Abdominal Aortic Aneurysm 가천대길병원 이상준

Abdominal Aortic Aneurysm 가천대길병원 이상준

1 Definition Diameter of the aorta 1.5 times greater than normal. Most are infrarenal, and a significant number extend down into one or both iliac arteries

Abdominal Aortic Aneurysm

What types of AAA are there? 1Abdominal aortic aneurysms are commonly classified in terms of how close they are to the renal arteries Infra-renal (95% of all AAA) Juxta- renal Supra-renal 2Also classified in terms of causation/shape Saccular/fusiform

1. 적응증 가 ) 대동맥류 1) 복부대동맥류직경 5.0cm 이상 2) 4-5cm에서 6개월에 0.5cm이상크기가증가하거나관련된임상증상 ( 복부통증등 ) 이있는경우 나 ) 대동맥파열 다 ) 대동맥박리증 (Dissection) 1) 급성 : 직경이 4cm 이상인경우 (True lumen + False lumen) 만성 : 직경이 6cm 이상인경우 (True lumen + False lumen) 2) 기준이하의직경이지만 - - 분지된혈관의허혈성증후가있는경우 - 박리가진행되는경우

AAA Clinical Features Syncope (10-12%) 12%) Back and/or Abdominal Pain severe and abrupt, ripping or tearing sensation (50%) Shock intraperitoneal rupture, massive blood loss Sudden death

notable people affected by aneurysm disease Albert Einstein Died 1955 Ruptured AAA Lucille Ball Died 1989 Ruptured AAA Joe Dimaggio The Yankee Clipper Elective AAA repair In 1988 George C. Scott Died 1999 Ruptured AAA

WHO IS MOST AT RISK? Obesity High blood pressure High cholesterol Atherosclerosis Cardiovascular disease

WHO IS MOST AT RISK? Men over 60 Men are four times more likely to develop AAAs, but 20% do occur in women. Smokers Current smokers are seven times more likely to develop AAA than non-smokers. Former smokers are three times more likely. Family History 20% of AAA patients have a relative with the condition.

SYMPTOMS 1 Pain or tenderness in the lower back, Abdomen or side 2 Throbbing in the abdomen 3 Most are symptomless, especially when small 4 In thoracic aneurysm symptoms may include: pain in the shoulders, lower back, neck or abdomen 5 Symptoms occur in only 25% of patients

Diagnosis

TREATMENT OPTIONS 1 AAAs under 5 cm in diameter: usually monitored with serial ultrasound examinations 2 AAAs 5 cm and larger: usually repaired with open surgery or endovascular repair In considering these options, the most important deciding factors are the patients overall fitness and where the renal arteries are in relation to the aneurysm

AAA diameter predicts rupture risk AAA Diameter Annual Rupture Rate 4.0 5.4cm 0.5 1.0% 5.5 6.4cm 10% 6.5 6.9cm 19% 7.0 7.9cm 32% 8cm 이상 50%

Annual Incidence of Rupture

EVAR Option for Repair Open Surgery

Abdominal Aortic Aneurysms: Op vs. Stent-graft 수술적치료 Stent graft 마취전신국소 수술절개복부서혜부 적용범위거의모든환자선택적적용 사망률 3-5% 낮다 심각한합병증빈도술자에따라다르다상대적으로낮음 환자입원기간 1 주-10 일 2-3 일 통증및불편함상대적으로크다상대적으로적다 재시술의필요성낮다높다 시술후파열위험성거의없다있을수있다 소요경비낮다높다

Device Types Suprarenal Infrarenal

Currently Available Devices Endurant EXCLUDER Zenith S&G Seal

Aneurysm before and after Exclusion with Stent Graft

Pre-stent graft AAA measurement 1.Length 2Di 2.Diameter

Pre-stent graft AAA Length 의측정 1Lowest renal a. 로부터 aneurysm의시작부위. 2Lowest renal a. 로부터 aortic bifurcation. 3aortic bifurcation 부터 both hypogastric artery

Pre-stent graft AAA Diameter 의측정 A) Proximal neck diameter (outer to outer). B) Lowest renal a. 로부터 10-15mm 하방의proximal neck diameter. C) Maximal aneurysm diameter (outer to outer). D) Both common iliac a. 의 maximal outer diameter E) Both hypogastric a. 상방 5mm outer diameter..

Anatomic Requirements for EVAR Length : >15mm Diameter : < 30mm Angulation - Infrarenal : < 60º - Suprarenal : < 45 º Distal (iliac): Length : > 25mm Diameter : < 22mm EIA : >7.5mm

Exclusion criteria which limit application of technology Infrarenal Neck: Too Short Thrombus

Exclusion criteria which limit application of technology Iliacs: Tortuous Too Small

AAA Neck Characteristics Short neck Aortic angle Short neck + >60 Aortic angle > 60

AAA Neck Characteristics Hostile neck Short neck Aortic angle Short neck + >60 Aortic angle > 60

Diseased Infrarenal Neck

Healthy Infrarenal Neck

EVAR complications 와 endoleak 1 Stent-graft infection 2 Pelvic ischemia Internal iliac occlusion during EVAR Si/sx: buttock claudication (most common 16-50%), buttock necrosis, colon necrosis, spinal ischemia, lumbosacral plexus ischemia, Ischemic colitis < 2% 3 Puncture site complications 4 Vascular damage

Renal a rupture

Limb ischemia

Component separation

Endoleak Types Type I endoleak - Proximal or distal attachment Type II endoleak - Retrograde branch flow Type III endoleak - Structural defect or component junction Type IV endoleak - Trans-graft leakage or porosity

Follow-Up 1 Aneurysms too small to merit intervention i should be followed up with periodic surveillance imaging to monitor their size. 2 On the basis of an aneurysm s current size and its anticipated rate of growth, one can estimate how quickly an aneurysm might grow to a size large enough to merit repair and thus recommend appropriate intervals for reimaging.

M/65 C.C : Jaundice Risk Fx : Hypertension (+), heavy alcoholics BP : 120/70 mmhg, HR 72 BPM PE : palpable abdominal mass Echocardiogram : EF=76%

Abdominal CT Angiography Findings/Impressions: 1 Increase in size of infrarenal abdominal aortic aneurysm measuring up to 7cm 2 Neck measures 4.4 cm in length and 2.0 cm in Diameter

CT angiography g g p y( (2011.5.9) ) 72 6 72.6mm

CT angiography

F l i h Femoral angiography (2011.5.13)

Angiography

Deployment of stent-graft Endurant graft-stent 28X181mm

High flexibility, conformability and low profile of the delivery system

Wiring i for contralateral t l limb

Deployment of leg extension Endurant graft-stent 16X124mm

Ballooning RELIANT balloon

Ballooning

Final angiography

F/U CT angiography (2011.5.16)

F/U CT angiography (2011.5.16)

F/U CT angiography (2011.6.20)

Summary 1 Percutaneous EVAR is safe and effective 2 All patients should be informed of the advantages and disadvantages of EVAR 3 Screen as early as possible and refer to a specialist, as appropriate 4 Do not smoke as smoking is a potent cause of aneurysms 5 AAA because of problems such as remodeling and endoleak after the procedure requires continuous monitoring.

Any Questions?

Technology improvements to overcome the challeng es in AAA EVAR Supra-renal fixation devices High flexibility, conformability and ant dura End

Technology improvements to overcome the challeng es in AAA EVAR Supra-renal fixation devices High flexibility, conformability and low profile of the delivery system End dura ant - 14-20F - hydrophilic coating

Anatomy and Pathology The prevalence of AAA is 4.5% in men and 1. 0% in women (data f rom SAVE screenings) 1,152,294 Americans living with AAA Prevalence = 1,152,294 Diagnosed = 172,900 Total Treated = 69,300 Treated w / EVAR = 22,300 15% are diagnosed 6% are treated

Abdominal Aortic Aneurysm (AAA) How can you avoid one Do not smoke as smoking is a potent t cause of aneurysms Watch your diet and remember that vegetables are good for you Have your cholesterol checked and if it is high have it treated Have your blood pressure measured and if it is high get treatment Look into your family history and find out if any of your relatives died of this condition. If you are 65 and particularly if you are male,get a scan of your abdomen to check for an aneurysm.

Pre-stent graft AAA Angle 의측정. 인접한suprarenal neck & infrarenal neck의angle Proximal neck & aneurysm 의 longitudinal axis 의 angle

Natural History 1 The major risk posed by an abdominal aortic aneurysm is rupture and its high associated mortality. 2 The risk of rupture increases with aneurysm size. 3 A rapid rate of expansion predicts aneurysm rupture. 4 Baseline aneurysm size is the best predictor of aneurysm growth rate, with larger aneurysms expanding more rapidly than small ones. 5 Rupture is also more common among current smokers and those with hypertension.