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Endovascular Aortic Aneurysm Repair
The document discusses endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms. It presents a case of a 62-year-old male undergoing EVAR for a 5.5cm AAA. EVAR involves deploying a graft via catheter to exclude the aneurysm from blood flow. Complications can include endoleaks, where blood leaks outside the graft but within the aneurysm sac. The main types of endoleaks are type I (inadequate seal at graft ends), type II (collaterals inside the sac), and type III (graft component disruption). EVAR has advantages over open repair like less invasiveness but risks like increased reintervention rates.
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Endovascular Aortic Aneurysm Repair
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- 2. CASE PRESENTATION • 62-year-oldmale • AAA 5.5 cm • Ischemic cardiomyopathy • Hypertension • Dyslipidemia • Intact pedal pulses
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- 5. ABDOMINAL AORTIC ANEURYSMS AbdominalAortic Aneurysm is a permanent pathologic dilation of the abdominal aorta with a greater than 50% increase in its diameter The most significant pathology is “elastin degradation due to MMPs (mainly 2,9,12) in the aortic media Risk Factors: smoking, ♂, hypertension, genetics Annual risk of rupture of diameters between 5-5.9: 5%
- 6. ABDOMINAL AORTIC ANEURYSMS Managementof AAAs • Imaging: Plain radiographs, USS, CT, MRA • Screening: recommended for men over 65 years (single USS) • Treatment: Aim is to prevent death from aortic rupture Pharmacologic: control risk factors (e.g. Blood Pressure: β- blockers, Losartan), Doxycycline (↓ MMP 9), Statins (anti- inflammatory), Curcumin (reduces cytokines)
- 7. ABDOMINAL AORTIC ANEURYSMS Managementof AAAs • Treatment: Repair Open Repair (OR) Endovascular Aneurysm Repair (EVAR) Hybrid Repairs
- 8. ABDOMINAL AORTIC ANEURYSMS Managementof AAAs • Treatment: Repair Open Repair
- 9. ABDOMINAL AORTIC ANEURYSMS Managementof AAAs • Treatment: Repair Endovascular Aneurysm Repair
- 10. ABDOMINAL AORTIC ANEURYSMS Managementof AAAs • Treatment: Repair Hybrid Repairs
- 11. ABDOMINAL AORTIC ANEURYSMS INDICATIONSFOR AAA REPAIR • Diameter ≥ 5.5 cm (5 cm in females) • Diameter ≥ 2.5 times the normal aortic diameter • Aneurysm annual growth rate ≥ 1 cm • AAA rupture • Symptomatic (e.g. back pain)
- 12. ABDOMINAL AORTIC ANEURYSMS EVARversus OR • No laparotomy • Less postoperative pain • Shorter hospital stay • Lower operative mortality • Similar mid-term all cause mortality and quality of life • No survival benefit compared with “NO INTERVENTION” in unfit patients • Higher re-intervention rates and graft specific problems
- 13. EVAR EVAR for AAArepresents an advance in patient care, serving as an effective alternative to traditional open surgical AAA repair, and is now the most common treatment method for AAA repair in the United States.
- 14. EVAR Juan Carlos Parodi •1970s: Proposed the concept of using endoluminal route to deliver fabric grafts reinforced with metal stents • 1990: First Human Implant Unfit patient The patient lived for 9 years before dying from pancreatic carcinoma
- 15. EVAR Graft Characteristics • Activefixation at the proximal end (e.g. hooks) • Resting flow divider at the distal end • Low permeability ePTFE • Polymer filled ring at the proximal sealing zone to protect the aortic neck • Kink-resistant iliac limbs • Radio-opaque markers to assist positioning
- 16. EVAR Preoperative workup (almostidentical to OR) • Planning CT for accurate assessment of the aortic morphology: With contrast Arterial phase Reconstructed at a max. 3 mm axial slices (1.5 mm for fenestrated / branched grafts) Diaphragm – Groin Measurement: adventitia – adventitia (most grafts) Formally reported by a radiologist
- 17. EVAR Preoperative workup (almostidentical to OR) • Planning CT for accurate assessment of the aortic morphology: 1 – 2 mm diameter variation is expected (phase of cardiac cycle) Standard instructions for use IFUs (according to the graft)
- 18. EVAR EVAR is notfavored in the following: • Heavy calcifications • Excessive iliacs tortuosity • Excessive angulation of the aneurysm neck
- 19. EVAR Preoperative workup (almostidentical to OR) • Planning CT for accurate assessment of the aortic morphology • Theatre environment to reduce the infection rates • Fixed high specification angiographic fluoroscopy units • General / regional anaesthesia preferred (excessive patient discomfort may be encountered due to lower limb ischaemia as the delivery system may occludes femorals)
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- 25. EVAR Complications • Medical: lessthan OR, PIS (inflammatory response) • Deployment: renal, mesenteric, athero- embolism • Graft related: fracture, migration, thrombosis, limb ischaemia, ENDOLEAKS, …
- 26. EVAR Complications • Medical: lessthan OR, PIS (inflammatory response) • Deployment: renal, mesenteric, athero- embolism • Graft related: fracture, migration, thrombosis, limb ischaemia, ENDOLEAKS, …
- 27. EVAR Complications • Medical: lessthan OR • Deployment: renal, mesenteric, athero- embolism • Graft related: fracture, migration, thrombosis, limb ischaemia, ENDOLEAKS, …
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- 49. ENDOLEAKS Types of Endoleaks TypeIV Type IV endoleaks are not true leaks but represent passage of blood through the graft fabric as a result of porosity. Typically this type of endoleak is transient and only noted at the time of repair appearing as a blush on the post-deployment angiogram, when patients are often fully anticoagulated, and resolve spontaneously after the withdrawal of anticoagulation. This type of endoleak has been eliminated by changes in graft porosity
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