Less Invasive Interventional treatment can be recommended as 1 st line treatment for “Silent Killer”, AAA Guy’s & St. Thomas’ Hospital, London, UK TARUN SABHARWAL MD FSIR FCIRSE K Konstantinos, S.Black, S.Thomas, R.Salter, J.Reidy, C.Sandhu, R.Bell, M.Waltham, T.Carrel, P.Taylor SIR 2009

Abdominal Aortic Aneurysm Weakened area in the aorta Natural history of AAA is of slow expansion and rupture with catastrophic consequence

Role of IR in AAA The goal is to prevent aneurysms from rupturing

AAA Silent Killer AAA occurs in 5-7% population older than 60yrs Affects 2.7m Americans and is the 13 th death Risk factors : age, smoking, male sex and family history Asymptomatic in majority Back pain, abdominal pain

Rupture Manifest with unheralded rupture and death Prognosis after rupture is grim with community based mortality as high as 79% 59-83% AAA die before reaching hospital Operative mortality rates are 40% Leaving at best 10-25% discharge

EVAR compared with Open Repair Mortality rate for elective surgical repair of nonruptured AAAs is 5% EVAR is associated with periprocedural mortality benefit compared with open repair (relative risk reduction 3.1) ↓ periprocedural complications Benefit of reduced aneurysm related mortality at 4yrs (4% vrs 7%) DREAM and EVAR 1 trials

EVAR offers a less invasive alternative to conventional open repair

Benefits of EVAR over Open repair in rAAA Local anesthesia Maintenance of abdominal wall and muscle tone Decreased aortic occlusion time Diminished blood loss Better thermoregulation

Common perceptions of EVAR High late complication rate High rate of secondary interventions Long term surveillance required: more expensive and risk of radiation cancers

Secondary Intervention rates Endoluminal repair  RETA (Thomas EJVES 2005 n=1823)38% at 5 y  EUROSTAR (Laheij BJS 2000 n=1023)38% at 4y  EVAR 1 (Lancet 2005 n=543 EVAR)20% at 4 y  EVAR 2 (Lancet 2005 n=166 EVAR)26% at 4 y  Greenberg (JVS 2008 n=739)20% at 5 y  Sampram (JVS 2002 n=703)35% at 3 y EVAR 1 Open repair cohort: 6% at 4 y

Aim of our Study Analyze the treatment of patients with AAA with EVAR Assess rate of secondary interventions Assess need for intense CT surveillance

Method  Prospective database  453 patients  2000 – 2008  Male/female = 11/1  Follow up30 months (2-90)  Age 76 (40 – 93)  Aneurysm diameter 6.1 (5.3 – 11)  Elective406 (89.8%)  Urgent 17 (3.6%)  Emergency30 (6.6%)

Results  30-day mortality: 15/453 (3.3%)  Technical Success: 451/453 (99.6%)  Open conversion: 1 urgent : 1 emergent  Secondary Interventions: 33/453 (7.2%) of which 6/453 (1.3%) from surveillance

Conclusion  Low secondary intervention rate for EVAR  Secondary interventions are effective  Surveillance with intensive CT scanning identifies few complications  Questionable benefit of intensive CT surveillance protocols  Suggested current protocol: 3/12 CT and yearly duplex thereafter

Conclusions  durability and effectiveness of EVAR EVAR ↓ risks of surgery, amount of pain, large incisions, hospital stay and much shorter recovery time