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Endovascular Repair of Endovascular Repair of Abdominal Aortic Aneurysms: Abdominal Aortic Aneurysms:
Preoperative EvaluationPreoperative Evaluation
Jean Kang, Harvard Medical School Year IIIGillian Lieberman, MD
Jean Kang, HMS IIIGillian Lieberman, MD
April 2002
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Jean Kang, HMS III
Gillian Lieberman, MD
Our PatientOur Patient74 yr old female with known AAA since 1992.Most recent US showed AAA with diameter of 4.8 cm.Referred from OSH to evaluate for possible endovascular repair of AAA.
Pertinent history include:– Type II DM– HTN– S/P LCEA
Jean Kang
Gillian Lieberman, MD
– FHx of MI– Smoker
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Jean Kang, HMS III
Gillian Lieberman, MD
DefinitionDefinitionDiameter exceeding the expected normal caliber by at least 50%.Normal diameter of abdominal aorta = 2.0 cm (1.4-3.0 cm).
Abdominal aorta is the most common site of arterial aneurysm.95% of AAA are infrarenal. www.yoursurgery.com
celiac arterySMA
IMA
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Jean Kang, HMS III
Gillian Lieberman, MD
EpidemiologyEpidemiology
Incidence of ~36 per 100,000.Up to 9% of persons > 65 yo.
Natural history of AAA is progressive expansion and eventual rupture.Overall mortality rate after rupture 78-94%.Ruptured AAA results in 15,000 deaths per year in the US.
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Jean Kang, HMS III
Gillian Lieberman, MD
Risk of RuptureRisk of RuptureSize of the aneurysmIncreased in women, patients with HTN and COPD.
When to offer AAA repair based on 1) Rupture risk
< 4 cm – follow w/ US q 6 mo4-5.5 cm – additional info needed> 5.5 cm or expands > 0.5 cm in 6 mo – repair indicated
2) Life expectancy3) Operative Risk
Hallett J 2000
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Jean Kang, HMS III
Gillian Lieberman, MD
Endovascular SurgeryEndovascular Surgery
First introduced by Parodi and associates in 1991.Less invasive than open surgery.– Shorter hospital stay– Shorter ICU stay– Less blood loss– Earlier return to function
Technical success of 98-99%.30-day mortality rate (~3%) comparable to open surgery.
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Jean Kang, HMS III
Gillian Lieberman, MD
Endovascular Surgery (Endovascular Surgery (con’tcon’t))
AneuRx stent-graft Ancure endograft
hooks of the proximal attachment systemYusuf 2000
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Jean Kang, HMS III
Gillian Lieberman, MD
Endovascular Surgery (Endovascular Surgery (con’tcon’t))
Yusuf 2000
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Jean Kang, HMS III
Gillian Lieberman, MD
Role of Radiologic Imaging in Role of Radiologic Imaging in Endovascular SurgeryEndovascular Surgery
Preoperative evaluationIntraoperative imaging– Proper endograft placement– A road map for orientation during procedure
Postoperative follow up– Immediate post op check– At 1, 6, and 12 mo post op, then q 1 yr thereafter– Endoleak, graft migration, stenosis, and kinking
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Jean Kang, HMS III
Gillian Lieberman, MD
Preoperative EvaluationPreoperative Evaluation
Determine the feasibility of an endograft.– Anatomy– Quality of the vessel wall
Determine the dimensions of endograft– Accurate measurements important to avoid
complications (eg endoleak, graft migration, graft kinking)
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Jean Kang, HMS III
Gillian Lieberman, MD
Preoperative Evaluation Preoperative Evaluation ((con’tcon’t))
proximal neck
aortic aneurysm
distal attachment sites Distal attachment
site may not be suitable.
Proximal neck may be too short.
Yusuf 2000
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Jean Kang, HMS III
Gillian Lieberman, MD
Preoperative ImagingPreoperative Imaging
CT with 3-D ReconstructionAngiographyMRAIVUS
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Jean Kang, HMS III
Gillian Lieberman, MD
Spiral CT with 3Spiral CT with 3--D D ReconstructionReconstruction
Primary imaging modality today to– Measure – Assess extent and complexity of the aneurysm– Assess quality of aorta proximal and distal
attachment sites– Evaluate occlusive disease
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Jean Kang, HMS III
Gillian Lieberman, MD
Spiral CT with 3Spiral CT with 3--D Reconstruction D Reconstruction ((con’tcon’t))
3D reconstruction allows accurate length and diameter measurements.
slice reformatted perpendicular to the
vessel
a conventional axial CT slice
Fillinger 1999
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Jean Kang, HMS III
Gillian Lieberman, MD
Spiral CT with 3Spiral CT with 3--D Reconstruction D Reconstruction ((con’tcon’t))
Specialized measurement software allows additional features.
centerline measurement
visualize endograft
Fillinger 1999 Yusuf 2000
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Jean Kang, HMS III
Gillian Lieberman, MD
Our Patient: CTOur Patient: CT
CT without contrast CT with contrast
calcification
BIDMC PACS
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Jean Kang, HMS III
Gillian Lieberman, MD
Our Patient: CT (Our Patient: CT (con’tcon’t))
right renal artery
SMA
left renal artery
at the level of the right renal artery
15mm below the right renal artery
BIDMC PACS
s/p cholecystectomy
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Jean Kang, HMS III
Gillian Lieberman, MD
Our Patient: CT (Our Patient: CT (con’tcon’t))
BIDMC PACS
Maximum diameter = 52 x 54.2 mm Bifurcation of the aorta
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Jean Kang, HMS III
Gillian Lieberman, MD
Our Patient: CT Our Patient: CT 33--D Reconstruction (MIP)D Reconstruction (MIP)
Maximum intensity projection
3-D imaging technique that permits separation of the enhanced lumen from high attenuation structures within the vessel wall
Can readily detect calcification in the vessel wall
Poor depiction of vessels that overlap each other– Circumvent this problem by generating multiple MIPs
that rotate about an imaginary axis
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Jean Kang, HMS III
Gillian Lieberman, MD
Our Patient: CT Our Patient: CT 33--D Reconstruction (MIP)D Reconstruction (MIP)
BIDMC PACS
calcifications
poor depiction of vessels that overlap
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Jean Kang, HMS III
Gillian Lieberman, MD
Our Patient: CT Our Patient: CT 33--D Reconstruction (MIP)D Reconstruction (MIP)
BIDMC PACS
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Jean Kang, HMS III
Gillian Lieberman, MD
AngiographyAngiography
Used as part of preoperative evaluationSensitive for evaluating occlusive diseaseOnly the inner lumen is imaged– Cannot evaluate the true lumen diameter,
extent of thrombus, plaque and calcification2-D projection of a 3-D structureInvasive
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Jean Kang, HMS III
Gillian Lieberman, MD
Angiography (Angiography (con’tcon’t))
Fillinger 1999
Angiogram 3-D reconstruction from CT data
calcified plaque
noncalcified plaque and a thrombus
•Angiography may underestimate the true diameter of the aneurysm.
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Jean Kang, HMS III
Gillian Lieberman, MD
Angiography (Angiography (con’tcon’t))
Calibrated catheter may underestimate the length of the aneurysm.
Fillinger 1999
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Jean Kang, HMS III
Gillian Lieberman, MD
Our Patient: AngiogramOur Patient: Angiogram
BIDMC PACS
calibrated catheter
frontal view lateral view
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Jean Kang, HMS III
Gillian Lieberman, MD
MRAMRAPoorer resolution compared to CTPatient discomfort, contraindicationsCostReserved for patients with severe renal insufficiency
IVUSIVUSOperator dependentInvasiveExcellent for post op completion studies to evaluate
graft approximationgraft stenosis
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Jean Kang, HMS III
Gillian Lieberman, MD
Our Patient: Preoperative Our Patient: Preoperative Evaluation SummaryEvaluation Summary
“Fusiform infrarenal abdominal aortic aneurysm with diameter of 52 x 52mm and length of 12.5cm”“Moderate calcification of the aorta”“Good length of infrarenal abdmonial aortic neck”“Without evidence of iliac or aortic stenotic disease”
Our patient underwent endovascular repair of AAA…
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Jean Kang, HMS III
Gillian Lieberman, MD
Our Patient: Endovascular RepairOur Patient: Endovascular Repair
BIDMC PACS
preoperative angiogram
postoperative angiogram
proximal graft attachment site
distal graft attachment sites
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Jean Kang, HMS III
Gillian Lieberman, MD
Our Patient: Postoperative CTOur Patient: Postoperative CT
BIDMC PACS
thrombus within the aneurysm sac
iv contrast within the endograft
axial view
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Jean Kang, HMS III
Gillian Lieberman, MD
Our Patient: Postoperative CTOur Patient: Postoperative CT
BIDMC PACS
3D reconstruction
proximal attachment site
thrombus within the aneurysm sac
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Jean Kang, HMS III
Gillian Lieberman, MD
In SummaryIn Summary
Radiologic imaging plays an important role in preoperative, intraoperative, and postoperative evaluation for endovascular repair.
Preoperatively, CT with 3-D reconstruction and angiography are used to – assess suitability for endovascular repair and– measure endograft dimensions
Accurate assessment is essential in order to avoid any complications.
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Jean Kang, HMS III
Gillian Lieberman, MD
ReferencesReferencesBrink, J. Technical Aspects of Helical (Spiral) CT. Radiologic Clinics of North America 1995; 33(5): 825-841.Fillinger M. New Imaging Techniques in Endovascular Surgery. Surgical Clinics of North America 1999; 79(3): 451-475.Hallet J. Management of Abdominal Aortic Aneurysms. Mayo Clinic Proceedings2000; 75(4): 395-399.Rubin G, Silverman S. Helical (Spiral) CT of the Retroperitoneum. Radiologic Clinics of North America 1995; 33(5): 913-932.Thompson R. Detection and Management of Small Aortic Aneurysms. NEJM 2002; 346(19): 1484-1486.Yusuf S, Marin M, Ivancev K, Hopkinson B, eds. Operative Atlas of EndoluminalAneurysm Surgery. Oxford, UK: Isis Medical Media Ltd, 2000.Zarins C, Wolf Y, Lee A, Hill B, Olcott C, Harris E, Dalman R, Fogarty T. Will Endovascular Repair Replace Open Surgery for Abdominal Aortic Aneurysm Repair? Annals of Surgery 2000; 232(4): 501-507.www.uptodate.comwww.yoursurgery.com
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Jean Kang, HMS III
Gillian Lieberman, MD
AcknowledgementsAcknowledgements
Matthew Spencer, MDDaniel Saurborn, MDGillian Lieberman, MDPamela LepkowskiLarry Barbaras and Cara Lyn D’amour