16. 16Schanzer A - Circulation 2011;123:2848
EVAR – Instructions for use (IFU)
17. 17Schanzer A - Circulation 2011;123:2848
Aneurysm sac enlargement following EVAR
conservative IFU liberal IFU date of implantation
n = 10.228 (1999-2008)
AAA Ø < 55 mm 59 %
Conservative IFU 42 %
Liberal IFU 69 %
Sac enlargement at 5 yrs 41 %
18. 18Wyss TR – Ann Surg 2010;252:805
Complications following EVAR
n = 848 (EVAR 1 & 2) mean F-U 4.8 a
Late rupture: 27 (3 % - mortality 67 %) Crude rate 0.7/100 pt.yr
HR complication/rupture: 8.83 (p<0.0001)
19. 19
CAESAR trial – Surveillance vs small AAA repair
AAA 4.1 to 5.4 cm - n=360 – f-u 54 months
Cao P – Eur J Vasc Endovasc Surg 2011;41:13
24. 24
Lesperance K - JVS 2008;47:1165
National Inpatient SampleMedicare Inpatient Database
Mureebe L - JVS 2008;48:1101
Visser JJ - Radiology 2007;245:122
EVAR for ruptured AAA - mortality
Review - n=478 - EVAR vs OPEN = 22% vs 38%
25. 25
Diagnosis: rAAA
permissive hypotension, no intubation, sonography
OPEN
EVAR suitable & available
EVAR
CTA
no yes
Stable hemodynamicsUnstable hemodynamics
Treatment algorithm for ruptured AAA
26. 26
Consideration
for repair
Assessment of fitness Assessment of morphology
Fit for repair
optimisation Standard
AAA repair
OPEN or EVAR
Transabdominal
Unfit for repair
optimisation
Fit
Unfit for
OPEN or EVAR
Manage conservatively
Suitable for
EVAR
Not suitable for
EVAR
Custom Open Laparoscopic
Retroperitoneal
Patient preference
Center preference
> 8cm
urgent
Guidelines from the European Society for Vascular Surgery – EJVES 2011;41:S1
Treatment algorithm for unruptured AAA
27. 27
Choosing the best management of AAA for individual pts.
Cronenwett JL – Lancet 2005;365:2156
28. 28
Conclusions
The anatomical suitability for EVAR is a proxy for
subsequent complications and potential aneurysm-
related mortality
The rate of re-intervention continues to increase with
time regardless of the device
The compliance with EVAR device guidelines is far too
liberal (demand & supply, profiling, curiosity,
industrial interests)
Patients with acceptable operative risk and longer
life-expectancy are the best candidates for open
repair
29. 29
Conclusions
High-risk patients with marginal anatomical suitability
or short life-expectancy will not benefit from EVAR
Early repair of small aneurysms gives no substantive
advantage over surveillance
The promising results of EVAR for ruptured AAA are
not fairly conclusive because of the heterogenity of
the cases and significant logistic limitations
Whilst the overall management of abdominal aortic
aneurysms has undoubtedly benefited from the
introduction of stent-grafts, open repair currently
remains the gold standard treatment
Editor's Notes
There was no significant difference in cumulative mortality for open vs endovascular repair (hazard ratio, 0.7; 95% confidence interval, 0.4-1.1; log-rank P = .13).
Kaplan-Meier curve of survival free of death or reintervention after open surgical repair (OSR) or endovascular aneurysm repair (EVAR).
Kaplan–Meier estimates for time to first cardiovascular event stratified by randomised group.
Multiple correspondence analysis (MCA); the original variables are represented in a space defined by factorial axes, which are characterized by a percentage of inertia (i.e. the amount of total variability explained by the axis itself). The distance between points indicates the dissimilarities between categories, while categories that plot close to each other are statistically related and are similar with regard to the pattern of relative frequencies.12 COPD, chronic obstructive pulmonary disease.
Hilpold, Hermann – 04.08.33
Aortic aneurysm sac freedom from enlargement after endovascular aortic repair stratified according to (A) conservative instructions for use (IFU), (B) liberal instructions for use, (C) time-dependent instructions for use, and (D) year of procedure performed before or after January 1, 2004.