Honorary Editor : Dr. Urmil Shah

From the Desk of Hon. Editor:

Dear Friends,Endovascular repair of the aorta, also referred to as endovascular aortic repair (EVAR), refers to a minimally invasive approach that involves placing a stent-graft in the thoracic or thoracoabdominal aorta for the treatment of a variety of aortic pathologies.EVAR was initially used to provide treatment to patients who were not considered to be surgical candidates, but it is now the preferred technique for treatment given the improved risk profile compared with open thoracic aortic surgery.The emergence of endovascular stent grafting as an alternative therapy to open surgical repair of abdominal and thoracic aneurysms is an exciting advance. It is a less invasive alternative to open surgery for the treatment of thoracic as well as abdominal (Especially below renal artery) aortic aneurysms, dissections, or rupture, and thus has the potential to reduce the morbidity of open surgery. Long term outcome (upto 15 Years ) of open surgery and EVAR are comparable.

- Dr. Urmil Shah

Volume-8 | Issue-87 | February 5, 2017

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Case 1- 55 year old male presented with

Hypertension , Asymmetrical pulse and

Chest Pain. BP difference of upper limb

and lower limb was 40 mm of Hg. ECG

showed mild

Left Ventricular

H y p e r t r o p h y

(LVH) ,chest X-

r a y s h o w e d

possible dilated

d e s c e n d i n g

aorta(Fig.1). ECHO showed severe co-

arctation with gradient of 60mm

o f H g a n d d i l a t e d a o r t a .

CT angiography confirmed severe co-

arctation with large secular aneurysm

(Fig. 2)

So balloon dilatation of coarctation

segment with endo placement of valiant

stent - EVAR (Fig 3) was planned in this

patient.

Successful bal loon di latat ion of

coarctation segment and endo placement

of Valiant Stent Graft done through right

femoral arteriotomy. Procedure was

completed in one and half hours. Precise

placement of valiant endovascular stent

graft procedure was done with help of

aortic angiogram (4a) and Digital

subtraction angiography (DSA) (Fig 4b)

with no gradient across coarctation

segment. Post procedure hospital course

was uneventful.Patient was discharged

on 2nd day. BP in both upper limb was 140

/ 80 and in both lower limb was 146 / 86

mmHg. Echo showed 8 mm gradient

across coarctation segment. Patient was

discharged on amlodipine 5 mg bd,

aspirin 75 mg, clopidogrel 75 mg.

At 3 month Follow-up BP in both upper

limbs and in both lower limb were 130 /

80 mm Hg and 140/90 mm Hg

respectively. He was continued with

Fig 1 : Chest X-ray

Possible Dilated Aorta

Fig 3: EVAR Procedure

a) Pre-Prcedure b) Post-Prcedure

c) Follow Up at 3 months

CT Angio

Fig 2: CT angio showing coarctationand large saccular aneurysm

coarctation segment

Large saccluar Aneurysm

Fig 4

2

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Volume-8 | Issue-87 | February 5, 2017

amlodipine 5 mg bd and aspirin 75 mg

daily. Follow-up CT Angio showed

completely sealed aneurysm with no

narrowing at co-arctation segment (Fig

4c).

Aortic Aneurysm

Aneurysm of aorta can be classified by

their macroscopic shape and size and are

described as either saccular or fusiform

(Fig5).

Saccular aneurysms are spherical in shape

and involve only a portion of the vessel

wall; they vary in size from 5 to 20 cm (8

inches) in diameter, and are often filled,

either partially or fully, by thrombus.

Fusiform (“spindle-shaped') aneurysms

are variable in both their diameter and

length; their diameter can extend up to 20

cm (8 in). They often involve large

portions of the ascending and transverse

aortic arch, the abdominal aorta, or less

frequently the iliac arteries.

Etiologies

• Atherosclerosis

• Marfan's

• Type IV Ehlers-Danlos

• Infection (syphilis)

• Arteritis (giant cell, Takayasu,

Behcet's)

• Trauma

• Congenital - Aberrant subclavian -

Coarctation with aneurysm

Risk Factors

1. Age > 65 years

2. Peripheral vascular disease

3. Smoking

4. Chronic obstructive pulmonary

disease (COPD)

5. Hypertension

6. High Body Mass Index (BMI)

7. Family history of aneurysms (up to

20% / more common with thoracic

aneurysms)

In addition, less frequent genetic

syndrome like Marfan and Ehlers-Danlos

syndromes, collagen vascular diseases,

and mycotic aneurysm are associated

with aortic aneurysm.

Epidemiology

Although findings from autopsy series

vary widely, the prevalence of aortic

aneurysms probably exceeds 3-4% in

individuals older than 65 years.

Death from aneurysmal rupture is one of

the 15 leading causes of death in most

series. The overall prevalence of aortic

a n e u r y s m s ( A A ) h a s i n c r e a s e d

significantly in the past 30 years. This is

partly due to an increase in diagnosis

based on the widespread use of imaging

techniques. However, the prevalence of

fatal and nonfatal rupture has also

increased, suggesting a true increase in

prevalence. Population-based studies

suggest an incidence of acute aortic

rupture of 3.5 per 100,000 persons.

Presentation

• Most asymptomatic

• Superior vena cava syndrome

• Hoarseness

• Bronchial obstruction

• Dysphagia

• Hemoptysis

• Paralysis/paraplegia

• Lower extremity embolism

• Dull abdominal pain / dyspepsia

Average growth of aneurysm is 0.2 cm

per year - faster when size of aneurysm is

big. Annual surveillance is recommend

when size of aneurysm is < 4 cm whereas

bi annual when size of aneurysm > 4 cm.

Aortic size is a very strong predictor of

rupture, dissection, and mortality. At

aortic sizes of 6.0 cm or greater, there is a

marked step up in the average yearly rate

of complications (rupture or acute

dissection) to 6.9% per year (Fig 6).

At size greater than 6.0 cm, the odds ratio

f o r r u p t u r e i n c r e a s e s 2 7 - f o l d

(p = 0.0023).

Fig 6: Average yearly rates of negative outcomes (rupture, dissection, and death).

Fig 5

Genetic Syndromes Associated With Aortic Aneursym

Genetics Syndrome

Common Clinical Feactures Genetic Defect

Marfan Syndrome

Skeletal features,Ectopia lentis Dural ectasia

FBN1 mutations*

Loeys-Dietz syndrome

Bifid uvula or cleft palate Arterial tortuosity, Hypertelorism Skeletal features similar to MFS Craniosynostosis Aneurysms and dissections of other arteries

TGFBR2 or TGFBR1 mutations

Ehlers-Danlos syndrome, vascular form

Thin, translucent skin Gastrointestinal rupture Rupture of the gravid uterus Rupture of medium-sized to large arteries

COL3A1 mutations

Turner syndrome Short stature Primary amenorrhea Bicuspid aortic valve Aortic coarctation Webbed neck,low-set ears,low hairline,board chest

45,X karyotype

a) Fusiform Aneurysm b) Saccular Aneurysm

3.5 to 3.9 cm 4.0 to 4.9 cm 5.0 to 5.9 cm > 6.0 cm

Avera

ge Y

earl

y R

ate

Outcome

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Healthy HeartVolume-8 | Issue-87 | February 5, 2017

Medical Treatment :

1. Stringent control of hypertension,

lipid profile optimization (target LDL

cholesterol of less than 70 mg/dL),

s m o k i n g c e s s a t i o n , a n d o t h e r

atherosclerosis risk-reduction measures

should be instituted for all patient with

aneurysm.

2. Antihypertensive therapy should be

administered to hypertensive patients

with aortic diseases to achieve a goal of

less than 130/80 mm Hg to reduce the risk

of stroke, myocardial infarction, heart

failure, and cardiovascular death. Beta

blockers and angiotensin-converting

enzyme inhibitors or angiotensin receptor

blockers should be given to the highest

point patients can tolerate without

adverse effects.

3. Beta adrenergic–blocking drugs

should be administered to all patients

with Marfan syndrome and aortic

aneurysm to reduce the rate of aortic

dilatation unless contraindicated. An

angiotensin receptor blocker (losartan) is

reasonable for patients with Marfan

syndrome, to reduce the rate of aortic

dilatation unless contraindicated.

As might be expected, a larger aneurysm

carries a higher risk of rupture and

ensuing morbidity and mortality even

when treated promptly. A smaller

aneurysm still carries a risk of rupture, but

the risk is so small that elective repair is

not indicated, despite the low incidence

of complications from such treatment.

The UK Small Aneurysm Trial showed that

aneurysms smaller than 5.5 cm do not

benefit from early intervention as

compared with those larger than 5.5 cm.

Elective intervention carries less risk and

better outcome compared to emergency

intervention so elective inervention is

always preferred (Fig 7).

Indications for Intervention

• Aortic size

– Ascending diameter >5.5 cm

– Descending diameter >6.5 cm

– Growth rate >1 cm/yr (avg ascending

0.07 cm/yr; descending 0.19 cm/yr)

• Symptomatic aneurysm

• Traumatic rupture

• Pseudo-aneurysm

• Large saccular aneurysm

• Mycotic aneurysm

• Aortic co-arctation

• Bronchial compression

• Aorto-bronchial or aorto esophageal

fistula

Intervention option

• Endovascular stent grafting (EVAR)

For patients with degenerative or

traumatic aneurysms of the aorta

exceeding 5.5 cm, saccular aneurysms, or

postoperat ive pseudoaneurysms,

endovascular stent grafting should be

strongly considered when feasible.

• Open repair

For patients with chronic dissection,

particularly if associated with a

connective tissue disorder, but without

significant comorbid disease and aortic

diameter exceeding 5.5 cm, open repair is

recommended.There are severa l

complications that can be associated with

open repair. Certainly, there’s an

increased risk of death associated with

the surgical procedure. There’s a risk of

paraplegia. There’s certainly a risk for

bleeding and risk for neurologic

c o m p l i c a t i o n s a n d a r i s k o f

intraabdominal complications.

With endovascular repair there is often a

quicker recovery because all you have is a

small groin incision. There is certainly less

risk of bleeding and less risk of wound

complications and there has been some

data to suggest that there is a lower

paraplegia risk compared to open surgical

repair.

The combined rate of operative mortality

and severe complications was 4.7% for

EVAR and 9.8% for open repair (Fig. 8).

Kaplan-Meier estimates for total survival

and aneurysm-related survival up to 15

years of follow-up. The hazard ratio is

1•05 (95% CI 0•92–1•19) (Fig 9) for total

mortality, and is 1•24 (0•84–1•83) for

aneurysm-related mortality. Long-term

outcomes of EVAR have been studied

through large registries such as

40%

50%

60%

70%

80%

90%

100%

Cu

mu

lati

ve S

urv

ival

Elective Surgery

Emergency Surgery

Medical Treatment

kaplan-meier cumulative survival

Fig. 7

0%

10%

20%

30%

Aneurysm-related survival log-rank p=0.29

Total survuval log-rank p=0.49

Su

rviv

al (%

)

Time since randomization (years)Fig. 9

Fig. 8Elective EVAR* Open Aneurysm Repair*

Mor

talit

y S

ever

e C

ompl

icat

ion

(%)

Fig. 8

Rate of Mortality and Severe Complications for Aneurysm Repair

4.7%

9.8%

4

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Volume-8 | Issue-87 | February 5, 2017

E U RO S TA R ; t h e a n n u a l ra te o f

reintervention for stent-graft–related

problems is approximately 5%, and the

annual risk of rupture after implantation

is approximately 1%.

Case 2- Here is a case of 45 years old

patient who had abdominal pain 2 to 3

months Patient had history of CNS

(central nervous system) bleed which was

fully recovered.

Multi slice CT Angiography of aorta

showed anomaly in aortic arch, fusiform

abdominal aortic aneurysmal of renal and

infra renal abdominal aorta, saccular

abdominal aortic aneurysm from fusiform

dilated abdominal aorta at level of renal

arteries, saccular aneurysm from inferior

aspect of right renal artery, fusiform

aneurysm of left renal artery (Fig 10).

Endovascular Aneurysm (EVAR) repair

was planned. CAG showed coronary

artery disease, aneurysmal coronaries,

occluded OM, aneurysmal of abdominal

aorta involving renal artery. Successful

EVAR of Abdominal Aortic aneurysm with

bilateral renal chimney graft done

through both femoral arterotomy and

both brachial access.(Fig 11 and 12)

Patient was discharged on 3rd day in

hemodynamically stable condition.

Annual screening with the help of

ultrasography (very rel iable ) is

re co m m e n d e d i n p at i e nt s w i t h

abdominal aortic when size of

aneurysm > 4cm. especially in elderly

individual.

Up to 30% to 40% of patients are

unsuitable anatomic candidates for

conventional endovascular aneurysm

repair (EVAR), most commonly due to

challenging proximal aortic neck anatomy

and renal artery involment.

Techniques Option for aneurysm repair

when renal artery is involved

Techniques for aneurysm repair include

O p e n r e p a i r , H y b r i d r e p a i r ,

Chimmney/Snorkel technique, In-suit

fenestration, Custom fenestration.

SNORKEL/CHIMNEY EVAR Technique

The chimney technique in endovascular

aortic aneurysm repair (Ch-EVAR)

involves placement of a stent or stent-

graft parallel to the main aortic stent-graft

to extend the proximal or distal sealing

zone while maintaining side branch

patency. This technic was used in case 2.

Fenestration/Scallop (FEVAR)

Endograft with circular (fenestration) and

s e m i c i r c u l a r ( s c a l l o p ) h o l e s

corresponding to aortic branch to

maintain renal artery patency.

aneurysm

Out of all abdominal aortic aneurysm 80%

are below renal. EVAR in below renal

artery aneurysm is relatively easy.

EVAR is associated with less 30 day

mortality compared to open repair (Fig

13). Long term outcome (15 years) with

EVAR is equal to open repair .

Conclusion

is

considered to be first line treatment for

descending aortic aneurysm, infra renal

abdominal aneurysm, selected cases of

supra renal aneurysm with suitable

anatomy as EVAR is associated with less

30 day mortality and equal long term

outcome compared to open repair.

As there is high mortality

(Fig 14)

associated with

aneurysm rupture annual screening is

highly recommended in all the patient

with aneurysm when size of aneurysm is

big. Planned intervention/surgery is

better then emergency surgery.

Endovascular Aortic Repair (EVAR)

Fig 13 - Comparison of EVAR with open repair of abdominal aneurysm

Fig. 10

Fig. 12

Fig. 11

Left brachial artery cut downfor right renal stenting.

Right brachial artery cut downfor left renal stenting.

Right femoral arteriotomyLeft femoral arteriotomy

Pre Procedure During Procedure Post Procedure

Large aneurysm

saccular Rt ilac

Renal

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