Abdominal Aortic and Thoracic Aneurysms
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Transcript of Abdominal Aortic and Thoracic Aneurysms
Abdominal Aortic & Thoracic Aneurysms
Andris Kazmers, MD, MSPH, FACSIntegrative Cardiovascular Health and Wellness
3250 Woods Way, Suite 9Petoskey, Michigan
231-881-9700
Aneurysms & Aortic Disease
• Abnormal dilation of vessel 1.5 – 2 X native size• True vs false• Mycotic• Dissecting• Saccular vs fusiform
Additional aortic abnormalities
Journal of Vascular Surgery 2008 47, 504-512DOI: (10.1016/j.jvs.2007.10.043)
Location Male Female
Ascending 4.0 3.4
Descending 3.2 2.8
Supraceliac 3.0 2.7
Suprarenal 2.8 2.7
Infrarenal 2.4 2.2
Aortic Bifurcation
2.3 2.0
Normal Aortic Size (cm)
Normal Aortic Size
Journal of Vascular Surgery 2008 47, 504-512DOI: (10.1016/j.jvs.2007.10.043)
AAA
• Most common aortic aneurysm– AAAs 21/100,000 person-years– TAAs 6/100,000 person-years
• Increasing incidence & prevalence? 13-15th leading cause of death in US Increasing number of total & ruptured AAA True worldwide, in US recent decline Women constitute higher proportion rAAA
• Asx unless expand, rupture or embolize
AAA Diagnosis: Physical Exam
Best Case• Sensitivity 68%• Specificity 75%
Sensitivity• Girth > 100 cm 53%• Girth < 100 cm 91%
Tends to overestimate AAA size
AAA Diagnosis
• Physical exam 38%
• Incidental 62%
Abdominal Aortic Aneurysm
AAA In USA
40,000 repairs annually
> 2,000,000 with undiagnosed AAA
Estimated 9,000 deaths from rupture
Incidence AAA
• 1.5% in unselected autopsies• 3.2% in unselected ultrasound studies• 5% in CAD patients screened by USN• 10% in PVOD patients screened by USN• 12 - 20% in those with family history• > 50% with femoral or popliteal aneurysms
Screening
• One time ultrasound screening recommended in men 65 – 75 years of age who have ever smoked
• No screening recommended in women
AAA Rupture Declining Before Screening
Diagnosis AAA: Imaging
• Abdominal x-ray• Ultrasound• CT• MRI• Angiography
Diagnosis AAA: Imaging
• Abdominal x-ray• Ultrasound• CT• MRI• Angiography
Diagnosis AAA: Imaging
• Abdominal x-ray• Ultrasound• CT• MRI• Angiography
Diagnosis AAA: Imaging
• Abdominal x-ray• Ultrasound• CT• MRI• Angiography
Diagnosis AAA: Imaging
• Abdominal x-ray• Ultrasound• CT• MRI• Angiography
AAA
• Once diagnosis made, most likely cause of death defined for that individual
• Usually asymptomatic• Expand & rupture unless patient first dies from
another cause
Surveillance AAA
• USN or CT: ? every 3, 4, 6, 12 or more months
• AAA repair in men• Symptoms • Expand to 5.5 cm or more • Growth > 1 cm in one year
• Repair in women ? size
AAA: Presentation
Abdominal or back pain with AAAIf:• No syncope• Stable vital signs• Chronic vs acute pain • Stable hematocrit,then proceed with CT scan
AAA & Back Pain
CT Not Arteriography for AAA Evaluation :Angio Done During EVAR
Defined By Preop CT
• Renal or visceral artery involvement• Accessory renal artery• Renal artery stenosis• Horseshoe kidney• Peripheral aneurysms (15%)• Status of pelvic circulation• Evaluation of associated PVOD• Assess candidacy for endovascular repair
Ruptured AAA: Presentation
• Painback or abdominalmay be in unusual location
• Pulsatile abdominal mass
• Shock
Ruptured AAA: Presentation
Abdominal or back pain and syncope
Proceed to OR!( or to Endovascular Suite?)
Inflammatory AAA
• 5 - 10% AAA• Thick wall on CT, USN suggestive• Abdominal or back pain• Elevated ESR• Duodenal, ureteral adhesion• Technically challenging• Greater mortality, morbidity
AAA: Other Modes of Presentation
• Atheroembolism
• Aortocaval fistula
AAA: Infrequent Modes of Presentation
• Aortoenteric fistula
• Duodenal obstruction
AAA Rupture
Risk factors for AAA rupture
Initial AAA size Diastolic hypertensionChronic obstructive pulmonary disease
Cronenwett et. al. Surgery 98:472 1985.
AAA: Natural History
• Growth rate 0.4 - 0.5 cm per year 4.5 – 4.9 cm AAA grew 0.7cm in 1 yr* Can rupture “without growth”
• Rupture at 3 years in unrepaired AAA > 5 cm 28%*
• Rupture at 3 years in those unfit for repair 5 – 5.9 cm 28%*** > 6 cm 41%
*Brown, et. al. J Vasc Surg 23:213, 1996**Glimaker, et.al. Eur J Vasc Surg 5:125, 1991***Jones, et. al. Br J Surg 85:1382, 1998
Small AAA Rupture
• Autopsy study of those dying with rAAA*9.5% had AAA < 4 cm33% had AAA < 5 cm
• Clinical study of r AAA10% rAAA < 5cm**
*Darling, et. al. Circulation 56(Suppl 2):161, 1977**Nicholls, et. al. J Vasc Surg 28:884, 1998
Surgical Treatment AAA
• First successful direct repair: 1951, Dubost
• Surgical treatment doubled life expectancy in the 60s, despite high elective mortality rate
• Mortality elective repair decreasing 15% < 5%
Endovascular Treatment AAA
• First endovascular AAA repair (EVAR): 1991, Parodi
• EVAR operative mortality lower than open repair
Endovascular AAA Repair:Gore Excluder
• Bifurcated, modular • Nitinol with PTFE• Proximal “fishscales”• No distal hooks• 16-20 Fr ipsilateral• 12-18 Fr contralateral
Endovascular AAA Repair: Gore Excluder
EVAR Complications
• Systemic– MI, CHF, arrhythmias, respiratory or renal insufficiency
• Procedure related– Femoral arterial injury: hemorrhage or occlusion– Groin wound infection – Iliac or aortic injury– Misplacement with vessel occlusion– Thromboembolizaton– Ischemic colitis
• Device related late complications– Migration, detachment, rupture, stenosis– Endoleak
Endoleaks
More common in older grafts
• Type I leak (a: proximal, b: distal)– Persistent flow in aneurysm sac– Incomplete exclusion
• Type II– Sac filled from branches
• Type III– Component disruption
• Type IV– Endograft porosity
• Type V – Endotension: sac enlargement with
no obvious leak
Endovascular AAA Repair
Endovascular repair not possible in everyone Highly complex repairs limited to referral centers Many devices recalled, removed from market Cost >> reimbursement Need for lifelong follow-up: more late interventions Early results better after EVAR Late results, durability: comparable to open repair
AAA Repair
• OpenAnatomically unsuitable for EVARMany, not all, ruptured AAA
• EVARLower morbidity, mortality with elective or rAAAEquivalent survival up to 4 years postop Increased need for secondary procedures
Controversies
• Wait until AAA 5.5 cm in male?– Bad idea in my opinion!
• What size AAA to fix in female?: 5cm – Higher rupture rate than men at same size
• Open vs endovascular– EVAR when possible
Thoracic Aortic Aneurysms
Ascending Aorta Descending Aorta
Thoracoabdominal Aortic Aneurysms
Iliac Artery Aneurysms
• Usually associated with AAA
• Natural history poorly defined, but dangerous
• Repair those > 3 cm – Common and external: endograft– Internal: exclude, embolize– Iliac branch graft
Endovascular Management:Wallgraft for Common Iliac Artery Aneurysm
Internal Iliac Artery Aneurysm Exclusion
Endovascular Management Suprarenal Aneurysms
Snorkel
Fenestrated Grafts
Open TAA Repair
Aortic Debranching: TAA
Descending Aortic Dissection
•Type A dissections
•Type B dissections
AcuteComplicated / symptomatic
Uncomplicated /asymptomatic
Chronic
Aortic Dissection
Dissection Trials and Registry
– Best medical therapy vs BMT + endograft
– No difference in initial survival, aortic related deaths or progression of disease in early studies
– Improvement in aortic remodeling
– Improvement in late survival in those with endografting
Acute Complicated Descending Dissection
Indications for Surgical or Endovascular Treatment• Rupture
• Malperfusion
• Pain/impending rupture
•Results – low mortality, low stroke, low paraplegia rates Retrograde dissection → Type A – 2%
Reinterventions – 26%
Summary
• EVAR safer approach with expanding indications• Advances have been fast and furious• TEVAR successful for thoracic aneurysms and dissections• Fenestrated and custom grafts available