1. Kentville EVAR Experience
Ryan Kelly, Dion Davidson, Ben Heisler
2014 Atlantic Vascular Conference
General Surgery R4
Dalhousie University
Halifax NS

2. AAA Background Permanent pathologic dilation of the aorta
Affects 5-7% of the population over 60
9000 AAA deaths annually
Open approach 30d mortality of 4-12%
EVAR repair 30d mortality of 1.2-2%
Open: lengthy operative/anesthesia/recovery time, prolonged hospital time including ICU, some patients unfit for open procedure
EVAR: More expensive, higher re-intervention rate, no advantage in all cause mortality long-term, committed to more expensive imaging followup
Cochrane Systematic Reviews 2014
EVAR1 Lancet 2005;365:
EUROSTAR Arch Surg 2007;142:33-41
DREAM N Engl J Med 2005;352:

3. Retrospective Analysis
June 2008 – April 2014
AAA Repairs
n = 149
Open
n = 97
EVAR
n = 52

4. Objectives Kentville experience vs. early EVAR RCTs
Volume - Outcome relationship for EVAR
Regional vascular care in Nova Scotia
EVAR1 Lancet 2004;364:843–48 RETA Eur J Vasc Endovasc Surg 2001;21:57–64
EUROSTAR Eur J Vasc Endovasc Surg 1999;17:507–16

5. Results
1987 Dr. Volodos performed the first endovascular thoracic aneurysm repair in Ukraine
Dr. Nikolay Volodos

6. * Surgeon 1 Surgeon 2 Open EVAR 2008 8 3 12 1 2009 10 2 7 5 2010 13 4
Surgeon 1
Surgeon 2
Open
EVAR
2008 8 3 12 1
2009 10 2 7 5
2010 13 4
2011
2012
2013 6
2014 55 24 42 28 79 70
Total
Open
EVAR 20 4 17 7 15 9 12 11 8 2 97 52
149 *

7. Open
EVAR

8. Characteristic n=52 % Mean Age (years) 75 (SD 7.0) Mean BMI (kg/m^2)
Table 1: Preop characteristics among EVAR patients
Characteristic
n=52 %
Mean Age (years)
75 (SD 7.0)
Mean BMI (kg/m^2)
28 (SD 5.3)
Female Gender 11
21%
Obese 18
35%
HTN 34
65%
CAD
Arrythmia 10
19%
CHF 4 8%
DLD 21
40%
Smoking 33
63%
COPD 24
46%
Previous Cancer 17
33%
Diabetes
Renal Failure 6
12%
CVD 9
17%
GERD 13
25%
OSA 5
10%
EtOH

9. Characteristic n=52 % n=531 n=611 n=899 Mean Age (years) 75 (SD 7.0)
Table 1: Preop characteristics among EVAR patients
EVAR 1
2004
RETA
2001
EUROSTAR
1999
Characteristic
n=52 %
n=531
n=611
n=899
Mean Age (years)
75 (SD 7.0)
74 (SD 6.0)
72 (SD 7.6)
69 (SD 7.1)
Mean BMI (kg/m^2)
28 (SD 5.3) 26
Female Gender 11
21% 49 9% 81
Obese 18
35%
192
HTN 34
65%
CAD
234
44%
Arrythmia 10
19%
CHF 4 8%
DLD 21
40%
Smoking 33
63%
470
89%
COPD 24
46%
Previous Cancer 17
33%
Diabetes
Renal Failure 6
12%
CVD 9
17%
GERD 13
25%
OSA 5
10%
EtOH
RETA fit vs unfit based on ASA

10. Characteristic n=52 % Graft Body Vascutek Anaconda 40 77% Cook Zenith
Table 2: Intraop characteristics among EVAR patients
Characteristic
n=52 %
Graft Body
Vascutek Anaconda 40
77%
Cook Zenith 9
17%
Cook Renu 2 4%
Medtronic Endurant 1 2%
Severity of Disease
Mean Size (mm)
60 (SD 6.6)
Iliac Aneurysm 4 8%
Procedure
EVAR only 50
96%
Conduits
Status
Elective (%) 43
83%
Urgent (%) 8
15%
Rupture (%)
Started with cook and then gained experience with anaconda and kept it to get comfortable

11. Characteristic n=52 % n=531 n=611 n=899 Graft Body Vascutek Anaconda
Table 2: Intraop characteristics among EVAR patients
EVAR 1
2004
RETA
2001
EUROSTAR
1999
Characteristic
n=52 %
n=531
n=611
n=899
Graft Body
Vascutek Anaconda 40
77%
Cook Zenith 9
17% 26 4%
Cook Renu 2 18 2%
Medtronic Endurant 1
*188
31%
Severity of Disease
Mean Size (mm)
60 (SD 6.6)
65 (SD 0.9)
61 (SD 1.2)
55 (SD 1)
Iliac Aneurysm 4 8%
Procedure
EVAR only 50
96%
Conduits
Status
Elective (%) 43
83%
502
84%
Urgent (%) 8
15% 86
14%
Rupture (%) 10
*AneurX, Talent, Medtronic devices
Vanguard BS
Excluder Gore
Talent Word Medical

12. Unplanned Bypass Required Conversion to Open 4% Death
Table 3: Intraop outcomes among EVAR patients
Outcome
n=52 %
Endoleak 1a 5
10% 1b 3 6% 2 19
37% 1 2%
Graft Limb Thrombosis
Unplanned Bypass Required
Conversion to Open 4%
Death
ENDOLEAKS: All but one type 1 endoleak corrected in OR. Type 3 was corrected in OR
CONVERSIONS:
Case 1 Funneled neck. body deployed, migrated, endoleak. Was bleeding around sheaths, conversion to open AAA repair. Cross femoral bypass, R ileofemoral bypass
Case 2 Symptomatic, dumbell aneurysm, short neck, small iliacs and distal Ao (14mm), plan for artouni-iliac with fem-fem: Unable to recapture the delivery system; stent migration; Intraop bleed/rupture; conversion to open; cardiac arrest; intraop death

13. Unplanned Bypass Required 0.05% Conversion to Open 4% 10 32 5% 18
Table 3: Intraop outcomes among EVAR patients
EVAR 1
2004
RETA
2001
EUROSTAR
1999
Outcome
n=52 %
n=531
n=611
n=899
Endoleak 1a 5
10% 39
4.3% 1b 3 6% 29
3.2% 2 19
37% 54 1 2% 0%
Graft Limb Thrombosis 13
0.5%
Unplanned Bypass Required
0.05%
Conversion to Open 4% 10 32 5% 18
Death

14. Length of Stay Outcome n=51 % Median Length of Stay (days) 3 (SD 6.6)
Table 4: In-hospital outcomes among EVAR patients
Outcome
n=51 %
Median Length of Stay (days)
3 (SD 6.6)
<4 day Admit 35
69%
>7 day Admit 7
14%
Myocardial Infarction 1 2%
CHF 3 6%
Pneumonia 4 8%
Wound Infection
UTI
Delerium 2 4%
GI bleed
Ileus
AKI
Reop
Death
Length of Stay
Reops:
-RW 2009 takeback for palmaz extension stent for type 1 endoleak 2009
2012 takeback for bilat femoral endart after subintimal dissection of LEIA 2012
2012 takeback for R SFA thrombus
Mention the fact the death occurred at >30 days

15. Median Length of Stay (days) 3 (SD 6.6) 7 6 <4 day Admit 35 69%
Table 4: In-hospital outcomes among EVAR patients
EVAR 1
2004
RETA
2001
EUROSTAR
1999
Outcome
n=52 %
n=531
n=611
n=899
Median Length of Stay (days)
3 (SD 6.6) 7 6
<4 day Admit 35
69%
>7 day Admit
14%
Myocardial Infarction 1 2% 23
3.8%
 36
CHF 3 6%
Pneumonia 4 8% 14
2.3%
26 
Wound Infection 46
7.5%
UTI
Delerium 2 4%
10 
GI bleed
17  
Ileus 5
0.8%
AKI 27
4.4%
32 
Reop
 246
27% 
Death 9
1.7% 39
6.4% 29
3.2%

16. 20/52 1 2 3 Outcome n=51 % Endoleak 3 6% Reoperation 9 18% Death 10
20/52
Table 5: Long Term Outcomes
Outcome
n=51 %
Endoleak 3 6%
Reoperation 9
18%
Death 10
20%
1 Year Survival
93.5% 
3 Year Survival
71.4% 
Endoleak: EVAR 2010  2012 R1b embolized and revision of the R graft then…
2014 L1b or 3a required restenting of the L limb.
2: endoleak postop day 10 (but after discharge) new limb… then below
Reops:
EVAR 2012  10 d later L1b Endoleak (thought to be repaired in OR) needed new limb  Then in 2014 coloaortic fistula = 2014/03/14 left hemicolectomy and irrigation of infected graft secondary to coloaortic fistula; 2014/03/17 reconstruction of common iliac and infrarenal aorta with femoral vein, hypotension upon closure, distal anastamosis; 2014/03/17 take back for hemorrhage and redo of distal anastamosis; 2014/03/18 take back for hemorrhage found to have coagulopathy; 2014/03/20 take back for hemorrhage, splenectomy
Deaths were all cause and none known to be attributed to graft failure or rupture

17. 100% 75% 50% 25% 2 4 6 8 EUROSTAR Only 10% unfit
EVAR2 N Engl J Med 2010;362:
EUROSTAR European Journal of Radiology 2001;39:34–41

18. Discussion
1990 Dr. Parodi performed the first EVAR in Argentina with a balloon expanded Dacron graft mounted on a Palmaz stent
Dr. Federico Parodi

19. Conversion to Open Associated with high mortality 2 Conversions
29% in RETA
50% in Kentville experience
2 Conversions
Aneurysm anatomy
Graft migration
Rupture

20. Conversion to Open
RETA Eur J Vasc Endovasc Surg 2001; 21: 57–64

21. Conversion to Open
RETA Eur J Vasc Endovasc Surg 2001; 21: 57–64

22. Intraop Technical Challenges
2812 patients
One case they didn’t mention:
Case with conduit clamp that fell off…
EUROSTAR European Journal of Radiology 2001; 39: 34–41

23. Volume Outcome Relationship
Open AAA literature
Center v. surgeon volume
Institutional support
Composite case volume
Minimal safe volumes?
Effect of caseload on elective aneurysm surgery outcomes have been derived by analysis of patients undergoing open repair
Hospital volume is significantly related to elective aneurysm mortality for open repair
Higher volume hospitals were more likely to adopt endovascular therapy (44% in high volume hospitals vs. 18% in low volume hospitals)
Surgeon volume matters more than insitutional volume J Vasc Surg 2011;53:591-9
Does it matter what a hospital is high volume for? BMJ 2004;328(7442):737–740
J Vasc Surg 2011;53:591-9
J Vasc Surg 2011;54:
Br J Surgery 2008;95:64-71
Curc Cardiovasc Qual Outcomes 2009;2:624-32

24. Minimal Safe Volumes London (2007) 13 cases/year/surgeon
London (2009) critical >8 cases/year/inst.
U Mass (2011) >9 cases/year/surgeon
Low
Med
High
Institution
<7
7-30
>30
Surgeon
< 2
3-9
>9
London AAA repairs meta analysis with critical volume of 13 cases/ year
London 2009 Holt across UK AAA repair (20% EVAR) done. Seperated in quintiles <8 <15 up to >100. (2/3 of all EVAR instuitions were <8/year) Large EVAR units also had better open outcomes.
U Mass study: cases 60% EVAR shows that surgeon open AAA volume is more predicative then institution (high volume is >9 per year). For EVAR neither institution or surgeon volume influenced mortality
J Vasc Surg 2012;55:924-8
J Vasc Surg 2007;46:
Cardiovasc Intervent Radiol 2009;32:918–922
J Vasc Surg 2011;53:591-9

25. 22 20 18 16 14 12 10 8 6 4 2
Number of cases performed by surgeons against the mortality rate for elective AAA (mostly open) repairs
The horizontal line represents the cohort mean mortality rate of 5.56%
The trend line is a line of best fit, and no statistical inferences have been made from this
J Vasc Surg 2007;46:

26. High Risk Elective Patients
Renal failure (esp with dialysis)
Lower extremity ischemia
Age > 85
CHF
Chronic liver disease
Female gender
NIH National Medicare database independent predictors of mortality
J Vasc Surg. 2009;50(6):1271–9

27. Lessons Pre-procedural imaging and planning
Appropriate graft and patient selection
Technical performance of the procedure
Post-procedural surveillance
Management of EVAR-related complications
IFU Zenith

28. Conclusions
VRH provides acceptable EVAR outcomes in a regional vascular surgery unit
Volume Outcome relationship for EVAR yet to be clarified
Preoperative planning, patient selection, and IFUs are crucial for improved outcomes

29. Kentville EVAR Experience
2014 Atlantic Vascular Conference
Questions?

30. s
1987 Dr. Volodos performed the first endovascular thoracic aneurysm repair in Ukraine
1990 Dr. Parodi performed the first EVAR in Argentina with a balloon expanded Dacron graft mounted on a Palmaz stent
1993 Dr. Lawrence-Brown Royal Perth Hospital group led to the manufacturing of the Cook Zenith graft
1999 FDA approval of two devices for widespread use medtronic and guident devices
2000s Fenestrated and branched grafts