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Contents AAA
General consideration Randomized Control Trials Comparing EVAR and Open AAA repair (OAR) Patient selection criteria for EVAR EVAR procedure Complications of EVAR ; endoleak Experience of SCHBC
Peripheral Disease ACA/AHA Practice Guideline Classification of peripheral arterial disease (PAD) Endovascular procedure Experience of SCHBC
Conclusions
Endovascular Treatment of AAA
; EndoVascular Aneurymal Repair : EVAR
Parodi JC, Palmaz JC, Barone HD.Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.
Ann Vasc Surg 1991;5:491-499
• Stent-graft design incorporating both
limited and adjustable dimensional
variability for maximum versatility. The
fixed attachment points on the left have
limited linear variability, whereas the
adjustable fixation points on the right
result in increased adaptability
• Modular endovascular bifurcation prosthesis including main bifurcation segment (A), contralateral leg (B), proximal aortic cuff (C), iliac cuff (D), and bifurcated (E) or straight (F) extenders. CTA, computed tomography-angiography; DSA, digital subtraction angiography
Dutch Randomized Endovascular Aneurysm
Management (DREAM) trial
• Between Nov. 2000 and Dec.2003, Netherlands
• 351 patients ( > 5cm AAA, suitable for both OSR and
EVAR )
• OSR = 174 pts vs. EVAR = 171 pts
• Primary end point – operative mortality & moderate or
severe complications NEJM 2004;351:1607-1618
Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1) : randomised controlled trial
Sept. 1999 ~ Dec. 2003, UK
1082 patients
> 60 years, > 5.5cm AAA
AAA was regarded as anatomically suitable for EVAR
OSR = 539 pts vs. EVAR = 543 pts
to assess long term survival, generalisability, graft durability, health-related
quality of life (HRQL), and hospital costs associated with both EVAR and OS
R
Lancet 2005 ; 365 :2179 - 86
Patient selection criteria for EVAR
Fusiform AAA ≥ 5 ~ 5.5cm in diameter
Saccular AAA Suggested aortic morphology
Proximal neck length ≥ 1.5 cm Neck diameter ≤ 2.8 cm Neck angulation ≤ 60 degrees Preservation of critical side branches Iliofemoral arteries of sufficient diameter for sheath access No severe iliac artery or aortic tortuosity
No hereditary connective tissue disorder Anesthesia clearance for possible conversion to open repair if necessary
Proximal neck length ≥ 1.5 cmNeck angulation ≤ 60 degrees
Fusiform AAA ≥ 5 ~ 5.5cm in diameter or Saccular AAA
Preservation of critical side branches
Iliofemoral arteries of sufficient diameter for sheath access
Patient selection criteria for EVAR
No severe iliac artery or aortic tort
uosity
Endoleak Type I, II, III, IV, V
Migration
Kink, Stenosis, and Occlusion
Graft infection
Rupture
Complications of EVAR
Endoleak
Type I : a leak between the stent-graft and the proximal or dist
al arterial wall attachment site
Type II : back-bleeding into the aneurysm sac from a patent inf
erior mesenteric (IMA), lumbar, internal iliac, accessory renal or g
onadal artery
Type III : between stent-graft components (e.g. the junction bet
ween the main body and limb of a device) or through a hole in the
fabric of the graft
Type IV : excessive graft porosity
Type V (endotension) : when the sac increases in size with
out a detectable endoleak
Endoleak
Result of Endoleak1. Many type II endoleaks undergo resolution by sponta
neous thrombosis
2.
Frank J. Veith et al. J Vasc Surg 2002;35:1029-35Nature and significance of endoleaks and endotension: Summary of opinions expressed at an international conference
Christopher K. Zarins et al. J Vasc Surg 2000;32:90-107 Endoleak as a predictor of outcome after endovascular aneurysm repair: AneuRx multicenter clinical trial
Result of Endoleak
Timothy Resch et al. J Vasc Surg 1998;28:242-9Persistent collateral perfusion of
abdominal aortic aneurysm after
endovascular repair does not lead to
progressive change in aneurysm
diameter
Experience of SCHBC- EVAR for AAA
Feb, 2008 to May, 2009 13 patients (M : F = 11 : 1) Mean age : 70.54 (54 – 82) Aneurysm size : 56.23mm (32-76.3mm)
Ruptured : 1 Impending rupture : 2 unruptured : 10
296 211
1520
550
8.2
0.7
60.86
20.2
21.8716
Op.time(min)
bleeding inOp(cc).
transfusion(pack)
ICU stay(hr) Hosp.stay(day)
OREVAR
Complication OR EVAR
Wound problem 3/15(20%) 1/13(8%)
Pulmonary Cx. 2/15(13%) 0/13(0%)
G-I complication 1/15(6%) 1/13(8%)
Acute thromboembolism 1/15(6%) 0/13(0%)
Mortality : 2/15(13%) in OR
1/13(8%) in EVAR
EVAR and OR in SCHBC
P<0.05
Experience of SCHBC- Endoleak
Endoleak : 6/13 (46%) type I : 2 ( Ia, Ib) type II : 2 type III : 2
Result of endoleaks type II & type III : improved, 2wks, 3mths Other
loss : 1 Follow up : 2
Mortality : 1 (type Ia endoleak)
ACA/AHA Practice Guideline – Endovascular treatment for Claudication
Recommandations Endovascular procedure is the treatment of choice for type A lesio
ns in iliac or femoral popliteal lesions
More evidence is needed to make firm recommendations about t
he type B and C lesions
Primary stent placement is not recommended in the femoral, popli
teal or tibial arteries
Subintimal Angioplasty (SI-PTA)
(A) The occlusion is approached away from a collateral
(B) The catheter/guidewire is advanced through the subintimal space, enabling it to take the path of least resistance
(C) The catheter is retracted back and the guidewire is manipulated into a wide loop
(D) The loop is advanced forward until it re-enters the true lumen
A schematic diagram to show the subintimal recanalization procedure
Semin Vasc Surg1995;8:253-264
Experience of SCHBC
July, 2007 to May, 2009 16 patients (M : F = 14 : 2) not suitable for bypass surgery
Anesthesia, poor run off or more peripheral lesion Mean age : 65.2 (47 – 77) Lesions
Iliac : 6 Femoropopliteal : 7 Combine : 3
Stent insertion : 14
Experience of SCHBC
ABI follow up (POD # 7) Pre PTA (mean) : Post PTA = 0.44 : 0.94
Post PTA amputation of extremities 2 pts (2nd toe Rt., BK amputation both)
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Pre PTA Post PTA
12345678910111213
P =0.009
Conclusions EVAR is a effective and feasible procedure in patients at low surgi
cal risk as well as at high risk
In randomized studies, EVAR is superior to the open repair at shor
t-term and midterm results
In SCHBC experience, perioperative results in EVAR are more acc
eptable than them of open repair
Conclusions
Endovascular procedure is an another option in
treatment methods of patient with PAD
Endovascular procedure, especially, is more effective
and feasible in PAD patients with high surgical risk,
poor run off and more peripheral lesions
More research is needed to make sure of the effects of
endovascular procedure for patients with PAD