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  • 1. Management of Vascular Disease Weighing Natural History Against Outcomes after Interventions Scott Berceli, MD PhD Associate Professor of Surgery
  • 2. Standard Vascular Surgical Practice (circa. 2000) Carotid Stenosis Carotid Endarterectomy 100% Aortic Aneurysm Open AAA Repair 100% Leg Ischemia Lower Extremity Bypass 100% Disease : Treatment :
  • 3. Standard Vascular Surgical Practice (circa. 2007) Carotid Stenosis Carotid Endarterectomy 60% + Carotid Stenting 40% Aortic Aneurysm Open AAA Repair 20% + Endograft AAA Repair 80% Leg Ischemia Lower Extremity Bypass 80% + SFA Stenting Tibial Angioplasty 20% Disease : Treatment :
  • 4. Abdominal Aortic Aneurysms
  • 5. Incidence
    • Found in 2-5% of individuals > 65 year old
    • Accounts for 1.2% of deaths in > 65 age group
    • 13 th leading cause of death in U.S.
    Risk Factors
    • Hypertension
    • Smoking
    • Family History (20% first degree relatives)
    • Male sex (4:1 M:F ratio)
    • Advancing age (rare in patients < 50 y.o.)
  • 6. Rupture Risk
    • 1960’s to
    • 1990’s
    Adapted from Szilagyi, Ann Surg, 1966 Determined from abd films and physical exam 2004 ADAMs Trial UK Small Aneurysm Patients with 4.0 to 5.5 cm AAA randomized to repair or observation
    • no difference in AAA related mortality
    • 5.0-5.5 cm rupture risk 2% per year
    ] VA Large Aneurysm Longitudinal study of high risk patients with > 6.0 AAA
    • 5.5 - 5.9 cm  9.2% per year
    • 6.0 - 6.4 cm  10.5 % per year
    • 6.5 - 6.9 cm  19.1% per year
    • > 7.0 cm  32.5% per year
    ]
  • 7. Revised Previous Timing of elective AAA Repair
    • Repair vs. continued observation offered for AAA 5.0-5.5 cm
    • Repair recommended for AAA 5.5 cm (good risk patients)
    +
    • Operative Mortality
    • (open and endovascular)
    • 2-4%
    =
  • 8. Presentation of Patients with Ruptured AAA
    • Classic Triad
    • Abdominal or back pain
    • Pulsatile abdominal mass
    • Hypotension
    • 95% of all patients with rupture have at least 1 of 3 signs
    • < 50% of patient with rupture have all 3 signs
    Treatment is immediate operative repair within minutes
  • 9. Symptomatic AAA
    • Acute presentation of back or abdominal pain in a patient with a AAA (4.0 cm or greater) without other identifiable etiology
    • Often accompanied by a tender aneurysm on exam
    • Hemodynamically stable, with no evidence of rupture on CT scan
    • Natural history his poorly known, felt to represent impending rupture (hours to day to weeks?)
    • Warrants emergent vascular surgery evaluation, usually leading to urgent operative repair within hours
    Symptomatic AAA = Ruptured AAA
  • 10. Methods of AAA Repair
    • Open
    • Endovascular
  • 11. Open operative repair
  • 12. Endovascular repair
    • Material Components
      • Graft: woven polyester
      • Stent: nitinol (nickel-titanium) exoskeleton
        • Thermal shape memory
      • Non-absorbable polyester sutures
        • >2000 hand-sewn suture/stent graft
  • 13. Primary Bifurcated Module Delivery Catheter Infrarenal Placement Completed Primary Deployment
  • 14. Contralateral Limb Delivery Catheter Access Contralateral Limb Deployment Completed Repair
  • 15. Carotid Artery Stenosis
  • 16. Pathophysiology
    • 50% or less due to disease of the carotid bifurcation
  • 17. Risk Factors
    • TIA’s
    • Hypertension
    • Cigarette smoking
    • Hyperlipidemia
    • Age, male sex, race, heredity
    • Diabetes
  • 18.  
  • 19.  
  • 20.  
  • 21. History of carotid endarterectomy in the U.S. Design a clinical trial
  • 22. NASCET
    • Design
    • 3000 patients randomized to medical or surgical therapy and followed for a minimum of 5 years
    • 50 selected centers (<6% peri op stroke/death rate), sxs within 3 months, <80 yo; specific angio criteria
  • 23. NASCET
    • 2 year estimate by life table of ipsilateral stroke 26% for medical, 9% for surgical (70-99%)
    • 18 mo mortality risk reduction 58%, stroke risk reduction 71%
  • 24. NASCET
    • 2 yr Estimate of Ipsilateral Stroke
    • Failure Rate NNT
    • Stenosis Medical Surgical
    • 70-99% 26.1% 12.9% 8
    • 50-69% 22.2% 15.7% 15
    • <50% 18.7% 14.9% 26
  • 25. ACAS
    • 39 centers, 17 credentialed surgeons (<3% for asymptomatic)
    • <80 yo
    • 1662 patients with >60% stenosis by angio
  • 26. ACAS
    • Operative and angio stroke morbidity/mortality 2.3% (1.2% angio)
    • Surgery No Surgery
    • Projected 5 yr 5.1% 11%
    • stroke event rate
    • Stroke risk reduction 55% (only 17% for females) 
  • 27. ACAS
    • Stroke risk reduces from 2%/yr to 1%/yr, or 5% at 5 yrs
    • One stroke prevented for every 20 CEAs done in asymptomatic patients