EVAR - Personal Experience
Transcript of EVAR - Personal Experience
Early and Long Term Results of EVAR:
Personal Experience
Giorgio M. Biasi, MChir FACS FRCS
Professor of Vascular Surgery
University of Milano Bicocca
Transfemoral Intraluminal Graft Implantation for Abdominal Aortic
Aneurysms
Parodi JC, Palmaz JC, Barone HD.Annals of Vascular Surgery 1991; 5: 491-9
EVAR vs OR(<30days)
• Decrease perioperative morbidity
• Decrease intensive care unit stay
• Decrease total hospital length of stay
• Increase quality of live in perioperative period.
• Increase ruptured rate/year
• Need continuous follow-up to detect and treat complications
• Increase the reintervention rate/year
EVAR vs OR(>30days)
Type I Endoleak
Type II Endoleak
Modular componentdisconnection
Endograft kinking
Surgical conversion
How to reduce early and late complications
Case selection Preprocedural investigations
Intraprocedural investigations Follow-up
How to reduce early and late complications
Case selection Preprocedural investigations
Intraprocedural investigations
Follow-up
Case Selection
Risk related to general conditions ( age- hostyle abdomen- cardio-respiratory conditions- large AAA - smokers - patient’s consensus- etc.)
Risk related to aortic anatomy
Aortic Angulation
Case SelectionProximal neck and iliacs angulation
Case Selection Proximal Neck
Compromised proximal neck anatomy is the
most frequent cause of EVAR failure.
Neck Angulation
Device migration due to neck angulation
Some technical tricks to avoid complications neck related
• Perform angiogram in several projections.
• C-Arm orientation.
• Lower renal artery selection.
• “Crossing the Limb” technique.
• Endograft selection.
Technical tricks Perform angiogram in several projection
Technical tricks C-Arm orientation
Technical tricks “Crossing the Limb”
technique
Free Flow
Hooks
Barbs
Endograft selection
• Unibody or bifurcated
• Modular or nonmodular
• Fully or partially stent-supported body
• Supra or below renal fixation
• Hooks and barbs
Endograft selection
How to reduce early and late complications
Case selection
Preprocedural investigations Intraprocedural investigations
Follow-up
Angio - CTAngio - CT
Preprocedural Investigations
How to reduce early and late complications
Case selection
Preprocedural investigations
Intraprocedural investigations Follow-up
Intraop. Angiogram
Intraprocedural Investigations
IVUS
Intraprocedural Investigations
How to reduce early and late complications
Case selection
Preprocedural investigations Intraprocedural investigations
Follow-up
FOLLOW UP
• CT Scan
• Duplex
• Angiography (in case of leaks)
Long term aortic evolution
• Proximal neck dilatation
• Shrinking – elongation or shortening
• Kinks
FOLLOW UP
Proximal neck dilatation
Type II Endoleak
Endograft migration
Particular situations
• Inflammatory Aneurysm
• Pararenal aortic aneurysm in high risk patients
• Aneurysm associated to an additional abdominal
pathology.
• Ruptured Aneurysms
Particular situations
• Inflammatory Aneurysm
• Pararenal aortic aneurysm in high risk patients
• Aneurysm associated to an additional abdominal
pathology.
• Ruptured Aneurysms
INFLAMMATORY AAAs
ACCOUNT FOR 3% TO 10% OF
ALL AAAs
PENDING ISSUES
HOSTILE OPERATIVE FIELD
RISK OF INJURY TO VITAL STRUCTURES
POTENTIAL FOR REGRESSION OF RETROPERITONEAL
INFLAMMATORY PROCESS
USE OF ORAL STEROID IN THE PRE AND POST
PROCEDURAL COURSE
INDUCTION OF RETROPERITONEAL FIBROSIS BY EVAR
URETERIC STENTING
Particular situations
• Inflammatory Aneurysm
• Pararenal aortic aneurysm in high risk patients
• Aneurysm associated to an additional abdominal
pathology.
• Ruptured Aneurysms
Compromised proximal neck
anatomy is the most frequent
rejection criteria for endovascular
treatment of AAA.
Which is the best endovascular strategy for
pararenal aortic aneurysm?
Endovascular treatment of pararenal aortic aneurysm
Infrarenal Fixation Endograft
Transrenal Fixation Endograft
Fenestrated Endograft
Technical tricks Lower renal artery selection
An accurate delivery of the graft just
below the lower renal artery is required
to maximize the sealing zone with
conventional endograft.
Infrarenal fixation endograft
Complete sealing and better attachment of the stent-graft.
Decreased incidence of endoleak.
Transrenal fixation endograft
Fenestrated Endovascular Graft
• Extend the proximal sealing zone
• Accomodate native arterial angulation
• Improve proximal fixation
Particular situations
• Inflammatory Aneurysm
• Pararenal aortic aneurysm in high risk patients
• Aneurysm associated to an additional abdominal
pathology.
• Ruptured Aneurysms
Aneurysm associated to an additional abdominal pathologies
• Abdominal pathologies : 3.4% - 12%
• Other pathologies: cardiomyophaty 25% -
50%
• Neoplastic pathologies: 7% - 9%
First EVAR Procedure
in our Institution
January 1997
Endograft usedAneuRx - MedtronicEndologix - Aptiva
Zenith -CookExcluder - Gore
Talent - MedtronicEndofit - Serom
Anaconda - Le Maitre
Ancure - GuidantQuantum - CordisLifepath - Edwards
1997 - Inclusion CriteriaElective Endograft
• Proximal neck lenght > 25 mm
• Proximal neck diameter < 26 mm
• Neck angulation < 40°
• Iliac arteries anatomy
2008 - Inclusion Criteria Elective Endograft
• Proximal neck lenght > 15 mm
• Proximal neck diameter < 28 mm
• Neck angulation < 60°
• Iliac arteries anatomy
2008 - Inclusion Criteria Elective Endograft
• Patient Age > 75 ys old
• Unsuitable for Surgery:
- Hostile Abdomen
- Higth risk for comorbilities
Present Indication
To EVAR in our Institution
30% of procedures
EVAR vs OR
EUROSTAR Registry Data
EVAR vs OR Percentage of patients
reintervention free
EUROSTAR Registry Data
PERSONAL EXPERIENCE
Elective AAA(August 2005/August 2008)
Number of Patients: 220
Male: 195 Female: 25
Age: average 77.5 years
Min.: 58 years Max.: 93 years
Early complications
Type I Endoleaks 9/218 (4.1%)
Type II Endoleaks 16/218
(7.3%)Type III Endoleaks 1/218 (0.4%)
Distal embolization 2/218 (0.9%)
Branch occlusion 3/218 (1.4%)
Early conversion 2/220 (0.9%)
Type I Endoleak
• Eight treated with a cuff.
Branch occlusion
• Two treated with embolectomy.• One treated with femoral-femoral
bypassDistal embolization
• Treated with major amputation one above and one below the knee.
Early Conversion• One due a common iliac artery
rupture.• One due a structural defect of
device.
Late conversion 8/218
(3.6%)Partial Graft Thrombosis 5/210
(2.3%)Branch occlusion 2/210
(0.9%)Death after conversion 1/10
(10.0%)
Late complications
Death after conversion
• Due a cardiac complications
Branch occlusion
• One treated with embolectomy and stenting.
• One treated with femoral-femoral bypassLate Conversion
• Two due to a ruptured aneurysm.• Three due to a enlargement of aneurysmal sac
without evidence of endoleaks.• One due to a proximal migration of graft.• Two due to a type one endoleak after a fibrinolitic
therapy
Reference AllEndoleaks
Distal embolization
Early and Late
Conversions
Branch occlusion
Death graft
related
Walschot, 2002
18.5% 6.4%
Thomas, 2000
6.0% 1.4% 5.0% 1.0% 0.5%
Diethrich, 2002
18.6% 3.0% 0% 2.1% 3.0%
Raithel, 2002
7.0% 1.2%
Liewald, 2001
16.0% 4.0% 3.0%
Mohan,2000
16.7% 1.5% 0.04%
Range 6-26% 0-10% 3-10% 0-6% 0-4%
Biasi 11,4% 0.9% 3,6% 2.8% 0.8%
Author Type IEndoleak
Type II Endoleak
Type III Endoleak
Graft/LimbOcclusion
Migration SecondaryIntervention
Late Ruptured
Becquemin2005
276 pts.
32% 39% 10% 13.5% 3.0% 22.0% 0.8%
EurostarRegistry
20062746 pts.
9.4% 15.3% 1.8% 2.4% 2.6% 8.7% 0.5%
Biasi 4.1% 7.3% 0.4% 2.3% 0.4% 1.4% 0.7%
• Avoid laparotomy
• Reduce cardiac complications
• Reduce septic complications
• Less invasive
• Rapid recovery
• Combined treatment?
Endovascular Treatment
Conclusion
EVAR is less invasive than open
repair, but the long term outcome
is still unknown.
Conclusion
The endovascular treatment of acute or ruptured AAA, could contribute in reducing the perioperatory morbidity and mortality in comparison to open repair .
In elective surgery, EVAR needs an accurate selection of patients.