Life after EVAR 1? The value of open repair for some patients reappears. D. Böckler University Hospital Heidelberg, Germany
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1 Life after EVAR 1? The value of open repair for some patients reappears D. Böckler University Hospital Heidelberg, Germany
2 Disclosure Speaker name: Dittmar Böckler I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Research Grant I do not have any potential conflict of interest
3 Everything changed on 7 th September 1990
4 Annual Proportion of Elective EVAR and OR Ref. Kent C, NEJM 2014
5 200 Shift from OR to EVAR - Heidelberg Oct. EVAR (AAA) OR (AAA) Year Total OR EVAR EVAR proportion in% % %
6 Open vs Endo (RCT) Early Benefit of EVAR RCT (n) 30 day endo mortality 30 day open mortality EVAR I (1082) 1.7% 4.7% 3 fold DREAM(345) 1.2% 4.6% 4 fold OVER (881) 0.5% 3% 6 fold EVAR II (338) 7 % Reduction in 30 day mortality Schermerhorn ML et al., NEJM 2008;358:
7 Value of Open Repair reappears... EVAR 1 Trial- 15 year results Beyond 8 yrs. open repair shows lower overall and AAA related Mortality mainly attributed to secondary rupture after EVAR (7%)
8 Indications for open AAA repair in 2017 Young & fit patients & morphologically unsuitable
9 100 % Endo-Repair in Ruptured AAA
10 Indications for open AAA repair in 2017 Young & fit patients & morphologically unsuitable Ruptured AAA
11 Shift of Indications for Open Repair in Heidelberg Indications 2004 (n=81) 2014 (n=40) Elective AAA 76 (82.7%) 26 (65.0%) Sympt. AAA 10 (12.3%) 1 (2.5%) Rupt. AAA 4 (5.0%) 13 (32.5%)
12 Indications for open AAA repair in 2017 Young & fit patients & morphologically unsuitable Ruptured AAA Rupture after EVAR
13 Increasing reported ruptures post EVAR
14 Indications for open AAA repair in 2017 Young & fit patients & morphologically unsuitable Ruptured AAA Rupture after EVAR Open surgical conversion
15 Conversion: Indications & Outcome Overall 30-day mortality: 9.1% Mortality after elective conversions: 3.2% Mortality after emergency conversions: 29.2% Indications for late conversions: Endoleak: 62.4% Infection: 9.5% Migration: 5.5% Thrombosis: 6.7% Kouvelos G J Vasc Surg 2015, Böckler, JEVT 2002
16 Indications for open AAA repair in 2017 Young & fit patients & morphologically unsuitable Ruptured AAA Rupture after EVAR Open surgical conversion Aorto-enteric fistula
17 Indications for open AAA repair in 2017 Young & fit patients & morphologically unsuitable Ruptured AAA Rupture after EVAR Open surgical conversion Aorto enteric fistula Mycotic AAA
18 Open AAA Repair after adoption of EVAR higher proportion of elderly patients > 80 years with increasing mortality risk with age Schermerhorn ML et al., NEJM 2008;358:
19 Open Repair in Octogenerians before and after adoption of EVAR Retrospective single center N = 111 patients > 80 yrs. Group 1: before EVAR (n=65) Balotta E et al, JVS 2008;47:23-30 Group 2: after adoption of EVAR (n=46)
20 Open Repair in Octogenerians Technical Details before EVAR after EVAR Balotta E et al, JVS 2008;47:23-30
21 Open Repair in Octogenerians 30 day mortality & morbidity before EVAR after EVAR Balotta E et al, JVS 2008;47:23-30
22 Literature Confirming these Observations More elderly patients with more comorbidities More complex surgery due to patient selection Same mortality but more complications
23 Retrospective single center study = pre-evar era n=99 OR = EVAR era n=135 OR Proportion of EVAR was 43%
24 AAA for open are more complex Reasons for exclusion from EVAR:
25 Technical Intraoperative Differences of OR
26 Technical Intraoperative Differences of OR
27 Outcome Mortality & Morbidity of OR
28 raaa In-Hospital Mortality for AAA and raaa Repair in Heidelberg in % % 12,0 In-Hospital-Mortality 10,0 8,0 6,0 4,0 2,0 0, OR 2,3 4,9 5,6 4,3 10,2 EVAR 2,1 4,7 0 2,5 1,3
29 Conclusions EVAR: first line therapy for AAA in 2017 > 70% of pat. Value of open repair today is unquestioned OR is more complex due to morphology Sofar, survival after OR is not significantly affected (yet) Increasing No. of octogenerians is of concern (mortality ) Training of young fellows is present and future challenge
30 Life after EVAR 1? The value of open repair for some patients reappears
31 Life after EVAR 1? The value of open repair for not some but quite a few patients remains!
32 Life after EVAR 1? The value of open repair for some patients reappears D. Böckler University Hospital Heidelberg, Germany
Disclosure. I do not have any potential conflict of interest
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