Disclosures. EVAR follow-up: actual recommendation. EVAR follow-up: critical issues

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1 Disclosures is it time to discuss individualized follow-up schemes based on preoperative anatomy and high quality completion angiography? Consultant / Speaker / Proctor Cook Cordis Medtronic Invatec W.L. Gore & Associates G Pratesi Vascular Surgery University of Rome Tor Vergata actual recommendation Management of Abdominal Aortic Aneurysms Clinical Practice Guidelines of the European Society for Vascular Surgery Eur J Vasc Endovasc Surg, 2011 Radiation exposure, contrast induced nephropathy and increasing costs associated with CTA Heterogeneity of intervals and methods Unpredictability of EVAR complications critical issues How to improve EVAR follow-up? 279 EVAR Total 1167 CT scan Only 27 patients benefitted of yearly CT scan for reintervention Less than 10% of the patients benefit from the yearly CT-FU after EVAR Pooled sensitivity was 0.77 and specificity 0.90 Pooled sensitivity was 0.98 and specificity 0.88 Dias NV et al., Eur J Vasc Endovasc Surg 2009 Mirza TA et al., Eur J Vasc Endovasc Surg 2010

2 Vascular Surgery - University of Florence, University of Rome Tor Vergata 969 EVAR: follow-up programs (January 2000 December 2012) 11 patients required secondary intervention: 3 initially identified by AXR 3 diagnosed with DUS 3 by both DUS and AXR 2 by CTA following undiagnostic DUS EVAR surveillance based on the complimentary findings of DUS and AXR is feasible and safe Harrison GJ et al., Eur J Vasc Endovasc Surg 2011 Group 1 ( , 261 pts): DUS and AXR at discharge CTA at 1, 12 months and yearly DUS at 1, 6, 12 months and every six month Group 2( , 708 pts): DUS and AXR at discharge CTA at 1 month DUS/CEUS, AXR at 6, 12 months and yearly Mean follow-up duration: 34.9 months ± 23.2 group 1: 65.6 months ±35.3; group 2: 23.4 months ±11.3 Follow-up program: DUS, CEUS, CT for type II EL 102 EVAR patients with paired DUS and CTA CTA + CTA - DUS DUS FN e 3 FP with DUS Sensitivity: 72%; Specificity: 96%; PPV: 81%; NPV: 94% 21 EVAR patients with AAA sac enlargment CTA + CTA - CEUS CEUS FN e 4 FP with CEUS Sensitivity: 90%; Specificity: 60 %; PPV: 71,4 %; NPV: 85,7 % 5 year freedom from Group 1 Group 2 Follow-up programs: results Endoleak 69.3% 67.5% ns Migration 97.7% 98.3% ns Conversion 96% 98.3% ns AAA rupture 98.6% 99.2% ns Reintervention 83.7% 82.3% ns p Accurate preoperative planning for a more accurate patient selection New-generation endograft reduced graft-related related complications Careful intraoperative technique increasead treatment durability Individualized follow-up schemes J Cardiovasc Surg 2011 preoperative anatomy Aortic neck diameter, length and angulation Aneurysm diameter Common iliac artery diameter Collateral vessels patency The reported incidence of AAA sac enlargement after EVAR was 41% at 5 years Schanzer A et al., Circulation 2011

3 challenging proximal aortic neck challenging proximal aortic neck high quality completion angiography Length<10 mm Angulation>60 Angulation>60 Diameter>28 mm Calcification>50% Thrombus>50% Reveserse tapered Patients with HFA have an higher rates of reintervention AbuRahma AF et al., J Vasc Surg 2011 Completion angiography: endograft reinforcing stenting Appropriate parallax correction (CC(CC-CL) for proximal and distal seal evaluation Iliac limbs analysis with multiple projections after stiff wires retraction Seal and patency: intraoperative correction high quality completion angiography Prolonged acquisition time to identify late type II EL and feeding vessels High selective sacculography for intrasac embolization Type II EL: direct impact on followfollow-up

4 Completion angiography: type II EL intrasac embolization Vascular Surgery - University of Florence, University of Rome Tor Vergata 372 EVAR: study group (January 2010 December 2012) 163 patients Stent graft: proximal aortic neck: -AFX 3 1.8% regular length > 15 mm, -Anaconda % - Excluder/C % % angulation< 60 -Incraft common iliac arteries: Endograft reinforcing diameter > 10 mm, < 20 mm stenting % Completion angiography: Type II endoleak % absence of type I/III EL no graft kinking/stenosis Intrasac type II EL embolization 5 3% Follow-up program: DUS/CEUS and AXR at discharge, CTA at 30-day, DUS/CEUS at 6, 12 months and yearly Follow-up outcomes Individualized follow-up program N % Mortality AAA-related mortality - Reinterventions 5 3 Migration - Limb occlusion Type II endoleak Sac enlargement Mean follow-up: 10.9 months ±9.3 (1-36) All 5 complications requiring reintervention were detected with DUS/CEUS and confirmed with CTA CTA did not provide any additional information in the remaining patients DUS was not adequate in 10 patients (6.1%) due to obesity Standard EVAR Favorable preoperative anatomy and completion angiography DUS, AXR yearly No 30 day DUS, AXR Endoleak Yes CEUS Sac enlargment No Yes CTA CTA only in presence of complications requiring reintervention Individualized follow-up program Patients with unfavorable preoperative anatomy Advanced EVAR and f-evarf CTA follow-up examination still necessary CEUS and CTA are equivalent in monitoring endoleaks, sac diameters, and target vessel patency of fenestrated endografts J Endovasc Ther 2012

5 Conclusions Follow-up intervals and modalities evolved towards a less invasive approach, with a reduced use of CTA Standard EVAR patients with favorable anatomy and completion angiography can be followed-up with a relaxed timeline mainly based on DUS/CEUS and abdominal radiography CTA follow-up is still necessary in patients with unfavorable anatomy and after advanced EVAR