Abdominal Aortic Aneurysms

Department of Surgery, University of Pennsylvania Health SystemDepartment of Surgery, University of Pennsylvania Health System

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Abdominal Aortic AneurysmsAbdominal Aortic Aneurysms

Omaida C. Velazquez, M.D., F.A.C.SOmaida C. Velazquez, M.D., F.A.C.S


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


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


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)


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.


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)


Open Surgical RepairOpen Surgical Repair


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


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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


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)


Endovascular AAA Repair (EVAR)Endovascular AAA Repair (EVAR)Illustrations Show Powerlink Stent-graft (Endologix)Illustrations Show Powerlink Stent-graft (Endologix)


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%

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ConservativeConservative

AverageAverage

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Endo-ApathyEndo-Apathy

Endo-ExuberanceEndo-Exuberance

Endo-RealismEndo-Realism

Documents

Abdominal Aortic Aneurysms