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Endovascular treatment of Abdominal Aortic Aneurysm
Aliu Sanni MDUniversity Hospital Brooklyn
September 8, 2011
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Case Presentation
53yr old male with an incidentally found AAA on routine MRI for chronic back pain.PMH-HTN, CAD s/p PCIX2 PSH-Umbilical hernia repairHigh cardiac risk for surgery.
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Case Presentation
Medications- Diovan, Aspirin, Clonidine, Methadone, Lipitor, TekturnaAllergy-NKDAFSHx-non contributory
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Case Presentation
Gen examination- not pale, anictericAbdominal exam-palpable pulsatile
intrabdominal mass. NT/NDVascular exam - palpable bilateral distal
pulsesChest-CTA bilatCVS-S1S2 no murmur
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Case Presentation
-Laboratory testsCBC: 7.5/10.8/33/288BMP:143/4.2/109/25/14/0.9/80Coagulation: 11.5/28/1CT Scan Abdomen/Pelvis- 7.5cm X 7.3cm
infrarenal AAA.
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Operative procedure
Endovascular repair of AAA with a bifurcated stent graft
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Hospital Course
POD#0- Admitted to CTICUPOD#1- Transferred to surgical step down
unitPOD#3-Discharged home
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Abdominal aortic aneurysms
Widening or increased diameter to 50% of baselineNormal aorta: 2-2.5cmAneurysm: 3-3.5cm3%-10% of men over age 50yearsM:F=5:1At least 15,000 deaths/year10th leading cause of death in men>55yrs
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Risk factors
Risk factor Odds ratio
Smoking 5.1
Family History AAA 1.9
Older age 1.7
Diabetes 0.5
Female gender 0.2
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AAA rupture risk
AAA size (cm) Annual rupture risk
<4 0%
4-5 0.5%-1.5%
5-6 3%-5%
6-7 10%-20%
7-8 20-40%
>8 50%
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Diagnosis
Usually asymptomaticPhysical exam- poor sensitivity & accuracy Imaging : USS, CT scanCT Scan- defines anatomy, excludes
rupture and evaluate other pathologyManagement- Open repair / Endovascular
repair
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EVAR requirements
Neck Parameters-Length: 15-20mm-Diameter: <30mm-Angulation: <60º-Minimal aortic thrombus
Common iliac parameters-Length: 20-25mm-Diameter: 6-7mm-Minimal thrombus
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EVAR Requirements- Exceptions
-Short distal landing zone in CIA1. Extend repair to external iliac arteryCoil embolization of unilateral hypogastricBilateral hypogastric occlusion- risk of
pelvic ischemia2. Use of “bell bottomed” or flared iliac limbsCapable of sealing ectatic or mild
aneurysmal common iliac arteries
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Contraindications
High grade stenosis/occlusion SMA/celiac axisNeck angulation >60º, diameter greater
than 32mm, or severe calcification or thrombus Iliac arteries-severe calcification or
tortuosityRenal insufficiency- contraindication to IV
contrast
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Endovascular stent graftswww.downstatesurgery.org
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Surgical techniquewww.downstatesurgery.org
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Open AAA vs. EVAR
Open AAA EVARBlood loss More LessMortality 3%-5% LowerAneurysm Gone RemainsRecovery Longer ShorterFollow up Minimal PersistentAnatomic exclusions
None Exclusions
ICU stay Longer Shorter
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Endovascular repair of ruptured AAAwww.downstatesurgery.org
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Surgical procedurewww.downstatesurgery.org
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Surveillance after EVAR
Interval ImagingInitial routine 1 month CT w/contrast
12 monthsNo leak; sac smaller 12 months Duplex USS
Type II endoleak 6 months CT w/contrast
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References
1. Cameron et al Current Surgical Therapy 9th Edition. Pgs.736-742
2. Hollier et al Haimovici’s Vascular Surgery 5th Edition. Pgs744-751.
3. Cronenwett et al Rutherford Vascular Surgery 6th edition.Pgs 1464-1471.
4. Blankensteijn JD et al .N Engl J Med 2005;352:2398-055. EVAR Trial Part Lancet 2005;365:2179-866. Costanza M et al General Surgery Qualifying: Vascular
Surgery Review. Pgs 10-12.ThePassMachine.com
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