Endovascular Aneurysm Repair

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Endovascular Aneurysm Repair
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The TeamDr Suresh Babu FRCP FRCRMr Stanley
Harry Silverman MD FRCSMr Philip Thomas Nicholl
FRCSDr Mark Stephen Moss FRCRDr John Francis
Leahy FRCR
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3A

• Rupture or Distal Embolism
• 90 Mortality after Rupture

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Size does not Matter

• 5cm
• Smaller if tender, abdo or back pain, distal
  embolisation, rapid growth or women

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Team

• IR
• Vascular Surgeon
• Anaesthetist
• Radiographer
• Scrub Nurse
• Theatre Assistant
• Coordinator

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Preop Work-up

• Screened from U/S
• CTA
• Angiogram
• MRA

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• Good
• Possible
• Difficult
• Impossible
• Fenestrated or Branch Grafts

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Cost

• 4500
• No ICU stay
• 2-3 inpatient days
• Back to work ASAP
• Life Long Follow-up CT/US
• Reinterventions

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EndoLeak

• Type I Attachment site leak
• Type II Branch to Branch
• Type III Device Dehiscence
• Type IV Graft Porosity
• Type V - Endotension

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Evidence
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EVAR 1

• EVAR 1 trial at a median follow-up of 35 months
  reported an aneurysm rupture rate of 0.9 (5/543)
  following endovascular repair, compared with 0.2
  (1/539) following open repair

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EVAR 1

• 16 (85/529) of patients required secondary
  intervention following stent-graft placement,
  compared with 7 (36/519) of patients following
  open repair

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EVAR 2

• EVAR 2 trial reported that at 4 years, 26 of the
  group who had had stent-graft placement had
  required at least one intervention compared with
  4 of the group who had received standard medical
  care. However, if crossovers are considered a
  secondary intervention, then the secondary
  intervention rate in the group who received
  standard medical care became comparable
  (approximately 30).

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RCT

• three RCTs, stent-graft placement was associated
  with a 30-day mortality rate of 2 (12/759
  patients) compared with 5 (33/709 patients) for
  open repair

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Test

• Europe Vascular Database UK Higher
  Mortality Aortic Surgery Sept 2007

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Hypothesis

• Failure to put Mortality through
• Operating on high risk Patients
• Lack of choice between EVAR and Open
• Technical
• ICU support
• Comorbidities in Patient Population or Lack of
  Will to live
• Weather/Water

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