Sean Tierney,

Consultant Vascular Surgeon

Adelaide & Meath National Children’s Hospital,

Tallaght

Issues Issues in in

AAA managementAAA management20132013

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AAA - Issues for discussionAAA - Issues for discussion

• Screening• Surveillance• Predicting Operative Risk

– Reducing operative risk

• Choosing operative option

• Perioperative issues

• Technical – Open repair– EVAR

• Complex anatomy– Fenestrated– Branched

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ScreeningScreening

“Multicentre Aneurysm Screening Study” Thompson S G et al. BMJ 2009

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ScreeningScreening

• £7600 after 10 years (per DALY gained)

• Impact of EVAR unknown

“Multicentre Aneurysm Screening Study” Thompson S G et al. BMJ 2009

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ScreeningScreening

Country Min diameter referred if Prevalence AAAWestern Australia >30 mm >50 mm >30 mm 7%; >55 mm 2.5%Denmark >30 mm >50 mm 3.30%England >30 mm >55mm 1.70%Norway >30 mm >55mm 3.40%New Zealand >30 mm >55mm 8.9% in high risk males >65 yearsScotland >30 mm >55mmSweden >30 mm >55mm 1.7% + 0.5% (known)Italy >30 mm >55mm 6.20%Wales >30 mm >55mmNorthern Ireland >30 mm >55mmUSA >30 mm >55mm

Criteria (England): 0–44 mm yearly45–54 mm 3 monthly

European Journal of Vascular and Endovascular SurgeryVolume 45, Issue 3, March 2013, Pages 231–234

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PrognosisPrognosis

Szilagyi 1966

% 5 year survival

6cm

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Law of Laplace (sphere) P =2T/R

0

20

40

60

80

<5cm 5.0-5.9cm >6.0-6.0cm >7.0cm

5 year risk of rupture

Aneurysm size

RisksRisks

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Operative mortality (open repair)Operative mortality (open repair)

Brady et al. BJS 2000 (Small AAA trial)

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Predictors of mortalityPredictors of mortality

0.04 0.01

0.01

Brady et al. BJS 2000 (Small AAA trial)

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Open surgeryOpen surgery

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New technologyNew technology

Parodi et al Ann Vasc 1991

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Anaesthesia & positionAnaesthesia & position

• Epidural/spinal• Occasionally GA• Possible under LA

∀ ± Central access• Arterial line

• OSI (radiolucent) table

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PositionPosition

• Arms tucked in by sides

• Contrast pressure injector (angio)

• C Arm

• 2 tables – open/endo

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Set up & equipmentSet up & equipment

1

2

Scrub/N 1

C-arm

Monitors

Injector

Scrub/N 2

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Draping & incisionDraping & incision

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ExposureExposure

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AnimationAnimation

Tri Fab design

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ClosureClosure

• Arteriotomy closure

• 6/0 prolene

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EVAR - 1 EVAR - 1 OutcomesOutcomes

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ReinterventionsReinterventions

Trial Year N AAA Reinterventions P valueEVAR Open

EVAR 2010 1252 > 5.5 cm 10% 28% <0.001

DREAM 2010 351 > 5 cm 30% 18% 0.03

ACE 2011 316 > 5 cm 24% 14% <0.01

OVER 2012 881 > 5 cm 22.1%b 17.8%b 0.12

European Journal of Vascular and Endovascular SurgeryVolume 45, Issue 4, April 2013, Pages 313–314

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EVAR - 2 EVAR - 2 OutcomesOutcomes

Lancet 2005; 365: 2187–92

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EndoleakEndoleak

“Persistent blood flow outside the endograft but contained within the aneurysm sac”

• Type I– failure of seal at the fixation points or at junctions between

graft components

• Type II– persistent backflow into the sac from patent native branches

(e.g lumbar arteries, IMA etc)

• Type III– graft failure or segment separation

• Type IV– graft porosity

• Type V– unknown

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OptionsOptions

??

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Fenestrated graftFenestrated graft

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Iliac branch graftIliac branch graft

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Iliac aneurysmIliac aneurysm

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Place for EVARPlace for EVAR

IndicationsIndications• still unresolved issues• anatomical suitability• older vs younger• ? high risk patient• significant costs

• Complement rather than replaces open surgery