Chapter 72 - Aortoiliac aneurysm - endovascular treatment Flashcards
Volodos 1986
first description of EVAR
Parodi 1990
First EVAR
When was EVAR first approved in Europe and US
Europe 1996 US 1999
Early models of EVAR grafts
AneuRx (Medtronic) - low profile, high migration Vanguard (Boston) - fabric tears and perf Excluder (Gore) - Type IV due to pores Talent - spring fractures and C-bar breaks AFX - passive fixation and sits at aortic bifurcation Aorfix - only graft with IFU 90 degree angulated necks
Perclose IFU size recommendations
1 perclose: 5-8F 2 percloses: - 8.5-21F
EVAR1 key points
1) UK study 2) 1082 patients fit for open 3) 1999-2003 4) 30d mortality 1.7 vs 4.7% 5) secondary intervention 9.8 vs 5.8%
DREAM key points
1) Multicenter 2) 345 patients 3) 2000-2003 4) Mortality 1.2 vs 4.6% 5) mortality and morbidity 4.7 vs 9.8% (mostly pulmonary)
OVER key points
1) 42 veteran affairs centres 2) 881 patients 3) mortality 0.5 vs 3% 4) 2 year mortality 7.0 vs 9.8%
FRENCH study on EVAR vs OPEN
in low to moderate risk patients there’s no difference between EVAR and open
EVAR1 long term outcome
1) 6 year no difference but only 24% had follow up 2) Initial benefit lost in 2 years 3) Higher graft-related complication needing reintervention at 4 years in EVAR
DREAM long term results
1) 2 year 2.1 vs 5.7% aneurysm-related mortality 2) all mortality same 3) higher reintervention at 6 year in EVAR 30 vs 19.1
OVER long term results
3 years EVAR and open converge in outcome
EUROSTAR registration on reintervention and rupture in EVAR
5% reintervention Rupture 1%/year
MEDICARE on follow up post EVAR
50% lost to f/u at 5 year
Difference in MEDICARE 2001-2004 vs 2003-2007
2001-2004: EVAR increases reintervention, rupture, long term mortality 2003-2007: sustained benefit at 5.7 years of EVAR
EVAR 2 key points
1) EVAR vs medical management 2) 338 patients 3) no difference in mortality…possible reasons: a) patients died waiting EVAR b) 25% medical group crossed to EVAR Conclusion: EVAR not indicated in high risk patients
EUROSTAR on different grafts (Aneurx, talent, zeneth, exluder)
Aneurx and Talent: higher migration and endoleak (I and III) Zeneth: higher sac shrinkage, limb occlusion; lowest migration Excluder: least limb occlusion
Forces required to migrate different grafts
Sewn on grafts: 150N Zenith: 24N Ancure: 12.5N Vanguard 9N Talent 4.5N
Patency of Aortouni with fem-fem bypass
90.9% at 54 months 97.7% primary patency at 66 months 100% secondary patency at 66 months
Rate of type 2 endoleak on post-op CT
10-20%
Type 2 endoleak natural course
80% resolve in 12 months no correlation with rupture based on EUROSTAR
Options/approach to treating type 2 endoleak
1) Transarterial 2) Translumbar
Type III endoleak rate
0-1.5%
Duplex sensitivity for endoleaks
67%
Migration causes of endografts
1) Neck dilatation 2) Sac shrinkage + shortenings 3) external compression
AneuRx migration risk
8.4%
Stent limb occlusion rates
3-7% at 4 year most occur in first 6 months
Risks of stent limb occlusions
1) Aortoiliac occlusive disease 2) Small aorta < 14 mm 3) Tortuous iliacs 4) landing in EIA
Are neck dilatations over time related to radial force of endografts
No unless it’s 1) AneuRx 2) >30% oversized
Infection rate of EVAR
0.2-0.7%
Current mortality rate of EVAR
3.6%
Pelvic ischemia symptoms
1) Butt claudication/necrosis 2) spinal cord ischemia 3) colorectal ischemia 4) erectile dysfunction
Unilateral and bilateral IIA embolize risk of butt claudication
52% and 63%
Natural course of IIA embolize induced butt claudication
2/3 improve in 1 year
Unilateral and bilateral IIA embolize risk of ED
17% and 24%
Risk of colonic ischemia in EVAR
1.7%
Risk of spinal cord ischemia with bilateral IIA occlusion
3% paraparesis
SVS guideline for follow up post CT
CTA 1 month and 12 month if endoleak then repeat in 6 months if no leak then duplex annually
What are CardioMEMS
30x5x1.5 mm sensory placed in sac at time of EVAR to measure endotension
Reintervention rates for zenith and talent at 4 year
7% Zenith 9.4% Talent
Rate of endoleak at 5 years
12-15%
Largest treatable CIA aneurysm
25mm with Endurant 28mm graft
In hospital cost of EVAR
$20000 USD
OVER trial on cost
EVAR cheaper initially but converges at 2 years
Surveillance strategy following endovascular aneurysm repair
Timeline for Endovascular Aneurysm Repair Development
Device Characteristics of Current Stent Grafts
