CASE PRESENTATION

2010-04-30R3 이진영

CASE 10051133 이준범 72/M

C.C: known abdominal aortic aneurysm with thrombus 로 본원 심장 내과 F/U 중 1year F/U CT image 상 AAA diameter 6cm -> 6.8cm 증가된 소견 본과에 stent graft 위해 의뢰됨 .

PMHx: COPD unstable angina & CVA

Aneurysm Definition

Abnormal dilation or bulging of artery > 50% of the normal segment Aortic diameter > 3 cm

Incidence: 6-9% over age 70 (4-8% men, 1% women)Causes: HTN, athrosclerosis, infection, trauma, connective tissue disorders, other

Risk Factors: increased age, smoking, male,

family hx, HTN, hyperlipidemia

Abdominal aortic aneurysmClinical Challenge

Often asymptomatic “silent killer”

40% w/ ruptured AAA die before ER

10-25% of ruptured AAA survive to discharge

Operative mortality rates of ruptured AAA: 40% (vs 5% w/ elective re-

pair)

Treatment Tx need related to size linked to rupture Size and rupture risk

Tx indication• Elective Repair >5 cm• Additional factors:

– >0.5cm increase in 6 months– Pain/tenderness– Thromboembolic complications

Abdominal aortic aneurysm

Goal of endovascular repair Elective repair associated w/ lower morbidity/mortality, especially for sicker pts Less invasive, decreased bl. loss Shorter hospital stays

Indication Emergency

• Rupture, sx, rapidly expanding aneurysm Elective

• Fusiform an. 5.0cm in diameter• Saccular an. twice diameter of normal infrarenal ao.• Uncontrolled HTN, living in remote area• Progressive enlargement on imaging • High risk patients

Abdominal aortic aneurysm

Prestent graft AAA measurement

Iliac artery 20% of AAA: iliac artery aneurysm W/O severe tortuosity, significant aneurysmal or occlu-

sive dzs

18-28mm

15mm

>18 mm

Device of endovascular repair of AAA Stent Grafts- metal stents covered w/ ma-

terial to exclude aneurysm Unsupported portion with metal stent -only the prox. and distal attachment site Variable configuration• Bifurcated endografts: unibody or modular

4 grafts FDA approvedA. Medtronic: AneuRx

B. Gore: ExcluderC. Cook: ZenithD. Endologix: Powerlink

Modular stentgraft deployment

AneuRx U.S. Clinical Trial4 Year Experience

(n = 1192)

Incidence: #Overall mortality 10.0 % 119

30 day 2.0% 23Aneurysm related 0.7 % 9Non-aneurysm 7.3% 87

Surgical conversion 2.8 %Secondary procedures 8.0 %

J Vasc Surg 2001;33:S135-45

N Engl J Med 2004;351:1607-18.

REFERENCE

Aortic stentgrafts and en dovascu-lar

abdominal aortic aneurysm repair CME July 2007 Vol.25 No.7 STEVE BENING-

FIELDClinical Decision Making for Endovas-

cularRepair of Abdominal Aortic AneurysmCirculation 2004;110;e517-e523

Screening guideline ultrasound screening

Abdominal aortic aneurysm

Exclusion criteria for endovascular repair ofabdominal aortic aneurysm

• Extensive aortic neck thrombus

• Aortic bifurcation diameter <18 mm

• Bilateral common iliac aneurysm requiring coverage of both hypogastric arteries

• Essential accessory renal artery