The document discusses the evolution of abdominal aortic aneurysm (AAA) repair techniques from open surgical methods to endovascular aneurysm repair (EVAR), emphasizing changes in patient management and survival outcomes. It highlights the reduced operative mortality and complications associated with EVAR, while also noting higher long-term risks of reintervention and graft-related issues compared to open repair. Ultimately, the shift in surgical practices raises concerns about training and proficiency in traditional techniques amidst increasing complexity in open repairs.

1. Open Aneurysm Repair
in Endovascular Era
Dicky A.Wartono, MD
Harapan Kita National Cardiovascular Centre
Jakarta 2016

2. •Disclosure : none

3. %
year
AAA 2005 - 2010
EVAR
OPEN
Vascular Surgery – Bologna University

4. Abdominal Aortic Aneurysm
• diameter ≥30 mm
• >50% increased diameter
• 55 mm
• symptomatic
• >10 mm/year
2014 ESC Guidelines on the diagnosis
and treatment of aortic diseases

6. 2014 ESC Guidelines on the diagnosis
and treatment of aortic diseases

7. Ann Intern Med. 2005 Feb 1. 142(3):198-202
AAA Size and Estimated Risk of Rupture
Diameter (cm) Risk (%/y)
< 4 0
4-5 0.5-5
5-6 3-15
6-7 10-20
7-8 20-40
>8 30-50

8. Open Surgical Repair of AAA
• Up to 3-hour procedure
• Significant incision
• 20-30 minute cross-clamp
• 1–2 days in ICU, 7–14 day
hospitalization, 4–6 weeks
recovery time
• 5-10% operative mortality in
population based studies
• Contraindicated in many
patients

9. Endovascular AAA Repair
• 1-2 hours prosedure
• Limited incisions
• No hemodynamic consc
• Reduced morbidity
• Reduced blood loss
• Shorter hospital stay
• Earlier return to function

11. • In less than 3 decades, (EVAR) has been converted from an
escape procedure exclusively confined to high-risk patients to
a primary choice.
• Open surgery has increased in technical complexity in the new
endovascular era
• patients who are not anatomically suitable
• patients with EVAR failure
• conversion after stent-graft migration,
• persisting endoleak with aneurysm growth,
• stent-graft rupture, etc.)
• Higher surgical risks and raises new challenges
Systematic review and meta-analysis of the early and late outcomes
of open and endovascular repair of abdominal aortic aneurysm
P. W. Stather1, D. Sidloff1, N. Dattani1, E. Choke1, M. J. Bown1,2 and R.
D. Sayers1

12. %
year
AAA 2005 - 2010
EVAR
OPEN
Vascular Surgery – Bologna University

13. Is Open Surgery for AAA Repair
a Reason for Concern
in the EVAR Era?

14. Anatomical Aspects
• Aortic neck diameter
• Size + 15-20%
• Sufficient radial force
• Oversize - Kinking,
thrombus form, endoleak
• Aortic neck
• 10-15mm (landing zone)
• Normal appearance

15. Anatomical Aspects
• Aortic neck
angulation
•<60°

16. Anatomical Aspects
• Iliac Arteries
• Minimal calcification /
tortuosity
• No stenosis or mural
thrombus
• Sufficient diameter & length
• If external Iliac art. = landing
zone, internal iliac art. should
be embolised (???)

19. Mechanisms of Evar Failure and new surveillance strategies
The rationale behind updating our surveillance protocols post-EVAR to decrease
patient risks, as well as costs.
By Jill K. Johnstone, MD, anD Gustavo s. oDerich, MD
Endovascular Today FEbruary 2014

20. Decrease in total aneurysm-related deaths in
the era of endovascular aneurysm repair. J
Vasc Surg. 2009;49(3):543-550.
Conclusion: Since the introduction of EVAR, the annual number of deaths from intact and
ruptured AAA has significantly decreased. This coincided with an increase in intact AAA
repair after the introduction of EVAR and a decrease in ruptured AAA diagnosis and repair
volume.

21. Anatomical Aspects
• Aortic neck diameter
• Size + 15-20%
• Sufficient radial force
• Oversize - Kinking,
thrombus form, endoleak
• Aortic neck
• 10-15mm (landing zone)
• Normal appearance

24. -80-yo female. Known for AAA
-electromechanical dissociation required
mechanical resuscitation

26. An 84-yo female
rapidly growing aortoiliac aneurysm

28. Front
Markers
Back
Markers
Fenestrated Endograft n. 1 – April 2006
SMA
RRA
LRA
aft n. 1 – April 2006
Vascular Surgery – Bologna University
Iuxtarenal AAA and fenestrated endografts

29. Results of the United States multicenter prospective study evaluating the
Zenith fenestrated endovascular graft for treatment of JAAA
Oderich GS et al
JVS 2014 ; 60: 1420-8
• Graft successfully implanted 67/67
• Patent target vessels 100%
• Perioperative mortality 1.5%
• Endoleak Type I and III at discharge 0%

30. Open repair of juxtarenal aortic aneurysms (JAA) remains
a safe option in the era of fenestrated endografts
Knott AW et al.
JVS 2008; 47: 695-701
• Negative predictive factors of cardiac complications
- age > 78 years
- male gender
- hypertension
- previuos myocardial infarction
- diabetes
• Negative predictive factors of renal insufficiency
- prolonged operative time
- prolonged renal ischemia
• Negative predictive factors of pulmonary complications
- renal artery revascularization
- prior MI
Conclusions: pts with a combination of physiologic and anatomic risk factors identified
on multivariate analysis may benefit from fenestrated endograft repair

31. - Open surgey has been the gold standard but with high mortality and
morbidity rate; today in low surgical risk patients
- Standard EVAR with SF in JAAA with straight neck lenght ≥ 7 mm in
patients unfit for OR and FEVAR is safe and effective
- FEVAR the future gold standard ? Today in high surgical risk patients and
hostile abdomen without large JAAA
- Ch-EVAR, initially used as a bailout procedure or in acute JAAA, gained
interest in centers where FEVAR was not yet available or reimbursed or in
patients unfit for OR with large JAAA

32. Anatomical Aspects
• Aortic neck
angulation
•<60°

33. http://ars.els-cdn.com/content/image/1-s2.0-
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http://ars.els-cdn.com/content/image/1-s2.0-
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34. Conclusion
Choosing flexible stent-graft system and various
alternative techniques may make the difficult cases
feasible, and achieve an encouraging early outcome.
Further long-term randomized studies are needed to
confirm the safety and durability of EVAR in patients
with hostile anatomy.
BMC Surgery (2015) 15:20 DOI 10
.1186/s12893-015-0005-5

35. Eur J Vasc Endovasc Surg (2015) 49, 19e27
Mid-Term Results of EVAR in Severe Proximal Aneurysm Neck
Angulation

36. Eur J Vasc Endovasc Surg (2015) 49, 19e27
Mid-Term Results of EVAR in Severe Proximal Aneurysm Neck
Angulation

37. Mid-term outcome and freedom from neck-related reinterventions were not
influenced by the severity of proximal neck angulation.
Aortic neck remodeling occurred more significantly in patients with adverse neck
anatomy but angulation changes were not marked and did not modify
significantly during follow-up
Eur J Vasc Endovasc Surg (2015) 49, 19e27
Mid-Term Results of EVAR in Severe Proximal Aneurysm Neck
Angulation

38. Anatomical Aspects
• Iliac Arteries
• Minimal calcification /
tortuosity
• No stenosis or mural
thrombus
• Sufficient diameter & length
• If external Iliac art. = landing
zone, internal iliac art. should
be embolised (???)

40. A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment
of aneurysmal extension to the iliac bifurcation
( J Vasc Surg 2012;55:956-62.)
N : 260

42. Is Open Surgery for AAA Repair
a Reason for Concern
in the EVAR Era?

43. Costin JA, Watson DR, Duff SB, Edmonson-Holt A, Shaffer L, Blossom GB.
Evaluation of the complexity of open abdominal aneurysm repair in the era of endovascular
stent grafting. J Vasc Surg. 2006;43(5):915-920.

44. Evaluation of the complexity of open abdominal aneurysm repair in the era of
endovascular stent grafting. J Vasc Surg. 2006;43(5):915-920.

45. Evaluation of the complexity of open abdominal aneurysm repair in the era of
endovascular stent grafting. J Vasc Surg. 2006;43(5):915-920.
Conclusions: Octogenarians can tolerate OAR with acceptable rates of
perioperative mortality and morbidity. Although the complexity of OAR has
increased significantly in the era of EVAR, the perioperative outcome has not
changed.

46. Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic
aneurysm
P. W. Stather1, D. Sidloff1, N. Dattani1, E. Choke1, M. J. Bown1,2 and R. D. Sayers1
1 Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, and 2 Leicester National Institute
for Health Research Cardiovascular Biomedical Research Unit, Leicester, UK
Correspondence to: Mr P. W. Stather, Vascular Surgery Group, Department of Cardiovascular Sciences, University of
Leicester, Leicester LE2 7LX, UK (e-mail: pws7@le.ac.uk)

48. Conclusion
There is no long-term survival benefit for patients who have
EVAR compared with open repair for AAA. There are also
significantly higher risks of reintervention and aneurysm
rupture after EVAR.
Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic
aneurysm
P. W. Stather1, D. Sidloff1, N. Dattani1, E. Choke1, M. J. Bown1,2 and R. D. Sayers1
1 Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, and 2 Leicester National Institute
for Health Research Cardiovascular Biomedical Research Unit, Leicester, UK
Correspondence to: Mr P. W. Stather, Vascular Surgery Group, Department of Cardiovascular Sciences, University of
Leicester, Leicester LE2 7LX, UK (e-mail: pws7@le.ac.uk)

49. N Engl J Med. 2010 May 20;362(20):1863-71. doi: 10.1056/NEJMoa0909305.
Epub 2010 Apr 11.
Endovascular versus open repair of abdominal aortic aneurysm.
United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, Powell JT,
Thompson SG, Epstein D, Sculpher MJ.

50. - EVAR was associated with a lower operative mortality
- However, no differences in total mortality or aneurysm-related
mortality
- In the long term
EVAR was associated with increased rates of :
- graft-related complications
- reinterventions
N Engl J Med. 2010 May 20;362(20):1863-71. doi: 10.1056/NEJMoa0909305.
Epub 2010 Apr 11.
Endovascular versus open repair of abdominal aortic aneurysm.
United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, Powell JT,
Thompson SG, Epstein D, Sculpher MJ.
cost

51. Knott AW, Kalra M, Duncan AA, et al.
Open repair of juxtarenal aortic aneurysms (JAA) remains a safe option in the era
of fenestrated endografts. J Vasc Surg. 2008;47(4):695-701

52. Open abdominal aortic aneurysm repair in the
endovascular era: effect of clamp site on outcomes.
Landry G, Lau I, Liem T, Mitchell E, Moneta G.
Arch Surg. 2009;144(9):811-816.
Suprarenal cross-clamping is associated with increased rates of
complications but similar mortality rates
With the disappearance of straightforward open aneurysm repair,
trainees in vascular surgery will have to learn AAA repair almost
exclusively by operating on patients with complex AAAs.
Fewer surgeons will perform these repairs, and fewer fellows will be
able to complete the operation independently immediately after
training

53. Perioperative outcomes for elective open abdominal aortic aneurysm
repair since the adoption of endovascular grafting procedures. Eur J Vasc
Endovasc Surg. 2011;42(2):178-184.

54. Perioperative outcomes for elective open abdominal aortic aneurysm
repair since the adoption of endovascular grafting procedures. Eur J Vasc
Endovasc Surg. 2011;42(2):178-184.

55. Although the number of more complex OAR procedures increased in the EVAR era,
- the morbidity rates in the two groups were less effect on the perioperative outcome
than OAR in the EVAR era.
- OAR remains a valid procedure for AAA repair.

56. Is Open Surgery for AAA Repair
a Reason for Concern
in the EVAR Era?

57. Choosing the best management of AAA for individual pts.
Cronenwett JL – Lancet 2005;365:2156

58. Choosing the best management of AAA for individual pts.
Cronenwett JL – Lancet 2005;365:2156

60. 8mm Graft
Splenic
Anastomosis

62. Combined open and endovascular treatment of thoracoabdominal aortic pathologies: a
systematic review and meta-analysis
Konstantinos G. Moulakakis1,2, Spyridon N. Mylonas1, Constantinos N. Antonopoulos1,
Christos D. Liapis1
1Department of Vascular Surgery, Athens University Medical School, Attikon University
Hospital, Athens, Greece; 2The Systematic Review Unit, The Collaborative Research
(CORE) Group, Sydney, Australia

63. Success rate
Viceral Patency Rate

64. SCI rate
CRF rate
30d Mortality

66. • Hybrid procedures have several advantages over conventional open
repair
• avoiding thoracotomy,
• single-lung ventilation,
• aortic cross-clamping,
• minimizing end-organ ischemia
• the hybrid technique is still associated with
• a considerable morbidity and mortality rate.
• have a role in those patients anatomically unsuitable for fenestrated and side
branched endografts.
• good option for elderly, high-risk patients
• should be reserved for high volume centers with accumulated experience and
high standards of perioperative management
• further concern is the durability and long-term outcome which is
related either to endograft complications

67. Conclusion
• Despite the advantages of EVAR, open surgical repair skill
remains a valuable choice for AAA treatment also in the post-
EVAR era.
• The noteworthy shift in trends and complexity of AAA repair for
open surgery in this new EVAR era is supported by a number of
studies and may raise issues of concern
• One of the main advantages of current safety in performance of
both EVAR and open surgery for AAA is to allow the use of one
or the other technique as alternative (but not competitive)

68. THANK YOU