Abdominal Aortic Aneurysms

Aurelia Thibonnier-Calero
PGY-2
Vascular Surgery
Types of Aneurysms
 True vs. False (pseudoaneurysm)
 True: involves all 3 layers of the arterial
wall
 False: presence of blood flow outside of
normal layers of arterial wall. Wall of false
aneurysm is compose of the compressed,
surrounding tissues.
Types of Aneurysms
 Etiology
 Degenerative- complex process that involves some degree of
calcification, atherosclerotic pathology as well as degeneration by
MMPs.
 Inflammatory- thick inflammatory wall with fibrotic process in
retroperitoneum that can encase aorta as well as surrounding
structures. Associated with other inflammatory conditions :
Takayasu’s, Giant cell arteritis, Polyarteritis nodosa, Behcet’s,
Cogans’.
 Post-dissection- up to 20% of aneurysms are related to previous
dissection. Overtime, develops into true aneurysm
 Traumatic- false aneurysms
 Developmental Anomalies- persistent sciatic arteries, aberrant right
subclavian artery.
 Infectious- Can be primary or secondary infections.
 Congenital- Tuberous sclerosis, aortic coarctation, Marfan’s.
Crawford Aneurysm Type
Assessing the AAA patient
 Normal - aorta 1-2.4cm & iliac 0.6-1.2cm
 Aneurysm - Aorta >3cm & iliac > 2cm
 RF for aneurysm
 Older age, male gender, white race, positive
family history, smoking, HTN,
hypercholesterolemia, PVD, CAD.
 Ultrasound
 used to diagnose and monitor AAA until aneurysm
approaches size at which repair considered.
 Computed Tomography
 used in preop assessment of AAA.
Ruptured AAA
 No significant overall change in mortality with
open repair from 1991-2006
 Overall mortality for ruptured AAA = 90%
 Mortality rate for patients who arrive at hosptial
alive = 40-70%
 High postop mortality rate due to MI, renal
failure, and multi-organ failure
 Ischemia-reperfusion injury, hemorrhagic shock,
lower torso ischemia
 rEVAR significantly reduces mortality of
ruptured AAA patients (31 vs 50%)
Screening for AAA
 US Preventive Services Task Force
 Men 65-75 yo who have ever smoked
 No for or against men 65-75yo who have never
smoked
 Does not recommend screening for women
 Society of Vascular Surgery, Medicare
Screening
 Men who have smoked at least 100 cigarettes
during their life
 men and women with a family history of AAA
 Only screen patients who are candidates for
repair.
Choosing between Surgery &
Observation
1. Risk for AAA rupture without surgery
2. Operative risk of repair
3. Patient’s life expectancy
4. Personal preferance of patient
1. Risk of Rupture
 Size matters:
 Aneurysm > 5cm 6-16% and > 7cm 33% annual
rupture rate
 Wall stress analysis
 Saccular aneurysm have higher rate of
rupture
 HTN, COPD, active smoking are independent
predictors of rupture
 (+) family hx tend to rupture
 Expansion rate
2. Operative Risk of Repair
 Mortality after:
 elective open AAA ~ 5%
 EVAR 1%
 6 independent RF’s for mortality Open repair
 Creatinine > 1.8, CHF, EKG detected ischemia,
Pulmonary dysfunction, older age, female gender.
 Cardiac, pulmonary, renal, and GI risks with
each proceudre.
3. Patient’s Life Expectancy
 Very difficult to assess due to patient’s
co-morbidities
 Typical 60yo surviving AAA repair has
13year life-expectacy, 70yo has 10year
life-expectancy, and 80 yo has 6 year
life-expectancy.
4. Personal Preference of
Patient
 Fear of AAA vs. Fear of surgery
 Anecdotal experiences of friends and
family
 Procedures provided in community by
interventional specialists and surgeons.
Medical Management of AAA
 Smoking Cessation- Single most important modifiable risk
factor
 Exercise Therapy- Evidence suggests may benefit small
aneurysms
 Beta Blockers- May decrease the rate of expansion?
Important cardiovascular effects thus use advocated.
 ACE inhibitors- Evidence is mixed, however, implicated in
less aneurysm rupture.
 Doxycycline
 Antibiotic activiety against chlamydia species
 Suppresses expression of MMP
 Statins - associated with reduced aneurysm expansion rates.
Decreases MMP-9 in aneurysm wall.
EVAR vs. OPEN
 EVAR-1 and DREAM Trials
 Randomized AAA > 5.5 cm to EVAR vs. open
repair
 Lower 30-day mortality for EVAR (1.6% EVAR vs.
4.6% open)
 Peripop mortality and severe complications 4.7%
EVAR & 9.8% open repair (DREAM)
 Similar all-cause mortality at 2 years
 Higher rate of secondary interventions in EVAR
group
 Total cost of Tx & 4 years of f/u is significantly
increased for EVAR.
Open Repair
 Transabdominal Approach
 Previous retroperitoneal
surgery
 Ruptured AAA
 Exposure of mid/distal
portions of visceral vessels
or R renal artery
 R internal or external iliac
artery
 Co-existant abdominal
pathology
 Left-sided vena cava
 Retroperitoneal
Approach
 Mult. Previous
intraperitoneal
procedures
 Abd wall stoma, ectopic/
anomaly of kidney
 Inflammatory aneurysm
 Proximal aortic access,
endarterectomy of
viceral/renal arteries
needed
 Obese patients
 Fewer GI complications
Open Repair-Complications
 Cardiac
 Pulmonary
 Renal
 Lower Extremity Ischemia
 Spinal Cord Ischemia
 Incisional Hernia
 14.2% ventral hernia, 9.7% SBO
 Graft Infection
Open Repair Complications:
Colon Ischemia
 Collaterals from SMA, IMA, internal iliac artery,
and profunda femoris supply sigmoid colon
 Mortality 40-65%, full-thickness necrosis 80-100%
 Occurs in 0.6-3% of elective and 7-27% of
ruptured AAA (much more common
endoscopically than clinically)
 Si/Sx: persistent acidosis & shock, increased
WBCs and lactate levels, fluid sequestration,
bloody bowel movements.
 TX:
 Ischemia limited to mucosa/submucosa- npo, IVF, IV abx
 Transmural ischemia- bowel resection, fecal diversion,
creation of ostomy, washout of abdomen, IV abx.
Open Repair- Concomitant
Pathology
 Treat the most life-threatening process first
 Avoid simultaneous operations that increase the risk
for prosthetic graft infection
 If secondary procedure can be staged without
increased risk - do aneurysm repair first
 Clean procedures (ie:nephrectomy, oophrectomy)
can be performed simultaneously with open AAA
repair
 GI procedures should not occur at same time as
open repair
 Abort surgery if metastatic disease or abscesses which
increase risk for graft infection discovered.
Inflammatory AAA
 Perianeurysmal fibrosis & inflammation
 5% of AAA
 Treatment of AAA resolves the periaortic
inflammation in 53% (open & EVAR)
 Duodenum, left renal vein, and ureters often
involved in inflammation.
 PreOp ureteral stent placement
recommended.
Infected AAA
 0.65% of AAA
 Can be primary or secondary infection
 Potential causes of infection:
 Continguous spread of local infxn, septic
embolization from distal site, bacteremia.
 In the past syphilis and steptococcal species was
common:
 Now: staph and salmonella.

 With HIV and wide-spread abx use- can be caused

by any bacterial or fungal infection
 Dx: fever, abdominal/back pain, high ESR,
bacteremia.
EVAR
Types of Endoleak
 Types of Endoleak
 Type I
 Usually identified and treated @ time of stent graft implantation
 Must be treated if found on post-op imaging
 Associated with high likelihood of AAA rupture
 Bridge with short aortic cuff, Palmaz stent
 Type II
 10-20% of post-op CT scan show Type II leak
 80% resolve spontaneously at 6 months
 Indication to treat: persistent leak, aneurysm growth
 Transcatheter tx (coil embolization)
 Type III
 0-1.5% incidence
 Strong predictor of rupture
 Tx: re-establish continuity by additional component to bridge gap or cover
hole.
 Type IV
 Majority resolve within one month of stent graft implantation
 EVAR Complications:
EuroSTAR Registry
 Annual Incidence of Complication (per 1,000 patients)
AneuRx Ancure Excluder Talent Zenith

Type I & II 52 86 50 66 41
endoleak
Migration 43 5 11 24 7

Graft 19 33 11 23 35
Occlusion
Rupture 4 0 1 5 2

 From Van Marrewijk CJ, Leurs LJ, Valabhaneni SR, et al. Risk-adjusted outcome analysis of
endovascular abdominal aortic aneurysm repair. J Endovasc Ther. 2005; 12; 417-429
EVAR complications
 Stent-graft infection
 Net infection rate of 0.43%
 Pelvic ischemia
 Internal iliac occlusion during EVAR
 Si/sx: buttock claudication (most common
16-50%), buttock necrosis, colon necrosis,
spinal ischemia, lumbosacral plexus
ischemia, ED (15-17%).
 Ischemic colitis < 2%
Long-Term Outcome of Open
or Endovascular Repair of
Abdominal Aortic Aneurysm

De Bruin et al.
DREAM study group
The New England Journal of Medicine
May 2010
Introduction
 Previous studies have shown initial survival benefit in
patients undergoing EVAR vs. Open repair of AAA

 Concern that EVAR is not as durable as AAA and is

associated with greater risk of rupture and secondary
interventions.

 Goal: Analyze results of Dutch Randomized

Endovascular Aneurysm Repair (DREAM) study to
provide long-term data comparing open repair vs.
EVAR
Methods
 Multicenter, randomized, controlled trial comparing
open repair vs. EVAR in 351 patients
 AAA > 5cm
 Patients had to be candidates for both techniques of
repair
 Exclusion Criteria:
 Ruptured or inflammatory aneurysms, anatomical variations,
connective-tissue diseases, hx of organ transplant or life-
expectancy < 2 years.
 F/U visits at 30 days, 6/12/18/24months after
procedure
 After first 2 years, pts received questionnaires every
6 months.
Methods
 EVAR patient received CT scan annually
 All patients were called at 5 years and invited
for f/u CT scan.
 Data acquisition stopped Feb 2009
 Primary outcome was rate of death from any
cause & reintervention
 Survival calculated on intention-to-treat basis.
 Results
 November 2000-December 2003
 178 patients Open repair vs. 173 EVAR
 Mean age 7yo, 91% male, 43.9% concomittant
cardiac disease.
 6 pts did not undergo aneurysm repair
 4 declined tx, 1 died from rupture, 1 died from
PNA.
 8 in hosptial deaths open vs. 2 EVAR
 Mean f/u 6.4 years
 25% of open patient underwent CT scan at 5
years, 100% of EVAR
Results
 @ 6 years post-op:
 Survival rate: 69.9% open, 68.9% EVAR
 Freedom from reintervention: 81.9% open vs.
70.4% EVAR
 Analysis of causes of death
 EVAR- mostly miscellaneous rather than CV
 Reintervention
 Open repair- majority done for hernia repair
 EVAR- endoleak, endograft migration
Discussion
 “No significant difference between
endovascular repair and open repair in rate of
overall survival at a median of 6.4 years.”
 Previously DREAM and EVAR-1 trials
demonstrated early (2years) survival
advantage for EVAR group.
 Significantly higher rate of reinterventions in
EVAR group than open group
 Study limited by difference in f/u between the
open and endovascular group.
Conclusion
 At 6 years, Open repair and EVAR have
similar rates of suvival
 EVAR has a greater rate of
reintervention
Total Percutaneous Access for
Endovascular Aortic Aneurysm
Repair (“Preclose” technique)

Lee WA, Brown MP, Nelson PR, Huber TS.

Journal of Vascular Surgery 2007 June;
45(6):1095-101
University of Florida, Gainesville
 large single institutional experience with the method and
outcomes of a variation of the Preclose technique using the 6F
Perclose Proglide (Abbott Vascular) device during endovascular
aortic repairs.
 Retrospective review of patient who underwent EVAR/TEVAR
from Oct 03-Aug06
 183 perc femoral access with 12-24F Perclose technique with
Proglide device compared to 154 patients with open surgical
exposure of femoral arteries
 Anesthia used for Preclose vs. open: general, 49% vs 55%;
regional, 45% vs 44%; and local, 5% vs 1% (P = .10).
 Percutaneous group broken down into group of smaller 12-16F
and group of larger 18-24F sheaths.
 Data points: perioperative outcomes, procedure times, operating
room usage costs, and technical success (in-hospital or 30-day).
 F/U: CT scan at 1 month post-op
 The list price for each Perclose Proglide device is (US) $295.
 Dilator set $170.44
 cost of the operating room is (US) $3935 for the first 60 minutes
(not prorated for shorter periods) and then $50/min thereafter.
Results
 137 EVAR, 118 TEVAR, 7 iliac repairs performed
 381 femoral arteries accessed with 12-24F sheaths
 279 were with 559 Proglide devices using
Preclose technique in 183 patients
 4 femoral artereries required 1 device (1.4%) -all
12F sheaths
 270 arteries (96.8%) required 2 devices

 5 arteries (1.8%) required 3 devices

 63% of sheaths were > 18F

 Overall technical success of Preclose technique was

94.3%
 99% for smaller sheaths and 91% for larger sheaths.
Results
 16 complications
 13 open repairs of femoral arteries
 2 emergent placement of covered stent for severe
retroperitoneal hemorrhage.
 1 necrotizing arteritis with mycotic
pseudoaneurysm requiring replacement of femoral
artery with autogenous femoral vein.
 All cause mortality 2.2%
 Access mortality 0%
Results
 Surgical Group- 154 endovascular repairs
 108 EVAR and 46 TEVAR

 258 femoral exposures

 Technical success rate 93.8%

 16 complications
 10 endarterectomies with patch angioplasty

 3 wound infections

 2 infected seromas requiring I&D

 1 severe arteritis requiring debridement and

replacement of CFA with autogenous femoral
vein.
 All cause mortality 1.3%
Results
 Significantly lower OR time for Preclose
group:
 EVAR: 115 vs 128 min
 TEVAR: 80 vs 112 min
 Cost: OR + Proglide vs. OR+ Surgery
 EVAR: $7881 vs $7351
 TEVAR: $5679 vs $6556
Discussion
 Percutaneous Access
 Shorter procedure time
 Fewer wound complications
 Increased patient comfort
 Limited by size of delivery system.
 In this study:
 Smaller sheaths had higher technical success
 All complications occurred intra-op
 No access-related mortality
 Accessing anterior aspect of mid-common femoral artery is
crucial in preventing hemorrhagic complications.
Discussion
 Contraindications to Preclose:
 Coagulopathy is contra-indication to use of this device due to
inability to control “needle-hole bleeding”
 Severe calcifications
 Groin scarring
 Obesity
 Previous use of percutaneous closure devices.
 High (suprainguinal ligament) femoral bifurcation
 Need for frequent introducer sheath removals and insertions
 Proximal iliac occlusive disease
 Small iliofemoral arteries relative to profile of device being
used
Conclusion
 Prospective, randomized study is
needed to truly validate this technique
 Percutaneous EVAR is safe and
effective
 Long-term data is needed to evaluate
effect on femoral artery.
 The End