evar - personal experience

Early and Long Term Results of EVAR:

Personal Experience

Giorgio M. Biasi, MChir FACS FRCS

Professor of Vascular Surgery

University of Milano Bicocca

Transfemoral Intraluminal Graft Implantation for Abdominal Aortic

Aneurysms

Parodi JC, Palmaz JC, Barone HD.Annals of Vascular Surgery 1991; 5: 491-9

EVAR vs OR(<30days)

• Decrease perioperative morbidity

• Decrease intensive care unit stay

• Decrease total hospital length of stay

• Increase quality of live in perioperative period.

• Increase ruptured rate/year

• Need continuous follow-up to detect and treat complications

• Increase the reintervention rate/year

EVAR vs OR(>30days)

Type I Endoleak

Type II Endoleak

Modular componentdisconnection

Endograft kinking

Surgical conversion

How to reduce early and late complications

Case selection Preprocedural investigations

Intraprocedural investigations Follow-up

How to reduce early and late complications

Case selection Preprocedural investigations

Intraprocedural investigations

Follow-up

Case Selection

Risk related to general conditions ( age- hostyle abdomen- cardio-respiratory conditions- large AAA - smokers - patient’s consensus- etc.)

Risk related to aortic anatomy

Aortic Angulation

Case SelectionProximal neck and iliacs angulation

Case Selection Proximal Neck

Compromised proximal neck anatomy is the

most frequent cause of EVAR failure.

Neck Angulation

Device migration due to neck angulation

Some technical tricks to avoid complications neck related

• Perform angiogram in several projections.

• C-Arm orientation.

• Lower renal artery selection.

• “Crossing the Limb” technique.

• Endograft selection.

Technical tricks Perform angiogram in several projection

Technical tricks C-Arm orientation

Technical tricks “Crossing the Limb”

technique

Free Flow

Hooks

Barbs

Endograft selection

• Unibody or bifurcated

• Modular or nonmodular

• Fully or partially stent-supported body

• Supra or below renal fixation

• Hooks and barbs

Endograft selection

How to reduce early and late complications

Case selection

Preprocedural investigations Intraprocedural investigations

Follow-up

Angio - CTAngio - CT

Preprocedural Investigations

How to reduce early and late complications

Case selection

Preprocedural investigations

Intraprocedural investigations Follow-up

Intraop. Angiogram

Intraprocedural Investigations

IVUS

Intraprocedural Investigations

How to reduce early and late complications

Case selection

Preprocedural investigations Intraprocedural investigations

Follow-up

FOLLOW UP

• CT Scan

• Duplex

• Angiography (in case of leaks)

Long term aortic evolution

• Proximal neck dilatation

• Shrinking – elongation or shortening

• Kinks

FOLLOW UP

Proximal neck dilatation

Type II Endoleak

Endograft migration

Particular situations

• Inflammatory Aneurysm

• Pararenal aortic aneurysm in high risk patients

• Aneurysm associated to an additional abdominal

pathology.

• Ruptured Aneurysms

Particular situations

• Inflammatory Aneurysm

• Pararenal aortic aneurysm in high risk patients

• Aneurysm associated to an additional abdominal

pathology.

• Ruptured Aneurysms

INFLAMMATORY AAAs

ACCOUNT FOR 3% TO 10% OF

ALL AAAs

PENDING ISSUES

HOSTILE OPERATIVE FIELD 

RISK OF INJURY TO VITAL STRUCTURES              

POTENTIAL FOR REGRESSION OF RETROPERITONEAL 

INFLAMMATORY PROCESS               

USE OF ORAL STEROID IN THE PRE AND POST

PROCEDURAL  COURSE   

INDUCTION OF RETROPERITONEAL FIBROSIS BY EVAR

URETERIC STENTING 

Particular situations

• Inflammatory Aneurysm

• Pararenal aortic aneurysm in high risk patients

• Aneurysm associated to an additional abdominal

pathology.

• Ruptured Aneurysms

Compromised proximal neck

anatomy is the most frequent

rejection criteria for endovascular

treatment of AAA.

Which is the best endovascular strategy for

pararenal aortic aneurysm?

Endovascular treatment of pararenal aortic aneurysm

Infrarenal Fixation Endograft

Transrenal Fixation Endograft

Fenestrated Endograft

Technical tricks Lower renal artery selection

An accurate delivery of the graft just

below the lower renal artery is required

to maximize the sealing zone with

conventional endograft.

Infrarenal fixation endograft

Complete sealing and better attachment of the stent-graft.

Decreased incidence of endoleak.

Transrenal fixation endograft

Fenestrated Endovascular Graft

• Extend the proximal sealing zone

• Accomodate native arterial angulation

• Improve proximal fixation

Particular situations

• Inflammatory Aneurysm

• Pararenal aortic aneurysm in high risk patients

• Aneurysm associated to an additional abdominal

pathology.

• Ruptured Aneurysms

Aneurysm associated to an additional abdominal pathologies

• Abdominal pathologies : 3.4% - 12%

• Other pathologies: cardiomyophaty 25% -

50%

• Neoplastic pathologies: 7% - 9%

First EVAR Procedure

in our Institution

January 1997

Endograft usedAneuRx - MedtronicEndologix - Aptiva

Zenith -CookExcluder - Gore

Talent - MedtronicEndofit - Serom

Anaconda - Le Maitre

Ancure - GuidantQuantum - CordisLifepath - Edwards

1997 - Inclusion CriteriaElective Endograft

• Proximal neck lenght > 25 mm

• Proximal neck diameter < 26 mm

• Neck angulation < 40°

• Iliac arteries anatomy

2008 - Inclusion Criteria Elective Endograft

• Proximal neck lenght > 15 mm

• Proximal neck diameter < 28 mm

• Neck angulation < 60°

• Iliac arteries anatomy

2008 - Inclusion Criteria Elective Endograft

• Patient Age > 75 ys old

• Unsuitable for Surgery:

- Hostile Abdomen

- Higth risk for comorbilities

Present Indication

To EVAR in our Institution

30% of procedures

EVAR vs OR

EUROSTAR Registry Data

EVAR vs OR Percentage of patients

reintervention free

EUROSTAR Registry Data

PERSONAL EXPERIENCE

Elective AAA(August 2005/August 2008)

  Number of Patients: 220  

 Male: 195 Female: 25

  Age: average 77.5 years  

 Min.: 58 years Max.: 93 years

Early complications

Type I Endoleaks 9/218 (4.1%)

Type II Endoleaks 16/218

(7.3%)Type III Endoleaks 1/218 (0.4%)

Distal embolization 2/218 (0.9%)

Branch occlusion 3/218 (1.4%)

Early conversion 2/220 (0.9%)

Type I Endoleak

• Eight treated with a cuff.

Branch occlusion

• Two treated with embolectomy.• One treated with femoral-femoral

bypassDistal embolization

• Treated with major amputation one above and one below the knee.

Early Conversion• One due a common iliac artery

rupture.• One due a structural defect of

device.

Late conversion 8/218

(3.6%)Partial Graft Thrombosis 5/210

(2.3%)Branch occlusion 2/210

(0.9%)Death after conversion 1/10

(10.0%)

Late complications

Death after conversion

• Due a cardiac complications

Branch occlusion

• One treated with embolectomy and stenting.

• One treated with femoral-femoral bypassLate Conversion

• Two due to a ruptured aneurysm.• Three due to a enlargement of aneurysmal sac

without evidence of endoleaks.• One due to a proximal migration of graft.• Two due to a type one endoleak after a fibrinolitic

therapy

Reference AllEndoleaks

Distal embolization

Early and Late

Conversions

Branch occlusion

Death graft

related

Walschot, 2002

18.5%   6.4%    

Thomas, 2000

6.0% 1.4% 5.0% 1.0% 0.5%

Diethrich, 2002

18.6% 3.0% 0% 2.1% 3.0%

Raithel, 2002

    7.0%   1.2%

Liewald, 2001

16.0%   4.0% 3.0%  

Mohan,2000

16.7%   1.5%   0.04%

Range 6-26% 0-10% 3-10% 0-6% 0-4%

Biasi 11,4% 0.9% 3,6% 2.8% 0.8%

Author Type IEndoleak

Type II Endoleak

Type III Endoleak

Graft/LimbOcclusion

Migration SecondaryIntervention

Late Ruptured

Becquemin2005

276 pts.

32% 39% 10% 13.5% 3.0% 22.0% 0.8%

EurostarRegistry

20062746 pts.

9.4% 15.3% 1.8% 2.4% 2.6% 8.7% 0.5%

Biasi 4.1% 7.3% 0.4% 2.3% 0.4% 1.4% 0.7%

• Avoid laparotomy

• Reduce cardiac complications

• Reduce septic complications

• Less invasive

• Rapid recovery

• Combined treatment?

Endovascular Treatment

Conclusion

EVAR is less invasive than open

repair, but the long term outcome

is still unknown.

Conclusion

The endovascular treatment of acute or ruptured AAA, could contribute in reducing the perioperatory morbidity and mortality in comparison to open repair .

In elective surgery, EVAR needs an accurate selection of patients.

giorgio.biasi@unimib.it