Newest Advances in the Treatment of Aortic Aneurysms

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Newest Advances in the Treatment of Aortic
Aneurysms

• Mark D. Gonze MD FACS
• Upper Chesapeake Health
• Chief Division of Vascular Surgery
• CoDirector Cardiovascular Institute
• Surgical Director Wound Center
• St. Joseph Medical Center
• Chief Division of Vascular Surgery

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• Ruptured Aortic Aneurysm

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Abdominal Aortic Aneurysm

• 36.2/100,000 rate in USA
• 50, 000 surgeries yearly
• 16,000 deaths in men gt55

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Abdominal Aortic Aneurysm

• Incidence
• Incidence increasing (mainly small AAA)
• Symptomatic AAA?
• Ruptured AAA ?

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Abdominal Aortic Aneurysm

• Etiology
• 15 family history
• reduced type 3 collagen
• Marfans
• Ehlers danlos
• proteolytic enzymes
• collagenase, elastase
• infections
• bacterial, syphilis

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Abdominal Aortic Aneurysm

• What size is an aneurysm
• 1991 SVS/ISCVS localized dilation of the aorta
  with 50 increase diameter compared to normal (3
  cm)

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Abdominal Aortic Aneurysm
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Abdominal Aortic Aneurysm
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Abdominal Aortic Aneurysm

• Aneurysm Complications
• thrombosis
• infection
• mass effect
• fistula
• enteric
• caval
• RUPTURE

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Abdominal Aortic AneurysmRisk of Rupture

• lt4.0 cm rare
• 4.0-5.0 cm 0.5-5
• 5.0-6.0 cm 3-15
• 6.0-7.0 cm 10-20
• 7.0-8.0 cm 20-40
• gt8.0 cm 30-50

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Abdominal Aortic AneurysmWho should be repaired?

• All symptomatic AAA
• All saccular AAA
• Size gt 6 cm, poor risk patients
• Size gt 5 cm, good risk patients
• Size 4.5-5 cm, young (lt60 yo) excellent risk
  patients

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Abdominal Aortic Aneurysm

• Aneurysm detection and management (ADAM) VA study
  group
• 1000 patients for 4.9 year follow-up
• No immediate survival advantage for early surgery
  (AAA 4-5.4cm)
• 81 patients with AAA 5.0-5.4 eventually
  underwent surgery

N ENGL J MED 20023461437-44
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Guidelines for the treatment of abdominal aortic
aneurysm

• No single threshold value
• Early surgery is comparable to surveillance and
  late surgery for sizes 4.5-5.5 cm
• Women 4.5-5.0 cm
• Endovascular aneurysm repair does NOT change
  indications for surgery

J VASC SURG 2003371106-17
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Abdominal Aortic Aneurysm

• Increase risk of rupture
• COPD
• Tobacco abuse
• Hypertension
• Marfans Syndrome
• Rapid growth (gt1 cm/year)

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Abdominal Aortic Aneurysm

• Goals of aneurysm surgery
• prevent rupture
• prolong life

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Abdominal Aortic Aneurysm

• Patient selection
• aneurysm rupture risk
• elective operative mortality risk
• life expectancy
• patient preference

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Abdominal Aortic Aneurysm

• Preoperative Evaluation
• Cardiac Risk Stratification
• Low risk (active, no risk factors)
• Minimal evaluation
• Moderate risk (mild symptoms, sedentary life)
• Stress test
• High risk (CHF, Class III, IV angina)
• Heart catheterization

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Abdominal Aortic Aneurysm

• Surgical approaches
• transperitoneal
• retroperitoneal

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Abdominal Aortic Aneurysm
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Abdominal Aortic Aneurysm

• Vascular Control
• Opening aneurysm

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Abdominal Aortic Aneurysm

• Open Repair
• Vascular Control

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Abdominal Aortic Aneurysm

• Evacuation of
• mural thrombus

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Abdominal Aortic Aneurysm

• Bypass grafts
• Dacron
• PTFE
• Cadaver

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Abdominal Aortic Aneurysm
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Abdominal Aortic Aneurysm
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Abdominal Aortic Aneurysm

• Open Repair
• Aneurysm exclusion

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Abdominal Aortic Aneurysm
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Abdominal Aortic Aneurysm

• Aortobi-iliac graft
• Bypass to superior mesenteric artery

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Abdominal Aortic Aneurysm

• Open AAA Repair
• Mortality lt5
• Morbidity 15-30
• MI, pneumonia, DVT, infection, ileus
• Length of stay 6-10 days
• Recovery 1-2 months

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Abdominal Aortic Aneurysm

• Williamson et al.
• S/P Open AAA repair
• 33 not back to presurgical health 34 months
  after surgery
• 18 would not have undergone surgery

J VASC SURG 200133913-20
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Abdominal Aortic Aneurysm

• Endovascular
• Stent Grafts

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Aortic Endovascular Grafts

• Transfemoral intraluminal graft implantation for
  abdominal aortic aneurysms
• Parodi JC, Palmaz JC, Barone HD
• Ann Vasc Surg 1991 Nov 5 (6)491-9

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Aortic Endovascular Grafts

• Goals
• durable aneurysm exclusion
• less mortality and morbidity
• hospitalization
• length of stay
• quicker recuperation
• minimally invasive approach
• include high risk patients
• improve quality of life

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Aortic Endovascular Grafts

• Feasibility Studies
• Chuter, Green, Ouriel Rochester 1994
• Parodi, Criado, Barone Buenos Aires 1994
• Palmaz, Tio San Antonio1995
• May, White, Yu Sydney 1995

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Aortic Endovascular Grafts

• Ancure
• AneuRx
• Talent
• Excluder
• Cordis
• Montefiore
• Zenith

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Aortic Endovascular Grafts(AneuRx?)

• Medtronic/AVE
• FDA 11/99
• Modular configuration
• treatment broader spectrum of diseases
• customization to individual patients anatomy in
  vivo

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Aortic Endovascular Grafts(AneuRx?)

• Thin wall polyester graft
• External nitinol stent (Nickel-Titanium)
• 2000 hand sewn connections
• Radiopaque markers

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Aortic Endovascular Grafts

• Work-up (sizing graft)
• Ultrasound
• Abdominal CT
• Angiogram

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Aortic Endovascular Grafts
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Aortic Endovascular Grafts
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Aortic Endovascular Grafts(AneuRx?)

• Graft chosen based on CT and Angio measurements

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Endovascular Surgery

• OEC 9800 portable fluoroscopy unit

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Endovascular Surgery

• Meditech contrast injector

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Aortic Endovascular Grafts

• Anesthesia
• General
• Regional
• Local

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Aortic Endovascular Grafts

• Flouroscopy table

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Aortic Endovascular Grafts

• Bilateral femoral incisions
• Wire placement

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Aortic Endovascular Grafts(AneuRx?)

• 21 French delivery catheter

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Aortic Endovascular Grafts(AneuRx?)
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Aortic Endovascular Grafts(AneuRx?)
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Aortic Endovascular Grafts(AneuRx?)
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Aortic Endovascular Grafts(AneuRx?)
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Aortic Endovascular Grafts(AneuRx?)
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Aortic Endovascular Grafts(AneuRx?)
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Aortic Endovascular Grafts(AneuRx?)
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Aortic Endovascular Grafts

• Complications
• Access Site
• Device related
• Contrast induced
• Radiation exposure
• Conversion
• Long-term

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Aortic Endovascular Grafts

• Access site
• dissection
• pseudoaneurysm
• atheroembolism
• blood loss

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Aortic Endovascular Grafts

• Contrast induced
• nephropathy
• allergy (0.4-2)
• cortical blindness (0.3-1)

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Aortic Endovascular Grafts

• Radiation exposure
• surgical team
• patient

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Aortic Endovascular Grafts

• Conversion
• incidence
• risks
• prognosis

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Aortic Endovascular Grafts

• Longterm
• durability
• endoleak
• aneurysm expansion

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Aortic Endovascular Grafts

• Endoleak
• Type 1 (BAD)
• Proximal/distal attachment
• Type 2
• IMA, lumbar, median sacral, hypogastric
• Type 3
• transgraft blush
• Type 4 (BAD)
• tear fabric

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Endovascular Aneurysm RepairPoor Patient
Selection
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Endovascular Grafts

• PATIENT Follow-up
• Contrast CT Scan
• 1 month
• 6 month
• 12 month
• Yearly
• (KUB Yearly)

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Aortic Endovascular Grafts

• Savings?
• Reduced hospitalizations
• Reduced ICU needs
• Reduced metabolic stress
• Preserved nutritional function
• Shorter recuperation time

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Endovascular Aneurysm Repair

• PATIENT SELECTION
• is the best way to reduce risk of late rupture

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Abdominal Aortic AneurysmConclusion

• Disease process with increasing incidence
• High risk groups (male, gt65, smokers, family
  history)
• Serial ultrasound
• Open vs endovascular repair

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Aortic Endovascular Grafts(AneuRx?)