Abdominal Aortic Aneurysm 2015

Sean Tierney,
Consultant Vascular Surgeon
Adelaide & Meath
National Children’s Hospital,
Tallaght
IssuesIssues
inin
AAA managementAAA management
20132013

http://www.perfuse.netVascular surgery @ Tallaght
AAA - Issues for discussionAAA - Issues for discussion
• Screening
• Surveillance
• Predicting Operative Risk
– Reducing operative risk
• Choosing operative
option
• Perioperative issues
• Technical
– Open repair
– EVAR
• Complex anatomy
– Fenestrated
– Branched

ScreeningScreening
“Multicentre Aneurysm Screening Study” Thompson S G et al. BMJ 2009

ScreeningScreening
• £7600 after 10 years (per DALY
gained)
• Impact of EVAR unknown
“Multicentre Aneurysm Screening Study” Thompson S G et al. BMJ 2009

ScreeningScreening
Country Min diameter referred if Prevalence AAA
Western Australia >30 mm >50 mm >30 mm 7%; >55 mm 2.5%
Denmark >30 mm >50 mm 3.30%
England >30 mm >55mm 1.70%
Norway >30 mm >55mm 3.40%
New Zealand >30 mm >55mm 8.9% in high risk males >65 years
Scotland >30 mm >55mm
Sweden >30 mm >55mm 1.7% + 0.5% (known)
Italy >30 mm >55mm 6.20%
Wales >30 mm >55mm
Northern Ireland >30 mm >55mm
USA >30 mm >55mm
Criteria (England): 0–44 mm yearly
45–54 mm 3 monthly
European Journal of Vascular and Endovascular Surgery
Volume 45, Issue 3, March 2013, Pages 231–234

PrognosisPrognosis
Szilagyi 1966
% 5 year survival
6cm

Law of Laplace (sphere)
P =2T/R
0
20
40
60
80
<5cm 5.0-5.9cm >6.0-6.0cm >7.0cm
5 year risk of rupture
Aneurysm size
RisksRisks

Operative mortality (open repair)Operative mortality (open repair)
Brady et al. BJS 2000 (Small AAA trial)

Predictors of mortalityPredictors of mortality
0.04 0.01
0.01
Brady et al. BJS 2000 (Small AAA trial)

Open surgeryOpen surgery

New technologyNew technology
Parodi et al Ann Vasc 1991

Anaesthesia & positionAnaesthesia & position
• Epidural/spinal
• Occasionally GA
• Possible under LA
∀ ± Central access
• Arterial line
• OSI (radiolucent) table

PositionPosition
• Arms tucked in by
sides
• Contrast pressure
injector (angio)
• C Arm
• 2 tables – open/endo

Set up & equipmentSet up & equipment
1
2
Scrub/N 1
C-arm
Monitors
Injector
Scrub/N 2

Draping & incisionDraping & incision

ExposureExposure

AnimationAnimation
Tri Fab design

ClosureClosure
• Arteriotomy
closure
• 6/0 prolene

EVAR - 1EVAR - 1 OutcomesOutcomes

ReinterventionsReinterventions
Trial Year N AAA Reinterventions P value
EVAR Open
EVAR 2010 1252 > 5.5 cm 10% 28% <0.001
DREAM 2010 351 > 5 cm 30% 18% 0.03
ACE 2011 316 > 5 cm 24% 14% <0.01
OVER 2012 881 > 5 cm 22.1%b 17.8%b 0.12
European Journal of Vascular and Endovascular Surgery
Volume 45, Issue 4, April 2013, Pages 313–314

EVAR - 2EVAR - 2 OutcomesOutcomes
Lancet 2005; 365: 2187–
92

EndoleakEndoleak
“Persistent blood flow outside the endograft but
contained within the aneurysm sac”
• Type I
– failure of seal at the fixation points or at junctions between
graft components
• Type II
– persistent backflow into the sac from patent native branches
(e.g lumbar arteries, IMA etc)
• Type III
– graft failure or segment separation
• Type IV
– graft porosity
• Type V
– unknown

OptionsOptions
??

Fenestrated graftFenestrated graft

Iliac branch graftIliac branch graft

Iliac aneurysmIliac aneurysm

Place for EVARPlace for EVAR
IndicationsIndications
• still unresolved issues
• anatomical suitability
• older vs younger
• ? high risk patient
• significant costs
• Complement rather than
replaces open surgery

Abdominal Aortic Aneurysm 2015

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