MODERN METHODS FOR TREATING ABDOMINAL ANEURYSMS AND THORACIC AORTIC DISEASE

Transcription

1 MODERN METHODS FOR TREATING ABDOMINAL ANEURYSMS AND THORACIC AORTIC DISEASE AAA FACTS 200,000 New Cases Each Year Ruptured AAA = 15,000 Deaths per Year in U.S. 13th Leading Cause of Death 80% Chance of Fatality if an Untreated AAA Ruptures AAA EPIDEMIOLOGY Incidence = 3-6 % of Population in Western Countries Men Present 4:1 over women % males years old % Over age 65 Infra-renal (most common) Hypertension Smoking Atherosclerosis Genetic Susceptibility 1 1

2 RISK OF AAA RUPTURE Rupture Risk Diameter (cm) (% per year) < 4 0% % % % % > % B-5 DIAGNOSTIC METHODS Physical Exam Radiography (KUB) Ultrasound Angiography Computed Tomography (3-D) Magnetic Resonance Imaging ULTRASOUND A very good screening tool for patients with extensive risk factors and/or symptoms. Not useful for extensive evaluation for potential endovascular repair. 2 2

3 2 Dimensional view - multiple views required to demonstrate actual tortuosity CONVENTIONAL ANGIOGRAPHY Excellent for making length measurements Can not visualize plaque and/or calcium contained within the vessels AXIAL COMPUTED TOMOGRAPHY Excellent for seeing plaque and/or calcium within the vessels. Excellent for making accurate diameter measurements. Difficult to make accurate length measurements. SAGITAL RECONSTRUCTIVE CT Excellent for seeing anterior / posterior angulation of the vessels as well as plaque and thrombus. 3 3

4 CORONAL RECONSTRUCTIVE CT Excellent for seeing lateral angulation of the vessels as well as plaque and thrombus. 3D RECONSTRUCTIVE CT ANGIOGRAPHY Rotational views show actual tortuosity of vessels Good for making length measurements Not Ideal for looking at plaque and/or calcium contained within the vessels MAGNETIC RESONANCE ANGIOGRAPHY Rotational views show actual tortuosity of vessels Good for making length measurements Not Ideal for measuring diameters 4 4

5 IMAGING SUMMARY The single best modality for evaluating aortic anatomy is CT with Axial, 3D, and multi-planar reconstruction views. A combination of CT and Angiography or CT and MRA can be helpful in complex anatomical presentations. TREATMENT OPTIONS Medical Management. Conventional Surgical Repair Endovascular Repair OPEN REPAIR RISK / BENEFIT Cardiac Complications = 20% Respiratory Complications= 22% Blood Loss = 800ml ml Operative Mortality = 2.7% Graft Infection Does Not Require Annual Follow up Can Treat difficult anatomy 5 5

6 EVAR RISK Access Site Complications Endoleak Type I, II, III, IV Migration Infection Can Not Treat All Anatomical Presentations Requires Annual Follow up Minimally Invasive Lower Mortality (Less than 1%) Shorter Hospital Stay: 1-2 VS 7-14 Days Safer Option for High Risk Patients More Anesthesia Options: Shorter Operative Time (60 minutes) Less Blood Loss (usually less than 200ml) Patient comfort EVAR BENEFIT Physician and patient preference ANIMATION OF EVAR 6 6

7 Case Studies Jim Melton, DO Case 1 Typical Fusiform Aneurysm 7 7

8 Case 1 Post Treatment Case 2 Severely Angled Neck Post Treatment 8 8

9 Revision for Iliac Aneurysm Revision for Iliac Aneurysm Follow-up CT Iliac Preservation 9 9

10 ENDOVASCULAR CHALLENGES Freedom From Rupture Freedom From Endoleaks Device Durability Tears / Abrasion Freedom from Migration Freedom From Modular Disconnects Management of Endoleaks Follow-up Compliance ENDOLEAK Classification system for Endoleak: Type I: Attachment Site Leak 1a Proximal 1b - Distal B-12 ENDOLEAK Classification system for Endoleak: Type 2: Sac Filling from Branch Vessel 2a single branch vessel 2b two or more branch vessels B

11 ENDOLEAK Classification system for Endoleak: Type 3: Leak due to defect in graft 3a component separation 3b Hole or tear in fabric B-12 ENDOLEAK Classification system for Endoleak: Type 4: Leak due to fabric porosity B-12 SIGNIFICANCE OF ENDOLEAKS Type I - Leads to Aneurysm Growth and is Directly Related to Rupture Type II - Higher prevalence (5-30%) may or may not cause aneurysm growth Type III - Directly related to aneurysm growth Type IV Usually only seen intra-operatively while heparin is active 11 11

12 ENDOLEAK TREATMENT OPTIONS Observation/Surveillance Embolization Translumbar Transarterial/Transcatheter Laparoscopic Ligation Explant/Conversion (Open) Preoperative Embolization SURVEILLANCE WATCHFUL EYE Advantages Spontaneous sealing reported as many as 53% within first 6 months. Disadvantages Costly follow-up diagnostic procedures Studies show as many as 20% that seal, reopen at months. WHEN AND HOW TO TREAT Type I or III: Immediate treatment Balloons/Stents Extenders / Cuffs Coils Surgical Conversion 12 12

13 WHEN AND HOW TO TREAT Type II Significance is uncertain Open to interpretation With increase sac diameter/volume treatment needed Coils Glue Endoscopic Staple Conversion NEW ADVANCES IN ENDOVASCULAR REPAIR TAG Thoracic Aortic Graft Aneurysm Transsection Acute Dissection Chronic Dissection PAU / Intramural Hematoma TSS Thoracic Side Branch Fenestrated / Branched Grafts Iliac Visceral ADVANTAGES OF THORACIC ENDOGRAFTING 1/6 Operative Mortality (1% vs. 6%) 1/5 Paralysis / Paraplegia (3% vs. 14%) 80% Less Blood Loss 85-90% Access Through Femoral Artery Faster Recovery: 2-3 Day hospital stay 13 13

14 TAG PROCEDURE 14 14

15 TAG CASE - PRE TAG CASE - POST TAG CASE - PRE 15 15

16 TAG CASE - POST NEW INNOVATIONS NOT AVAILABLE IN THE U.S. Iliac Branch Graft Abdominal Aortic Branch Graft Thoracic Single Side Branch SUMMARY EVAR has had a dramatic effect on the reduction of major complications associated with traditional open repair EVAR is highly favorable for patient satisfaction due to minimally invasive approach and quick recovery EVAR is becoming accepted as the New Standard for Aortic Aneurysm Repair 16 16

17 CONCLUSION Major advances have been made over the last few years which allow more complex aneurysm disease to be treated from an endovascular approach. Future advances will continue to expand the application of endovascular repair