Abdominal Aortic Aneurysms

Aurelia Thibonnier-Calero
PGY-2
Vascular Surgery

Types of Aneurysms

True vs. False (pseudoaneurysm)

True: involves all 3 layers of the arterial

wall
False: presence of blood flow outside of
normal layers of arterial wall. Wall of false
aneurysm is compose of the compressed,
surrounding tissues.

Types of Aneurysms

Etiology

Degenerative- complex process that involves some degree of

calcification, atherosclerotic pathology as well as degeneration by
MMPs.
Inflammatory- thick inflammatory wall with fibrotic process in
retroperitoneum that can encase aorta as well as surrounding
structures. Associated with other inflammatory conditions : Takayasus,
Giant cell arteritis, Polyarteritis nodosa, Behcets, Cogans.
Post-dissection- up to 20% of aneurysms are related to previous
dissection. Overtime, develops into true aneurysm
Traumatic- false aneurysms
Developmental Anomalies- persistent sciatic arteries, aberrant right
subclavian artery.
Infectious- Can be primary or secondary infections.
Congenital- Tuberous sclerosis, aortic coarctation, Marfans.

Crawford Aneurysm Type

Assessing the AAA patient

Normal - aorta 1-2.4cm & iliac 0.6-1.2cm

Aneurysm - Aorta >3cm & iliac > 2cm
RF for aneurysm

Ultrasound

Older age, male gender, white race, positive family

history, smoking, HTN, hypercholesterolemia, PVD, CAD.
used to diagnose and monitor AAA until aneurysm
approaches size at which repair considered.

Computed Tomography

used in preop assessment of AAA.

Ruptured AAA

No significant overall change in mortality with open

repair from 1991-2006
Overall mortality for ruptured AAA = 90%

High postop mortality rate due to MI, renal failure,

and multi-organ failure

Mortality rate for patients who arrive at hosptial alive =

40-70%

Ischemia-reperfusion injury, hemorrhagic shock, lower

torso ischemia

rEVAR significantly reduces mortality of ruptured

AAA patients (31 vs 50%)

Screening for AAA

US Preventive Services Task Force

Society of Vascular Surgery, Medicare Screening

Men 65-75 yo who have ever smoked

No for or against men 65-75yo who have never smoked
Does not recommend screening for women
Men who have smoked at least 100 cigarettes during
their life
men and women with a family history of AAA

Only screen patients who are candidates for

repair.

Choosing between Surgery &

Observation
1.
2.
3.
4.

Risk for AAA rupture without surgery

Operative risk of repair
Patients life expectancy
Personal preferance of patient

1. Risk of Rupture

Size matters:

Aneurysm > 5cm 6-16% and > 7cm 33% annual

rupture rate

Wall stress analysis

Saccular aneurysm have higher rate of rupture
HTN, COPD, active smoking are independent
predictors of rupture
(+) family hx tend to rupture
Expansion rate

2. Operative Risk of Repair

Mortality after:

6 independent RFs for mortality Open repair

elective open AAA ~ 5%

EVAR 1%
Creatinine > 1.8, CHF, EKG detected ischemia,
Pulmonary dysfunction, older age, female gender.

Cardiac, pulmonary, renal, and GI risks with

each proceudre.

3. Patients Life Expectancy

Very difficult to assess due to patients

co-morbidities
Typical 60yo surviving AAA repair has
13year life-expectacy, 70yo has 10year
life-expectancy, and 80 yo has 6 year
life-expectancy.

4. Personal Preference of
Patient

Fear of AAA vs. Fear of surgery

Anecdotal experiences of friends and
family
Procedures provided in community by
interventional specialists and surgeons.

Medical Management of AAA

Smoking Cessation- Single most important modifiable risk factor

Exercise Therapy- Evidence suggests may benefit small
aneurysms

Beta Blockers- May decrease the rate of expansion? Important

cardiovascular effects thus use advocated.

ACE inhibitors- Evidence is mixed, however, implicated in less

aneurysm rupture.

Doxycycline

Antibiotic activiety against chlamydia species

Suppresses expression of MMP

Statins - associated with reduced aneurysm expansion rates.

Decreases MMP-9 in aneurysm wall.

EVAR vs. OPEN

EVAR-1 and DREAM Trials

Randomized AAA > 5.5 cm to EVAR vs. open repair

Lower 30-day mortality for EVAR (1.6% EVAR vs.
4.6% open)
Peripop mortality and severe complications 4.7%
EVAR & 9.8% open repair (DREAM)
Similar all-cause mortality at 2 years
Higher rate of secondary interventions in EVAR group
Total cost of Tx & 4 years of f/u is significantly
increased for EVAR.

Open Repair

Transabdominal Approach

Previous retroperitoneal
surgery
Ruptured AAA
Exposure of mid/distal
portions of visceral vessels
or R renal artery
R internal or external iliac
artery
Co-existant abdominal
pathology
Left-sided vena cava

Retroperitoneal Approach

Mult. Previous
intraperitoneal procedures
Abd wall stoma, ectopic/
anomaly of kidney
Inflammatory aneurysm
Proximal aortic access,
endarterectomy of
viceral/renal arteries
needed
Obese patients
Fewer GI complications

Open Repair-Complications

Cardiac
Pulmonary
Renal
Lower Extremity Ischemia
Spinal Cord Ischemia
Incisional Hernia

14.2% ventral hernia, 9.7% SBO

Graft Infection

Open Repair Complications:

Colon Ischemia

Collaterals from SMA, IMA, internal iliac artery, and

profunda femoris supply sigmoid colon
Mortality 40-65%, full-thickness necrosis 80-100%
Occurs in 0.6-3% of elective and 7-27% of ruptured AAA
(much more common endoscopically than clinically)
Si/Sx: persistent acidosis & shock, increased WBCs and
lactate levels, fluid sequestration, bloody bowel
movements.
TX:

Ischemia limited to mucosa/submucosa- npo, IVF, IV abx

Transmural ischemia- bowel resection, fecal diversion, creation
of ostomy, washout of abdomen, IV abx.

Open Repair- Concomitant

Pathology

Treat the most life-threatening process first

Avoid simultaneous operations that increase the risk
for prosthetic graft infection
If secondary procedure can be staged without
increased risk - do aneurysm repair first
Clean procedures (ie:nephrectomy, oophrectomy) can
be performed simultaneously with open AAA repair
GI procedures should not occur at same time as open
repair

Abort surgery if metastatic disease or abscesses which

increase risk for graft infection discovered.

Inflammatory AAA

Perianeurysmal fibrosis & inflammation

5% of AAA
Treatment of AAA resolves the periaortic
inflammation in 53% (open & EVAR)
Duodenum, left renal vein, and ureters often
involved in inflammation.
PreOp ureteral stent placement
recommended.

Infected AAA

0.65% of AAA
Can be primary or secondary infection
Potential causes of infection:
Continguous spread of local infxn, septic embolization
from distal site, bacteremia.
In the past syphilis and steptococcal species was
common:
Now: staph and salmonella.
With HIV and wide-spread abx use- can be caused by
any bacterial or fungal infection
Dx: fever, abdominal/back pain, high ESR, bacteremia.

EVAR

Types of Endoleak

Types of Endoleak

Type I

Usually identified and treated @ time of stent graft implantation

Must be treated if found on post-op imaging

Associated with high likelihood of AAA rupture

Bridge with short aortic cuff, Palmaz stent

Type II

10-20% of post-op CT scan show Type II leak

80% resolve spontaneously at 6 months

Indication to treat: persistent leak, aneurysm growth

Transcatheter tx (coil embolization)

Type III

0-1.5% incidence

Strong predictor of rupture

Tx: re-establish continuity by additional component to bridge gap or cover

hole.
Type IV

Majority resolve within one month of stent graft implantation

EVAR Complications:
EuroSTAR Registry

Annual Incidence of Complication (per 1,000 patients)

AneuRx

Ancure

Excluder

Talent

Zenith

Type I & II
endoleak

52

86

50

66

41

Migration

43

11

24

Graft
Occlusion

19

33

11

23

35

Rupture

From Van Marrewijk CJ, Leurs LJ, Valabhaneni SR, et al. Risk-adjusted outcome analysis
of endovascular abdominal aortic aneurysm repair. J Endovasc Ther. 2005; 12; 417-429

EVAR complications

Stent-graft infection

Net infection rate of 0.43%

Pelvic ischemia

Internal iliac occlusion during EVAR

Si/sx: buttock claudication (most common
16-50%), buttock necrosis, colon necrosis,
spinal ischemia, lumbosacral plexus
ischemia, ED (15-17%).
Ischemic colitis < 2%

Long-Term Outcome of Open

or Endovascular Repair of
Abdominal Aortic Aneurysm
De Bruin et al.
DREAM study group
The New England Journal of Medicine
May 2010

Introduction

Previous studies have shown initial survival benefit in

patients undergoing EVAR vs. Open repair of AAA

Concern that EVAR is not as durable as AAA and is

associated with greater risk of rupture and secondary
interventions.

Goal: Analyze results of Dutch Randomized

Endovascular Aneurysm Repair (DREAM) study to
provide long-term data comparing open repair vs.
EVAR

Methods

Multicenter, randomized, controlled trial comparing open

repair vs. EVAR in 351 patients
AAA > 5cm
Patients had to be candidates for both techniques of
repair
Exclusion Criteria:

Ruptured or inflammatory aneurysms, anatomical variations,

connective-tissue diseases, hx of organ transplant or lifeexpectancy < 2 years.

F/U visits at 30 days, 6/12/18/24months after procedure

After first 2 years, pts received questionnaires every 6
months.

Methods

EVAR patient received CT scan annually

All patients were called at 5 years and invited
for f/u CT scan.
Data acquisition stopped Feb 2009
Primary outcome was rate of death from any
cause & reintervention
Survival calculated on intention-to-treat basis.

Results

November 2000-December 2003

178 patients Open repair vs. 173 EVAR
Mean age 7yo, 91% male, 43.9% concomittant
cardiac disease.
6 pts did not undergo aneurysm repair

4 declined tx, 1 died from rupture, 1 died from

PNA.

8 in hosptial deaths open vs. 2 EVAR

Mean f/u 6.4 years
25% of open patient underwent CT scan at 5
years, 100% of EVAR

Results

@ 6 years post-op:

Analysis of causes of death

Survival rate: 69.9% open, 68.9% EVAR

Freedom from reintervention: 81.9% open vs.
70.4% EVAR
EVAR- mostly miscellaneous rather than CV

Reintervention

Open repair- majority done for hernia repair

EVAR- endoleak, endograft migration

Discussion

No significant difference between

endovascular repair and open repair in rate of
overall survival at a median of 6.4 years.
Previously DREAM and EVAR-1 trials
demonstrated early (2years) survival advantage
for EVAR group.
Significantly higher rate of reinterventions in
EVAR group than open group
Study limited by difference in f/u between the
open and endovascular group.

Conclusion

At 6 years, Open repair and EVAR have

similar rates of suvival
EVAR has a greater rate of
reintervention

Total Percutaneous Access for

Endovascular Aortic Aneurysm
Repair (Preclose technique)
Lee WA, Brown MP, Nelson PR, Huber TS.
Journal of Vascular Surgery 2007 June;
45(6):1095-101
University of Florida, Gainesville

large single institutional experience with the method and outcomes

of a variation of the Preclose technique using the 6F Perclose
Proglide (Abbott Vascular) device during endovascular aortic repairs.
Retrospective review of patient who underwent EVAR/TEVAR from
Oct 03-Aug06
183 perc femoral access with 12-24F Perclose technique with
Proglide device compared to 154 patients with open surgical
exposure of femoral arteries
Anesthia used for Preclose vs. open: general, 49% vs 55%; regional,
45% vs 44%; and local, 5% vs 1% (P = .10).
Percutaneous group broken down into group of smaller 12-16F and
group of larger 18-24F sheaths.
Data points: perioperative outcomes, procedure times, operating
room usage costs, and technical success (in-hospital or 30-day).
F/U: CT scan at 1 month post-op
The list price for each Perclose Proglide device is (US) $295.

Dilator set $170.44

cost of the operating room is (US) $3935 for the first 60 minutes (not
prorated for shorter periods) and then $50/min thereafter.

Results

137 EVAR, 118 TEVAR, 7 iliac repairs performed

381 femoral arteries accessed with 12-24F sheaths
279 were with 559 Proglide devices using Preclose
technique in 183 patients
4 femoral artereries required 1 device (1.4%) -all 12F
sheaths
270 arteries (96.8%) required 2 devices
5 arteries (1.8%) required 3 devices
63% of sheaths were > 18F
Overall technical success of Preclose technique was 94.3%

99% for smaller sheaths and 91% for larger sheaths.

Results

16 complications

13 open repairs of femoral arteries

2 emergent placement of covered stent for severe
retroperitoneal hemorrhage.
1 necrotizing arteritis with mycotic
pseudoaneurysm requiring replacement of femoral
artery with autogenous femoral vein.

All cause mortality 2.2%

Access mortality 0%

Results

Surgical Group- 154 endovascular repairs

108 EVAR and 46 TEVAR
258 femoral exposures
Technical success rate 93.8%
16 complications
10 endarterectomies with patch angioplasty
3 wound infections
2 infected seromas requiring I&D
1 severe arteritis requiring debridement and replacement of
CFA with autogenous femoral vein.
All cause mortality 1.3%
0% access-related mortality

Results

Significantly lower OR time for Preclose

group:

EVAR: 115 vs 128 min

TEVAR: 80 vs 112 min

Cost: OR + Proglide vs. OR+ Surgery

EVAR: $7881 vs $7351

TEVAR: $5679 vs $6556

Discussion

Percutaneous Access

Shorter procedure time

Fewer wound complications
Increased patient comfort
Limited by size of delivery system.

In this study:

Smaller sheaths had higher technical success

All complications occurred intra-op
No access-related mortality
Accessing anterior aspect of mid-common femoral artery is
crucial in preventing hemorrhagic complications.

Discussion

Contraindications to Preclose:

Coagulopathy is contra-indication to use of this device due to

inability to control needle-hole bleeding
Severe calcifications
Groin scarring
Obesity
Previous use of percutaneous closure devices.
High (suprainguinal ligament) femoral bifurcation
Need for frequent introducer sheath removals and insertions
Proximal iliac occlusive disease
Small iliofemoral arteries relative to profile of device being
used

Conclusion

Prospective, randomized study is

needed to truly validate this technique
Percutaneous EVAR is safe and
effective
Long-term data is needed to evaluate
effect on femoral artery.

The End