Shonak Patel MD Vascular Specialists of Central Florida Assistant Professor at UCF

Transcription

1 Shonak Patel MD Vascular Specialists of Central Florida Assistant Professor at UCF

2 Evaluating Aortic Disease Consider the process degenerative Atherosclerosis, dissection, connective tissue disease Treatment objectives Prevent rupture Extend life, maintain health Comparing Treatment Modalities Re-intervention, Survival

3 Case 1 74 year old male from Guam Undergoing surveillance Slowly increasing pararenal AAA 6.2cm Develops acute abdominal pain

4 AAA visible

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6 Simplifying the Decision to Rx THREE MANAGEMENT OPTIONS 1. ENDOVASCULAR (EVAR) 2. OPEN (OR) 3. CONTINUING SURVEILLANCE (OBS)

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9 THREE CONSIDERATIONS 1. AAA SIZE/DIAMETER WHAT IS RISK OF RUPTURE OF A PARTICULAR AAA AS A BASIS FOR THE NEED FOR INTERVENTION 2. OPERATIVE RISK IS THE PT ACCEPTABLE RISK FOR OPEN REPAIR? 3. AAA ANATOMY SUITABLE FOR ENDOVASCULAR REPAIR?

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11 ELECTIVE OPTIONS: Case 1 OPEN FENESTRATED STENT GRAFT CHIMNEY/SNORKEL URGENT DO HIS TREATMENT OPTIONS CHANGE?

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13 Decision-making for Elective AAA Repair INFRA-RENAL JUXTA/PARARENAL THORACOABDOMINAL (TAA) Endovascular repair Open repair Branched/Fenestrated Endografts Suprarenal aortic clamp TAA Refer to units specializing in the treatment of these more complex, higher-risk cases

14 Management of Abdominal Aortic Aneurysms Clinical Practice Guidelines of the European Society for Vascular Surgery. Moll et al 2010 See Algorithm

15 ANATOMIC SUITABLITY OR PROCEDURAL RISK

16 CTA EVAR AAA Size/Extent Landing Zones Length, Angulations Calcifications, Thrombus Distal length of neck Access Vessels OPEN AAA anatomy Surrounding structures Inflammatory changes Developemental anomalies Ie RARV

17 Management of Abdominal Aortic Aneurysms Clinical Practice Guidelines of the European Society for Vascular Surgery. Moll et al 2010

18 Management of Abdominal Aortic Aneurysms Clinical Practice Guidelines of the European Society for Vascular Surgery. Moll et al 2010 Custom EVAR

19 GOAL PREVENT RUPTURE & EXTEND LIFE

20 12 month AAA rupture risk by diameter AAA Diameter Rupture Risk (%) > *RISK FACTORS other than SIZE The care of patients with an abdominal aortic aneurysm: The Society of Vascular Surgery practice guidelines. Chaikof et al. JVS. 2009

21 WILL SCREENING PROGRAMS REDUCE THE RISK OF RUPTURE?

22 As elective repair of aneurysms has become safer and more routine, there has been little improvement in the outcome of ruptured aneurysms repair We therefore want to steer all our patients toward elective repair, whether open or endovascular

23 Group Recommendations ACC/AHA Men who have smoked Men 60 who are the sibling or offspring of AAA patient SVS, SVMB Men Women with cardiovascular risk factors Men or women > 55 with family history of AAA USPSTF (U.S. Preventive Services Task Force ) Men who have ever smoked No recommendation for those who never smoked Not recommended for women and with family history* *but recognize individualizing patient care ACPM (American College of Preventative Medicine) Men who have ever smoked Not recommended for women Management of Abdominal Aortic Aneurysms Clinical Practice Guidelines of the European Society for Vascular Surgery. Moll et al 2010

24 SAAAVE ACT 1 time AAA screening: Male Medicare recipients who have a history of smoking Females with + family history of AAA Welcome to Medicare physical Additional surveillance if positive

25 Surveillance frequency of screendetected UKSAT Modelling Study Surveillance Interval (months) cm 24 SVS Guidelines Surveillance Interval (months) cm cm cm cm cm 12 >5.0 cm cm 6 The care of patients with an abdominal aortic aneurysm: The Society of Vascular Surgery practice guidelines. Chaikof et al. JVS. 2009

26 OPEN vs ENDO AS OPEN AAA REPAIR BECOMES MORE CHALLENGING NEWER ENDOVASCULAR THERAPIES EMERGE

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28 FENESTRATED GRAFTS

29 SNORKLE/CHIMNEY TECHNIQUES

30 DURABILITY? WHEN CONSIDERING ENDOVASCULAR REPAIR ANATOMY WILL HELP PREDICT LATE FAILURES Migration Component Separation Stent Fracture Neck/Aneurysm Dilation

31 The Goal: Long Term Durability Can EVAR rival open AAA repair? Pyrrhic Victory We win the battle with AAA repair but we often lose the war Atherosclerosis is widespread disease that ultimately kills patient Endograft with fixation below renals Let s consider durability

32 Post-Operative Surveillance

33 60 year-old male FINAL CASE Rt Hemispheric CVA 12/2014 CT Incidental 8cm AAA - Pararenal Asymptomatic 8cm AAA Exam Alert Residual Lt sided weakness

34 Carotid duplex Work-Up >90% Rt ICA stenosis CAD +Stress Lateral wall/apex Cath Medical therapy

35 CT Imaging

36 Asx 8cm AAA starts above renals >90% Rt ICA hemisphere at risk? Cardiac fxn medically optimized WHAT IS THE BEST MANAGEMENT OPTION???

37 Conclusion Referral to Vascular Surgeon INDIVIDUALIZE DECISION AAA size PLUS Operative Risks for OR Anatomic Suitability for EVAR ALL in the context of the patients estimated LONGEVITY Durability Late Failures Young pt vs Old pt Lifelong surveillance

38 Vascular Specialists of Central Florida Chuck Thompson Jon Wesley Adam Levitt Mike Muehlberger QUESTIONS? Shonak Patel