Endovascular Treatment of Symptomatic Abdominal Aortic Aneurysms
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1 춘계심장학회, April 2013 Endovascular Treatment of Symptomatic Abdominal Aortic Aneurysms Seung-Hyuk Choi Division of Cardiology Samsung Medical Center SungKyunKwan Univ.
2 Contents Introduction EVAR vs. Open repair Ruptured AAA EVAR vs. Open repair for ruptured AAA Real world registry data RCT s
3 Endovascular Repair of AAA Greenhalgh RM & Powell JT. NEJM 2008;358:494
4 Treatment Modality Surgical open repair standard of care EVAR, since early 1990 s, has received widespread acceptance for elective Tx of AAA Schwarze ML, et al. J Vasc Surg 2009;50:722
5 EVAR vs. Open repair 4 RCT s Country Numb of Patients Median Publication F/U EVAR OR EVAR-1 UK y NEJM 2010 DREAM Dutch y NEJM 2010 OVER USA y NEJM 2012 ACE France y J Vasc Surg 2011
6 In-hospital Mortality In-hospital Mortality EVAR Open Repair EVAR-1 2.1% 6.2% DREAM 1.2% 4.6% OVER 0.5% 3% ACE 1.3% 0.6% EVAR is better than OR
7 No Survival difference EVAR-1 DREAM p = 0.73 p = 0.72 p = 0.97 De Bruin JL, et al. NEJM 2010;362:1881 UK EVAR investigators. NEJM 2010;362:1863
8 No Survival difference OVER ACE Mean : 5.2 year Lederle FA, et al. NEJM 2012;367:1988 Becquemin J, et al. J Vasc Surg 2011;53:1167
9 Hazard ratio for death OVER Lederle FA, et al. NEJM 2012;367:1988
10 Analysis for Re-Interventions 1986 procedures in 1908 patients 1066 EVAR Open repair Mean F/U 27 months Secondary intervention Vascular Aorta and Non-aorta Non vascular GI related (incisional hernia) 21.3% Secondary intervention 21.9% in EVAR 21.2% in OR 25% 20% 15% 10% 5% 0% EVAR(n=230) Open(n=194) Aorta related Vascular(Non-aortic) GI related Quinney BE, et al. J Vasc Surg 2011;54:1592-8
11 Re-Interventions OVER Secondary therapeutic procedure included Incisional hernia repair laparotomy for bowel obstructions Lederle FA, et al. NEJM 2012;367:1988
12 Risk of aneurysmal rupture Achilles heel of EVAR EVAR-1 : 4.6% at 6 year f/u DREAM : 1.7% at 6.4 year f/u OVER : 1.4% at 5.2 year f/u ACE : 2% at 3 year f/u Higher mortality rate in ruptured patients Causes of rupture were identified by radiologists before ruptures in many of the patients Annual imaging follow up after EVAR is important to reduce the rupture Wyss TR, Ann Surg 2010;805-12
13 Data from EVAR trials EVAR 1 & 2 trial : EVAR group : 848 patients OR group : 594 patients Follow up data OR 0 rupture EVAR 27 ruptures 5(18.5%) : perioperative ruptures 5(18.5%) : late rupture without prior complications 17(63%) : late rupture with prior complications 18(67%) died within 30 days of rupture 12 urgent procedure 7 OR 5 EVAR modification 15 died before intervention 2 died 1 died Wyss TR, Ann Surg 2010;805-12
14 EVAR vs. Open Repair Early survival benefit in EVAR & late equivalence in both group Pros. Cons. Less invasive Short procedure time Short ICU & hospital stay Less blood loss & transfusion Less GI related complications Require long-term monitoring (contrast, radiation, ) Higher reintervention rate Higher rupture rate Higher cost
15 Symptomatic (ruptured) AAA
16 Open repair for ruptured AAA Perioperative mortality 32-53% in R-AAA repair % in S-AAA repair 3.5-5% in E-AAA repair Symptomatic AAA without rupture : abdominal / back pain associated with aneurysmal tenderness impending rupture
17 EVAR for ruptured AAA S.W. Yusuf 1994 First case of successful EVAR of a ruptured AAA Lancet 1994;344:1645 T. Ohki, FJ Veith ruptured AAA Aorto-uniiliac (AUI) stent graft 16% mortality J Am Coll Surg 1999;189:102
18 EVAR vs. Open repair for r-aaa Sep 2002-Dec 2004 EVAR(n=11) OR(n=12) 30day mortality 53% 53% Complications 77% 80% Hinchliffe RJ, Eur J Vasc Endovasc Surg 2006;32:506-13
19 FDA approved Endovascular Grafts Excluder Gore Zenith Cook Endurant Medtronic PowerLink Endologix Ovitation Trivascular Aortix Lombard
20 EVAR vs. Open repair for r-aaa Vs. Veith FJ, Ann Surg 2009;250:818-24
21 338,278 patients : intact AAA 69,653 patients : ruptured AAA Ann Surg 2012:256:651-8
22 Trend of management for r- AAA Open repair 30 day mortality EVAR Eefting D, J Cardiovasc Surg 2013;54:47 78 EVAR 236 OR Netherlands Defting D, J Cardiovasc Surg 2013;54:47-53
23 Trend of management for r- AAA 120 EVAR 167 OR Albany, NY Mehta M, J Vasc Surg 2013;57:368-75
24 Hemodynamic status impacts outcomes of EVAR for r-aaa From 2001 to patients with r-aaa underwent EVAR Mehta M, J Vasc Surg 2013 in press
25 ENGAGE registry sites in 30 countries 1200 AAA patients Endurant 17.9% treated outside of IFU All patients at 30 day f/u 500 patients at 1 year f/u 98.8% 91.6% 1.4% type 1 Endoleak 9.9% type II Endoleak 0% Migration 0% Rupture 0.6% surgical conversion 4.9% secondary procedure Stokmans RA, Eur J Vasc Endovasc Surgery 2012: 1-7
26 Stokmans RA, Eur J Vasc Endovasc Surgery 2012: 667-3
27 Case M/82 C.C : Abdominal pain, nausea, vomiting for 8 hours PHx. Hypertension for 20 years nephrectomy d/t malignacy of renal pelvis, Lt in April 2006 Hemodialysis since NSTEMI, stenting at m-rca in July 2012 BP : 120/77mmHg, HR 76min/min
28 Previous CT 34mm 2007/6/8
29 Previous CT 46mm 2012/6/1
30 Previous CT 52mm 2012/11/19
31 Ruptured AAA 2013/1/4
32 Ruptured AAA 2013/1/4
33 Emergency EVAR RIIA embolization Amplatzer plug 16mm Main body Zenith mm Lt limb 18-56mm Rt limb 12-90mm Baseline Angiogram Post-EVAR
34 1 week F/U CTA No endoleak
35 AJAX trial (preliminary data) April 2004 Feb ruptured AAA 395 evaluated with CT 155 suitable anatomy for EVAR (AUI with fem fem bypass) 116 randomized : 57 EVAR vs. 59 OR 30 day mortality : 21% EVAR vs. 25% OR 34 th Charing Cross Symposium 2012
36 Ongoing RCT s for r-aaa EVAR vs. open repair ESCAR trial : started at Jan 2008 total 160 patients IMPROVE trial : start at Oct 2009 total 600 patients
37 Management Algorithm for Rupture AAA Ruptured AAA Hemodynamic Stable Y N Open repair Symptomatic Impending rupture AAA Spiral CT N Suitable for EVAR Y EVAR
38 경청해주셔서감사합니다
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