Epidemiology

 Age:
 5-7% of population 60+yrs age
 US: reported incidence of 5-7%
 Mean age 70-75yrs

 Sex:
 M:F = 1.6-4.5:1
 Race:
 White M > Blacks M
 White F = Black F
 Mortality/Morbidity:
 Grows ~0.4 cm/year
 75% mortality (upon rupture)
 13th leading cause of death in the US (~15,000 deaths per year)
 Overall mortality 0.9%-5% after repair
 Rupture is based on size
Pathophysiology & Risk Factors
 Atherosclerosis
 Elastin
 Wall Structure
 Genetics
 Smoking
 Brady AR, Thompson SG, Greenhalgh RM, et al. Br J
Surg 90:492, 2003.
 90% had smoking history
 Others: HTN, infection, trauma, arteritis, cystic
medial necrosis, Marfan Syndrome, Ehlers-Danlos
Syndrome
Symptoms and Signs
 Asymptomatic
 Inflammatory AAA may cause back pain
 Pulsatile abdominal mass
 Mid-abdomen just above and left of the umbilicus
 Lederle FA, Wilson SE, Johnson GR, et al. N Engl J Med
346:1437, 2002.

 Ruptured AAA
 Triad (50%):
1. Sudden onset abdominal pain
2. Pulsatile mass
3. Hypotension
Imaging
Incidental, ultrasound, CT angiogram
and angiogram
Diagnosis
 Physical exam
◦ Firm, pulsatile abdominal mass
◦ Overall sensitivity of 52%
 Sensitivity increases with diameter
 29% for 3.0 to 3.9cm
 50% for 4.0-4.9 cm
 76% for > 5.0 cm
◦ Extension into iliac arteries is not appreciated
 X-ray
◦ About 70% of cases
◦ Characteristic eggshell pattern of calcification
◦ Accurate determination of size difficult
◦ Negative AXR does NOT rule out diagnosis
 Ultrasound
◦ Most widely used noninvasive test
◦ Provides structural detail of vessel wall
◦ Can accurately measure the size in longitudinal and
cross sectional directions
◦ Advantages
 Noninvasive, low cost, wide availability
 Good for initial evaluation or pts, screening and
surveillance
 Diagnosis
 CT
◦ Most precise test for imaging AAA
◦ Can identify
 Proximal and distal extent of
aneurysm, including thoracic portion
 Occlusive aneurysmal disease
 Presence of multiple and accessory
renal arteries
 Seize of aortic lumen, amount of
thrombus, and presence of calcific
disease
 MRI
◦ Imaging of choice for patients with renal
insufficiency
◦ High quality images of aorta
◦ However, less sensitive in identifying
accessory renal arteries or renal artery
stenosis
 Arteriography
◦ Reliable information on size of aortic
lumen and branch vessel disease
◦ However, due to thrombus, aortic lumen is
near normal in size so inaccurate
assessment of size or aneurysm
◦ Helpful for assessment of associated
arterial disease in pre-op eval
Screening
 SVMB/SVS/AAVS (2004)
 Kent KC, Zwolak RM et al: Screening for abdominal aortic aneurysm: a consensus statement. J
Vasc Surg 39(1):267, 2004

 Men: Recommends for screening in all men age 60-85 years

 Women: Recommends for screening in women age 60-85 years with a family history of AAA

 USPSTF (2005)

 Men: Recommends for screening in men age 65-75 years who have ever smoked. Recommends
against screening in men age 65-75 years who have never smoked

 Women: Recommends against screening in all women

 ACC/AHA (2006)

 Men: Recommends for screening in men age 65 years or older who have ever smoked.
Recommends for screening in men age 60 or older with a family history of AAA
 Women: None
Screening for Aneurysms
 4 randomized trials of AAA screening have been performed
◦ Reduction in AAA related mortality ranging from 21-68%
◦ Reduction in AAA rupture ranging from 45-49%
 Multicentre Aneurysm Screening Study
◦ >70,000 men screened between ages of 65-74
◦ Aneurysms >5.5 cm referred for repair
◦ After 4 years there was 42% reduction in AAA related deaths in
the screened group
 Society for Vascular Surgery screening recommendations
◦ Baseline ultrasound screening for AAA in
 Men 60-85
 Women 60-85 with cardiovascular risk factors
 Men and women older than 50 with a family history of AAA
◦ Yearly ultrasound for AAA 4.0-4.5cm
◦ Ultrasound every 6 months for AAA larger than 4.5cm
AAA Expansion and Rupture
 Average growth rate: ~0.4cm per year
 Factors: BP, size at detection, COPD

 Size is the best determinant of rupture

 40% of untreated aneurysms 5.5-6cm or larger will
rupture within 5 years
 Average survival without treatment: 17 months
 Lederle FA et al. JAMA 2002;287:2968.
Rupture Repair – EVAR is superior
 30 day mortality
 EVAR 19%, Open 47%
 LOS
 EVAR 6, Open 18.5
 D/C to home
 EVAR 55%, open 20%
 Major complication
 EVAR 36%, Open 80%
 OR time
 EVAR 3 hours, Open 4.5 hours
 Blood loss
 EVAR 200 cc, Open 4 liters
Treatment
Joint Council of the American Association for Vascular Surgery and Society for
Vascular Surgery (Brewster DC, Cronenwett JL, Hallett JW, et al. Vasc Surg 37:1106,
2003)

1. The arbitrary setting of a single threshold diameter for elective AAA repair that is
applicable to all patients is not appropriate, as the decision for repair must be
individualized in each case.

2. Randomized trials have shown that the risk of rupture of small (<5 cm) AAAs is quite low
and that a policy of careful surveillance up to a diameter of 5.5 cm is safe, unless rapid
expansion (>1 cm/y) or symptoms develop. However, early surgery is comparable to
surveillance with later surgery, so patient preference is important, especially for AAAs 4.5
to 5.5 cm in diameter.

3. Based upon the best available current evidence, a diameter of 5.5 cm appears to be an
appropriate threshold for repair in an "average" patient. However, subsets of younger,
low-risk patients with long projected life expectancy may prefer early repair. If the
surgeon's personal documented operative mortality rate is low, repair may be indicated at
smaller sizes (4.5 to 5.5 cm) if that is the patient's preference.
4. For women, or AAAs with greater-than-average rupture risk, 4.5 to 5.0 cm is an
appropriate threshold for elective repair.

5. For high-risk patients, delay in repair until larger diameter is warranted, especially if
endovascular aortic repair (EVAR) is not possible.

6. In view of its uncertain long-term durability and effectiveness, as well as the increased
surveillance burden, EVAR is most appropriate for patients at increased risk for
conventional open aneurysm repair.

7. EVAR may be the preferred treatment method if anatomy is appropriate for older, high-
risk patients, those with "hostile" abdomens, or other clinical circumstances likely to
increase the risk of conventional open repair.

8. Use of EVAR in patients with unsuitable anatomy markedly increases the risk of adverse
outcomes, the need for conversion to open repair, or AAA rupture.

9. At present, there does not appear to be any justification that EVAR should change the
accepted size thresholds for intervention in most patients.

10. In choosing between open repair and EVAR, patient preference is of great importance. It
is essential that the patients be well informed to make such choices.
Surgery
Open repair with synthetic graft
 35% of current cases
 Primarily for poor anatomy
 Ocassionally young age
Endovascular aneurysm repair
(EVAR)
 65% of current cases
Anatomic Requirements for EVAR
 Anatomic Criteria
 Length, angulation, and diameter of infrarenal neck
 > 60° neck angulation – 70% complication rate
 Minimum adequate length is 8 mm
 Desireable length is 1.5 cm
 Iliac artery diameter
 Large enough to accommodate device (7 mm)
 Small enough to allow device to seal (1.5 cm)
 Concurrent common or internal iliac artery aneurysm
 Can be difficult to manage
 Absence of thrombus at aortic neck
 Thrombus does not allow for a good neck seal
Standard Open Repair
Complications of Open Repair
 Mortality rate less than 5% in good risk pts
◦ Most frequent cause of death is ischemic myocardial injury
 Complications following elective open repair occur in 10-30% of cases
◦ Most frequent complication is nonfatal MI (avg. 6.9%) usually within first
48 hours post-op
◦ Renal failure (6%)
◦ Pneumonia (5%)
◦ Bleeding
◦ Ileus
◦ Ischemia of left colon and rectum
◦ Lower extremity ischemia from embolization of thrombus or
atherosclerotic plaque
◦ Ischemic injury to lumbosacral plexus or to the spinal cord
◦ Post-op sexual dysfunction from injury to autonomic nerves during
dissection (up to 25% of patients)
◦ DVT in as many as 18% of patients
Complications of Open Repair
 Late complications after successful repair are rare
◦ Only occurs in about 7% of patients, but Late
complications more common in repair of rupture (17%)
◦ Complications include:
 Anastomic pseudoaneurysm (3%)
 Graft thrombosis (2%)
 Graft-enteric erosion or fistula (1.6%)
 Graft infection (1.3%)
 Anastomotic hemorrhage (1.3%)
 Colonic ischemia (0.7%)
 Atheroembolism (0.3%)
Endovascular Aneurysm Repair (EVAR)
Potential Drawbacks of EVAR
 Need for frequent CT scans/follow up
 1 month, 3 months, 6 months, one year and every year
thereafter
 90 % efficacious at 6 year mark
 Need for conversion
 Late rupture rate
 Up to 25% of patients need reintervention within the
first year
Complication of EVAR: Endoleaks

 Type I: Lack of complete seal between stent graft

and vessel wall at attachment sites
 Type II: Back filling of the aneurysm sac via such
branch vessels as the lumbar of inferior mesenteric
arteries
 Type III: Leaks at connections of modular
components, device disruption, fabric tears
 Type IV: Extravasation of contrast material
through interstices in the grafted artery
 White GH, May J, Waugh RC, et al. J Endovasc Surg 1998;5:189–193.
Open vs. EVAR
Follow 30d Total
Study Patients
up (yrs) Mortality Death
Mayo Clinic AAA
307 36 5 7.6
(Open)
Canadian AAA
680 6 5.4 5.8
(Open)
AneuRx I–III
1192 4 1.9 2.4
(EVAR)
EUROSTAR
2955 4 1.7 2.5
(EVAR)
St Luke’s- Roosevelt Last Evaluated 124 case –
Endoleak and rate and aneurysm follow up data

Time 0 1 mo. 6 mo. 1 year 2 years 3 years

Persistent 21% 5.9% 7.5% 10.1% 8.5% 8.5%
endoleak
rate

New - 5.9% 4.3% 2.5% 2.8% 2.8%

endoleak
rate

Total 21% 11.8% 11.8% 12.6% 11.4% 11.4%

endoleak
rate

Migration - 4% 1.0% 1.2% 1.4% 0%

rate
Aortic size 5.4 cm 5.3 cm 5.1 cm 4.8 cm 4.5 cm 4.0 cm
Reinterventi - .83% 2.0% 0% 2.8% 0%
on rates
Trials
 EVAR (Greenlagh, R)
 DREAM (Blankensteijn, J)
 ACE (Becquemin, J)
 OVER (Lederle, F)
DREAM (Dutch Randomized Endovascular
Aneurysm Management)
 Prinssen M, Verhoeven EL, Buth J, et al. N Engl J Med
2004;351:1607–1618.

 Open vs. EVAR

 Radomized controlled trial of 345 patients with AAA >5cm
 EVAR operative mortality 1.2%
 Open repair operative mortality 4.6%

 Blankensteijn JD, de Jong SE, Prinssen M, et al. N Engl J

Med 2005;352:2398–2405.

 Evaluation of perioperative period

 Cumulative survival rate were similar (89.6% vs. 89.7%)
 EVAR had lower aneurysm-related death (2.1% vs. 5.7%)
Dutch Randomized Endovascular
Management Trial (DREAM)
 30 day mortality was better in EVAR group (1.2% vs..
4.6%)
 EVAR group showed less operative mortality and post-
op complications (4.7% vs.. 9.8%)
 No overall survival difference at 2 years
 Aneurysm related death less in EVAR group (2.1% vs..
5.7%)
Endovascular Aneurysm Repair Trial -1 (EVAR-1)

 Short term survival benefit of EVAR

 30 day mortality rate 1.7% vs.. 4.7%
 At 4 years, no difference in mortality
 Aneurysm related death less in EVAR group (4% vs.. 7%)
 Greater post-op complications over 4 year follow-up in
the EVAR group (41% vs. 9%)
 No difference in quality of life
 Hospital costs higher in EVAR group
EVAR-2 Trial
 Looked at effectiveness of EVAR in high risk patients
 Compared EVAR to observation
 No benefit of EVAR over observation
 30 day mortality rate after EVAR was 9%
 4 year mortality rate in EVAR group 64%
 No difference in late overall mortality
 No difference in aneurysm related mortality
 Higher hospital costs in EVAR group
 No health-related quality of life benefit to EVAR
Where are we going next?
 Suprarenal fixation
 Including renal stent grafts
 Branched grafts
 Including visceral artery stent graft

 More skills?
 Less access?
 More cost?
 More morbidity?
Questions?