1. Department of Surgery, University of Pennsylvania Health System 1 Abdominal Aortic Aneurysms Omaida C. Velazquez, M.D., F.A.C.S

2. Department of Surgery, University of Pennsylvania Health System AAA Prevalence Most AAA's are Never Detected.Most AAA's are Never Detected. –Approximately 70% to 80% of AAA Patients are Asymptomatic at Initial Diagnosis –AAA's are Generally Discovered Inadvertently during Procedures to Diagnose Unrelated Medical Conditions Nearly 200,000 people in the U.S. are diagnosed with AAA annuallyNearly 200,000 people in the U.S. are diagnosed with AAA annually –Approximately 15,000 Die Each Year from a Ruptured AAA –45,000 - 50,000 Patients Undergo Surgery –AAA's are More Prevalent in People Over the Age of 60 –More Common in Men than in Women

3. Department of Surgery, University of Pennsylvania Health System AAA Symptoms A pulsing feeling in the abdomen, similar to a heartbeatA pulsing feeling in the abdomen, similar to a heartbeat Severe, sudden pain in the abdomen or lower back. (aneurysm may be about to rupture)Severe, sudden pain in the abdomen or lower back. (aneurysm may be about to rupture) On rare occasions, feet may develop pain, discoloration, or soreness because of material shed from the aneurysmOn rare occasions, feet may develop pain, discoloration, or soreness because of material shed from the aneurysm

4. Department of Surgery, University of Pennsylvania Health System AAA Screening Tests Abdominal aortic aneurysms are most often found when a physician is performing an imaging test, such as an ultrasound, Hip X- RAY, CT scan, or MRI, for other conditions.Abdominal aortic aneurysms are most often found when a physician is performing an imaging test, such as an ultrasound, Hip X- RAY, CT scan, or MRI, for other conditions. Recommend tests:Recommend tests: –Abdominal ultrasound –Computed Tomography (CT) Scan –Magnetic Resonance Imaging (MRI)

5. Department of Surgery, University of Pennsylvania Health System The Screening Abdominal Aortic Aneurysms Very Efficiently Act (SAAVE) - 2007 Important topic right now beginning in January 2007 Medicare will offerImportant topic right now beginning in January 2007 Medicare will offer –One-time free AAA ultrasound screening to qualified seniors as part of their Welcome to Medicare physical. »Men who have smoked at any time during their life »Men and women with a family history of AAA are eligible for the new Medicare benefit.

6. Department of Surgery, University of Pennsylvania Health System How to Proceed After Diagnosis of AAA Vascular ConsultationVascular Consultation Patient EducationPatient Education Observation with serial Ultrasounds when less than 5 cm in diameter, when asymptomaticObservation with serial Ultrasounds when less than 5 cm in diameter, when asymptomatic EVAR Vs. Open RepairEVAR Vs. Open Repair

7. Growth Rate Four hundred ninety-two patients were entered into the study with AAAs smaller than 5 cm when first seen. Entry Size (cm) Patients Entered Mean Expansion Rate (cm/yr) SD (± cm) 2.0 – 2.4 60.170.11 2.5 – 2.9 260.220.27 3.0 – 3.4 1050.330.59 3.5 – 3.9 1060.410.53 4.0 – 4.4 1620.540.54 4.5 – 4.9 870.710.78 Brown PM, Pattenden R, Vernooy C, Zelt DT, Gutelius JR. Selective management of abdominal aortic aneurysms in a prospective measurement program. J Vasc Surg 1996;23:213-220.

8. UK Small Aneurysm Trial 4.0-5.4 cm Randomized Surgery or Surveillance Only 39 pts. (3.5%) Survived without Surgery - “All Roads Lead to Rome” 1276 Patients Eligible 186 Declined Randomization 527 Assigned to Ultrasonographic Surveillance 200 Did Not Undergo Surgery by June 1998 43 Did Not Undergo Surgery by June 1998 563 Assigned to Early Elective Surgery 327 Underwent Surgery by June 1998 289 According to Protocol 38 In Violation of Protocol 80 Died by June 1998 120 Surviving as of June 1998 23 Died by June 1998 20 Surviving as of June 1998 520 Underwent Surgery by June 1998 62 Underwent Surgery by August 2001 48 Open 13 Endovascular 1 Laparoscopic 33 Surviving without Surgery as of August 2001 6 Surviving without Surgery as of August 2001 6 Underwent Surgery by August 2001 5 Open 1 Laparoscopic 1090 Underwent Randomization (1991 – 1995)

9. Department of Surgery, University of Pennsylvania Health System Open Surgical Repair

10. Department of Surgery, University of Pennsylvania Health System Morbidity 30 day post-op complications after elective AAA repair:30 day post-op complications after elective AAA repair: –MI2%-8% –All pulmonary8%-12% –Reduced renal function5%-12% –Dialysis1%-6% 70% 5 year survival for elective AAA repair70% 5 year survival for elective AAA repair Taylor Ann Vasc Surg 1986; 1: 502

11. Functional Outcomes 11% transferred to S.N.F 3.66m + 2.9m11% transferred to S.N.F 3.66m + 2.9m All patients were ambulatory pre-opAll patients were ambulatory pre-op At median follow up of 25 monthsAt median follow up of 25 months –22% of patients required assistance –14% were non-ambulatory –33% of patients reported a decrease in functional status 18% reported that they would not undergo a repair knowing the recovery process in spite of the risks.18% reported that they would not undergo a repair knowing the recovery process in spite of the risks. W. Kent Williamson, MD et al. Functional outcome after open repair of abdominal aortic aneurysm J Vasc Surg: May 2001 33 Number 5 p913 to p920

12. Department of Surgery, University of Pennsylvania Health System 12 Open vs. EVAR (Endovasc ular AAA Repair) Juxtarenal or suprarenal aortic aneurysms, likely need Open Repair

13. Department of Surgery, University of Pennsylvania Health System Most Infrarenal Abdominal Aortic Aneurysms (AAA) May be treated by EVAR Glass Model Shows Zenith Stent-graft (COOK)

14. Department of Surgery, University of Pennsylvania Health System Endovascular AAA Repair (EVAR) Illustrations Show Powerlink Stent-graft (Endologix)

15. Department of Surgery, University of Pennsylvania Health System Open vs. EVAR Open Surgical RepairOpen Surgical Repair –Longer Recovery Time –Longer Hospital Stay –90% Long Term Success –Younger patients typically EVAREVAR –Shorter length of stay –Reduction in blood loss –Reduction in OR Time –ICU utilization reduced –Reduced 30 d morbidity/mortality –Older patients typically –Needs long-term follow-up –May need secondary procedures for endoleaks

16. “Paradox of Success” Successful Exclusion Anatomy Changes Limb Disconnections Migration Late Failure and/orand/or Parra et al. Journal of Vascular Surgery Vol. 37, No. 1:109 1 month 12 month 24 month

17. Distribution of Stent Graft Fatigue by Device Device for Aortic Aneurysm Repair Total Implanted Radiographs Reviewed Total Fatigue/Fracture Average Time to Fracture/Fatigue (mo;range) Average Follow-up Since Fracture/Fatigue (mo;range) † ABDOMINAL Vanguard Vanguard26 22 (85%) 16 (72%) 26 * (3-48) 13 (1-39) Talent Talent337 232 (69%) 24 (10%) 13 (1-31) 5 (1-12) Modified Parodi Modified Parodi164 24 (15%) 5 (21%) 38 (33-48) 6 (1-8) EVT/Ancure EVT/Ancure9/207/6 1/0 (14%) 8 24 and then lost to fu AneuRx AneuRx39 33 (85%) 3 (10%) 10 (1-24) 3 (1-6) Gore Gore18 18 (100%) 0 Teramed Teramed10 10 (100%) 0 THORACIC Gore TAG Gore TAG22 19 (86%) 7 (37%) 24 (3-38) 12 (1-42) Talent Talent 41 ‡ 33 (80%) 4 (12%) 9.5 (1-24) 4 (2-7) TOTAL68640460198 * Excluding patient with acute conversion † Excluding those patients who underwent open conversion and stent graft explanation ‡ Including emergent use not part of clinical study Jacobs TS, Won J, Graveraux EC, Faries PL, Morrissey N, Teodorescu VJ, et al. Mechanical failure of prosthetic human implants: a ten-year experience with aortic stent graft devices. J Vasc Surg 2003;37:16-21.

18. Viable Technology Institutions performing far greater than 75% of all AAA repairs with EVAR may be experiencing “Endo-Exuberance,” while those with less than a 25% utilization may be suffering from “Endo-Apathy.” w. Charles Sternbergh, III, et Endo-Exuberance to Endo-Reality: Trends in the Management of 431 AAA Repairs Between 1996 and 2002. Journal of Endovascular Therapy: Vol. 10, No. 3, pp. 418-423. 100%75% 60% 40% 25% Increasing Use of EVAR as a Percentage of All AAA Repairs Conservative Average Aggressive Endo-Apathy Endo-Exuberance Endo-Realism