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Abdominal Aortic Aneurysm Review and Radiologic Considerations

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Abdominal Aortic Aneurysm Review and Radiologic Considerations Jeffry Cardneau, MD Vascular / Endovascular Surgeon Kaiser San Rafael * * * * * Figure 1. – PowerPoint PPT presentation

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Title: Abdominal Aortic Aneurysm Review and Radiologic Considerations


1
Abdominal Aortic Aneurysm Review and Radiologic
Considerations
  • Jeffry Cardneau, MD
  • Vascular / Endovascular Surgeon
  • Kaiser San Rafael

2
Objectives
  • Review
  • History of aneurysm repair
  • Pathophysiology
  • Treatment options and benefits
  • Discuss
  • Endovascular repair
  • Radiologic considerations

3
Abdominal Aortic Aneurysm (AAA)
  • First described by Vesalius in 16th century
  • although, other types of aneurysms described in
    Ebers Papyrus (Egypt, 2000 B.C.)
  • Most common type of true aneurysm
  • 200,000 new cases diagnosed each year
  • 40,000 elective AAA repairs in U.S. annually
  • AAA rupture is 14th leading cause of death in
    U.S.
  • 15,000 deaths annually from rupture
  • operative mortality for ruptured AAA has not
    changed in last 20 years
  • prevalence
  • 7.5 of men older than 65
  • 1.3 of women older than 65

4
Aortic Aneurysms
  • Types
  • Thoracic (19)
  • Thoracoabdominal (2)
  • Abdominal (AAA) (78)
  • Infrarenal (95 of all AAA)
  • Juxtarenal
  • Pararenal
  • False aneurysms (pseudoaneurysms)
  • Traumatic
  • anastomotic

5
AAA Remains an Important Problem
  • 4-8 men have AAA
  • Higher in smokers and pts with CAD (14)
  • Mortality from ruptured AAA is 80-90
  • gt50 mortality in those who make it to OR

6
Risk Factors for Detecting a AAA
  • Risk Factor Odds Ratio
  • Smoking history 5.6
  • Family history of AAA 2.0
  • Older age (per 7 years interval) 1.7
  • CAD 1.6
  • High cholesterol 1.5
  • COPD 1.3
  • Height (per 7 cm interval) 1.2
  • DVT history 0.7
  • Diabetes 0.6
  • Black race 0.5
  • Female gender 0.2

From Lederle FA, et al. Ann Intern Med.
1997126(6) 441
7
Abdominal Aortic Aneurysm (AAA)
  • Detection
  • physical exam
  • X rays, CT scans, ultrasounds
  • often done for other reasons and found
    incidentally
  • most common
  • screening of patients at risk
  • Ultrasound
  • symptoms

8
Abdominal Aortic Aneurysm (AAA)
  • screening
  • Medicare AAA screening benefit
  • Screening Abdominal Aortic Aneurysms Very
    Efficiently (SAAAVE)
  • law effective Jan 1, 2007
  • provided by lobbying from Society of Vascular
    Surgery
  • part of Welcome to Medicare physical for at
    risk patient
  • men who have smoked sometime in lifetime
  • men and women with family history
  • screening expected to save thousands of lives

9
Evolution of AAA Repair
  • Focus of early interventions was ligation or
    banding
  • Results usually poor due to failure to totally
    exclude the AAA from proximal or distal flow,
    collateral flow into sac, or erosion of ligatures

Matas first successful ligation of the human
aorta, 1923
10
Modern Aortic Surgery
Dubosts Operation, 1951
  • Homograft insertion
  • an early breakthrough
  • but degeneration soon recognized
  • problems of procurement and availability
  • prosthetic arterial substitutes
  • the true leap forward

11
Modern Aortic Surgery
  • 1947-1948 surgical resident - 1 year research
    fellowship.
  • Chance observation that an errant silk suture
    bridging a dogs ventricular cavity was coated
    with a glistening film of what appeared to be
    endocardium. Speculated that a piece of cloth
    might react in a similar way.
  • First graft fabricated on his wifes sewing
    machine from a silk handkerchief functioned one
    hour.

Arthur Voorhees, MD (1921-1992)
12
Modern Aortic Surgery
  • Voorheess subsequent work with Blakemore during
    his residency utilized Vinyon-N, a cloth for
    spinnaker sails
  • Original report in 1952
  • First human implant in 1953 for ruptured AAA, no
    homograft available
  • Forerunner of Dacron fabric graft

Vinyon-N Prosthesis
8-year Explant
13
Results of Open AAA Repair
  • BUT...

Effective and Durable
  • 5-10 mortality in population-based studies
  • 15-30 significant morbidity substantially
    higher in elderly patients with co-morbidity
  • Recovery 2-3 months
  • High risk patients often denied repair

14
Abdominal Aortic Aneurysm (AAA)
  • What size to treat?
  • Traditional threshold was about 5 cm
  • Any advantage to treating earlier (smaller AAA)?

15
Rupture Risk
  • Low Risk Average Risk High Risk
  • Diameter lt5 cm 5-6 cm
    gt6cm
  • Expansion lt0.3 cm/year
    0.3-0.6 cm/year gt0.6 cm/year
  • Smoking/COPD None, mild Moderate
    Severe/steroids
  • Family history No relatives One
    relative Numerous
    relatives
  • Hypertension Normal blood
    Controlled Poorly controlled
    pressure
  • Gender Male Female
  • Shape Fusiform Saccular
    Very eccentric
  • Wall stress Low (35N/cm2)
    Med(40N/cm2) High (45N/cm2)

16
Abdominal Aortic Aneurysm (AAA)
  • almost uniformly fatal if AAA ruptures
  • BUT, most AAA never rupture
  • size predicts rupture
  • size (cm) annual rupture risk () 4 year rupture
  • lt 3 0 0
  • 3 3.9 0.4 1.6
  • 4 4.9 1.1 4.4
  • 5 5.9 3.3 13.2
  • 6 6.9 9.4 37.6
  • 7 7.9 24 96

17
Abdominal Aortic Aneurysm (AAA)
  • UK Small Aneurysm Trial
  • Lancet 19983521649-1655.
  • NEJM 20023461445-1452.
  • 1090 patients (age 60 79)
  • Aneurysms 4.0 5.5 cm
  • Two groups
  • Early elective surgery
  • Observation / surveillance with ultrasound
  • Average follow-up 8 years
  • Mean duration of survival
  • Early surgery 6.7 years
  • Surveillance 6.5 years

18
Abdominal Aortic Aneurysm (AAA)
19
Abdominal Aortic Aneurysm (AAA)
  • ADAM (Aneurysm Detection And Management)
  • NEJM 2002346(10)1437-1444
  • 1136 patients (ages 50 79)
  • Aneurysms 4.0 5.5 cm
  • open repair
  • surveillance
  • mean duration of follow-up 4.9 years
  • operative mortality 2.7
  • rate of aneurysm rupture 0.6 per year
  • no difference in groups
  • overall survival
  • deaths related to aneurysm

20
Abdominal Aortic Aneurysm (AAA)
21
Abdominal Aortic Aneurysm (AAA)
  • repair methods
  • Open with dacron graft
  • Since 1953
  • Endovascular repair (EVAR)
  • First done in 1991 by Parodi et al.

22
- Trade Off -
ENDOVASCULAR VS. OPEN REPAIR
Con
Pro
Less secure repair Possibility of rupture Chance
of device failure ? Re-interventions ? ?
Surveillance ? Cost
? Risk ? Procedure time ? Blood loss ? ICU ?
LOS ? Recovery
23
Preoperative statin therapy in AAA J Vasc Surg.
June 2010511390-6
Reviewed 401 patients to examine perioperative
results with statins OPEN REPAIR (228) EVAR
(173) statin no statin statin no
statin Death () 0.0 5.9 0.0 3.6 MI
() 0.0 3.7 1.1 1.1 Renal failure
() 0.0 3.7 1.2 2.3 Any comp.
() 4.4 14.7 4.4 4.8 LOS (days) 8.2 9.1 2.3 2
.8 Total cost () 18647 22440 33237 36442
24
EVAR-1 trial Lancet 2004 364 843-848. Lancet
2005 365 2179-2186.
25
EVAR-1 trial Lancet 2004 364 843-848. Lancet
2005 365 2179-2186.
  • 1082 patients enrolled 1999 2004
  • 37 hospitals across UK
  • all patients gt 60 years old
  • aneurysms gt 5.5 cm in diameter
  • All patients considered fit for open or
    endovascular repair
  • No financial support from pharmaceutical or
    device companies

26
EVAR-1 trial Lancet 2004 364 843-848. Lancet
2005 365 2179-2186.
  • RESULTS
  • open endo P value
  • mean hospital stay (days) 12 7 lt.0001
  • 30 day mortality 4.6 1.6 .011
  • 30 day secondary interventions5.8 9.8 .025
  • 4 year aneurysm mortality 7 4 .04
  • 4 year cumulative mortality 29 26 .46
  • 4 year complication rate 9 41 lt.0001
  • 4 year reintervention rate 6 20 lt.0001
  • HRQL (SF36) No difference after 3 months
  • CONCLUSION

27
EVAR-1 trial NEJM 2010362(20)1863-1871.
  • up to 10 years of followup, with at least 5
    years followup
  • open endo P value
  • aneurysm related deaths
  • lt6 months (/100 pt-yrs) 10.0 4.6 .03
  • gt4 years (/100 pt-yrs) 0.2 0.8
  • graft related complications
  • lt6 months (/100 pt-yrs) 15.6 48.7 lt.001
  • gt4 years (/100 pt-yrs) 1.4 5.1 lt.001
  • reinterventions
  • lt6 months (/100 pt-yrs) 13.8 22.9 .007
  • gt4 years (/100 pt-yrs) 0.8 2.4 .003
  • 8 year costs
  • aneurysm procedures 18,586 23,153
  • does NOT include CTs

28
Kaplan-Meier Estimates for Total Survival and
Aneurysm-Related Survival during 8 Years of
Follow-up
The United Kingdom EVAR Trial Investigators. N
Engl J Med 20103621863-1871
29
Kaplan-Meier Estimates for the Time to the First
Graft-Related Reintervention during 8 Years of
Follow-up
30
Kaplan-Meier Estimates for the Time to the First
Graft-Related Complication during 8 Years of
Follow-up
The United Kingdom EVAR Trial Investigators. N
Engl J Med 20103621863-1871
31
Operative Mortality open vs endo
J Vasc Surg 200643446-452
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