Endovascular treatment of Abdominal Aortic Aneurysm

Aliu Sanni MDUniversity Hospital Brooklyn

September 8, 2011

www.downstatesurgery.org

Case Presentation

53yr old male with an incidentally found AAA on routine MRI for chronic back pain.PMH-HTN, CAD s/p PCIX2 PSH-Umbilical hernia repairHigh cardiac risk for surgery.

Case Presentation

Medications- Diovan, Aspirin, Clonidine, Methadone, Lipitor, TekturnaAllergy-NKDAFSHx-non contributory

Case Presentation

Gen examination- not pale, anictericAbdominal exam-palpable pulsatile

intrabdominal mass. NT/NDVascular exam - palpable bilateral distal

pulsesChest-CTA bilatCVS-S1S2 no murmur

Case Presentation

-Laboratory testsCBC: 7.5/10.8/33/288BMP:143/4.2/109/25/14/0.9/80Coagulation: 11.5/28/1CT Scan Abdomen/Pelvis- 7.5cm X 7.3cm

infrarenal AAA.

Operative procedure

Endovascular repair of AAA with a bifurcated stent graft

Hospital Course

POD#0- Admitted to CTICUPOD#1- Transferred to surgical step down

unitPOD#3-Discharged home

Abdominal aortic aneurysms

Widening or increased diameter to 50% of baselineNormal aorta: 2-2.5cmAneurysm: 3-3.5cm3%-10% of men over age 50yearsM:F=5:1At least 15,000 deaths/year10th leading cause of death in men>55yrs

Risk factors

Risk factor Odds ratio

Smoking 5.1

Family History AAA 1.9

Older age 1.7

Diabetes 0.5

Female gender 0.2

AAA rupture risk

AAA size (cm) Annual rupture risk

4-5 0.5%-1.5%

5-6 3%-5%

6-7 10%-20%

7-8 20-40%

>8 50%

Diagnosis

Usually asymptomaticPhysical exam- poor sensitivity & accuracy Imaging : USS, CT scanCT Scan- defines anatomy, excludes

rupture and evaluate other pathologyManagement- Open repair / Endovascular

repair

EVAR requirements

Neck Parameters-Length: 15-20mm-Diameter: <30mm-Angulation: <60º-Minimal aortic thrombus

Common iliac parameters-Length: 20-25mm-Diameter: 6-7mm-Minimal thrombus

EVAR Requirements- Exceptions

-Short distal landing zone in CIA1. Extend repair to external iliac arteryCoil embolization of unilateral hypogastricBilateral hypogastric occlusion- risk of

pelvic ischemia2. Use of “bell bottomed” or flared iliac limbsCapable of sealing ectatic or mild

aneurysmal common iliac arteries

Contraindications

High grade stenosis/occlusion SMA/celiac axisNeck angulation >60º, diameter greater

than 32mm, or severe calcification or thrombus Iliac arteries-severe calcification or

tortuosityRenal insufficiency- contraindication to IV

contrast

Endovascular stent graftswww.downstatesurgery.org

Surgical techniquewww.downstatesurgery.org

Open AAA vs. EVAR

Open AAA EVARBlood loss More LessMortality 3%-5% LowerAneurysm Gone RemainsRecovery Longer ShorterFollow up Minimal PersistentAnatomic exclusions

None Exclusions

ICU stay Longer Shorter

Endovascular repair of ruptured AAAwww.downstatesurgery.org

Surgical procedurewww.downstatesurgery.org

Surveillance after EVAR

Interval ImagingInitial routine 1 month CT w/contrast

12 monthsNo leak; sac smaller 12 months Duplex USS

Type II endoleak 6 months CT w/contrast

References

1. Cameron et al Current Surgical Therapy 9th Edition. Pgs.736-742

2. Hollier et al Haimovici’s Vascular Surgery 5th Edition. Pgs744-751.

3. Cronenwett et al Rutherford Vascular Surgery 6th edition.Pgs 1464-1471.

4. Blankensteijn JD et al .N Engl J Med 2005;352:2398-055. EVAR Trial Part Lancet 2005;365:2179-866. Costanza M et al General Surgery Qualifying: Vascular

Surgery Review. Pgs 10-12.ThePassMachine.com

Endovascular treatment of Abdominal Aortic Aneurysm · Endovascular treatment of Abdominal Aortic...

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