Marc Coggia Service de Chirurgie Vasculaire CHU Ambroise Paré, Boulogne-Billancourt

1. Laparoscopie pour AAA: État de l’art Marc Coggia Service de Chirurgie Vasculaire CHU Ambroise Paré, Boulogne-Billancourt Collège Français de Chirurgie Vasculaire, Paris, 15 mai 2009

2. 2001: Coelioscopie / AAA sous-rénaux(Y.M. Dion / J Vasc Surg 2001;33:181-5) January 2001 • Volume 33 • Number 1 Case ReportsTotally laparoscopic abdominal aortic aneurysm repair Yves Marie Dion, Carlos R. Gracia, Hassen Ben El Kadi The introduction of laparoscopy in general surgery for procedures like hernia repair, cholecystectomy, and fundoplication was associated with less early postoperative pain and disability and an earlier return to full activity.4,13,14 Similar advantages are expected for patients who undergo AAA repair. Recent studies6,7,15 confirmed that laparoscopic AAA repair is a feasible technique. The studies also suggest that the benefits of laparoscopy seen in general surgery could be translated to AAA repair. Among the various approaches currently described (ie, transperitoneal vs retroperitoneal, AAA exclusion vs AAA endoaneurysmorrhaphy), we believe that the peritoneal apron technique, which provides an adequate exposure to the aorta with no intrusion of any peritoneal organ in the operative field, coupled with endoaneurysmorrhaphy, is the technique of choice, after our studying of animals and humans.5,10,16

3. 2004:Coelioscopie / AAA sous-rénaux (M. Coggia / J Vasc Surg 2004;40:448-454) November 2004 • Volume 40 • Number 3 Clinical research studyTotal laparoscopic infrarenal aortic aneurysm repair: Preliminary results Marc Coggia, Isabelle Javerliat, Isabelle Di Centa, Giovanni Colacchio, Pierre Cerceau, Michel Kitzis, Olivier Goëau-Brissonnière Laparoscopic treatment of infrarenal aortic aneurysms has been recently reported.10-18 It appears to be a reproducible technique for dissection. Previously described techniques of laparoscopic AAA repair have been performed either in an assisted fashion10, 12-15, 17, 18 or with aneurysm exclusion.11,14 However, exclusion is not a definitive repair because of the persistent flow in the aneurysmal sac in about 4% to 7%, with a possible progression to rupture.19 Only 1 case of laparoscopic AAA repair was performed according to the criterion standard endoaneurysmorrhaphy.16 This short series demonstrates that total laparoscopic AAA repair is feasible with acceptable short-term outcomes. Our transperitoneal laparoscopic approach allows a stable aortic exposure during the performance of endoaneurysmorrhaphy and anastomoses. The operative field remains free from intrusion of intra-abdominal organs, which are dropped in the right part of the abdomen.

4. 2008: Coelioscopie / AAA juxta-rénaux(M. Coggia / J Vasc Surg 2008;48:37-42) July 2008 • Volume 48 • Number 1 Clinical research studyTotal laparoscopic juxtarenal abdominal aortic aneurysm repair Marc Coggia, Pierre Cerceau, Isabelle DiCenta, Isabelle Javerliat, Giovanni Colacchio, Olivier Goëau-Brissonnière. Postoperative data No in-hospital deaths occurred (Table II). A severe systemic nonlethal complication occurred in one patient (7.7%), whose indication for surgery was a growing and painful JAAA that reached 8 cm diameter. Five months before, he underwent a coronary angioplasty with a coated stent for unstable angina. He was treated with clopidogrel and aspirin until the procedure. Laparoscopic JAAA repair was uneventful, with suprarenal clamping time of 24 minutes and blood loss of 1500 mL. We observed a postoperative hemorrhagic syndrome, probably due to the double antiplatelet therapy. The patient required intensive medical care and a prolonged ICU stay but no reintervention. His further postoperative course was uneventful.

5. Traumatisme Résulats tardifs ! ! Endoprothèse Chirurgie open Fiabilité 100% Résultat tardifs ++ Fiabilité 85% Traumatisme limité ++ Coelioscopie Pas de laparotomie+++

6. Sécurité / Fiabilité / Durabilité Laparotomie / Lombotomie Clampage aortique CHIRURGIE OPEN !

7. June 2002 • Volume 35 • Number 6 Open infrarenal abdominal aortic aneurysm repair: The Cleveland Clinic experience from 1989 to 1998 Norman R. Hertzer, Edward J. Mascha, Mathew T. Karafa, Patrick J. O'Hara, Leonard P. Krajewski, Edwin G. Beve Nine hundred and thirty-nine patients (83%) had no complications of any kind, and the median hospital length of stay was 8 days (quartiles: 7 days, 11 days) for the entire series. The median postoperative length of stay declined from 10 days in 1989 to 8 days in 1998 (P < .001), and the median length of the entire hospitalization (including preoperative days) declined from 13 days in 1989 to 8 days in 1998 (P < .001). Single complications occurred in 150 patients (13%), and 46 patients (4.1%) had multiple complications (Table III). Cardiac complications were most common (5.2%), but most of these (38/59) were confined to arrhythmias that responded to medical management. At least one set of postoperative cardiac isoenzymes was routinely obtained in most patients, and 16 perioperative MIs (1.4%) were documented. Postoperative pulmonary events occurred in 4.1% of patients, wound complications in 3.3%, and renal insufficiency (defined as an increase in the serum creatinine level of 1 mg/dL or more in comparison with the preoperative value) in 1.7%. Only six patients (0.5%) who were not undergoing preoperative dialysis needed new dialysis after surgery, however, and the incidence rate of most other serious complications was similarly low. Forty-five early reoperations were necessary in 28 patients (2.5%), the most frequent indication being a fascial wound dehiscence (n = 15; 1.3%). The overall complication rate was higher in men and in patients who had a previous history of CHF, COPD, renal insufficiency, or dialysis. Advancing age contributed to the incidence of cardiac complications. Otherwise, the incidence of organ-specific (ie, cardiac, pulmonary, or renal) complications was predictably related to preoperative risk factors, such as CHF, remote CABG, COPD, and severe renal dysfunction. Late survivalIn addition to the 14 postoperative deaths, another 300 of the 1185 patients (25%) eventually died at a mean follow-up interval of 44.4 ± 31.6 months (median, 38 months). The principal causes of these 314 deaths were card Table III. 30-day mortality and complication rates

8. September 2008 • Volume 48 • Number 3 Lifeline registry of endovascular aneurysm repair: Open repair surgical controls in clinical trials Robert M. Zwolak, MD, Anton N. Sidawy, Roy K. Greenberg, Marc L. Schermerhorn, Rebecca J. Shackelton, Flora S. Siami, Society for Vascular Surgery Outcomes Committee* This aggregate data set represents a contemporary group of patients treated with open surgery for infrarenal aortic aneurysms at institutions participating in IDE clinical endograft trials. Patients were enrolled prospectively, and follow-up was carefully monitored with comprehensive adjudication of events. Although the four trials enrolled different numbers of patients, and they differed to some extent in inclusion and exclusion criteria, definitions, and end points, it was determined that the data were poolable. Specific differences noted between the trials included the incidence of hypertension, smoking, cardiac arrhythmias, and aneurysm size. AAA size variation was likely related to the 2002 publication of the prospective randomized trial of immediate open surgical repair vs closely monitored watchful waiting for AAAs <5.5 cm diameter. That study failed to demonstrate a survival benefit for immediate open surgical repair, and recruitment for the ongoing and subsequent EVAR trials was likely shifted towards larger diameter AAAs after its release.13 Our analysis failed to demonstrate a difference in operative mortality between large and small AAAs, with rates of 3.6% and 2.4%, respectively (P = .54). Operative mortality for men and women undergoing elective open surgical repair has been reported in population-based reports to be 3.5% to 4.6%, whereas the mortality rate in these four pooled studies was 2.8%.14-18. Open surgical repair of abdominal aortic aneurysms is safe and effective in preventing aneurysm rupture and avoiding AAA-related death.

9. February 1997 • Volume 25 • Number 2 Graft-related complications after abdominal aortic aneurysm repair: Reassurance from a 36-year population-based experience John W. Hallett Jr., Donna M. Marshall, BA, Tanya M. Petterson, Darryl T. Gray, MD, Thomas C. Bower, Kenneth J. Cherry Jr., Peter Gloviczki, Peter C. Pairolero. Since the initial EVAR performed at our hospital in 1994, the debate relative to the compromise between improved perioperative morbidity and mortality and uncertain long-term durability of EVAR has evolved considerably. Impressed with EVAR results in clinical trial data, we have progressively applied EVAR to an increasing percentage of patients after Food and Drug Administration approval in 1999, and indeed, recently reported data from our institution indicate that in the calendar year 2005, 70% of our AAA repairs were performed with EVAR.10 Reduced morbidity and mortality with EVAR compared with open AAA is documented with level I evidence.6,12,17 As anticipated, particular benefit is seen in high-risk patients.11 Clinically relevant late outcomes are also favorable except for a 10% to 14% need for secondary interventions.10,18,19 Because EVAR and open repair are compared with short-term and intermediate follow-up, the early advantage of lower perioperative morbidity and mortality seen with EVAR may be negated by the need for long-term surveillance, frequent reinterventions, and the perhaps undue emphasis on a lack of a late survival benefit after EVAR.10,18,20 However, the advantage in perioperative mortality seen with EVAR is apparent neither in single-center studies nor in our own experience. Contemporary series with EVAR indicate perioperative mortality rates ranging from 1.2% to 3% in patients who were considered fit for open repair.6,12,21 These figures are then often compared with open mortality rates exceeding 5% (particularly in administrative database studies),22 thus promulgating the notion that EVAR is safer in the perioperative period. Indeed, a recent survey of the National Surgical Quality Improvement Program database showed that after risk-adjusted analysis, the 30-day morbidity and mortality of open repair were more than twofold higher than those of EVAR.11 In this series, the perioperative mortality of 3%

10. ! Volume 358:464-474 • January 5, 2008 •Number 31 Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Results Randomized trials have shown reductions in perioperative mortality and morbidity with endovascular repair of abdominal aortic aneurysm, as compared with open surgical repair. Longer-term survival rates, however, were similar for the two procedures. There are currently no long-term, population-based data from the comparison of these strategies. METHODS: We studied perioperative rates of death and complications, long-term survival, rupture, and reinterventions after open as compared with endovascular repair of abdominal aortic aneurysm in propensity-score-matched cohorts of Medicare beneficiaries undergoing repair during the 2001-2004 period, with follow-up until 2005. RESULTS: There were 22,830 matched patients undergoing open repair of abdominal aortic aneurysm in each cohort. The average age of the patients was 76 years, and approximately 20% were women. Perioperative mortality was lower after endovascular repair than after open repair (1.2% vs. 4.8%, P<0.001), and the reduction in mortality increased with age (2.1% difference for those 67 to 69 years old vs. 8.5% for those 85 years or older, P<0.001). Late survival was similar in the two cohorts, although the survival curves did not converge until after 3 years. By 4 years, rupture was more likely in the endovascular-repair cohort than in the open-repair cohort (1.8% vs. 0.5%, P<0.001), as was reintervention related to abdominal aortic aneurysm (9.0% vs. 1.7%, P<0.001), although most reinterventions were minor. In contrast, by 4 years, surgery for laparotomy-related complications was more likely among patients who had undergone open repair (9.7%, vs. 4.1% among those who had undergone endovascular repair; P<0.001), as was hospitalization without surgery for bowel obstruction or abdominal-wall hernia (14.2% vs. 8.1%, P<0.001). by 4 years, surgery for laparotomy-related complications was more likely among patients who had undergone open repair (9.7%...)… as was hospitalization without surgery for bowel obstruction or abdominal-wall hernia (14.2% …).

11. Sécurité / Fiabilité / Durabilité à 5 ans Pas de laparotomie COELIOSCOPIE

12. Traumatisme pariétal réduit Pas de manipulation digestive ↓ ↓ douleurs postop. Réhabilitation précoce ↓↓ complications pulmonaires ↓ ↓ adhérences péritonéales ↓↓↓ risque d’éventration +++ Pas de laparotomie

13. Technique chirurgicale classique • Anastomoses classiques, mise-à-plat AAA • Prothèse vasculaire standard  Résultats à long terme

14. Exposition aortique +++ Restauration aortique Procédure standardisée

15. Voie d’abord aortique sous coelioscopie Voie d’abord aortique traditionnelle + Technique d’exposition coelioscopique

16. TPRC: VRG rétroAo Rate fixée Obèse ? Petite cavité ? TPRR: Cas standards TPD: Néphrec G RP: Abd .hostile

17. AAA / TPRR: clamp proximal

18. AAA / TPRR: Fil tracteur dans le sac

19. AAA / TPRR: contrôle des lombaires

20. AAA / TPRR : clampage iliaque

21. AAA / TPRR: Mise-à-plat de l’AAA

22. AAA / TPRR: anastomoses distales 1ères

23. AAA / voie TPRR

24. Cas 1

25. Cas 2

26. Cas 3

27. Cas 4

28. Données peropératoires * Conversion immédiate

29. Données postopératoires

30. Données postopératoires

31. December 2008 • Volume 48 • Number 6S Laparoscopic aortic surgery: Technique and results Jérôme Cau, Jean-Baptiste Ricco, Jean Marc Corpataux. Since the initial EVAR performed at our hospital in 1994, the debate relative to the compromise between improved perioperative morbidity and mortality and uncertain long-term durability of EVAR has evolved considerably. Impressed with EVAR results in clinical trial data, we have progressively applied EVAR to an increasing percentage of patients after Food and Drug Administration approval in 1999, and indeed, recently reported data from our institution indicate that in the calendar year 2005, 70% of our AAA repairs were performed with EVAR.10 Reduced morbidity and mortality with EVAR compared with open AAA is documented with level I evidence.6,12,17 As anticipated, particular benefit is seen in high-risk patients.11 Clinically relevant late outcomes are also favorable except for a 10% to 14% need for secondary interventions.10,18,19 Because EVAR and open repair are compared with short-term and intermediate follow-up, the early advantage of lower perioperative morbidity and mortality seen with EVAR may be negated by the need for long-term surveillance, frequent reinterventions, and the perhaps undue emphasis on a lack of a late survival benefit after EVAR.10,18,20 However, the advantage in perioperative mortality seen with EVAR is apparent neither in single-center studies nor in our own experience. Contemporary series with EVAR indicate perioperative mortality rates ranging from 1.2% to 3% in patients who were considered fit for open repair.6,12,21 These figures are then often compared with open mortality rates exceeding 5% (particularly in administrative database studies),22 thus promulgating the notion that EVAR is safer in the perioperative period. Indeed, a recent survey of the National Surgical Quality Improvement Program database showed that after risk-adjusted analysis, the 30-day morbidity and mortality of open repair were more than twofold higher than those of EVAR.11 In this series, the perioperative mortality of 3%

32. Data postopératoiresPatients à bon risque (AFSSAPS=0)

33. Data postopératoiresPatients à haut risque (AFSSAPS ≥1)

34. Patients à haut risque opératoireBénéfice pour les obèses et les octogénaires

35. OPEN ou COELIO pour AAA ? EVAR Hybride OPEN Haut risque COELIO Discussion cas par cas: ATCD abdominaux VRG rétroaortique Morphologie AAA Bon risque OPEN

36. Conclusion (1) • La COELIO pour AAA est sûre et fiable

37. Conclusion (2) • La coelioscopie est complémentaire des autres techniques • Dans les équipes entraînées, la coelioscopie remplace la chirurgie OPEN • La chirurgie OPEN est réservée aux cas difficiles et à certains malades à haut risque

38. Conclusion 3: Règle d’Or +++ Conversion toujours possible!!