Abdominal Aortic Aneurysm and

Peripheral Disease

순천향대학교 부천병원 흉부외과학교실

원 용 순

Contents AAA

General consideration Randomized Control Trials Comparing EVAR and Open AAA repair (OAR) Patient selection criteria for EVAR EVAR procedure Complications of EVAR ; endoleak Experience of SCHBC

Peripheral Disease ACA/AHA Practice Guideline Classification of peripheral arterial disease (PAD) Endovascular procedure Experience of SCHBC

Conclusions

Endovascular Treatment of AAA

; EndoVascular Aneurymal Repair : EVAR

Parodi JC, Palmaz JC, Barone HD.Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.

Ann Vasc Surg 1991;5:491-499

• Stent-graft design incorporating both

limited and adjustable dimensional

variability for maximum versatility. The

fixed attachment points on the left have

limited linear variability, whereas the

adjustable fixation points on the right

result in increased adaptability

• Modular endovascular bifurcation prosthesis including main bifurcation segment (A), contralateral leg (B), proximal aortic cuff (C), iliac cuff (D), and bifurcated (E) or straight (F) extenders. CTA, computed tomography-angiography; DSA, digital subtraction angiography

Dutch Randomized Endovascular Aneurysm

Management (DREAM) trial

• Between Nov. 2000 and Dec.2003, Netherlands

• 351 patients ( > 5cm AAA, suitable for both OSR and

EVAR )

• OSR = 174 pts vs. EVAR = 171 pts

• Primary end point – operative mortality & moderate or

severe complications NEJM 2004;351:1607-1618

DREAM trial

NEJM 2004;351:1607-1618

DREAM trial

NEJM 2004;351:1607-1618

Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1) : randomised controlled trial

Sept. 1999 ~ Dec. 2003, UK

1082 patients

> 60 years, > 5.5cm AAA

AAA was regarded as anatomically suitable for EVAR

OSR = 539 pts vs. EVAR = 543 pts

to assess long term survival, generalisability, graft durability, health-related

quality of life (HRQL), and hospital costs associated with both EVAR and OS

R

Lancet 2005 ; 365 :2179 - 86

EVAR trial 1

Lancet 2005 ; 365 :2179 - 86

EVAR trial 1

Lancet 2005 ; 365 :2179 - 86

Patient selection criteria for EVAR

Fusiform AAA ≥ 5 ~ 5.5cm in diameter

Saccular AAA Suggested aortic morphology

Proximal neck length ≥ 1.5 cm Neck diameter ≤ 2.8 cm Neck angulation ≤ 60 degrees Preservation of critical side branches Iliofemoral arteries of sufficient diameter for sheath access No severe iliac artery or aortic tortuosity

No hereditary connective tissue disorder Anesthesia clearance for possible conversion to open repair if necessary

Proximal neck length ≥ 1.5 cmNeck angulation ≤ 60 degrees

Fusiform AAA ≥ 5 ~ 5.5cm in diameter or Saccular AAA

Preservation of critical side branches

Iliofemoral arteries of sufficient diameter for sheath access

Patient selection criteria for EVAR

No severe iliac artery or aortic tort

uosity

EVAR procedure

Preop. CT angiography

EVAR procedure

EVAR procedure

Postop. CT angiography

Endoleak Type I, II, III, IV, V

Migration

Kink, Stenosis, and Occlusion

Graft infection

Rupture

Complications of EVAR

Endoleak

Type I : a leak between the stent-graft and the proximal or dist

al arterial wall attachment site

Type II : back-bleeding into the aneurysm sac from a patent inf

erior mesenteric (IMA), lumbar, internal iliac, accessory renal or g

onadal artery

Type III : between stent-graft components (e.g. the junction bet

ween the main body and limb of a device) or through a hole in the

fabric of the graft

Type IV : excessive graft porosity

Type V (endotension) : when the sac increases in size with

out a detectable endoleak

Endoleak

Types of Endoleaks

II

III

I

I

IV

Result of Endoleak1. Many type II endoleaks undergo resolution by sponta

neous thrombosis

2.

Frank J. Veith et al. J Vasc Surg 2002;35:1029-35Nature and significance of endoleaks and endotension: Summary of opinions expressed at an international conference

Christopher K. Zarins et al. J Vasc Surg 2000;32:90-107 Endoleak as a predictor of outcome after endovascular aneurysm repair: AneuRx multicenter clinical trial

Result of Endoleak

Timothy Resch et al. J Vasc Surg 1998;28:242-9Persistent collateral perfusion of

abdominal aortic aneurysm after

endovascular repair does not lead to

progressive change in aneurysm

diameter

Experience of SCHBC- EVAR for AAA

Feb, 2008 to May, 2009 13 patients (M : F = 11 : 1) Mean age : 70.54 (54 – 82) Aneurysm size : 56.23mm (32-76.3mm)

Ruptured : 1 Impending rupture : 2 unruptured : 10

296 211

1520

550

8.2

0.7

60.86

20.2

21.8716

Op.time(min)

bleeding inOp(cc).

transfusion(pack)

ICU stay(hr) Hosp.stay(day)

OREVAR

Complication OR EVAR

Wound problem 3/15(20%) 1/13(8%)

Pulmonary Cx. 2/15(13%) 0/13(0%)

G-I complication 1/15(6%) 1/13(8%)

Acute thromboembolism 1/15(6%) 0/13(0%)

Mortality : 2/15(13%) in OR

1/13(8%) in EVAR

EVAR and OR in SCHBC

P<0.05

Experience of SCHBC- Endoleak

Endoleak : 6/13 (46%) type I : 2 ( Ia, Ib) type II : 2 type III : 2

Result of endoleaks type II & type III : improved, 2wks, 3mths Other

loss : 1 Follow up : 2

Mortality : 1 (type Ia endoleak)

Peripheral Arterial Disease(PAD)

ACA/AHA Practice Guideline

Iliac lesion

TransAtlantic Inter-Society Consensus (TASC) Working Group

Femoral popliteal lesion

TransAtlantic Inter-Society Consensus (TASC) Working Group

ACA/AHA Practice Guideline – Endovascular treatment for Claudication

Recommandations Endovascular procedure is the treatment of choice for type A lesio

ns in iliac or femoral popliteal lesions

More evidence is needed to make firm recommendations about t

he type B and C lesions

Primary stent placement is not recommended in the femoral, popli

teal or tibial arteries

Subintimal Angioplasty (SI-PTA)

(A) The occlusion is approached away from a collateral

(B) The catheter/guidewire is advanced through the subintimal space, enabling it to take the path of least resistance

(C) The catheter is retracted back and the guidewire is manipulated into a wide loop

(D) The loop is advanced forward until it re-enters the true lumen

A schematic diagram to show the subintimal recanalization procedure

Semin Vasc Surg1995;8:253-264

Endovascular procedure

Endovascular procedure

Experience of SCHBC

July, 2007 to May, 2009 16 patients (M : F = 14 : 2) not suitable for bypass surgery

Anesthesia, poor run off or more peripheral lesion Mean age : 65.2 (47 – 77) Lesions

Iliac : 6 Femoropopliteal : 7 Combine : 3

Stent insertion : 14

Experience of SCHBC

ABI follow up (POD # 7) Pre PTA (mean) : Post PTA = 0.44 : 0.94

Post PTA amputation of extremities 2 pts (2nd toe Rt., BK amputation both)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Pre PTA Post PTA

12345678910111213

P =0.009

Conclusions EVAR is a effective and feasible procedure in patients at low surgi

cal risk as well as at high risk

In randomized studies, EVAR is superior to the open repair at shor

t-term and midterm results

In SCHBC experience, perioperative results in EVAR are more acc

eptable than them of open repair

Conclusions

Endovascular procedure is an another option in

treatment methods of patient with PAD

Endovascular procedure, especially, is more effective

and feasible in PAD patients with high surgical risk,

poor run off and more peripheral lesions

More research is needed to make sure of the effects of

endovascular procedure for patients with PAD

Thank you for your

attention!