PowerPoint Presentation
Open Aneurysm Repair in Endovascular EraDicky A.Wartono,
MDHarapan Kita National Cardiovascular CentreJakarta 2016
Disclosure: none
Abdominal Aortic Aneurysmdiameter 30 mm>50% increased
diameter
55 mm symptomatic >10 mm/year
2014 ESC Guidelines on the diagnosis and treatment of aortic
diseases
The management of AAA depends on aneurysm diameter. The
indication for AAA repair needs to balance the risk of aneurysm
surveillance and the associated risk of rupture against the
surgical risk at a certain threshold diameter. Today, periodic
ultrasound surveillance of the aneurysmuntil it reaches 55 mm or
becomes symptomatic or fast growing (>10 mm/year)is regarded as
a safe strategy for patients with small AAAs. This is based on the
findings of two large multicentre RCTs (UKSAT and ADAM), both
launched in the early 1990s.348,373 Few women were included in
these trials and neither had the power to detect differences in
all-cause mortality in this specific subgroup; however, there is
evidence that women are more likely to rupture under surveillance
and tend to suffer AAA rupture at a smaller aortic diameter than
men.348,365,374 Even though evidence for threshold diameter in
women is scarce, intervention at a smaller diameter (>50 mm) may
be justified.
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2014 ESC Guidelines on the diagnosis and treatment of aortic
diseases
Ann Intern Med. 2005 Feb 1. 142(3):198-202AAA Size and Estimated
Risk of Rupture
Diameter (cm) Risk (%/y)<
404-50.5-55-63-156-710-207-820-40>830-50
Open Surgical Repair of AAA
Up to 3-hour procedureSignificant incision 20-30 minute
cross-clamp
12 days in ICU, 714 day hospitalization, 46 weeks recovery
time5-10% operative mortality in population based studies
Contraindicated in many patients
Endovascular AAA Repair1-2 hours prosedureLimited incisionsNo
hemodynamic consc
Reduced morbidityReduced blood loss
Shorter hospital stayEarlier return to function
In less than 3 decades, (EVAR) has been converted from an escape
procedure exclusively confined to high-risk patients to a primary
choice.
Open surgery has increased in technical complexity in the new
endovascular erapatients who are not anatomically suitablepatients
with EVAR failure conversion after stent-graft migration,
persisting endoleak with aneurysm growth,stent-graft rupture,
etc.)
Higher surgical risks and raises new challenges Systematic
review and meta-analysis of the early and late outcomes of open and
endovascular repair of abdominal aortic aneurysmP. W. Stather1, D.
Sidloff1, N. Dattani1, E. Choke1, M. J. Bown1,2 and R. D.
Sayers1
. This new high-complexity open surgery for AAA exposes to
higher surgical risks and raises new challenges regarding surgical
training, surgical indications, and perioperative management
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Is Open Surgery for AAA Repair a Reason for Concern in the EVAR
Era?
Anatomical AspectsAortic neck diameterSize + 15-20% Sufficient
radial forceOversize - Kinking, thrombus form, endoleakAortic
neck10-15mm (landing zone)Normal appearance
Anatomical AspectsAortic neck angulation
