THE ROLE OF OPEN SURGERY FOR AAA IN THE ENDOVASCULAR ERA
Prof. Franco GregoVascular and EndovascularSurgery
University of Padua
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Disclosure of Interest
Speaker name: FRANCO GREGO
• I do not have any potential conflict of interest
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MODERN AAA REPAIR: Open or EVAR?
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EVAR represents the first choice today
When is OPEN REPAIR recommended?
1. Selected cases, in elective AAA repair
2. Challenging cases for EVAR / FEVAR
3. Infections
4. Post-EVAR complications ,with no otherendovascular options
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AAA
High risk Low risk
Favourable
Anatomy for EVARFavourable
Anatomy for EVAR
Conventional surgery
after evaluation of: age
and predisposition to type
II endoleaks
Unfavourable
Anatomy for EVAR
EVAR
Unfavourable
Anatomy for EVAR
Conventional
surgery
Conventional surgery
Accepting increased
surgical risk
FEVAR or
other endovascular
solution
EVAR
AAA repair: our flow chart today
Selected cases in elective AAA repair
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Challenging cases for EVAR
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Exclusion Criteria:
• Severe aorto-iliac occlusive disease, tortuosity or calcification;
• Circumferential thrombus/ateroma in the sealing region;
• Unsuitable artery anatomy -Inability to maintainpatency of onehypogastric-Inadequate (<15mm) main renal artery lenght-renal stenosis >50%
Not feasible because of:-angulation of thoracic descending aorta
and abdominal subrenal aorta;
-median arcuate ligament compression on celiac trunk;
-diameters and morpholgy of renal arteries.
Challenging cases for FEVAR
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Juxta-renal aneurysm
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Juxta-renal aneurysm
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Para-renal aneurysm
Aortic blister
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Horsehoe kidney
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Ectopic kidney
Posterior viewAnterior view
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Graft or Endograft infections
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Graft or Endograft infections
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Aorto-enteric fistula
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Aorto-enteric fistula
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Post-EVAR complications
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Endoleak type I:Open coversion
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Endoleak type I:Open coversion
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Conversion to open repair:Neoneck technique
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Early conversion
Aortic rupture caused by endograft’s hooks
AngioTC pre AngioTC post Angiography post
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Early conversion
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Open repair maintains its role in the treatment of abdominalaneurysms, thanks to its efficacy and long term durability.
o It is the primary choice in young patients.
o It represents the preferential choice in low risk patients withcomplex aorto-iliac anatomies
o It is the only solution in infected cases
o It is the only solution in cases with EVAR complications,otherwise untreatable with other endovascular options.
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Conclusions
TAKE-HOME MESSAGE
THIS MUST NOT BE OUR DESTINY
Vasc and Endovasc Surg Clinic Padua University
Chief: Franco Grego M.D.
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Surgery in the Past
Surgery Today
Surgery in the Future
Low risk patients
Low and high risk patients
Low and high risk patients
High risk patients
Open Surgery
EVAR
Unfit for endovascular
EVAR
Open Surgery
EVAR
Unfit for endovascular INOPERABLE
THANK YOU FOR THE ATTENTION
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