abdominal aortic aneurysms
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Abdominal Aortic Aneurysms. Omaida C. Velazquez, M.D., F.A.C.S. AAA Prevalence. Most AAA's are Never Detected. Approximately 70% to 80% of AAA Patients are Asymptomatic at Initial Diagnosis - PowerPoint PPT PresentationTRANSCRIPT
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
1
Abdominal Aortic AneurysmsAbdominal Aortic Aneurysms
Omaida C. Velazquez, M.D., F.A.C.SOmaida C. Velazquez, M.D., F.A.C.S
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
AAA PrevalenceAAA Prevalence
• Most AAA's are Never Detected. Most AAA's are Never Detected. – Approximately 70% to 80% of AAA Approximately 70% to 80% of AAA
Patients are Asymptomatic at Initial Patients are Asymptomatic at Initial Diagnosis Diagnosis
– AAA's are Generally Discovered AAA's are Generally Discovered Inadvertently during Procedures to Inadvertently during Procedures to Diagnose Unrelated Medical Diagnose Unrelated Medical ConditionsConditions
• Nearly 200,000 people in the U.S. are Nearly 200,000 people in the U.S. are diagnosed with AAA annually diagnosed with AAA annually
– Approximately 15,000 Die Each Year Approximately 15,000 Die Each Year from a Ruptured AAA from a Ruptured AAA
– 45,000 - 50,000 Patients Undergo 45,000 - 50,000 Patients Undergo Surgery Surgery
– AAA's are More Prevalent in People AAA's are More Prevalent in People Over the Age of 60 Over the Age of 60
– More Common in Men than in More Common in Men than in WomenWomen
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
AAA SymptomsAAA Symptoms
• A pulsing feeling in the A pulsing feeling in the abdomen,abdomen,similar to a heartbeat similar to a heartbeat
• Severe, sudden pain in the Severe, sudden pain in the abdomen or lower back. abdomen or lower back. (aneurysm may be about to (aneurysm may be about to rupture)rupture)
• On rare occasions, feet On rare occasions, feet may develop pain, may develop pain, discoloration, or soreness discoloration, or soreness because of material shed because of material shed from the aneurysmfrom the aneurysm
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
AAA Screening TestsAAA Screening Tests
• Abdominal aortic aneurysms are Abdominal aortic aneurysms are most often found when a physician most often found when a physician is performing an imaging test, is performing an imaging test, such as an ultrasound, Hip X-such as an ultrasound, Hip X-RAY, CT scan, or MRI, for other RAY, CT scan, or MRI, for other conditions. conditions.
• Recommend tests: Recommend tests: – Abdominal ultrasoundAbdominal ultrasound– Computed Tomography (CT) ScanComputed Tomography (CT) Scan– Magnetic Resonance Imaging (MRI)Magnetic Resonance Imaging (MRI)
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
The Screening Abdominal Aortic Aneurysms The Screening Abdominal Aortic Aneurysms Very Efficiently Act (SAAVE) - 2007Very Efficiently Act (SAAVE) - 2007
• Important topic right now beginning in Important topic right now beginning in January 2007 Medicare will offerJanuary 2007 Medicare will offer
– One-time free AAA ultrasound screening to One-time free AAA ultrasound screening to qualified seniors as part of their Welcome to qualified seniors as part of their Welcome to Medicare physical. Medicare physical.
» Men who have smoked at any time during their lifeMen who have smoked at any time during their life
» Men and women with a family history of AAA are Men and women with a family history of AAA are eligible for the new Medicare benefit.eligible for the new Medicare benefit.
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
How to Proceed After Diagnosis of How to Proceed After Diagnosis of AAAAAA
• Vascular ConsultationVascular Consultation
• Patient EducationPatient Education
• Observation with serial Ultrasounds when Observation with serial Ultrasounds when less than 5 cm in diameter, when less than 5 cm in diameter, when asymptomaticasymptomatic
• EVAR Vs. Open RepairEVAR Vs. Open Repair
Growth RateGrowth RateFour hundred ninety-two patients were entered into the study with AAAs smaller Four hundred ninety-two patients were entered into the study with AAAs smaller
than 5 cm when first seen. than 5 cm when first seen.
Entry SizeEntry Size(cm)(cm)
PatientsPatientsEnteredEntered
Mean Expansion Rate Mean Expansion Rate (cm/yr)(cm/yr) SD (± cm)SD (± cm)
2.0 – 2.42.0 – 2.4 66 0.170.17 0.110.11
2.5 – 2.92.5 – 2.9 2626 0.220.22 0.270.27
3.0 – 3.43.0 – 3.4 105105 0.330.33 0.590.59
3.5 – 3.93.5 – 3.9 106106 0.410.41 0.530.53
4.0 – 4.44.0 – 4.4 162162 0.540.54 0.540.54
4.5 – 4.94.5 – 4.9 8787 0.710.71 0.780.78
Brown PM, Pattenden R, Vernooy C, Zelt DT, Gutelius JR. Selective management of abdominal aortic aneurysms in a prospective measurement program. J Vasc Surg 1996;23:213-220.
UK Small Aneurysm TrialUK Small Aneurysm Trial4.0-5.4 cm Randomized Surgery or Surveillance4.0-5.4 cm Randomized Surgery or Surveillance
Only 39 pts. (3.5%) Survived without Surgery - Only 39 pts. (3.5%) Survived without Surgery - “All Roads Lead to Rome”“All Roads Lead to Rome”
1276 Patients Eligible186 Declined
Randomization
527 Assigned toUltrasonographic Surveillance
200 Did NotUndergo Surgery
by June 1998
43 Did NotUndergo Surgery
by June 1998
563 Assigned toEarly Elective Surgery
327 Underwent Surgery byJune 1998
289 According to Protocol38 In Violation of Protocol
80 Diedby June
1998
120 Survivingas of
June 1998
23 Diedby June
1998
20 Survivingas of
June 1998
520 UnderwentSurgery byJune 1998
62 Underwent Surgery by August 2001 48 Open 13 Endovascular 1 Laparoscopic
33 Survivingwithout
Surgery as ofAugust 2001
6 Survivingwithout
Surgery as ofAugust 2001
6 Underwent Surgery by August 2001 5 Open 1 Laparoscopic
1090 Underwent Randomization(1991 – 1995)
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
Open Surgical RepairOpen Surgical Repair
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
MorbidityMorbidity
• 30 day post-op complications after elective 30 day post-op complications after elective AAA repair:AAA repair:– MIMI 2%-8%2%-8%– All pulmonaryAll pulmonary 8%-12%8%-12%– Reduced renal functionReduced renal function 5%-12%5%-12%– DialysisDialysis 1%-6%1%-6%
• 70% 5 year survival for elective AAA repair70% 5 year survival for elective AAA repair
Taylor Ann Vasc Surg 1986; 1: 502Taylor Ann Vasc Surg 1986; 1: 502
Functional OutcomesFunctional Outcomes
• 11% transferred to S.N.F 3.66m + 2.9m11% transferred to S.N.F 3.66m + 2.9m
• All patients were ambulatory pre-opAll patients were ambulatory pre-op
• At median follow up of 25 monthsAt median follow up of 25 months– 22% of patients required assistance22% of patients required assistance
– 14% were non-ambulatory14% were non-ambulatory
– 33% of patients reported a decrease in functional status33% of patients reported a decrease in functional status
• 18% reported that they would not undergo a repair 18% reported that they would not undergo a repair knowing the recovery process in spite of the risks.knowing the recovery process in spite of the risks.
W. Kent Williamson, MD et al. Functional outcome after open repair of abdominal W. Kent Williamson, MD et al. Functional outcome after open repair of abdominal aortic aneurysm J Vasc Surg: May 2001 33 • Number 5 • p913 to p920 aortic aneurysm J Vasc Surg: May 2001 33 • Number 5 • p913 to p920
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
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Open vs. EVAROpen vs. EVAR (Endovasc(Endovascular AAA ular AAA Repair)Repair)
Juxtarenal or suprarenal aortic aneurysms, likely need Open Repair
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
Most Infrarenal Abdominal Aortic Most Infrarenal Abdominal Aortic Aneurysms (AAA) May be treated by Aneurysms (AAA) May be treated by
EVAREVAR
Glass Model Shows Zenith Stent-graft (COOK)
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
Endovascular AAA Repair (EVAR)Endovascular AAA Repair (EVAR)Illustrations Show Powerlink Stent-graft (Endologix)Illustrations Show Powerlink Stent-graft (Endologix)
Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System
Open vs. EVAROpen vs. EVAR
• Open Surgical RepairOpen Surgical Repair
– Longer Recovery TimeLonger Recovery Time
– Longer Hospital StayLonger Hospital Stay
– 90% Long Term Success90% Long Term Success
– Younger patients typicallyYounger patients typically
• EVAREVAR
– Shorter length of stayShorter length of stay
– Reduction in blood lossReduction in blood loss
– Reduction in OR TimeReduction in OR Time
– ICU utilization reducedICU utilization reduced
– Reduced 30 d Reduced 30 d morbidity/mortalitymorbidity/mortality
– Older patients typicallyOlder patients typically
– Needs long-term follow-upNeeds long-term follow-up
– May need secondary May need secondary procedures for endoleaksprocedures for endoleaks
““Paradox of Success”Paradox of Success”
Successful Exclusion Successful Exclusion
Anatomy ChangesAnatomy Changes
Limb DisconnectionsLimb Disconnections
MigrationMigration
Late FailureLate Failure
and/orand/orand/orand/or
Parra et al. Journal of Vascular Surgery Vol. 37, No. 1:109 Parra et al. Journal of Vascular Surgery Vol. 37, No. 1:109
1 month1 month
12 month12 month
24 month24 month
Distribution of Stent Graft Fatigue by DeviceDistribution of Stent Graft Fatigue by Device
Device for Aortic Device for Aortic Aneurysm RepairAneurysm Repair
TotalTotalImplantedImplanted
RadiographsRadiographsReviewedReviewed Total Fatigue/FractureTotal Fatigue/Fracture
Average Time to Average Time to Fracture/Fatigue Fracture/Fatigue
(mo;range)(mo;range)
Average Follow-up Since Average Follow-up Since Fracture/Fatigue Fracture/Fatigue
(mo;range)(mo;range)††
ABDOMINALABDOMINAL
VanguardVanguard 2626 22 (85%)22 (85%) 16 (72%)16 (72%) 2626** (3-48) (3-48) 13 (1-39)13 (1-39)
TalentTalent 337337 232 (69%)232 (69%) 24 (10%)24 (10%) 13 (1-31)13 (1-31) 5 (1-12)5 (1-12)
Modified ParodiModified Parodi 164164 24 (15%)24 (15%) 5 (21%)5 (21%) 38 (33-48)38 (33-48) 6 (1-8)6 (1-8)
EVT/AncureEVT/Ancure 9/209/20 7/67/6 1/0 (14%)1/0 (14%) 88 24 and then lost to fu24 and then lost to fu
AneuRxAneuRx 3939 33 (85%)33 (85%) 3 (10%)3 (10%) 10 (1-24)10 (1-24) 3 (1-6)3 (1-6)
GoreGore 1818 18 (100%)18 (100%) 00
TeramedTeramed 1010 10 (100%)10 (100%) 00
THORACICTHORACIC
Gore TAGGore TAG 2222 19 (86%)19 (86%) 7 (37%)7 (37%) 24 (3-38)24 (3-38) 12 (1-42)12 (1-42)
TalentTalent 4141‡‡ 33 (80%)33 (80%) 4 (12%)4 (12%) 9.5 (1-24)9.5 (1-24) 4 (2-7)4 (2-7)
TOTALTOTAL 686686 404404 6060 1919 88
*Excluding patient with acute conversion †Excluding those patients who underwent open conversion and stent graft explanation‡Including emergent use not part of clinical study
Jacobs TS, Won J, Graveraux EC, Faries PL, Morrissey N, Teodorescu VJ, et al. Mechanical failure of prosthetic Jacobs TS, Won J, Graveraux EC, Faries PL, Morrissey N, Teodorescu VJ, et al. Mechanical failure of prosthetic human implants: a ten-year experience with aortic stent graft devices. J Vasc Surg 2003;37:16-21.human implants: a ten-year experience with aortic stent graft devices. J Vasc Surg 2003;37:16-21.
Viable TechnologyViable TechnologyInstitutions performing far greater than 75% of all AAA repairs with EVAR Institutions performing far greater than 75% of all AAA repairs with EVAR may be experiencing “Endo-Exuberance,” while those with less than a 25% may be experiencing “Endo-Exuberance,” while those with less than a 25%
utilization may be suffering from “Endo-Apathy.”utilization may be suffering from “Endo-Apathy.”
w. Charles Sternbergh, III, et Endo-Exuberance to Endo-Reality: Trends in the Management of 431 w. Charles Sternbergh, III, et Endo-Exuberance to Endo-Reality: Trends in the Management of 431 AAA Repairs Between 1996 and 2002. Journal of Endovascular Therapy: Vol. 10, No. 3, pp. 418-423.AAA Repairs Between 1996 and 2002. Journal of Endovascular Therapy: Vol. 10, No. 3, pp. 418-423.
100%100%
75%75%
60%60%
40%40%
25%25%
Incr
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se o
f EVA
R a
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Incr
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se o
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R a
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Perc
enta
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AA
A R
epai
rsPe
rcen
tage
of A
ll A
AA
Rep
airs
ConservativeConservative
AverageAverage
AggressiveAggressive
Endo-ApathyEndo-Apathy
Endo-ExuberanceEndo-Exuberance
Endo-RealismEndo-Realism