Aneurysm Repair Where are we now?

Richard Parsons M.D. FACS

Endovascular treatment of aortic disease

Anatomy

Indications for repair of AAA

• Size > than 5cm

• Expansion greater than 0.2-.4 cm/year

• Symptomatic aneurysm

• Rupture

Endovascular stent graft repair of Abdominal Aortic Aneurysm(EVAR)

• First performed in the US in 1994

• Has become the most common way to repair AAA 90+% at Abington Hospital

• From 2014-2016 we have performed 83 EVARs

• Length of stay is usually 1 night

Endovascular repair of Abdominal Aortic Aneurysm

Technically challenging features of endovascular aneurysm repair

Inverted funnel

Technically challenging features of endovascular repair

Thrombus

thrombus

neck Accessory rena artery

Angulated neck

Complications of repair

• Renal failure

• Colonic ischemia

• Aortic rupture

• Endoleaks

Bowel ischemia Bowel ischemia

Colon ischemia

Renal ischemia

CAUTION—Investigational device. Limited by Federal (or United States) law to investigational use.

Juxtarenal: AAA

Post treatment leaks

Endoleak classification types I-V

Type I endoleak

Type II endoleak from IMA retrograde flow

Thoracic aneurysm

Endovascular thoracic aortic aneurysm repair

Endovascular vs open Thoracic Aneurysm Repair

• Repair when 6cm or greater • Less painful • Shorter length of stay • Less morbidity and mortality

Complications of TAA repair

• Endoleak • Graft migration • Stent fracture • Delayed rupture • Infection • Paraplegia

Best case scenario rare ! • Left subclavian artery not involved • Does not extend below diaphragm • Spinal ischemia risk diminished

LSCA

Risk factors for paraplegia

• Long thoracic segment coverage

• Previous abdominal aortic repair

• Intra or postoperative hypotension

Mechanisms to decrease paraplegia risk

• Avoid hypotension • Stage thoracic and abdominal repair

– 3-6 months apart • CSF catheter drainage to decrease spinal cord

pressures to be below 10mm • Evoked potential monitoring using balloon

occlusion • Temporarily creating an endoleak that is later

closed

Thoracic dissection

Treatment of type B dissection

• 90 % can be treated with BP control and pain medication

• Continued pain or aortic rupture requires immediate repair

• Invasive treatment is reserved for nonperfused vascular beds

–Mesenteric –Renal –Lower extremity –Late aneurysmal degeneration

Treatment strategies

• Open fenestration • Endovascular fenestration • Proximal endograft placement to

open the true lumen and close the false lumen

Risks of treatment

• Aortic rupture • Stroke • Spinal cord ischemia( paraplegia) • Ischemia of branch vessels( renal,

mesenteric,extremeties)

Dissection Endovascular Stents

STABLE I Trial Enrollment • 83 pts. enrolled • US and OUS centers

CAUTION—Investigational device. Limited by Federal (or United States) law to investigational use.

Remodeling of the aorta after dissection flap is closed

Treatment of asymptomatic aortic dissection

• Prevention of late aneurysm dilatation • Aortic remodeling occurs in 90% of treated

patients • Only 70% of untreated patients remodeled

30% have aneurysmal dilatation • Unclear if treatment of all asymptomatic

dissections is justified

Traumatic aortic dissection

• High speed deceleration injury • The aorta is tethered at the

ligamentum arteriosum dissection occurs just distal to subclavian

• Wide mediastinum on chest X-ray • CTA confirms dissection

Thank you!

Richard Parsons MD