EpidemiologyAge:

5-7% of population 60+yrs age US: reported incidence of 5-7%

Mean age 70-75yrsSex:

M:F = 1.6-4.5:1Race:

White M > Blacks M White F = Black F

Mortality/Morbidity: Grows ~0.4 cm/year 75% mortality (upon rupture)

13th leading cause of death in the US (~15,000 deaths per year) Overall mortality 0.9%-5% after repair Rupture is based on size

Pathophysiology & Risk FactorsAtherosclerosisElastinWall StructureGeneticsSmoking

Brady AR, Thompson SG, Greenhalgh RM, et al. Br J Surg 90:492, 2003.

90% had smoking historyOthers: HTN, infection, trauma, arteritis,

cystic medial necrosis, Marfan Syndrome, Ehlers-Danlos Syndrome

Symptoms and Signs Asymptomatic

Inflammatory AAA may cause back pain Pulsatile abdominal mass

Mid-abdomen just above and left of the umbilicus

Lederle FA, Wilson SE, Johnson GR, et al. N Engl J Med 346:1437, 2002.

Ruptured AAA Triad (50%):

1. Sudden onset abdominal pain2. Pulsatile mass3. Hypotension

ImagingIncidental, ultrasound, CT angiogram and angiogram

Diagnosis Physical exam

◦ Firm, pulsatile abdominal mass◦ Overall sensitivity of 52%

Sensitivity increases with diameter 29% for 3.0 to 3.9cm 50% for 4.0-4.9 cm 76% for > 5.0 cm

◦ Extension into iliac arteries is not appreciated

X-ray◦ About 70% of cases◦ Characteristic eggshell pattern of

calcification◦ Accurate determination of size difficult◦ Negative AXR does NOT rule out diagnosis

Ultrasound◦ Most widely used noninvasive test◦ Provides structural detail of vessel wall ◦ Can accurately measure the size in

longitudinal and cross sectional directions◦ Advantages

Noninvasive, low cost, wide availability Good for initial evaluation or pts, screening

and surveillance

Diagnosis CT

◦ Most precise test for imaging AAA◦ Can identify

Proximal and distal extent of aneurysm, including thoracic portion

Occlusive aneurysmal disease Presence of multiple and

accessory renal arteries Seize of aortic lumen, amount of

thrombus, and presence of calcific disease

MRI◦ Imaging of choice for patients with

renal insufficiency◦ High quality images of aorta◦ However, less sensitive in

identifying accessory renal arteries or renal artery stenosis

Arteriography◦ Reliable information on size of

aortic lumen and branch vessel disease

◦ However, due to thrombus, aortic lumen is near normal in size so inaccurate assessment of size or aneurysm

◦ Helpful for assessment of associated arterial disease in pre-op eval

Screening SVMB/SVS/AAVS (2004)

Kent KC, Zwolak RM et al: Screening for abdominal aortic aneurysm: a consensus statement. J Vasc Surg 39(1):267, 2004

Men: Recommends for screening in all men age 60-85 years Women: Recommends for screening in women age 60-85 years with a family

history of AAA

USPSTF (2005)

Men: Recommends for screening in men age 65-75 years who have ever smoked. Recommends against screening in men age 65-75 years who have never smoked

Women: Recommends against screening in all women

ACC/AHA (2006)

Men: Recommends for screening in men age 65 years or older who have ever smoked. Recommends for screening in men age 60 or older with a family history of AAA

Women: None

Screening for Aneurysms4 randomized trials of AAA screening have been

performed◦ Reduction in AAA related mortality ranging from 21-

68%◦ Reduction in AAA rupture ranging from 45-49%

Multicentre Aneurysm Screening Study◦ >70,000 men screened between ages of 65-74◦ Aneurysms >5.5 cm referred for repair◦ After 4 years there was 42% reduction in AAA related

deaths in the screened groupSociety for Vascular Surgery screening

recommendations◦ Baseline ultrasound screening for AAA in

Men 60-85 Women 60-85 with cardiovascular risk factors Men and women older than 50 with a family history of AAA

◦ Yearly ultrasound for AAA 4.0-4.5cm◦ Ultrasound every 6 months for AAA larger than 4.5cm

AAA Expansion and RuptureAverage growth rate: ~0.4cm per year

Factors: BP, size at detection, COPD

Size is the best determinant of rupture40% of untreated aneurysms 5.5-6cm or larger

will rupture within 5 yearsAverage survival without treatment: 17

months Lederle FA et al. JAMA 2002;287:2968.

Rupture Repair – EVAR is superior

30 day mortalityEVAR 19%, Open 47%

LOSEVAR 6, Open 18.5

D/C to homeEVAR 55%, open 20%

Major complicationEVAR 36%, Open 80%

OR timeEVAR 3 hours, Open 4.5 hours

Blood lossEVAR 200 cc, Open 4 liters

TreatmentJoint Council of the American Association for Vascular Surgery and

Society for Vascular Surgery (Brewster DC, Cronenwett JL, Hallett JW, et al. Vasc Surg 37:1106, 2003)

1.   The arbitrary setting of a single threshold diameter for elective AAA repair that is applicable to all patients is not appropriate, as the decision for repair must be individualized in each case.  

2.   Randomized trials have shown that the risk of rupture of small (<5 cm) AAAs is quite low and that a policy of careful surveillance up to a diameter of 5.5 cm is safe, unless rapid expansion (>1 cm/y) or symptoms develop. However, early surgery is comparable to surveillance with later surgery, so patient preference is important, especially for AAAs 4.5 to 5.5 cm in diameter.  

3.   Based upon the best available current evidence, a diameter of 5.5 cm appears to be an appropriate threshold for repair in an "average" patient. However, subsets of younger, low-risk patients with long projected life expectancy may prefer early repair. If the surgeon's personal documented operative mortality rate is low, repair may be indicated at smaller sizes (4.5 to 5.5 cm) if that is the patient's preference.  

4.   For women, or AAAs with greater-than-average rupture risk, 4.5 to 5.0 cm is an appropriate threshold for elective repair.  

5.   For high-risk patients, delay in repair until larger diameter is warranted, especially if endovascular aortic repair (EVAR) is not possible.

  6.   In view of its uncertain long-term durability and effectiveness, as well as the

increased surveillance burden, EVAR is most appropriate for patients at increased risk for conventional open aneurysm repair.  

7.   EVAR may be the preferred treatment method if anatomy is appropriate for older, high-risk patients, those with "hostile" abdomens, or other clinical circumstances likely to increase the risk of conventional open repair.  

8.   Use of EVAR in patients with unsuitable anatomy markedly increases the risk of adverse outcomes, the need for conversion to open repair, or AAA rupture. 

 9.   At present, there does not appear to be any justification that EVAR should

change the accepted size thresholds for intervention in most patients.  

10.  In choosing between open repair and EVAR, patient preference is of great importance. It is essential that the patients be well informed to make such choices.

SurgeryOpen repair with synthetic graft35% of current casesPrimarily for poor anatomyOcassionally young age

Endovascular aneurysm repair (EVAR)65% of current cases

Anatomic Requirements for EVARAnatomic Criteria

Length, angulation, and diameter of infrarenal neck > 60° neck angulation – 70% complication rate Minimum adequate length is 8 mm

Desireable length is 1.5 cm Iliac artery diameter

Large enough to accommodate device (7 mm) Small enough to allow device to seal (1.5 cm)

Concurrent common or internal iliac artery aneurysm Can be difficult to manage

Absence of thrombus at aortic neck Thrombus does not allow for a good neck seal

Standard Open Repair

Complications of Open Repair Mortality rate less than 5% in good risk pts

◦ Most frequent cause of death is ischemic myocardial injury Complications following elective open repair occur in 10-30% of

cases◦ Most frequent complication is nonfatal MI (avg. 6.9%) usually

within first 48 hours post-op ◦ Renal failure (6%)◦ Pneumonia (5%)◦ Bleeding◦ Ileus ◦ Ischemia of left colon and rectum◦ Lower extremity ischemia from embolization of thrombus or

atherosclerotic plaque◦ Ischemic injury to lumbosacral plexus or to the spinal cord ◦ Post-op sexual dysfunction from injury to autonomic nerves

during dissection (up to 25% of patients)◦ DVT in as many as 18% of patients

Complications of Open RepairLate complications after successful repair are

rare◦ Only occurs in about 7% of patients, but Late

complications more common in repair of rupture (17%)

◦ Complications include: Anastomic pseudoaneurysm (3%) Graft thrombosis (2%) Graft-enteric erosion or fistula (1.6%) Graft infection (1.3%) Anastomotic hemorrhage (1.3%) Colonic ischemia (0.7%) Atheroembolism (0.3%)

Endovascular Aneurysm Repair (EVAR)

Potential Drawbacks of EVARNeed for frequent CT scans/follow up

1 month, 3 months, 6 months, one year and every year thereafter

90 % efficacious at 6 year markNeed for conversionLate rupture rate

Up to 25% of patients need reintervention within the first year

Complication of EVAR: Endoleaks

Type I: Lack of complete seal between stent graft and vessel wall at attachment sites

Type II: Back filling of the aneurysm sac via such branch vessels as the lumbar of inferior mesenteric arteries

Type III: Leaks at connections of modular components, device disruption, fabric tears

Type IV: Extravasation of contrast material through interstices in the grafted artery

White GH, May J, Waugh RC, et al. J Endovasc Surg 1998;5:189–193.

Open vs. EVARStudy Patients

Follow up (yrs)

30d Mortality

Total Death

Mayo Clinic AAA

(Open)307 36 5 7.6

Canadian AAA

(Open)680 6 5.4 5.8

AneuRx I–III (EVAR)

1192 4 1.9 2.4

EUROSTAR

(EVAR)2955 4 1.7 2.5

Time 0 1 mo. 6 mo. 1 year 2 years 3 years

Persistent endoleak rate

21% 5.9% 7.5% 10.1% 8.5% 8.5%

New endoleak rate

- 5.9% 4.3% 2.5% 2.8% 2.8%

Total endoleak rate

21% 11.8% 11.8% 12.6% 11.4% 11.4%

Migration rate

- 4% 1.0% 1.2% 1.4% 0%

Aortic size 5.4 cm 5.3 cm 5.1 cm 4.8 cm 4.5 cm 4.0 cm

Reintervention rates

- .83% 2.0% 0% 2.8% 0%

St Luke’s- Roosevelt Last Evaluated 124 case – Endoleak and rate and aneurysm follow up data

TrialsEVAR (Greenlagh, R)DREAM (Blankensteijn, J)ACE (Becquemin, J)OVER (Lederle, F)

DREAM (Dutch Randomized Endovascular Aneurysm Management) Prinssen M, Verhoeven EL, Buth J, et al. N Engl J

Med 2004;351:1607–1618.

Open vs. EVAR Radomized controlled trial of 345 patients with AAA >5cm EVAR operative mortality 1.2% Open repair operative mortality 4.6%

Blankensteijn JD, de Jong SE, Prinssen M, et al. N Engl J Med 2005;352:2398–2405.

Evaluation of perioperative period Cumulative survival rate were similar (89.6% vs. 89.7%) EVAR had lower aneurysm-related death (2.1% vs. 5.7%)

Dutch Randomized Endovascular Management Trial (DREAM)

30 day mortality was better in EVAR group (1.2% vs.. 4.6%)

EVAR group showed less operative mortality and post-op complications (4.7% vs.. 9.8%)

No overall survival difference at 2 years Aneurysm related death less in EVAR group

(2.1% vs.. 5.7%)

Endovascular Aneurysm Repair Trial -1 (EVAR-1)

Short term survival benefit of EVAR 30 day mortality rate 1.7% vs.. 4.7%

At 4 years, no difference in mortality Aneurysm related death less in EVAR group (4% vs..

7%)Greater post-op complications over 4 year

follow-up in the EVAR group (41% vs. 9%)No difference in quality of lifeHospital costs higher in EVAR group

EVAR-2 TrialLooked at effectiveness of EVAR in high risk

patientsCompared EVAR to observationNo benefit of EVAR over observation30 day mortality rate after EVAR was 9%4 year mortality rate in EVAR group 64%No difference in late overall mortality No difference in aneurysm related mortality Higher hospital costs in EVAR groupNo health-related quality of life benefit to

EVAR

Where are we going next?Suprarenal fixation

Including renal stent graftsBranched grafts

Including visceral artery stent graft

More skills?Less access?More cost?More morbidity?

Questions?