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Abdominal Aortic Aneurysm and Peripheral Disease

Abdominal Aortic Aneurysm and Peripheral Disease. 순천향대학교 부천병원 흉부외과학교실 원 용 순. Contents. AAA General consideration Randomized Control Trials Comparing EVAR and Open AAA repair (OAR) Patient selection criteria for EVAR EVAR procedure Complications of EVAR ; endoleak Experience of SCHBC

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Abdominal Aortic Aneurysm and Peripheral Disease

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  1. Abdominal Aortic Aneurysm and Peripheral Disease 순천향대학교 부천병원 흉부외과학교실 원 용 순

  2. Contents • AAA • General consideration • Randomized Control Trials Comparing EVAR and Open AAA repair (OAR) • Patient selection criteria for EVAR • EVAR procedure • Complications of EVAR ; endoleak • Experience of SCHBC • Peripheral Disease • ACA/AHA Practice Guideline • Classification of peripheral arterial disease (PAD) • Endovascular procedure • Experience of SCHBC • Conclusions

  3. Endovascular Treatment of AAA; EndoVascular Aneurymal Repair : EVAR • Parodi JC, Palmaz JC, Barone HD.Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:491-499

  4. •Modular endovascular bifurcation prosthesis including main bifurcation segment (A), contralateral leg (B), proximal aortic cuff (C), iliac cuff (D), and bifurcated (E) or straight (F) extenders. CTA, computed tomography-angiography; DSA, digital subtraction angiography •Stent-graft design incorporating both limited and adjustable dimensional variability for maximum versatility. The fixed attachment points on the left have limited linear variability, whereas the adjustable fixation points on the right result in increased adaptability

  5. Dutch Randomized Endovascular Aneurysm Management (DREAM) trial • Between Nov. 2000 and Dec.2003, Netherlands • 351 patients ( > 5cm AAA, suitable for both OSR and EVAR ) • OSR = 174 pts vs. EVAR = 171 pts • Primary end point – operative mortality & moderate or severe complications NEJM 2004;351:1607-1618

  6. DREAM trial NEJM 2004;351:1607-1618

  7. DREAM trial NEJM 2004;351:1607-1618

  8. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1) : randomised controlled trial • Sept. 1999 ~ Dec. 2003, UK • 1082 patients • > 60 years, > 5.5cm AAA • AAA was regarded as anatomically suitable for EVAR • OSR = 539 pts vs. EVAR = 543 pts • to assess long term survival, generalisability, graft durability, health-related quality of life (HRQL), and hospital costs associated with both EVAR and OSR Lancet 2005 ; 365 :2179 - 86

  9. EVAR trial 1 Lancet 2005 ; 365 :2179 - 86

  10. EVAR trial 1 Lancet 2005 ; 365 :2179 - 86

  11. Patient selection criteria for EVAR • Fusiform AAA ≥ 5 ~ 5.5cm in diameter • Saccular AAA • Suggested aortic morphology • Proximal neck length ≥ 1.5 cm • Neck diameter ≤ 2.8 cm • Neck angulation ≤ 60 degrees • Preservation of critical side branches • Iliofemoral arteries of sufficient diameter for sheath access • No severe iliac artery or aortic tortuosity • No hereditary connective tissue disorder • Anesthesia clearance for possible conversion to open repair if necessary

  12. Patient selection criteria for EVAR Preservation of critical side branches Proximal neck length ≥ 1.5 cm Neck angulation ≤ 60 degrees Fusiform AAA ≥ 5 ~ 5.5cm in diameter or Saccular AAA No severe iliac artery or aortic tortuosity Iliofemoral arteries of sufficient diameter for sheath access

  13. EVAR procedure Preop. CT angiography

  14. EVAR procedure

  15. EVAR procedure Postop. CT angiography

  16. Complications of EVAR • Endoleak • Type I, II, III, IV, V • Migration • Kink, Stenosis, and Occlusion • Graft infection • Rupture

  17. Endoleak • Type I : a leak between the stent-graft and the proximal or distal arterial wall attachment site • Type II : back-bleeding into the aneurysm sac from a patent inferior mesenteric (IMA), lumbar, internal iliac, accessory renal or gonadal artery

  18. Endoleak • Type III : between stent-graft components (e.g. the junction between the main body and limb of a device) or through a hole in the fabric of the graft • Type IV : excessive graft porosity • Type V (endotension) : when the sac increases in size without a detectable endoleak

  19. Types of Endoleaks I IV III II I

  20. Result of Endoleak • Many type II endoleaks undergo resolution by spontaneous thrombosis Frank J. Veithet al. J Vasc Surg 2002;35:1029-35 Nature and significance of endoleaks and endotension: Summary of opinions expressed at an international conference Christopher K. Zarinset al. J Vasc Surg 2000;32:90-107 Endoleak as a predictor of outcome after endovascular aneurysm repair: AneuRx multicenter clinical trial

  21. Result of Endoleak Timothy Reschet al. J Vasc Surg 1998;28:242-9 Persistent collateral perfusion ofabdominal aortic aneurysm afterendovascular repair does not lead toprogressive change in aneurysmdiameter

  22. Experience of SCHBC- EVAR for AAA • Feb, 2008 to May, 2009 • 13 patients (M : F = 11 : 1) • Mean age : 70.54 (54 – 82) • Aneurysm size : 56.23mm (32-76.3mm) • Ruptured : 1 • Impending rupture : 2 • unruptured : 10

  23. EVAR and OR in SCHBC P<0.05 Mortality : 2/15(13%) in OR 1/13(8%) in EVAR

  24. Experience of SCHBC- Endoleak • Endoleak : 6/13 (46%) • type I : 2 ( Ia, Ib) • type II : 2 • type III : 2 • Result of endoleaks • type II & type III : improved, 2wks, 3mths • Other • loss : 1 • Follow up : 2 • Mortality : 1 (type Ia endoleak)

  25. Peripheral Arterial Disease(PAD) ACA/AHA Practice Guideline

  26. Iliac lesion TransAtlantic Inter-Society Consensus (TASC) Working Group

  27. Femoral popliteal lesion TransAtlantic Inter-Society Consensus (TASC) Working Group

  28. ACA/AHA Practice Guideline – Endovascular treatment for Claudication • Recommandations • Endovascular procedure is the treatment of choicefor type A lesions in iliac or femoral popliteal lesions • More evidence is needed to make firm recommendations about the type B and C lesions • Primary stent placement is not recommended in the femoral, popliteal or tibial arteries

  29. Subintimal Angioplasty (SI-PTA) A schematic diagram to show the subintimal recanalization procedure (A) The occlusion is approached away from a collateral (B) The catheter/guidewire is advanced through the subintimal space, enabling it to take the path of least resistance (C) The catheter is retracted back and the guidewire is manipulated into a wide loop (D) The loop is advanced forward until it re-enters the true lumen Semin Vasc Surg1995;8:253-264

  30. Endovascular procedure

  31. Endovascular procedure

  32. Experience of SCHBC • July, 2007 to May, 2009 • 16 patients (M : F = 14 : 2) • not suitable for bypass surgery • Anesthesia, poor run off or more peripheral lesion • Mean age : 65.2 (47 – 77) • Lesions • Iliac : 6 • Femoropopliteal : 7 • Combine : 3 • Stent insertion : 14

  33. Experience of SCHBC • ABI follow up (POD # 7) • Pre PTA (mean) : Post PTA = 0.44 : 0.94 • Post PTA amputation of extremities • 2 pts (2nd toe Rt., BK amputation both) P =0.009

  34. Conclusions • EVAR is a effective and feasible procedure in patients at low surgical risk as well as at high risk • In randomized studies, EVAR is superior to the open repair at short-term and midterm results • In SCHBC experience, perioperative results in EVAR are more acceptable than them of open repair

  35. Conclusions • Endovascular procedure is an another option in treatment methods of patient with PAD • Endovascular procedure, especially, is more effective and feasible in PAD patients with high surgical risk, poor run off and more peripheral lesions • More research is needed to make sure of the effects of endovascular procedure for patients with PAD

  36. Thank you for your attention!

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