Indications for Not Doing EVAR Edward Woo Associate Professor Vice Chief/Program Director Director of Vascular Laboratory Division of Vascular Surgery and Endovascular Therapy University of Pennsylvania Health System

Disclosures Medtronic, Cook, Gore

AAA Affects 5-9% of men >65 in US Risk factors CMS approved screening abd u/s in men >65 Risk factors FH HTN Chol DM Tobacco

Indications for Repair Rupture Symptoms Growth 0.5cm-1cm/yr Size 5-5.5cm Annual rupture rates 5cm-5%;6cm-10%;7cm-20%;8cm-40% 90% mortality with rupture

Open vs Endovascular Repair pros/cons Gold standard Long term results No anatomic limitations Comorbidities increase risk-CHF,COPD,CRI (Hertzer et al. J Vasc Surg 2002) Endovascular (EVAR) Minimally invasive Decreased morbidity and mortality Shorter recovery time

Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group Decreased mortality with EVAR Prinssen et al, N Engl J Med. 2004 Oct 14;351(16):1607-18

Why ever perform open AAA repair?

Indications for Open Repair Anatomic Constraints Proximal Distal Other Endoleak Recurrent sac growth Infection Mycotic AAA Infected Stent graft

Proximal-Neck No neck Short neck Disadvantaged neck TAAA, suprarenal, juxtarenal Short neck <10mm Disadvantaged neck Trapezoidal neck >10% change over 10mm Thrombus lined Calcified Inability to obtain seal Inability to maintain seal Persistent proximal endoleak Aneurysm sac growth and rupture

Neck anatomy preclude EVAR in 64% of pts undergoing open AAA Dillavou et al., JVS Oct 2003

Type IV TAAA Juxtarenal

EVAR Constraints Not Limited to Proximal Neck Moise et al. Vasc Endovasc Srg 2006 Early and later experience groups Proximal and distal landing zones continue to limit EVAR

Distal Aortic length Narrow/calcified bifurcation Iliac aneurysms Preservation of hypogastrics Claudication Colonic ischemia Pelvic ischemia-impotence Spinal cord ischemia

Narrow Bifurcation

Other Anatomic Considerations Horseshoe kidney Preserve IMA Stenotic SMA Occluded hypogastrics Previous colectomy Ruppert et al. JVS 2004

Other Anatomic Considerations Access Less common now Stiffer wires Smaller devices Devices less stiff Female>male Tortuosity Uncommon unless at proximal neck

Indications for Open Repair Anatomic Constraints Proximal Distal Other Endoleak Recurrent sac growth Infection Mycotic AAA Infected Stent graft

Endoleak Type I Proximal and distal Type II Backbleeding from covered vessels (IMA, lumbar accessory…) Type III Junctional Fabric Type IV Porosity Type V Endotension

Endoleak Usually can be treated with endovascular secondary intervention Proximal extension Distal extension Embolization of feeding vessel Embolization of sac

Open Conversion Uncommon: 1-3% Neck dilatation Medtronic AnueRx Gore Excluder Cook Zenith Endologix Powerlink Medtronic Talent Neck dilatation Recurrent/inaccessible type II and sac enlargement Vessel preservation(hypogastrics)

Penn Experience

Outcome Related to Aortic Cross Clamp Site Initial Cross Clamp Site Supraceliac Suprarenal Infrarenal Patients (n=21) 9 (43%) 7 (33%) 5 (24%) Average Visceral Ischemic Time 15 min - Average Renal Ischemic Time 19 min 23 min Mean EBL 2.6L (600-6.0) 1.5L (400-2.8) 1.4L (600-2.0) Mean ICU Stay 3 days (2-5) 3 days (2-4) 3 days (2-6) Mean Hospital Stay 14 days (7-39) 9 days (6-10) 8 days (4-12) Major Complications* 2/9 (22%)* 0/7 (0%)* 1/5 (20%) Mortality 0/9 (0%) 0/7 (0%) 0/5 (0%) *complications of renal failure or visceral ischemia were not observed.

Indications for Open Repair Anatomic Constraints Proximal Distal Other Endoleak Recurrent sac growth Infection Mycotic AAA Infected Stent graft

Mycotic aneurysm Fever, increased WBC, +blood cx’s, saccular aneurysm, rapid enlargement, adjacent abscess Homograft vs Rifampin/Dacron vs extraanatomic repair EVAR-bailout or bridge

Infected Stent Graft Uncommon but incidence may be increasing

Infected Stent Graft All prosthetic needs to be explanted Difficult to oversew aortic stump and preserve renals Homograft DTA Aortoiliac graft SFA-renals Rifampin-soaked Dacron Extraanatomic

JVS 2011in press

Indications for Open Repair Anatomic Constraints Proximal Distal Other Endoleak Recurrent sac growth Infection Mycotic AAA Infected Stent graft Renal insufficiency, Age, patient preference…

CRI as indication for open AAA? Parmer et al. JVS, 2006 A comparison of renal function between open and endovascular aneurysm repair in patients with baseline chronic renal insufficiency

No preexisting CKD(GFR>20%) Mills et al. JVS 2008 Comparison of the effects of open and endovascular aortic aneurysm repair on long-term renal function using chronic kidney disease staging based on glomerular filtration rate Entire group No preexisting CKD(GFR>20%) Preexisting CKD

AGE Long-term f/u with contrast Long-term studies Secondary procedures Open cases can degenerate as well!

Healthy neck “friendly” anatomy 55yo CRI: Cr 1.8

Summary Open AAA indications Anatomy Recalcitrant endoleak Infection Other Can be done with low morbidity and mortality