Importance of changes in thoracic and abdominal aortic stiffness following stent graft implantation
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1 14/9/2018 Importance of changes in thoracic and abdominal aortic stiffness following stent graft implantation Christos D. Liapis, MD, FACS, FRCS, FEBVS Professor (Em) of Vascular Surgery National & Kapodistrian University of Athens Director Vascular & Endovascular Clinic Athens Medical Center
2 NO DISCLOSURES RELATED TO THE TOPIC
3 Network of mir-204-5p and mir-125b-5p and their target genes upregulated in patients with an aneurysm positive FDG uptake on PET Reeps, Eckstein et al J Vasc Surg 2008 Courtois, Sakalihasan et al J Vasc Surg 2018
4 Arterial Stiffness Arterial stiffening results in increased pulse pressure, left ventricular hypertrophy, subendocardial ischemia, endothelial dysfunction and cardiac fibrosis Liao J et al Curr Ather Reports 2014
5 Pulse wave velocity (PWV) and arterial stiffness Pulse wave velocity (PWV): the gold standard method of arterial stiffness measurement and a strong independent predictor of cardiovascular morbidity and mortality. CARDIOVASCULAR SURVIVAL months Blacher J. et al Circulation. 1999;99: Cavalcante JL et al JACC 2011; Ben-Shlomo Y et al JACC 2013
6 Arterial stiffness, circulating vascular calcification inhibitors and inflammatory mediators in pts with AAA PWV and hscrp, WBC, IL-6, Osteoprotegerin were significantly upregulated in pts with AAA. Independent association of PWV with mean blood pressure, OPG and AAA diameter Kadoglou NP, Liapis CD et al. Arterial stiffness and novel biomarkers in patients with abdominal aortic aneurysms. Regul Pept. 2012
7 Changes in arterial stiffness in patients undergoing EVAR and TEVAR Computational Fluid Dynamics Ongoing Trial
8 Cardiovascular magnetic resonance elastography Magnetic resonance elastography (MRE) is a phase contrast magnetic resonance imaging technique that measures tissue stiffness non invasively. Khan S. et.al NMR in Biomedicine. 2017
9 4D MRI and aortic stiffness Schäfer et al J Vasc Surg 2018
10 Arterial stiffness in patients with abdominal (AAA) or thoracic aortic aneurysms (TAA) Men with AAA presented with significantly elevated PWV levels compared to agematched controls Mean blood pressure, AAA diameter and age: independent determinants of PWV in AAA TAA is associated with increased augmentation index Shingu Y, et al Ann Thorac Surg 2009; Kadoglou NPE, Liapis C et al J Endovasc Surg 2012
11 Changes in arterial stiffness in patients undergoing AAA repair Open repair (n=39) ofaaa induced modest increase of PWV Stent-graft implantation (n=48) was associated with significant increase in PWV 6 months following EVAR Lantelme P et al J Hypertens 2009 Kadoglou NP, Moulakakis KG, Liapis CD. Changes in aortic pulse wave velocity of patients undergoing endovascular repair of abdominal aortic aneurysms. J Endovasc Ther. 2012
12 EVAR and cardiovascular Outcome A non-significant tendency toward cardiovascular deaths was apparent in the EVAR trials inthe endovascular group during the 24-month interval. Cardiovascular mortality was primarily due to the poor general health status of those patients or the required secondary interventions. A harmful effect of even slight alterations in aortic stiffness induced by endografts should be considered. 1. Brown LC, et al. EVAR trial participants. Does EVAR alter the rate of cardiovascular events in patients with AAA considered unfit for open repair? Results from the randomized EVAR trial 2. Eur J Vasc Endovasc Surg Brown LC, et al. EVAR trial participants. Incidence of cardiovascular events and death after open or endovascular repair of abdominal aortic aneurysm in the randomized EVAR trial 1. Br J Surg. 2011
13 Short-term vs. long-term MI following EVAR and Open AAA Repair b Stather et.al British Journal of Surgery 2013; 100:
14 EVAR alters cardiac structure and function increased bapwv and induced left ventricular hypertrophy, left atrium enlargement and impaired diastolic function Takeda Y et al Circ J 2014
15 Exercise tolerance PRE-OP LV COMPLIANCE CHANGE IN PWV CHANGE IN LEFT ATRIAL VOL Takeda Y. et al Circ J 2014;78:
16 Arterial stiffness and thoracic endografts M, 79y, Symptomatic 8cm TAA Medtronic VALIANT Thoracic 40X40, 46X46
17 Changes in Arterial Stiffness and N-terminal pro-brain natriuretic peptide Levels after Endovascular Repair of Descending Thoracic Aorta n=27 patients with TAA underwent elective TEVAR. Serum levels of NT-proBNP preoperatively, 24 hr, 48 hr, and 6 months postoperatively. PWV before and 6 months after TEVAR. One-way analysis of variance by ranks was used to test the alterations in PWV and NT-proBNP. Post hoc analyses were appropriately performed. Moulakakis K., Liapis CD et.al. Ann Vasc Surg 2017
18 PWV and NT-proBNP changes in pts following TEVAR Endovascular treatment of descending thoracic aortic aneurysms was associated with significantly increased NT-proBNP levels and arterial stiffness. An increased cardiac risk for patients with already impaired cardiac compensatory mechanism? Moulakakis K., Liapis CD et.al. Ann Vasc Surg 2017
19 Arterial stiffness and NT-proBNP changes following TEVAR Kaplan Meier survival curve estimate TEVAR Group, N=27, Baseline Characteristics Variable Mean ± SD or n (%) Age (years) 68.8 ± 11.3 Male Gender 24 (88.8) BMI (kg/m 2 ) ± 4.6 Indication for TEVAR Atherosclerotic Aneurysm Dissecting Aneurysm Pseudoaneurysm Intramural Hematoma 23 (85.2) 2 (7.4) 1 (3.7) 1 (3.7) TAA Diameter (N=26) (cm) 6.19 ± 1.3 Chronic Obstructive Pulmonary Disease 7 (25.9) Dyslipidemia 11 (40.7) CAD 9 (33.3) Diabetes Mellitus 6 (22.2) Smoking 15 (55.5) Hypertension 19 (70.3) History of Ascending Aorta Reconstruction 1 (3.7) History of AAA Reconstruction 10 (37) Operative Characteristics Aortic Pathology Length (cm) Subclavian Artery Coverage Carotid - Subclavian Bypass Celiac artery Coverage Number of endografts placed: 1/2/3 Duration of surgery (min) Blood loss (ml) 14.91± (22.2) 2 (7.4) 6 (22.2) 13/11/ ± ± 99.3 Follow-up 23.4 ± day Mortality 0 Mortality in Follow-up 9 (33.3) Follow-up: 23.4 ± 16.4 months (range 3-54 months). Overall Mortality : 33.3% Moulakakis K., Liapis CD et.al. Ann Vasc Surg 2017
20 Differential effects of stent-graft fabrics on arterial stiffness in patients undergoing EVAR N=118 pts Values of PWV and novel biomarkers at baseline and after 12 months PWV, OPG and IL-8 increase was more pronounced in Polyester Woven group compared to PTFE group (p=0.033, p=0.048, p<0.001 respectively) Kadoglou NP, Moulakakis KG, Liapis CD. Differential effects of stent-graft fabrics on arterial stiffness in patients undergoing endovascular aneurysm repair. J Endovasc Ther. 2014
21 Conclusions (I) TEVAR and EVAR are associated with lower perioperative mortality and morbidity rates compared to open surgical repair BUT this advantage is blunted at long term, mainly due to an increase in cardiovascular complications. Arterial stiffening together with adverse cardiac function after stent graft implantation may explain this change in the long-term outcome
22 Conclusions (II) There is evidence of increased arterial stiffness after EVAR related to graft type (polyester more than PTFE). The effect of endograft type in the thoracic aorta is under investigation. Arterial stiffness should be taken into consideration by the industry when designing new endografts. In the meantime patients after endovascular treatment of aneurysms are in need of intensive cardiac follow up.
23 Thank you for your attention
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