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EVAR - Personal Experience

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EVAR - Personal Experience

  1. 1. Early and Long Term Results of EVAR: Personal Experience Giorgio M. Biasi, MChir FACS FRCS Professor of Vascular Surgery University of Milano Bicocca
  2. 2. Transfemoral Intraluminal Graft Implantation for Abdominal Aortic Aneurysms Parodi JC, Palmaz JC, Barone HD. Annals of Vascular Surgery 1991; 5: 491-9
  3. 3. EVAR vs OR (<30days) • Decrease perioperative morbidity • Decrease intensive care unit stay • Decrease total hospital length of stay • Increase quality of live in perioperative period.
  4. 4. • Increase ruptured rate/year • Need continuous follow-up to detect and treat complications • Increase the reintervention rate/year EVAR vs OR (>30days)
  5. 5. Type I Endoleak
  6. 6. Type II Endoleak
  7. 7. Modular component disconnection
  8. 8. Endograft kinking
  9. 9. Surgical conversion
  10. 10. How to reduce early and late complications Case selection Preprocedural investigations Intraprocedural investigations Follow-up
  11. 11. How to reduce early and late complications Case selection Preprocedural investigations Intraprocedural investigations Follow-up
  12. 12. Case Selection  Risk related to general conditions ( age- hostyle abdomen- cardio-respiratory conditions- large AAA - smokers - patient’s consensus- etc.)  Risk related to aortic anatomy
  13. 13. Aortic Angulation Case Selection Proximal neck and iliacs angulation
  14. 14. Case Selection Proximal Neck Compromised proximal neck anatomy is the most frequent cause of EVAR failure.
  15. 15. Neck Angulation
  16. 16. Device migration due to neck angulation
  17. 17. Some technical tricks to avoid complications neck related • Perform angiogram in several projections. • C-Arm orientation. • Lower renal artery selection. • “Crossing the Limb” technique. • Endograft selection.
  18. 18. Technical tricks Perform angiogram in several projection
  19. 19. Technical tricks C-Arm orientation
  20. 20. Technical tricks “Crossing the Limb” technique
  21. 21.  Free Flow  Hooks  Barbs Endograft selection
  22. 22. • Unibody or bifurcated • Modular or nonmodular • Fully or partially stent-supported body • Supra or below renal fixation • Hooks and barbs Endograft selection
  23. 23. How to reduce early and late complications Case selection Preprocedural investigations Intraprocedural investigations Follow-up
  24. 24. Angio - CTAngio - CT Preprocedural Investigations
  25. 25. How to reduce early and late complications Case selection Preprocedural investigations Intraprocedural investigations Follow-up
  26. 26. Intraop. Angiogram Intraprocedural Investigations
  27. 27. IVUS Intraprocedural Investigations
  28. 28. How to reduce early and late complications Case selection Preprocedural investigations Intraprocedural investigations Follow-up
  29. 29. FOLLOW UP • CT Scan • Duplex • Angiography (in case of leaks)
  30. 30. Long term aortic evolution • Proximal neck dilatation • Shrinking – elongation or shortening • Kinks FOLLOW UP
  31. 31. Proximal neck dilatation Type II Endoleak Endograft migration
  32. 32. Particular situations • Inflammatory Aneurysm • Pararenal aortic aneurysm in high risk patients • Aneurysm associated to an additional abdominal pathology. • Ruptured Aneurysms
  33. 33. Particular situations • Inflammatory Aneurysm • Pararenal aortic aneurysm in high risk patients • Aneurysm associated to an additional abdominal pathology. • Ruptured Aneurysms
  34. 34. INFLAMMATORY AAAs ACCOUNT FOR 3% TO 10% OF ALL AAAs
  35. 35. PENDING ISSUES  HOSTILE OPERATIVE FIELD  RISK OF INJURY TO VITAL STRUCTURES  POTENTIAL FOR REGRESSION OF RETROPERITONEAL INFLAMMATORY PROCESS  USE OF ORAL STEROID IN THE PRE AND POST PROCEDURAL COURSE  INDUCTION OF RETROPERITONEAL FIBROSIS BY EVAR  URETERIC STENTING
  36. 36. Particular situations • Inflammatory Aneurysm • Pararenal aortic aneurysm in high risk patients • Aneurysm associated to an additional abdominal pathology. • Ruptured Aneurysms
  37. 37. Compromised proximal neck anatomy is the most frequent rejection criteria for endovascular treatment of AAA.
  38. 38. Which is the best endovascular strategy for pararenal aortic aneurysm?
  39. 39. Endovascular treatment of pararenal aortic aneurysm Infrarenal Fixation Endograft Transrenal Fixation Endograft Fenestrated Endograft
  40. 40. Technical tricks Lower renal artery selection
  41. 41. An accurate delivery of the graft just below the lower renal artery is required to maximize the sealing zone with conventional endograft. Infrarenal fixation endograft
  42. 42.  Complete sealing and better attachment of the stent-graft. Decreased incidence of endoleak. Transrenal fixation endograft
  43. 43. Fenestrated Endovascular Graft • Extend the proximal sealing zone • Accomodate native arterial angulation • Improve proximal fixation
  44. 44. Particular situations • Inflammatory Aneurysm • Pararenal aortic aneurysm in high risk patients • Aneurysm associated to an additional abdominal pathology. • Ruptured Aneurysms
  45. 45. Aneurysm associated to an additional abdominal pathologies • Abdominal pathologies : 3.4% - 12% • Other pathologies: cardiomyophaty 25% - 50% • Neoplastic pathologies: 7% - 9%
  46. 46. First EVAR Procedure in our Institution January 1997
  47. 47. Endograft used AneuRx - Medtronic Endologix - Aptiva Zenith -Cook Excluder - Gore Talent - Medtronic Endofit - Serom Anaconda - Le Maitre Ancure - Guidant Quantum - Cordis Lifepath - Edwards
  48. 48. 1997 - Inclusion Criteria Elective Endograft • Proximal neck lenght > 25 mm • Proximal neck diameter < 26 mm • Neck angulation < 40° • Iliac arteries anatomy
  49. 49. 2008 - Inclusion Criteria Elective Endograft • Proximal neck lenght > 15 mm • Proximal neck diameter < 28 mm • Neck angulation < 60° • Iliac arteries anatomy
  50. 50. 2008 - Inclusion Criteria Elective Endograft • Patient Age > 75 ys old • Unsuitable for Surgery: - Hostile Abdomen - Higth risk for comorbilities
  51. 51. Present Indication To EVAR in our Institution 30% of procedures
  52. 52. EVAR vs OR EUROSTAR Registry Data
  53. 53. EVAR vs OR Percentage of patients reintervention free EUROSTAR Registry Data
  54. 54. PERSONAL EXPERIENCE Elective AAA (August 2005/August 2008) Number of Patients: 220 Male: 195 Female: 25 Age: average 77.5 years Min.: 58 years Max.: 93 years
  55. 55. Early complications Type I Endoleaks 9/218 (4.1%) Type II Endoleaks 16/218 (7.3%) Type III Endoleaks 1/218 (0.4%) Distal embolization 2/218 (0.9%) Branch occlusion 3/218 (1.4%) Early conversion 2/220 (0.9%)
  56. 56. Type I Endoleak • Eight treated with a cuff. Branch occlusion • Two treated with embolectomy. • One treated with femoral-femoral bypass Distal embolization • Treated with major amputation one above and one below the knee. Early Conversion • One due a common iliac artery rupture. • One due a structural defect of device.
  57. 57. Late conversion 8/218 (3.6%) Partial Graft Thrombosis 5/210 (2.3%) Branch occlusion 2/210 (0.9%) Death after conversion 1/10 (10.0%) Late complications
  58. 58. Death after conversion • Due a cardiac complications Branch occlusion • One treated with embolectomy and stenting. • One treated with femoral-femoral bypass Late Conversion • Two due to a ruptured aneurysm. • Three due to a enlargement of aneurysmal sac without evidence of endoleaks. • One due to a proximal migration of graft. • Two due to a type one endoleak after a fibrinolitic therapy
  59. 59. Reference All Endoleaks Distal embolization Early and Late Conversions Branch occlusion Death graft related Walschot, 2002 18.5% 6.4% Thomas, 2000 6.0% 1.4% 5.0% 1.0% 0.5% Diethrich, 2002 18.6% 3.0% 0% 2.1% 3.0% Raithel, 2002 7.0% 1.2% Liewald, 2001 16.0% 4.0% 3.0% Mohan, 2000 16.7% 1.5% 0.04% Range 6-26% 0-10% 3-10% 0-6% 0-4% Biasi 11,4% 0.9% 3,6% 2.8% 0.8%
  60. 60. Author Type I Endoleak Type II Endoleak Type III Endoleak Graft/Limb Occlusion Migration Secondary Intervention Late Ruptured Becquemin 2005 276 pts. 32% 39% 10% 13.5% 3.0% 22.0% 0.8% Eurostar Registry 2006 2746 pts. 9.4% 15.3% 1.8% 2.4% 2.6% 8.7% 0.5% Biasi 4.1% 7.3% 0.4% 2.3% 0.4% 1.4% 0.7%
  61. 61. • Avoid laparotomy • Reduce cardiac complications • Reduce septic complications • Less invasive • Rapid recovery • Combined treatment? Endovascular Treatment
  62. 62. Conclusion EVAR is less invasive than open repair, but the long term outcome is still unknown.
  63. 63. Conclusion The endovascular treatment of acute or ruptured AAA, could contribute in reducing the perioperatory morbidity and mortality in comparison to open repair . In elective surgery, EVAR needs an accurate selection of patients.
  64. 64. giorgio.biasi@unimib.it

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