Aortic Neck Issues Associated Clinical Sequelae/Implications for Graft Choice
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1 Aortic Neck Issues Associated Clinical Sequelae/Implications for Graft Choice 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 Endologix Consultant
3 Case 1: Failed 2xFEVAR F372
4 Partial opening of graft
5
6 Case 2: 4xFEVAR 61 YO Male AAA 65mm EVAR 4 yrs ago
7 Plan 4x FEVAR Easy CT and SMA Adequate sealing zone Proximal extension still possible
8 Case 3: 3xFEVAR 65 YO Male Juxtarenal AAA Dmax: 53 mm Saccular Co-morbidity CAD PAD
9 Proximal Neck?? Proximal neck length: 0 or 40 mm?
10 3x FEVAR Plan
11 Postop CTA
12 Case 5: 3xFEVAR (wrong choice) 71 YO Male 2011 Juxtarenal AAA Dmax: 54 mm Co-morbidity CAD
13 Proximal Neck Proximal neck length: 4-5mm, conical
14 Problem: Dilated Thoracic Aorta Dmax above Celiac trunk: 36-37mm
15 Plan 36-37mm 3x FEVAR
16 3x FEVAR
17 Postop CTA 36mm
18 1 year 39 mm
19 2 years 41mm
20 4 years 44 mm
21 6 years 45 mm
22 Treatment Plan Redo F/BEVAR 1x Branch for CA 3x Fenestrations
23 Infrarenal Aortic Neck Dilates after open Surgery
24 Conflicting- Controversial Data
25
26 Proximal neck at all? AAA growth from 5.5 to 8cm
27 AND after EVAR Meta-analysis Inclusion criteria 1. To report AND after EVAR 2. To include at least 5 patients 3. To provided data on AND quantification Kouvelos et a, J Endovasc Ther 2017
28 AND after EVAR 26 articles published between 1998 and patients Kouvelos et a, J Endovasc Ther 2017
29 Incidence of aortic neck dilatation 12 studies 8550 pts 24.6% of the patients (95% CI 18.6% to 31.8%)
30 Clinical outcome during FU 7 studies 1759 pts endoleak type I, migration, reintervention 26% 2%
31 High-risk for AND Graft oversizing Small/Large size proximal neck Type of endograft (Sx vs Bx)
32 Aortic Neck Enlargement after EVAS (BES) and EVAR (SES) vs. Savlovskis et al. J Vasc Surg 2015;62:541-9
33 AND Not Associated with EVAS Savlovskis et al. J Vasc Surg 2015;62:541-9
34 Aortic Neck Stability after Polymer Sealing with Ovation 161 patients Mean follow-up 32mo (24-50) CT scans with 2yr follow-up for 89 cases Three zones (A, B, C) examined separately Morphological comparison between preoperative and postoperative images De Donato et al. J Vasc Surg 2016;63(1):8 15
35 Aortic Neck Stability after Polymer Sealing with Ovation No AND after a minimum 2 year follow-up 0.1 mm (0,-0.3) 0.18 ± 0.22mm 0.0 mm (0,-0.6mm) ± 0.87mm 0.0 mm (+0.4,- 0.3mm) ± 0.97mm De Donato et al. J Vasc Surg 2016;63(1):8 15
36 Aortic Neck Stability after Polymer Sealing with Ovation Core lab results demonstrate stable neck diameter and durable seal with Ovation through 5 years Open Repair 2 Ovation Pivotal Trial data as of August 2, 2016 Self- Expanding Stents 1 Ovation System 3 1 Monahan JVS 2010: 52: N=46. Devices: Cook Zenith / 2 Rodway EJVES 2008;35: EVAR: N=67, Open N=56 3 Ovation Global Pivotal Trial. N=94. Data as of Aug 2, 2016
37 Wide Infrarenal Neck Wide infrarenal neck seems to be associated with worse outcome
38 Mean increase 11% for the lowest renal 3% to 5% at the level of the renal arteries <3% for the SMA and CT 12% type I endoleak
39 EVAR in Wide Infrarenal Necks The evolution of aortic neck dilatation (AND) may lead to the loss of an adequate proximal seal. Seventy-four patients (17.3%) with a neck diameter of >30 mm were compared with a control group of 353 patients. standard EVAR with an Endurant stent graft Median follow-up 3.1 years Oliveira et al, J Vasc Surg 2017
40 EVAR in Wide Infrarenal Necks
41 Discussion Literature Definition & Quality of Proximal Neck (Length) Degree of oversizing? AND and BE Stents Seem to treat the neck better. Why better than open repair?
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