Aortic aneurysmmanagement

Dr Frijo Jose A

TA Aneurysm

• Essentials of Diagnosis– Asc Ao diameter > 4 cm on imaging study– Desc Ao diameter > 3.5 cm on imaging study

Asc Ao aneurysms – 3 common patterns

Crawford classification - aneurysm in desc Ao and thoracoabdominal Ao

Types of aneurysms, classified according to the EUROSTAR study (classification according to

Schumacher).

• Marfan disease- fibrillin• 21% of aneurysm probands have a first-degree

relative with known/likely Ao aneurysm• TAAD1 (Thoracic Aortic Aneurysm and

Dissection 1) locus

Ao Manifestation of Connective Tissue Disease

In VivoMechanicalPropertiesOf Human AscendingAorta

Depiction of “HingePoints” for Lifetime Natural History Complications at Various Sizes of the Aorta

Survival With Thoracic Aneurysms of Various Sizes

Yearly Rates of Rupture, Dissection, or Death Related to Aortic Size

• Diameter 6 cm- very dangerous size threshold• At/above this – yearly risk for rupture ≈4%– yearly risk of dissection ≈ 4%– Yearly risk of death ≈ 11%– Chance of any one of these phenomena occurring

— 14%/year

Size Criteria for Surgical Intervention for Asymptomatic Thoracic Aortic Aneurysm

• For pts with a positive family hx, but without Marfan disease, the same criteria is applied as for Marfan disease

• BAV also have inherently deficient Ao- lower intervention dimensions are used

• Size criteria apply only to asymptomatic aneurysms. – Symptomatic aneurysms should be resected regardless of size– If aneurysm increases in size by 1cm per year

How Fast Does the Thoracic Aorta Grow?

• Annual growth rate of an aneurysmal thoracic Ao- 0.12 cm on average

• Desc Ao grows faster than asc ao, at 0.19 cm/year compared with 0.07 cm/year

• The larger the aorta becomes, the faster it grows

SYMPTOMS AND SIGNS

• Most asymptomatic - detected fortuitously • When symptomatic– deep visceral pain – not usually ppted by exertion nor relieved by rest/NTG– often constant-not influ by body motion/position

• Rupture of thoracic aneu - excruciating pain, profound dyspnea and quickly shock – A large asc Ao aneu – occ dysphagia/stridor/bone pain

“SilverLining” in Ascending AneurysmDisease: Protection From Arteriosclerosis

• New pts, for whom only one size data point is available- imaging at short intervals until the behavior of aorta is understood (3-6/12)– Compare present scan with the pt's first scan, not

with the last prior scan• Stable, asymptomatic pts- imaging every 2 yrs

(aneu Ao grows at ≈1 mm/yr)– New onset of sympts- imaging should be done

promptly, regardless of the interval

• Once the aorta has dissected- prognosis is thereafter adversely affected

• Pts who required emergency sx- higher rate of early mortality & survival curve poor– Even after sx replacement of portions of Ao, the

remainder will forever remain dissected– Ao wall was deficient to start with, after dissection-

more vulnerable to enlargement & rupture• Elective sx- survival rate very similar to N

population

• Aneu evaluated using a 3-dimensional reconstruction from CTA/MRA or aortography with a calibrated catheter

• Access arteries are measured- FA –retroperitoneal access to iliacs or aorta entertained

• Iliac A assessed for tortuosity & calcification

Endovascular Repair Of AAA

• older • substantial comorbidities (renal, respiratory, &

cardiac dysfunction)• Females & those with a smallerbody habitus -

↑ EVAR abortion rate – smaller access arteries

Anatomic requirements for endovascular repair of TAA

• A proximal neck at least 15 to 25mm from the origin of the left subclavian artery

• A distal neck at least 15 to 25mm proximal to the origin of the celiac artery

• Adequate vascular access—absence of severe tortuosity,calcification,or atherosclerotic plaque burden involving the aortic or pelvic vasculature

• The transverse diameter of the proximal and distal neck should be within the range that available devices can appropriately accommodate

Endovascular repair of thoracic aneurysms

Multilayered stents

EVAR Complications• Access-related

– Hematoma– Lymphocele– Infection– Embolization– Ischemic limb

• Deployment-related– Failed deployment– Arterial rupture– Dissection– Device-related– Structural failure

• Implant-related– Endoleaks– Limb occlusion– Stent graft kink

– Sac enlargement– Proximal neck dilatation– Stent migration– AAA rupture– Infection– Buttock/leg claudication

• Systemic– Cardiac– Pulmonary– Renal insufficiency– Cerebrovascular– Deep vein thrombosis– Pulmonary embolism– Coagulopathy– Bowel ischemia– Spinal cord ischemia– Erectile dysfunction

Treatment of Endoleaks

– Methods employed- coil embolization, placement of stent-graft cuffs and extensions, laparoscopic ligation of inferior mesenteric and lumbar arteries, open surgical repair, and EVAR redo procedures

• Type I and III - urgent intervention- blood flow & sac pressure will continue to ↑→ rupture

• Type IV - resolve on their own• Type II – controversial

– Some of them will thrombose on their own while others will lead to sac enlargement

– Challenge - when to intervene– One approach - monitor with a 6/12 post-procedure CT scan- If aneu

has increased- plan intervention – 3 approaches : transarterial, translumbar embolization, laparoscopic

ligation

EUROSTAR

• Secondary interventions following endovascular AAA repair using endografts

• 2846 pts- In 8.7% 2⁰procedure at some time• Annual rate of 2⁰ intv- 4.6%• proximal type I endoleak evident on completion angio-

predictive of later 2⁰ intv• Mortality rate 2⁰ intv -15% >peri-op mortality aft elect open

repair• Aneurysm expansion -17%pts 2⁰ intv• Continuing need for surveillance for device-related compli-

necessaryJ vasc Surg 2006;43:896-902

EVAR trial 1• Comparison of endovascular aneu repair with open repair in

AAA• 1082 elect- EVAR(n=543) /open repair(n=539)• 30-d mortality- EVAR (1·7%-9/531) v/s (4·7%-24/516) in

open gp• 2⁰ intv more in EVAR (9·8% vs 5·8%, p=0·02)• In large AAAs, EVAR reduced 30-d operative mortality by

two-thirds compared with open repair

• Long term- EVAR 1 - 3% lower initial mortality for EVAR, with a persistent ↓ in aneu-related death at 4 ys- Improvement in overall late survival was not demonstrated

Lancet 2004; 364: 843–48

EVAR trial 2

• Endovasc aneu repair and outcome in pts unfit for open repair of AAA

• 338 pts- EVAR (n=166) /no intrv (n=172)• 30-day op mortality in EVAR- 9% (13/150) • No intrv rupture rate- 9·0/100 person years• overall mortality aft 4 yrs- 64%• No signi diff betw EVAR v/s no intrv for all-cause mortality

(hazard ratio 1·21, p=0·25)• No diff in aneu-related mortality• EVAR did not improve survival over no intrv, asso with a need

for continued surveillance & reintrv, at substantially ↑ costLancet 2005; 365: 2187–92

Data From the EVAR-2 Trial Showing No Benefitof Stent Therapy of Abdominal Aneurysm Over

Medical Therapy

DREAM

• Comparing conventional and endovascular repair of AAA

• 345 patients-30 d• Combined- op mortality + severe compli- 9.8% (open)

v/s 4.7% (EVAR)- risk ratio- 2.1• EVAR preferable to open AAA at least 5 cm

Two-year outcomes• Cum survival rates- 89.6% open v/s 89.7% EVAR• The perioperative survival adv with EVAR- not

sustained aft 1st post-op year

N Engl J Med. 2004 Oct 14;351(16):1677-9

N Engl J Med. 2005 Jun 9;352(23):2398-405

CAESAR

• Comparison of Surveillance Versus EVAR for Small Aneurysm Repair

• AAA 4.1-5.4 cm - imm EVAR v/s surveillance by USG &CT →repair aft defined threshold (D≥5.5 cm, enlargement >1 cm/y, sympts)

• 360 pts (early EVAR = 182; surv = 178)• At 54/12- no significant difference• Mortality & rupture rates in AAA <5.5 cm are low and no

clear adv shown betw early or delayed EVAR strategy• <36/12- 3/5 small aneu under surveillance might grow to

require repairEur J Vasc Endovasc Surg. 2010 Sep 23

• The PIVOTAL study: a randomized comparison of endovascular repair versus surveillance in patients with smaller abdominal aortic aneurysms

• The ACE trial: a randomized comparison of open versus endovascular repair in good risk patients with abdominal aortic aneurysm

Death at 2-3Yrs for TEVAR v/s Open Surgery

Stroke for TEVAR v/s Open Surgery

Paraplegia orPareparesis for TEVAR v/s Open Surgery

AAA

Class I1. Pts with infrarenal/juxtarenal AAAs ≥5.5 cm should undergo

repair to eliminate risk of rupture. ( B)2. Pts with infrarenal/juxtarenal AAAs 4.0-5.4 cm should be

monitored by USG/CT every 6 -12/12 to detect expansion. ( A)Class IIa1. Repair can be beneficial in infrarenal/juxtarenal AAAs 5.0-5.4

cm. (B)2. Repair is probably indicated in pts with suprarenal/type IV

thoracoabdominal AA 5.5 to 6.0 cm. (B)3. In pts with AAAs <4.0 cm, monitoring by USG every 2-3 yrs is

reasonable. (B)ACC/AHA 2005 Practice Guidelines

Class I1. In pts with the clinical triad of abd and/or

back pain, a pulsatile abdominal mass, and hypotension, imm surgical evaluation is indicated. (B)

2. In pts with symptomatic AA, repair is indicated regardless of diameter. (C)

ACC/AHA 2005 Practice Guidelines

Th AA

Class I1. Asympt degenerative thoracic aneu , who are otherwise

suitable candidates and for whom the asc aorta or aortic sinus diameter is ≥5.5 cm should be evaluated for surgical repair. (C)

2. Marfan syndrome or other genetically mediated disorders (vascular EDS,Turner , BAV, or familial thoracic AA) should undergo elective Sx at smaller diameters (4.0 to 5.0cm) (C)

3. Pts with a growth rate >0.5 cm/y in an aorta <5.5 cm should be considered for Sx. (C)

4. Pts undergoing AV repair/replacement and who have an asc aorta or aortic root >4.5 cm should be considered for concomitant repair of Ao root or replacement of asc Ao. (C)

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines

Desc Th Ao and Thoracoabd AA

Class I1. Desc tho Ao >5.5cm, saccular aneurysms, or

postoperative pseudoaneurysms, endovascular stent grafting should be strongly considered when feasible.(B)

2. Thoracoabd A, in whom EVAR options are limited and surgical morbidity is elevated, elective sx recommended if the Ao >6.0 cm, or less if Marfan (C)

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines

Evaluation of Family Members

• A CT scan recommended for adult males & females beyond childbearing age

• For children & females of childbearing age, echo of the asc Ao & abd Ao recommended