1. 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

2. Disclosures
Medtronic, Cook, Gore

3. 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

4. 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

5. 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

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

7. Why ever perform open AAA repair?

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

9. 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

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

11. Type IV TAAA
Juxtarenal

12. 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

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

14. Narrow Bifurcation

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

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

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

19. 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

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

21. 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)

24. Penn Experience

25. 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 ( )
1.5L ( )
1.4L ( )
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.

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

27. 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

29. Infected Stent Graft
Uncommon but incidence may be increasing

30. 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

31. JVS 2011in press

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

34. 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

35. 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

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

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

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