked Does not recommend screening for women

Society of Vascular Surgery, Medicare Screening

Men who have smoked at least 100 cigarettes during their life men and women with a family history of AAA

Only screen patients who are candidates for repair.

Choosing between Surgery & Observation


1. 2. 3.

4.

Risk for AAA rupture without surgery Operative risk of repair Patients life expectancy Personal preferance of patient

1. Risk of Rupture

Size matters:

Aneurysm > 5cm 6-16% and > 7cm 33% annual rupture rate

Wall stress analysis Saccular aneurysm have higher rate of rupture HTN, COPD, active smoking are independent predictors of rupture (+) family hx tend to rupture Expansion rate

2. Operative Risk of Repair

Mortality after:

elective open AAA ~ 5% EVAR 1%

6 independent RFs for mortality Open repair

Creatinine > 1.8, CHF, EKG detected ischemia, Pulmonary dysfunction, older age, female gender.

Cardiac, pulmonary, renal, and GI risks with each proceudre.

3. Patients Life Expectancy

Very difficult to assess due to patients co-morbidities Typical 60yo surviving AAA repair has 13year life-expectacy, 70yo has 10year life-expectancy, and 80 yo has 6 year life-expectancy.

4. Personal Preference of Patient


Fear of AAA vs. Fear of surgery Anecdotal experiences of friends and family Procedures provided in community by interventional specialists and surgeons.

Medical Management of AAA

Smoking Cessation- Single most important modifiable risk


factor

Exercise Therapy- Evidence suggests may benefit small


aneurysms

Beta Blockers- May decrease the rate of expansion?


Important cardiovascular effects thus use advocated.

ACE inhibitors- Evidence is mixed, however, implicated in


less aneurysm rupture.

Doxycycline

Antibiotic activiety against chlamydia species Suppresses expression of MMP

Statins - associated with reduced aneurysm expansion rates.


Decreases MMP-9 in aneurysm wall.

EVAR vs. OPEN

EVAR-1 and DREAM Trials

Randomized AAA > 5.5 cm to EVAR vs. open repair Lower 30-day mortality for EVAR (1.6% EVAR vs. 4.6% open) Peripop mortality and severe complications 4.7% EVAR & 9.8% open repair (DREAM) Similar all-cause mortality at 2 years Higher rate of secondary interventions in EVAR group Total cost of Tx & 4 years of f/u is significantly increased for EVAR.

Open Repair

Transabdominal Approach

Previous retroperitoneal surgery Ruptured AAA Exposure of mid/distal portions of visceral vessels or R renal artery R internal or external iliac artery Co-existant abdominal pathology Left-sided vena cava

Retroperitoneal Approach

Mult. Previous intraperitoneal procedures Abd wall stoma, ectopic/ anomaly of kidney Inflammatory aneurysm Proximal aortic access, endarterectomy of viceral/renal arteries needed Obese patients Fewer GI complications

Open Repair-Complications

Cardiac Pulmonary Renal Lower Extremity Ischemia Spinal Cord Ischemia Incisional Hernia

14.2% ventral hernia, 9.7% SBO

Graft Infection

Open Repair Complications: Colon Ischemia


Collaterals from SMA, IMA, internal iliac artery, and profunda femoris supply sigmoid colon Mortality 40-65%, full-thickness necrosis 80-100% Occurs in 0.6-3% of elective and 7-27% of ruptured AAA (much more common endoscopically than clinically) Si/Sx: persistent acidosis & shock, increased WBCs and lactate levels, fluid sequestration, bloody bowel movements. TX:

Ischemia limited to mucosa/submucosa- npo, IVF, IV abx Transmural ischemia- bowel resection, fecal diversion, creation of ostomy, washout of abdomen, IV abx.

Open Repair- Concomitant Pathology

Treat the most life-threatening process first Avoid simultaneous operations that increase the risk for prosthetic graft infection If secondary procedure can be staged without increased risk - do aneurysm repair first Clean procedures (ie:nephrectomy, oophrectomy) can be performed simultaneously with open AAA repair GI procedures should not occur at same time as open repair

Abort surgery if metastatic disease or abscesses which increase risk for graft infection discovered.

Inflammatory AAA

Perianeurysmal fibrosis & inflammation 5% of AAA Treatment of AAA resolves the periaortic inflammation in 53% (open & EVAR) Duodenum, left renal vein, and ureters often involved in inflammation. PreOp ureteral stent placement recommended.

Infected AAA

0.65% of AAA Can be primary or secondary infection Potential causes of infection: Continguous spread of local infxn, septic embolization from distal site, bacteremia. In the past syphilis and steptococcal species was common: Now: staph and salmonella. With HIV and wide-spread abx use- can be caused by any bacterial or fungal infection Dx: fever, abdominal/back pain, high ESR, bacteremia.

EVAR

Types of Endoleak

Types of Endoleak

Type I Usually identified and treated @ time of stent graft implantation Must be treated if found on post-op imaging Associated with high likelihood of AAA rupture Bridge with short aortic cuff, Palmaz stent Type II 10-20% of post-op CT scan show Type II leak 80% resolve spontaneously at 6 months Indication to treat: persistent leak, aneurysm growth Transcatheter tx (coil embolization) Type III 0-1.5% incidence Strong predictor of rupture Tx: re-establish continuity by additional component to bridge gap or cover hole. Type IV Majority resolve within one month of stent graft implantation

EVAR Complications: EuroSTAR Registry

Annual Incidence of Complication (per 1,000 patients)


AneuRx Type I & II endoleak Migration Graft Occlusion Rupture 52 43 19 4 Ancure 86 5 33 0 Excluder 50 11 11 1 Talent 66 24 23 5 Zenith 41 7 35 2

From Van Marrewijk CJ, Leurs LJ, Valabhaneni SR, et al. Risk-adjusted outcome analysis of endovascular abdominal aortic aneurysm repair. J Endovasc Ther. 2005; 12; 417-429

EVAR complications

Stent-graft infection

Net infection rate of 0.43% Internal iliac occlusion during EVAR Si/sx: buttock claudication (most common 16-50%), buttock necrosis, colon necrosis, spinal ischemia, lumbosacral plexus ischemia, ED (15-17%). Ischemic colitis < 2%

Pelvic ischemia

Long-Term Outcome of Open or Endovascular Repair of Abdominal Aortic Aneurysm


De Bruin et al. DREAM study group
The New England Journal of Medicine May 2010

Introduction

Previous studies have shown initial survival benefit in patients undergoing EVAR vs. Open repair of AAA Concern that EVAR is not as durable as AAA and is associated with greater risk of rupture and secondary interventions. Goal: Analyze results of Dutch Randomized Endovascular Aneurysm Repair (DREAM) study to provide long-term data comparing open repair vs. EVAR

Methods

Multicenter, randomized, controlled trial comparing open repair vs. EVAR in 351 patients AAA > 5cm Patients had to be candidates for both techniques of repair Exclusion Criteria:

Ruptured or inflammatory aneurysms, anatomical variations, connective-tissue diseases, hx of organ transplant or lifeexpectancy < 2 years.

F/U visits at 30 days, 6/12/18/24months after procedure After first 2 years, pts received questionnaires every 6 months.

Methods

EVAR patient received CT scan annually All patients were called at 5 years and invited for f/u CT scan. Data acquisition stopped Feb 2009 Primary outcome was rate of death from any cause & reintervention Survival calculated on intention-to-treat basis.

Results

November 2000-December 2003 178 patients Open repair vs. 173 EVAR Mean age 7yo, 91% male, 43.9% concomittant cardiac disease. 6 pts did not undergo aneurysm repair

4 declined tx, 1 died from rupture, 1 died from PNA.

8 in hosptial deaths open vs. 2 EVAR Mean f/u 6.4 years 25% of open patient underwent CT scan at 5 years, 100% of EVAR

Results

@ 6 years post-op:

Survival rate: 69.9% open, 68.9% EVAR Freedom from reintervention: 81.9% open vs. 70.4% EVAR EVAR- mostly miscellaneous rather than CV

Analysis of causes of death

Reintervention

Open repair- majority done for hernia repair EVAR- endoleak, endograft migration

Discussion

No significant difference between endovascular repair and open repair in rate of overall survival at a median of 6.4 years. Previously DREAM and EVAR-1 trials demonstrated early (2years) survival advantage for EVAR group. Significantly higher rate of reinterventions in EVAR group than open group Study limited by difference in f/u between the open and endovascular group.

Conclusion

At 6 years, Open repair and EVAR have similar rates of suvival EVAR has a greater rate of reintervention

Total Percutaneous Access for Endovascular Aortic Aneurysm Repair (Preclose technique)
Lee WA, Brown MP, Nelson PR, Huber TS. Journal of Vascular Surgery 2007 June; 45(6):1095-101 University of Florida, Gainesville

large single institutional experience with the method and outcomes of a variation of the Preclose technique using the 6F Perclose Proglide (Abbott Vascular) device during endovascular aortic repairs. Retrospective review of patient who underwent EVAR/TEVAR from Oct 03-Aug06 183 perc femoral access with 12-24F Perclose technique with Proglide device compared to 154 patients with open surgical exposure of femoral arteries Anesthia used for Preclose vs. open: general, 49% vs 55%; regional, 45% vs 44%; and local, 5% vs 1% (P = .10). Percutaneous group broken down into group of smaller 12-16F and group of larger 18-24F sheaths. Data points: perioperative outcomes, procedure times, operating room usage costs, and technical success (in-hospital or 30-day). F/U: CT scan at 1 month post-op The list price for each Perclose Proglide device is (US) $295.

Dilator set $170.44

cost of the operating room is (US) $3935 for the first 60 minutes (not prorated for shorter periods) and then $50/min thereafter.

Results

137 EVAR, 118 TEVAR, 7 iliac repairs performed 381 femoral arteries accessed with 12-24F sheaths 279 were with 559 Proglide devices using Preclose technique in 183 patients 4 femoral artereries required 1 device (1.4%) -all 12F sheaths 270 arteries (96.8%) required 2 devices 5 arteries (1.8%) required 3 devices 63% of sheaths were > 18F Overall technical success of Preclose technique was 94.3%

99% for smaller sheaths and 91% for larger sheaths.

Results

16 complications

13 open repairs of femoral arteries 2 emergent placement of covered stent for severe retroperitoneal hemorrhage. 1 necrotizing arteritis with mycotic pseudoaneurysm requiring replacement of femoral artery with autogenous femoral vein.

All cause mortality 2.2% Access mortality 0%

Results

Surgical Group- 154 endovascular repairs 108 EVAR and 46 TEVAR 258 femoral exposures Technical success rate 93.8% 16 complications 10 endarterectomies with patch angioplasty 3 wound infections 2 infected seromas requiring I&D 1 severe arteritis requiring debridement and replacement of CFA with autogenous femoral vein. All cause mortality 1.3%

Results

Significantly lower OR time for Preclose group:


EVAR: 115 vs 128 min TEVAR: 80 vs 112 min EVAR: $7881 vs $7351 TEVAR: $5679 vs $6556

Cost: OR + Proglide vs. OR+ Surgery

Discussion

Percutaneous Access

Shorter procedure time Fewer wound complications Increased patient comfort Limited by size of delivery system.
Smaller sheaths had higher technical success All complications occurred intra-op No access-related mortality Accessing anterior aspect of mid-common femoral artery is crucial in preventing hemorrhagic complications.

In this study:

Discussion

Contraindications to Preclose:

Coagulopathy is contra-indication to use of this device due to inability to control needle-hole bleeding Severe calcifications Groin scarring Obesity Previous use of percutaneous closure devices. High (suprainguinal ligament) femoral bifurcation Need for frequent introducer sheath removals and insertions Proximal iliac occlusive disease Small iliofemoral arteries relative to profile of device being used

Conclusion

Prospective, randomized study is needed to truly validate this technique Percutaneous EVAR is safe and effective Long-term data is needed to evaluate effect on femoral artery.

The End