Abdominal Aortic Aneurysms Diagnosis and treatment
AAA  defintion <ul><li>Varies by age, gender, body surface area </li></ul><ul><li>Typically diagnosed if aortic diameter i...
Prevalence of AAA <ul><li>In the US, AAA causes almost 14 000 deaths each year and accounts for 63 000 hospital discharges...
Risk factors associated with AAA <ul><li>Older age </li></ul><ul><li>Male sex </li></ul><ul><li>Family hx </li></ul><ul><l...
Types of AAA <ul><li>Morphological classification </li></ul><ul><ul><li>fusiform aneurysms </li></ul></ul><ul><ul><li>sacc...
AAA Sequelae <ul><li>Natural history </li></ul><ul><ul><li>gradual and/or sporadic expansion </li></ul></ul><ul><ul><li>ac...
Progression of a AAA <ul><li>Pathological changes cause the aorta wall to </li></ul><ul><ul><li>become thinner </li></ul><...
Growth rate of AAA Tan W  Abdominal Aortic Aneurysm Rupture   www.emedicine.com  0.16-1.10  0.64  6.0-6.9 0.27-0.60  0.43 ...
Symptoms of AAA rupture <ul><li>Abdominal/back pain </li></ul><ul><li>Pulsatile abdominal mass </li></ul><ul><li>Hypotensi...
AAA: risk of rupture Simplifed estimates based on various studies Tan W  Abdominal Aortic Aneurysm Rupture   www.emedicine...
Rupture outcomes <ul><li>Mortality rate can be as high as 80% [1] </li></ul><ul><li>More than one third of rupture cases d...
Operative mortality <ul><li>35-70% for ruptured aneurysm  </li></ul><ul><li>Pae.  J Am Surg  2007; Qureshi.  Ann Vasc Surg...
ACC/AHA screening high-risk <ul><li>Men  ≥ 60 yrs who are siblings or offspring of AAA patients </li></ul><ul><li>Men 65-7...
Diagnosis: physical exam <ul><li>In one study (N=198) </li></ul><ul><li>48% of AAA cases were diagnosed clinically </li></...
Sensitivity of physical exam Lederle.  JAMA  1999;281:77-82. Pooled analysis of 15 studies 76% ≥  5.0 cm 50% 4.0-4.9 cm 29...
Sensitivity of ultrasound <ul><li>Ranges from 82% to 99% </li></ul><ul><li>Approx 100% in cases with a pulsatile mass </li...
Ultrasound screening  Lindholdt.  BMJ  2005;330:750. Controlled screening trial of men age 65 to 73  ITT analysis n=6333 s...
ACC/AHA Guidelines AAA repair <ul><li>Infrarenal/juxtarenal AAA  ≥5.5 cm should undergo repair;  4.0-5.4 cm, ultrasound/CT...
Treatment options <ul><li>Open surgery </li></ul>Endovascular stent grafting
Open repair: advantages <ul><li>Established procedure more than 40 years of clinical experience </li></ul><ul><li>Excludes...
Open surgical repair (OSR): drawbacks <ul><li>Significant incision in the abdomen </li></ul><ul><li>30 – 90 minute cross-c...
Contraindications to OSR <ul><ul><li>High anesthesia risk </li></ul></ul><ul><ul><li>Severely obese </li></ul></ul><ul><ul...
Early OSR vs watchful waiting Combined ADAM and UKSAT trials of early/immediate OSR vs surveillance/delayed OSR for AAA < ...
Endovascular aneurysm repair (EVAR) <ul><li>Benefits </li></ul><ul><ul><li>minimally invasive </li></ul></ul><ul><ul><li>r...
Preoperative angiogram Postoperative angiogram ® AAA repair with stent graft
EVAR <ul><li>Drawbacks </li></ul><ul><ul><li>Complications and re-interventions </li></ul></ul><ul><ul><ul><li>intrasac en...
<ul><li>Morphology suitable for endovascular repair </li></ul><ul><ul><li>adequate vascular access </li></ul></ul><ul><ul>...
EVAR vs OSR 30-day outcomes 1.  Lancet  2004;364:843-8. 2.  N Engl J Med  2004;351:1607-1618. 0.1 0.1 0.02 0.009 P 4.7 % 1...
EVAR vs OSR 2-year outcomes DREAM N Engl J Med  2005;352:2398-405. 0.05 0.88 0.86 P 2.1% 65.6% 89.7% EVAR Aneurysm-related...
DREAM: sexual dysfunction* <ul><li>Both EVAR and open repair have a negative impact on sexual function in the early postop...
Erectile dysfunction <ul><li>Erectile function worsened after open repair (p=0.002) </li></ul><ul><li>Orgasmic function de...
Agency for Healthcare Research & Quality review of EVAR vs open surgical repair <ul><li>Lower perioperative morbidity and ...
Medicare cohort 4 yr outcomes Schmermerhorn  N Engl J Med  2008;358:464-474. * All 4 yr except perioperative mortality N=2...
Ongoing studies EVAR vs OSR <ul><li>France </li></ul><ul><li>Anévrisme de l’aorte abdominale: chirurgie versus endoprothès...
Upcoming SlideShare
Loading in …5
×

Slide 1 - theheart.org: Cardiology news, educational programming ...

745 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
745
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
37
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Aneurysm Classification Fusiform aneurysm is a cylindrical and symmetrical dilatation that involves the entire circumference of the aortic wall.And is more common than saccular. Saccular aneurysm is more a localized outpouching of only a portion of the aortic wall. Dissecting aneurysm is a hemorrhagic separation of the medial layer of the vessel wall which creates a false lumen. Pseudo or false aneurysm is a well defined collection of blood and connective tissues outside the vessel wall. This may be a consequence of a contained aortic wall rupture from trauma or anastomotic disruption. Aortic aneurysms can also be classified according to the segment involved, thoracic, thoracoabdominal and abdominal (may occur in the branches of the aorta as well. The clinical presentation and treatment depend greatly on their location
  • A review of six case-series including 703 cases of ruptured aneurysm estimated that only 18% of all patients with ruptured AAA reached a hospital and survived surgery. (See Ref 25)
  • Open Surgical Repair of AAA Contraindicated in many patients, usually due to advanced age and associated medical problems. The surgery requires a significant incision in the patient’s abdomen. Full-length (xiphoid to pubis) midline incision provides access to the entire abdominal cavity, including the supraceliac aorta and iliac arteries. The aorta is cross clamped for a period of 30-90 minutes. The aneurysm is opened and cleaned of any thrombus and debris. A prosthetic graft of polyester or PTFE is then selected based on the size of the aneurysm and sewn to the aorta, below the renal arteries and above the distal aortoiliac arteries. The wall of the aorta is wrapped and sewn around the graft to protect it. The incision site is then closed with sutures and staples. Surgical repair can take up to four hours to perform. The patient is typically admitted to the intensive care unit for one to two days post-operatively, in addition to seven to 14 days of routine hospitalization. Total recovery time is four to six weeks. Open surgical repair has a reported mortality rate of 2 to 5 %. Complications which include bleeding, bowel ischemia, infection, cardiopulmonary morbidity, and wound problems have been reported as high as 20 %. Emergent surgical treatment for ruptured aneurysm is much more costly, and mortality rates have been reported to vary from 20-90 %, with an average mortality rate of approximately 50 %. See Ref 35-36
  • Slide 1 - theheart.org: Cardiology news, educational programming ...

    1. 1. Abdominal Aortic Aneurysms Diagnosis and treatment
    2. 2. AAA defintion <ul><li>Varies by age, gender, body surface area </li></ul><ul><li>Typically diagnosed if aortic diameter is ≥ 3.0 cm* </li></ul>*ACC/AHA Guidelines on PAD Circulation 2006;113:e463-465. Normal aorta Aorta with an abdominal aneurysm
    3. 3. Prevalence of AAA <ul><li>In the US, AAA causes almost 14 000 deaths each year and accounts for 63 000 hospital discharges </li></ul>ACC/AHA Guidelines on PAD Circulation 2006;113:e463-465. 5.2% 12.5% 75-84 0% 1.3% 45-54 2.9 - 4.9 cm Women Men Age (years)
    4. 4. Risk factors associated with AAA <ul><li>Older age </li></ul><ul><li>Male sex </li></ul><ul><li>Family hx </li></ul><ul><li>Smoking </li></ul><ul><li>Hypertension </li></ul><ul><li>Dyslipidemia </li></ul><ul><li>Atherosclerotic disease </li></ul><ul><li>COPD </li></ul>ACC/AHA Guidelines on PAD Circulation 2006;113:e463-465.
    5. 5. Types of AAA <ul><li>Morphological classification </li></ul><ul><ul><li>fusiform aneurysms </li></ul></ul><ul><ul><li>saccular aneurysms </li></ul></ul><ul><ul><li>dissecting aneurysms </li></ul></ul><ul><ul><li>pseudo-aneurysms </li></ul></ul><ul><li>Segments involved </li></ul><ul><ul><li>thoracic </li></ul></ul><ul><ul><li>thoraco-abdominal </li></ul></ul><ul><ul><li>abdominal </li></ul></ul><ul><ul><li>main branches of the aorta </li></ul></ul><ul><ul><li>iliac arteries </li></ul></ul>
    6. 6. AAA Sequelae <ul><li>Natural history </li></ul><ul><ul><li>gradual and/or sporadic expansion </li></ul></ul><ul><ul><li>accumulation of mural thrombus </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>rupture </li></ul></ul><ul><ul><li>thromboembolic events </li></ul></ul><ul><ul><li>compression of adjacent structures </li></ul></ul>
    7. 7. Progression of a AAA <ul><li>Pathological changes cause the aorta wall to </li></ul><ul><ul><li>become thinner </li></ul></ul><ul><ul><li>bulge </li></ul></ul><ul><ul><li>tear </li></ul></ul><ul><ul><li>rupture </li></ul></ul>
    8. 8. Growth rate of AAA Tan W Abdominal Aortic Aneurysm Rupture www.emedicine.com 0.16-1.10 0.64 6.0-6.9 0.27-0.60 0.43 5.0-5.9 0.21-0.50 0.36 4.0-4.9 0.20-0.57 0.39 3.0- 3.9 95% CI Mean growth rate (cm/yr) Initial size (cm)
    9. 9. Symptoms of AAA rupture <ul><li>Abdominal/back pain </li></ul><ul><li>Pulsatile abdominal mass </li></ul><ul><li>Hypotension </li></ul><ul><li>Clinical triad occurs in only about one-third of cases. </li></ul>ACC/AHA Guidelines on PAD Circulation 2006;113:e463-465.
    10. 10. AAA: risk of rupture Simplifed estimates based on various studies Tan W Abdominal Aortic Aneurysm Rupture www.emedicine.com 0 Risk of rupture for untreated aneurysm within 5 years (%) 10 70 60 40 50 30 20 80 25% 35% 75% Aneurysm size 5-5.9cm 6-6.9cm ≥ 7cm
    11. 11. Rupture outcomes <ul><li>Mortality rate can be as high as 80% [1] </li></ul><ul><li>More than one third of rupture cases die outside the hospital [2] </li></ul><ul><li>Adam. J Vasc Surg 1999;30:922-8. </li></ul><ul><li>Thomas. Br J Surg  Aug 1988 </li></ul>Ruptured AAA
    12. 12. Operative mortality <ul><li>35-70% for ruptured aneurysm </li></ul><ul><li>Pae. J Am Surg 2007; Qureshi. Ann Vasc Surg 2007; Greco. J Vasc Surg 2006; Pepplenbosch. J Vasc Surg 2006; Visser. Eur J Vasc Endovasc Surg 2005; Brown. Br J Surg 2002; Heller. J Vasc Surg 2000; Adam. J Vasc Surg 1999; Johansen. J Vasc Surg 1991; Ouriel. J Vasc Surg 1990. </li></ul><ul><li>1.0-8.0% for elective AAA cases </li></ul><ul><li>Qureshi. Ann Vasc Surg 2007; Cowan. Ann NY Acad Sci 2006; Heller. J Vasc Surg 2000; Bradbury. Br J Surg 1998; Blankensteijn. Br J Surg 1998. </li></ul>
    13. 13. ACC/AHA screening high-risk <ul><li>Men ≥ 60 yrs who are siblings or offspring of AAA patients </li></ul><ul><li>Men 65-75 yrs who have ever smoked </li></ul><ul><li>Physical exam and ultrasound </li></ul>ACC/AHA Guidelines on PAD Circulation 2006;113:e463-465. Class I Class IIa Class IIb Class III
    14. 14. Diagnosis: physical exam <ul><li>In one study (N=198) </li></ul><ul><li>48% of AAA cases were diagnosed clinically </li></ul><ul><li>physical exam missed 38% of cases detected radiologically </li></ul>Karkos CD. Eur J Vasc Endovasc Surg 2000;19:299-303.
    15. 15. Sensitivity of physical exam Lederle. JAMA 1999;281:77-82. Pooled analysis of 15 studies 76% ≥ 5.0 cm 50% 4.0-4.9 cm 29% 3.0-3.9 cm Sensitivity Aneurysm diameter
    16. 16. Sensitivity of ultrasound <ul><li>Ranges from 82% to 99% </li></ul><ul><li>Approx 100% in cases with a pulsatile mass </li></ul><ul><li>In a small proportion of patients, visualization of the aorta inadequate due to obesity, bowel gas, or periaortic disease </li></ul>Quill. Surg Clin North Am 1989;69:713-20.
    17. 17. Ultrasound screening Lindholdt. BMJ 2005;330:750. Controlled screening trial of men age 65 to 73 ITT analysis n=6333 screened, n=6306 control P=0.002 P=0.001 P=0.003
    18. 18. ACC/AHA Guidelines AAA repair <ul><li>Infrarenal/juxtarenal AAA ≥5.5 cm should undergo repair; 4.0-5.4 cm, ultrasound/CT scans every 6-12 mo </li></ul><ul><li>Repair can be beneficial for infrarenal/juxtarenal AAAs 5.0-6.0 cm </li></ul><ul><li>Repair probably indicated for suprarenal/type IV thoracoabdominal AA >5.5-6.0cm </li></ul><ul><li>AAA <4.0cm, ultrasound every 2-3 years is reasonable </li></ul><ul><li>Intervention not recommended asymptomatic infrarenal/ juxtarenal AAAs <5.0 cm (men) or <4.5 cm (women) </li></ul>ACC/AHA Guidelines on PAD Circulation 2006;113:e463-465. Class I Class IIa Class IIb Class III
    19. 19. Treatment options <ul><li>Open surgery </li></ul>Endovascular stent grafting
    20. 20. Open repair: advantages <ul><li>Established procedure more than 40 years of clinical experience </li></ul><ul><li>Excludes aneurysm and prevents sac growth </li></ul><ul><li>Proven, long-term results </li></ul>
    21. 21. Open surgical repair (OSR): drawbacks <ul><li>Significant incision in the abdomen </li></ul><ul><li>30 – 90 minute cross-clamp </li></ul><ul><li>Up to 4-hour procedure </li></ul><ul><li>1–2 days intensive care 7–14 days hospitalization 4–6 weeks recovery time </li></ul>
    22. 22. Contraindications to OSR <ul><ul><li>High anesthesia risk </li></ul></ul><ul><ul><li>Severely obese </li></ul></ul><ul><ul><li>Significant cardiac co-morbidities </li></ul></ul><ul><ul><li>Previous abdominal surgery/hostile abdomen </li></ul></ul><ul><ul><li>Difficult recovery for patient: </li></ul></ul><ul><ul><li>risks functional impairment [1] </li></ul></ul><ul><ul><li>risk of erectile dysfunction [2] </li></ul></ul>1. Williamson. J Vasc Surg 2001;33:913-920. 2. Le e. Ann Vasc Surg 2000;14:13-19.
    23. 23. Early OSR vs watchful waiting Combined ADAM and UKSAT trials of early/immediate OSR vs surveillance/delayed OSR for AAA < 5.5 cm N = 2226 Lederle. Ann Intern Med 2007;146:735-741. 0.56-1.10 0.78 Aneurysm-related mortality 0.77-1.32 1.01 All cause mortality 95% CI Relative risk Endpoint
    24. 24. Endovascular aneurysm repair (EVAR) <ul><li>Benefits </li></ul><ul><ul><li>minimally invasive </li></ul></ul><ul><ul><li>reduced risk of perioperative death </li></ul></ul><ul><ul><li>faster recovery </li></ul></ul>
    25. 25. Preoperative angiogram Postoperative angiogram ® AAA repair with stent graft
    26. 26. EVAR <ul><li>Drawbacks </li></ul><ul><ul><li>Complications and re-interventions </li></ul></ul><ul><ul><ul><li>intrasac endoleaks </li></ul></ul></ul><ul><ul><ul><li>stent graft migration </li></ul></ul></ul><ul><ul><ul><li>modular dislocation </li></ul></ul></ul>
    27. 27. <ul><li>Morphology suitable for endovascular repair </li></ul><ul><ul><li>adequate vascular access </li></ul></ul><ul><ul><li>appropriate aortic neck length and angulation </li></ul></ul>Endovascular stent grafting
    28. 28. EVAR vs OSR 30-day outcomes 1. Lancet 2004;364:843-8. 2. N Engl J Med 2004;351:1607-1618. 0.1 0.1 0.02 0.009 P 4.7 % 1.2 % 9.8 % 1.7 % EVAR Mortality & severe complications Mortality Secondary interventions Mortality Endpoint Trial OPEN EVAR [1] N=1082 ≥ 5.5 cm 4.7 % 5.8 % DREAM [2] N=345 ≥ 5.0 cm 4.6 % 9.8 %
    29. 29. EVAR vs OSR 2-year outcomes DREAM N Engl J Med 2005;352:2398-405. 0.05 0.88 0.86 P 2.1% 65.6% 89.7% EVAR Aneurysm-related death Survival free of moderate-severe complications Survival Endpoint OPEN 89.6% 65.9% 5.7%
    30. 30. DREAM: sexual dysfunction* <ul><li>Both EVAR and open repair have a negative impact on sexual function in the early postoperative period. </li></ul><ul><li>After EVAR, recovery to preoperative levels is faster than after open repair. </li></ul><ul><li>At 3 months, sexual dysfunction levels are similar in both groups. </li></ul><ul><li>*Measured 5 aspects (interest, pleasure, engagement, orgasm, erection) </li></ul><ul><li>N=153 </li></ul>Prinssen. J EndovascTher 2004;11:613-620.
    31. 31. Erectile dysfunction <ul><li>Erectile function worsened after open repair (p=0.002) </li></ul><ul><li>Orgasmic function deteriorated after open repair (p=0.001) </li></ul><ul><li>Endovascular repair was not accompanied by decreased erectile or orgasmic function (p=0.057 and p=0.068, respectively) </li></ul><ul><li>Impairment not associated with age, diabetes, or number of patent hypogastric arteries after repair </li></ul><ul><li>Significant association between impaired erectile function and open aneurysm repair (p=0.036) </li></ul><ul><li>N=90 </li></ul>Xenos. Ann Vasc Surg 2003;17:530-538.
    32. 32. Agency for Healthcare Research & Quality review of EVAR vs open surgical repair <ul><li>Lower perioperative morbidity and mortality </li></ul><ul><li>Persistent reduction in AAA-defined mortality to 4 years </li></ul><ul><li>No improvement in long-term overall survival or health status </li></ul><ul><li>For AAA ≥ 5.5 cm </li></ul>AHRQ Publication No. 06-E017 August 2006
    33. 33. Medicare cohort 4 yr outcomes Schmermerhorn N Engl J Med 2008;358:464-474. * All 4 yr except perioperative mortality N=22 830 matched patients Laparotomy-related <0.001 14.2% 8.1% Hospitalization <0.001 9.7% 4.1% Reintervention <0.001 1.7% 9.0% AAA reintervention <0.001 <0.001 P 1.8 % 1.2 % EVAR Endpoint* OPEN Periop mortality 4.8 % AAA rupture 0.5 %
    34. 34. Ongoing studies EVAR vs OSR <ul><li>France </li></ul><ul><li>Anévrisme de l’aorte abdominale: chirurgie versus endoprothèse (ACE) ClinicalTrials.gov identifier: NCT00224718 </li></ul><ul><li>US </li></ul><ul><li>Open versus endovascular repair (OVER) trial for AAA </li></ul><ul><li>ClinicalTrials.gov identifier: NCT00094575 </li></ul>

    ×