Considerations for a Durable Repair
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1 Considerations for a Durable Repair Eric Verhoeven, MD, PhD, A. Katsargyris, MD Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
2 Disclosures William Cook Europe/Cook Inc. Consultant & Research grants W.L. Gore & Associates Consultant & Research grants Atrium Consultant Siemens Consultant Bentley Consultant
3 Aortic Disease is Progressive The progression of aortic aneurysms is a reflection of the degenerative process of the aorta as a result of biological aging, constant pressure and fatiguing pulsating forces at times we even feel the hammering to which our arteries are subjected. Lawrence-Brown M, Progressive aortic aneurysm disease. Endovasc Today. 2014;(13)(5)(suppl) 3.
4 How to Manage Endovascular AAA Repair? 1. Durability: Resistance to Migration/Endoleak 2. Personalized solutions: Portfolio 3. Precise and controlled delivery 4. Seal in Healthy Tissue
5 Cook Product Portfolio A complete portfolio designed to address the progressive nature of aortic disease from the arch to the iliacs Zenith Alpha Abdominal
6 Current treatments (Surgery/EVAR) treat the result of the disease but not the disease
7 The disease continues after Surgery/EVAR
8 Infrarenal Aortic Neck Dilates after open Surgery
9
10 Proximal neck: extension of disease
11 Proximal neck at all? AAA growth from 5.5 to 8cm
12 How to solve the problem? FEVAR as a primary solution or repair of failed EVAR Endoanchoring? Pharmaceutical Freezing of Aortic Degeneration?
13 FEVAR
14 Prevention: FEVAR? Suprarenal aorta does not seem to dilate significantly over time (5 studies) Differences in stiffness, thickness between suprarenal and infrarenal aorta Fenestrated EVAR has shown low rates of migration and type I endoleak, although AND following fenestrated EVAR has not been investigated adequately. Verhoeven et al. Eur J Vasc Endovasc Surg. 2016;51: Kouvelos et al. J Endovasc Ther 2016
15 Endoanchoring
16 Prevention: Endostapling? ANCHOR Registry: 257 patients with baseline challenging neck anatomy, treated with EndoAnchors to secure fixation and Two cohorts: 66% prophylactic use; 34% with acute Type Ia endoleak Aortic diameter measurements: 1. Level 0 (at lowest renal artery) 2. Level 5 (5mm distal) 3. Level 10 (10mm distal) 4. Suprarenal (20mm proximal) Tassiopoulos et al. J Vasc Surg 2017 [e-pub, ahead of print]
17 Prevention: Endostapling? Aneurysm neck still dilates at 1 year after endovascular aneurysm repair with EndoAnchors, particularly in those with large aortic diameter, more oversizing, neck angulation, and suprarenal fixation. No significant difference in AND among prophylactic and acute endoleak cohorts EndoAnchors have a protective effect on neck dilatation at usual deployment level Tassiopoulos et al. J Vasc Surg 2017 [e-pub, ahead of print]
18 Discussion Definition & Quality of Proximal Neck (Length) Diameter (vs. Suprarenal diameter) Look at CT scan with conservative eye Do not forget the Sagital view
19 Conclusions Careful with EVAR in hostile neck anatomy (when there is another option!) Follow-up of patients with hostile anatomy!! NO to presentations on short-term good results in short-neck EVAR.. Choose your graft carefully to allow for additional more proximal repair later
20 Considerations for a Durable Repair Eric Verhoeven, MD, PhD, A. Katsargyris, MD Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
Aortic Neck Issues Associated Clinical Sequelae/Implications for Graft Choice
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