EVAR inInflammatory AAA

Fady Haddad, MD, FACSVascular & Endovascular Surgery

American University Of Beirut Medical Center

ASVS, Turkish Society & Asian Venous Forum meeting

Istanbul, October 2013

Inflammatory AAA

• EVAR has changed the way we look at AAA.

• More than 50 % of overall cases in the US today are done using endovascular approach.

• Large data supports at least early and mid term reduced mortality & morbidity, particularly in high risk patients. 1, 2, 3

1.Giles KA, et al. Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair. J Vasc Surg

2009;49:543-51.

2.Schermerhorn ML et al. Endovascular vs. open repair of abdominal aortic aneurysms in the medicare population.

N Engl J Med 2008; 358:464-47.

3.Greenhald R et al. Endovascular Repair of Abdominal Aortic Aneurysm. N Engl J Med 2008; 358:494-501.

• Inflammatory AAA (I-AAA) constitutes around 5% of all AAA.

• It carries its own challenges in terms of anatomic and technical difficulties, procedural morbidity, and associated retroperitoneal fibrosis and inflammation.

• Little is known about singularities of this disease in the endovascular era

• Recent literature suggests efficiency and safety of EVAR in I-AAA .*

*Coppi G, et al. Inflammatory Abdominal Aortic Aneurysm Endovascular Repair into the Long-Term Follow-Up. Ann Vasc Surg. 2010; 24(8):1053-9

Inflammatory AAA

• 67 y male, smoker

• Back pain 6 month

• Hx of spine disease

• US abdomen AAA5.5cm

• CT angio: – 5.5cm AAA with

periaortic inflammation up to 7cm

– Bilateral hydronephrosismore on the left.

Inflammatory AAA

Main features of I-AAA

• Unusual expansion of the adventitia

• Thickening of the aneurysm wall

• Fibrosis of the adjacent retroperitoneum

• Rigid adherence of the adjacent structures to the anterior aneurysm wall

• ↗ ↗ ESR or abnormalities of other serum inflammatory markers.

Chronic Peri Aortitis

• Retroperitoneal fibrosis

• Inflammatory AAA

• BOTH

Inflammatory AAA

Relevant lab results:

– CRP 83mg/l (Nl <5)

– ESR 100mm first hour

– Creatinine 1.4mg/dl

– ANA, C-ANCA, p-ANCA negative

– Urine Cx negative

Double J stenting

Copyright © 2012 American Medical

Association. All rights reserved.

From: Inflammatory Abdominal Aortic Aneurysm

JAMA. 2007;297(4):395-400. doi:10.1001/jama.297.4.395

Treatment of I-AAA

• The aim of surgical treatment is to prevent rupture.

• Data suggest that an inflammatory AAA is less liable to rupture.*

• Intervention appears prudent once the diameter exceeds 5.5 cm.

*Lindblad B, Almgren B, Bergqvist D, et al. Abdominal aortic aneurysm with perianeurysmalfibrosis: experience from 11 Swedish vascular centers. J Vasc Surg. 1991;13:231-239.

• Open repair for I-AAA remain a very challenging surgery.

• Complication rates are still slightly higher than atherosclerotic aneurysm*

• Over the past decade, outcome has significantly improved with better knowledge of the disease and some modifications of the technique.*

* Hellmann DB, Grand DJ, Freischlag JA. JAMA 2007; 297(4):395-400

Inflammatory AAA

*Lindblad B et al. J Vasc Surg. 1991;13:231-239.

• EVAR recently reported to adequately exclude the I-AAA and reduce the size of the sac.

• Review of the Eurostardata on I-AAA cases:– No difference in technical

success in anatomically suitable cases with ~90% sac ↘

– No difference in Mortality 1.9 vs 2.2% (NS)

C. Lange et al, On Behalf of the EUROSTAR Collaborators: Results of Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms. A Report from the EUROSTAR Database Eur J Vasc Endovasc Surg 29, 363–370 (2005

Inflammatory AAA

C. Lange et al, On Behalf of the EUROSTAR Collaborators: Results of Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms. A Report from the EUROSTAR Database Eur J Vasc Endovasc Surg 29, 363–370 (2005)

Procedural details and outcomes (Eurostar)

Inflammatory 52

Non-Inflammatory 3613

P-

Device related Complications

6(11.5%) 261(7.2%) 0.16

Device Migration 0(0.0%) 48(1.3%)

Device Limb Stenosis/occlusion

2 (3.9%) 9 (0.3%) 0.0005

IIA occlusion 13 (25.0%) 488 (13.5%) 0.01

Mortality<30d 1 (1.9%) 81 (2.2%) 0.66

C. Lange et al, On Behalf of the EUROSTAR Collaborators: Results of Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms. A Report from the EUROSTAR Database Eur J Vasc Endovasc Surg 29, 363–370 (2005)

• This patient underwent EVAR 2 days after bilateral ureteral stenting.

• Zenith flex endograft was used.

• No endoleaks on completion.

• Still no or very little excretion from the left kidney.

EVAR for I-AAA: follow up

• Longest F/U in the literature , favourable reduction in periaortitisand sac diameter

• Tech success 100%

• Sac reduction 89%

• PAF ↘ or resolved in 77% and the rest unchanged.

• No endoleaks at F/U

• ! Hydronephrosispersisted when it was present.

Coppi G, et al. Inflammatory Abdominal Aortic Aneurysm Endovascular Repair into the Long-Term Follow-Up. Ann Vasc Surg. 2010; 24(8):1053-9

• Trend toward lower mortality and complications in EVAR for I-AAA is becoming solid; however is it enough?

• Hydronephrosis, does seem to respond less or SLOWER to EVAR*;

I-AAA Preop Early Late

11 Patient 5 (45%) 4 (36%) 3 (27%)

*Van Bommel EF, et al. Persisitent chronic peri-aortitis (‘inflammatory aneurysm’) after AAA repair: systemic review of the literature. Vasc Med 2008; 13 (4):293-303

Additional info on 11 patients from Eurostar

• Persistent PAF and hydronephrosis is a source of morbidity and increased mortality.

• Substantial targets for success should include the treatment of ureteral obstruction and regression of periaortic fibrosis.

*Van Bommel EF, et al. Persisitent chronic peri-aortitis (‘inflammatory aneurysm’) after AAA repair: systemic review of the literature. Vasc Med 2008; 13 (4):293-303

• Is EVAR a safer option for patients with peri-aneurysmal fibrosis? The debate still stands.

• To balance this, available data suggests that additional medical treatment should be considered at an earlier stage with EVAR

EFH van Bommel et al. Persistent peroartitis after AAA repair: systematic review.Vascular Medicine 2008; 13: 293–303

• Steroids therapy remain the backbone, with objective evidence of improvement.

– Side effects of long term steroids

– Some patients may not respond

• Corticosteroid-sparing agents, such as methotrexate, cyclophosphamide, and azathioprine, have also been reported effective.

Hellmann DB, Grand DJ, Freischlag JA. Inflammatory Abdominal Aortic Aneurysm. JAMA2007; 297(4):395-400.

I-AAA: medical therapy

I-AAA: medical therapy

• Chronicity of the PAF seems to be important in the response:*

– Old vs Yong PAF

• Cell to Fibrosis ratio<1 tends to respond less or slower

*Stella, A, et al. Postoperative course of inflammatory abdominal aortic aneurysms.

Ann Vasc Surg 1993; 7 (3): 229–238.

4 months F/U

• Our patient here was initiated on steroid– Initially 30mg daily

• Developped DM • Azathioprine added at 3

months to reduced the steroid– 50mg daily

• Patient developed neutropenia and UTI.

• Immunosuppressant stopped. Steroids tapered to 10mg and shortly after stopped.

• Addition or alternative to steroid therapy:– Azathioprine– Tamoxifen:*

• Anti-inflammatory• Anti Oxidant• Antiproliferative• Cardioprotective effect

• No available guidelines to help in the role or duration of those agents

I-AAA: medical therapy

Van Bommel et al. Tamoxifen therapy for nonmalignant retroperitoneal fibrosis. Ann ntern Med 2006;144:101-106

PAF and urinary obstruction

• In 15-30 % of I-AAA one or both ureterscould be involved

• Combination of renal drainage to medical therapy is important in some cases*

• Poor responders may have recurrent hydronephrosis.

*Deleersnijder R, et al. Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms with Special Reference to Concomitant Ureteric Obstruction. Eur J VascEndovasc Surg 2002: 24 (2):146-149

6 Months F/U

Evolution PAF & Ureteral ObstructionOpen vs Endo

EFH van Bommel et al. Persistent peroartitis after AAA repair: systematic review.Vascular Medicine 2008; 13: 293–303

Follow up after I-AAA treatment

• Persistent PAF (no regression)

– 14% after open repair

– Up to 40% after EVAR (p<0.0001)

• Persistent Ureteral obstruction more frequent after EVAR than after open repair (56% vs32%, p=0.09)*

• Time to regression of PAF, at least 4-6 months.

*Amongs patients who had it; excluding those with ureterolysis.

EFH van Bommel et al. Persistent peroartitis after AAA repair: systematic review.Vascular Medicine 2008; 13: 293–303

• EVAR offers reduced perioperative morbidity and mortality, specially in I-AAA.*

• Draw-back seems to be higher persistent or slower regression of PAF and Ureteral obstruction

• Watchful waiting before initiating medical therapy is accepted after open repair

• May not be the case after EVAR**

*Lindblad B et al. J Vasc Surg. 1991;13:231-239.*Ockert et al, Long term outcome of operated I-AAA. Vascular 2006;14;206211

**EFH van Bommel et al. Vascular Medicine 2008; 13: 293–303

• Double J ureteral stents were both replaced at 3 months.

• Right removed at 6 months and the left at 10 months.

• CT at 1 year: no recurrence of hydronephrosis

• Normal inflammatory markers:– ESR=10 (↘100)

– CRP=2.5 (↘83)

– Creat=1.1(↘1.4)

Pyeloureterography at 3 months

Duplex f/u at 3 years

• After EVAR– Low threshold for urinary drainage (Stents or PNS)

– Early initiation of medical therapy (steroids, Azathioprine, Tamoxifen, combinations) may balance the higher post operative PAF.

• Most available data comes from registries and retrospective studies. Still no clear cut recommendation.

• ?Ground for a prospective study specifically looking at I-AAA?

Follow up after I-AAA treatment

• Concerns:

– In this era of endovascular thrive, will surgeons accept to randomize and subject anatomically suitable patients to an open repair

– In the hands of new generation vascular specialists, more exposed to EVAR, will we have outcomes in I-AAA comparable to historical series done by more experienced “open” surgeons.

In summary,

• EVAR is effective and safe for I-AAA

• Procedural success and aneurysm shrinkage comparable to atherosclerotic aneurysms

• Both Retroperitoneal fibrosis and Ureteralobstruction, when present respond significantly less than with open repair

• Low threshold for ureteral drainage

• Early medical treatment may balance the persistent RPF

The Cedars, February 2012

EFH van Bommel et al. Persistent peroartitis after AAA repair: systematic review.Vascular Medicine 2008; 13: 293–303

• CT scan done 7 months in this patient showed significant reduction in peria