EVAR is an effective treatment for inflammatory abdominal aortic aneurysms (I-AAA), providing reduced perioperative mortality and complications compared to open repair. However, EVAR may be associated with higher rates of persistent peri-aortic fibrosis and ureteral obstruction compared to open repair. Close monitoring and early initiation of medical therapies like steroids, immunosuppressants, and tamoxifen may help reduce these complications after EVAR for I-AAA. While EVAR is generally safer, more research is still needed to determine the best treatment strategies for this condition.

1. EVAR in
Inflammatory AAA
Fady Haddad, MD, FACS
Vascular & Endovascular Surgery
American University Of Beirut Medical Center
ASVS, Turkish Society & Asian Venous Forum meeting
Istanbul, October 2013

2. Inflammatory AAA
• EVAR has changed the way we look at AAA.
• More than 50 % of overall cases in the US
today are done using endovascular approach.
• Large data supports at least early and mid
term reduced mortality & morbidity,
particularly in high risk patients. 1, 2, 3
1.Giles KA, et al. Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair. J Vasc Surg
2009;49:543-51.
2.Schermerhorn ML et al. Endovascular vs. open repair of abdominal aortic aneurysms in the medicare population.
N Engl J Med 2008; 358:464-47.
3.Greenhald R et al. Endovascular Repair of Abdominal Aortic Aneurysm. N Engl J Med 2008; 358:494-501.

3. • Inflammatory AAA (I-AAA) constitutes around 5%
of all AAA.
• It carries its own challenges in terms of anatomic
and technical difficulties, procedural morbidity,
and associated retroperitoneal fibrosis and
inflammation.
• Little is known about singularities of this disease
in the endovascular era
• Recent literature suggests efficiency and safety of
EVAR in I-AAA .*
*Coppi G, et al. Inflammatory Abdominal Aortic Aneurysm Endovascular Repair into the Long-
Term Follow-Up. Ann Vasc Surg. 2010; 24(8):1053-9
Inflammatory AAA

4. • 67 y male, smoker
• Back pain 6 month
• Hx of spine disease
• US abdomen AAA5.5cm
• CT angio:
– 5.5cm AAA with
periaortic inflammation
up to 7cm
– Bilateral hydronephrosis
more on the left.
Inflammatory AAA

5. Main features of I-AAA
• Unusual expansion of the
adventitia
• Thickening of the aneurysm wall
• Fibrosis of the adjacent
retroperitoneum
• Rigid adherence of the adjacent
structures to the anterior
aneurysm wall
• ↗ ↗ ESR or abnormalities of other
serum inflammatory markers.
Chronic Peri Aortitis
• Retroperitoneal fibrosis
• Inflammatory AAA
• BOTH
Inflammatory AAA

6. Relevant lab results:
– CRP 83mg/l (Nl <5)
– ESR 100mm first hour
– Creatinine 1.4mg/dl
– ANA, C-ANCA, p-ANCA
negative
– Urine Cx negative
Double J stenting

7. Copyright © 2012 American Medical
Association. All rights reserved.
From: Inflammatory Abdominal Aortic Aneurysm
JAMA. 2007;297(4):395-400. doi:10.1001/jama.297.4.395

8. Treatment of I-AAA
• The aim of surgical
treatment is to prevent
rupture.
• Data suggest that an
inflammatory AAA is
less liable to rupture.*
• Intervention appears
prudent once the
diameter exceeds 5.5
cm.
*Lindblad B, Almgren B, Bergqvist D, et al. Abdominal aortic aneurysm with perianeurysmal
fibrosis: experience from 11 Swedish vascular centers. J Vasc Surg. 1991;13:231-239.

9. • Open repair for I-AAA remain a very
challenging surgery.
• Complication rates are still slightly higher
than atherosclerotic aneurysm*
• Over the past decade, outcome has
significantly improved with better knowledge
of the disease and some modifications of the
technique.*
* Hellmann DB, Grand DJ, Freischlag JA. JAMA 2007; 297(4):395-400
Inflammatory AAA
*Lindblad B et al. J Vasc Surg. 1991;13:231-239.

10. • EVAR recently reported to
adequately exclude the I-
AAA and reduce the size
of the sac.
• Review of the Eurostar
data on I-AAA cases:
– No difference in technical
success in anatomically
suitable cases with ~90%
sac ↘
– No difference in Mortality
1.9 vs 2.2% (NS)
C. Lange et al, On Behalf of the EUROSTAR Collaborators: Results of Endovascular Repair of Inflammatory
Abdominal Aortic Aneurysms. A Report from the EUROSTAR Database Eur J Vasc Endovasc Surg 29, 363–370
(2005
Inflammatory AAA

11. C. Lange et al, On Behalf of the EUROSTAR Collaborators: Results of Endovascular Repair of Inflammatory
Abdominal Aortic Aneurysms. A Report from the EUROSTAR Database Eur J Vasc Endovasc Surg 29, 363–
370 (2005)

12. Procedural details and outcomes (Eurostar)
Inflammatory
52
Non-Inflammatory
3613
P-
Device related
Complications
6(11.5%) 261(7.2%) 0.16
Device Migration 0(0.0%) 48(1.3%)
Device Limb
Stenosis/occlusion
2 (3.9%) 9 (0.3%) 0.0005
IIA occlusion 13 (25.0%) 488 (13.5%) 0.01
Mortality<30d 1 (1.9%) 81 (2.2%) 0.66
C. Lange et al, On Behalf of the EUROSTAR Collaborators: Results of Endovascular Repair of Inflammatory
Abdominal Aortic Aneurysms. A Report from the EUROSTAR Database Eur J Vasc Endovasc Surg 29, 363–
370 (2005)

13. • This patient underwent
EVAR 2 days after bilateral
ureteral stenting.
• Zenith flex endograft was
used.
• No endoleaks on
completion.
• Still no or very little
excretion from the left
kidney.

14. EVAR for I-AAA: follow up
• Longest F/U in the
literature , favourable
reduction in periaortitis
and sac diameter
• Tech success 100%
• Sac reduction 89%
• PAF ↘ or resolved in
77% and the rest
unchanged.
• No endoleaks at F/U
• ! Hydronephrosis
persisted when it was
present.
Coppi G, et al. Inflammatory Abdominal Aortic Aneurysm Endovascular
Repair into the Long-Term Follow-Up. Ann Vasc Surg. 2010; 24(8):1053-9

15. • Trend toward lower mortality and complications in EVAR
for I-AAA is becoming solid; however is it enough?
• Hydronephrosis, does seem to respond less or SLOWER
to EVAR*;
I-AAA Preop Early Late
11 Patient 5 (45%) 4 (36%) 3 (27%)
*Van Bommel EF, et al. Persisitent chronic peri-aortitis (‘inflammatory aneurysm’) after AAA
repair: systemic review of the literature. Vasc Med 2008; 13 (4):293-303
Additional info on 11 patients from Eurostar

16. • Persistent PAF and hydronephrosis is a source
of morbidity and increased mortality.
• Substantial targets for success should include
the treatment of ureteral obstruction and
regression of periaortic fibrosis.
*Van Bommel EF, et al. Persisitent chronic peri-aortitis (‘inflammatory aneurysm’) after AAA
repair: systemic review of the literature. Vasc Med 2008; 13 (4):293-303

17. • Is EVAR a safer option for patients with peri-
aneurysmal fibrosis? The debate still stands.
• To balance this, available data suggests that
additional medical treatment should be
considered at an earlier stage with EVAR
EFH van Bommel et al. Persistent peroartitis after AAA repair: systematic review.
Vascular Medicine 2008; 13: 293–303

18. • Steroids therapy remain the backbone, with
objective evidence of improvement.
– Side effects of long term steroids
– Some patients may not respond
• Corticosteroid-sparing agents, such as
methotrexate, cyclophosphamide, and
azathioprine, have also been reported effective.
Hellmann DB, Grand DJ, Freischlag JA. Inflammatory Abdominal Aortic Aneurysm. JAMA
2007; 297(4):395-400.
I-AAA: medical therapy

19. I-AAA: medical therapy
• Chronicity of the PAF seems to
be important in the response:*
– Old vs Yong PAF
• Cell to Fibrosis ratio<1 tends to
respond less or slower
*Stella, A, et al. Postoperative course of inflammatory abdominal aortic aneurysms.
Ann Vasc Surg 1993; 7 (3): 229–238.
4 months F/U

20. • Our patient here was
initiated on steroid
– Initially 30mg daily
• Developped DM
• Azathioprine added at 3
months to reduced the
steroid
– 50mg daily
• Patient developed
neutropenia and UTI.
• Immunosuppressant
stopped. Steroids tapered
to 10mg and shortly after
stopped.
• Addition or alternative to
steroid therapy:
– Azathioprine
– Tamoxifen:*
• Anti-inflammatory
• Anti Oxidant
• Antiproliferative
• Cardioprotective effect
• No available guidelines to
help in the role or duration
of those agents
I-AAA: medical therapy
Van Bommel et al. Tamoxifen therapy for nonmalignant retroperitoneal fibrosis. Ann ntern Med
2006;144:101-106

21. PAF and urinary obstruction
• In 15-30 % of I-AAA
one or both ureters
could be involved
• Combination of renal
drainage to medical
therapy is important in
some cases*
• Poor responders may
have recurrent
hydronephrosis.
*Deleersnijder R, et al. Endovascular Repair of Inflammatory Abdominal Aortic
Aneurysms with Special Reference to Concomitant Ureteric Obstruction. Eur J Vasc
Endovasc Surg 2002: 24 (2):146-149
6 Months F/U

22. Evolution PAF & Ureteral Obstruction
Open vs Endo
EFH van Bommel et al. Persistent peroartitis after AAA repair: systematic review.
Vascular Medicine 2008; 13: 293–303

23. Follow up after I-AAA treatment
• Persistent PAF (no regression)
– 14% after open repair
– Up to 40% after EVAR (p<0.0001)
• Persistent Ureteral obstruction more frequent
after EVAR than after open repair (56% vs
32%, p=0.09)*
• Time to regression of PAF, at least 4-6 months.
*Amongs patients who had it; excluding those with ureterolysis.
EFH van Bommel et al. Persistent peroartitis after AAA repair: systematic review.
Vascular Medicine 2008; 13: 293–303

24. • EVAR offers reduced
perioperative morbidity and
mortality, specially in I-AAA.*
• Draw-back seems to be
higher persistent or slower
regression of PAF and
Ureteral obstruction
• Watchful waiting before
initiating medical therapy is
accepted after open repair
• May not be the case after
EVAR**
*Lindblad B et al. J Vasc Surg. 1991;13:231-239.
*Ockert et al, Long term outcome of operated I-AAA. Vascular 2006;14;206211
**EFH van Bommel et al. Vascular Medicine 2008; 13: 293–303

25. • Double J ureteral stents
were both replaced at 3
months.
• Right removed at 6 months
and the left at 10 months.
• CT at 1 year: no recurrence
of hydronephrosis
• Normal inflammatory
markers:
– ESR=10 (↘100)
– CRP=2.5 (↘83)
– Creat=1.1(↘1.4)
Pyeloureterography at 3 months
Duplex f/u at 3 years

26. • After EVAR
– Low threshold for urinary drainage (Stents or PNS)
– Early initiation of medical therapy (steroids,
Azathioprine, Tamoxifen, combinations) may balance
the higher post operative PAF.
• Most available data comes from registries and
retrospective studies. Still no clear cut
recommendation.
• ?Ground for a prospective study specifically
looking at I-AAA?
Follow up after I-AAA treatment

27. • Concerns:
– In this era of endovascular thrive, will surgeons
accept to randomize and subject anatomically
suitable patients to an open repair
– In the hands of new generation vascular
specialists, more exposed to EVAR, will we have
outcomes in I-AAA comparable to historical series
done by more experienced “open” surgeons.

28. In summary,
• EVAR is effective and safe for I-AAA
• Procedural success and aneurysm shrinkage
comparable to atherosclerotic aneurysms
• Both Retroperitoneal fibrosis and Ureteral
obstruction, when present respond
significantly less than with open repair
• Low threshold for ureteral drainage
• Early medical treatment may balance the
persistent RPF

29. The Cedars, February 2012

32. EFH van Bommel et al. Persistent peroartitis after AAA repair: systematic review.
Vascular Medicine 2008; 13: 293–303

33. • CT scan done 7 months in
this patient showed
significant reduction in
peria