1. Aortic aneurysm management
Dr Frijo Jose A

2. TA Aneurysm Essentials of Diagnosis
Asc Ao diameter > 4 cm on imaging study
Desc Ao diameter > 3.5 cm on imaging study

3. Asc Ao aneurysms – 3 common patterns

6. Crawford classification - aneurysm in desc Ao and thoracoabdominal Ao

7. Types of aneurysms, classified according to the EUROSTAR study (classification according to Schumacher).

8. Marfan disease- fibrillin
21% of aneurysm probands have a first-degree relative with known/likely Ao aneurysm
TAAD1 (Thoracic Aortic Aneurysm and Dissection 1) locus

9. Ao Manifestation of Connective Tissue Disease

12. In Vivo Mechanical Properties Of Human Ascending Aorta

13. Depiction of “HingePoints” for Lifetime Natural History Complications at Various Sizes of the Aorta

14. Survival With Thoracic Aneurysms of Various Sizes

15. Yearly Rates of Rupture, Dissection, or Death Related to Aortic Size

16. Diameter 6 cm- very dangerous size threshold At/above this
yearly risk for rupture ≈4%
yearly risk of dissection ≈ 4%
Yearly risk of death ≈ 11%
Chance of any one of these phenomena occurring— 14%/year

17. Size Criteria for Surgical Intervention for Asymptomatic Thoracic Aortic Aneurysm
For pts with a positive family hx, but without Marfan disease, the same criteria is applied as for Marfan disease
BAV also have inherently deficient Ao- lower intervention dimensions are used
Size criteria apply only to asymptomatic aneurysms.
Symptomatic aneurysms should be resected regardless of size
If aneurysm increases in size by 1cm per year

18. How Fast Does the Thoracic Aorta Grow?
Annual growth rate of an aneurysmal thoracic Ao cm on average
Desc Ao grows faster than asc ao, at 0.19 cm/year compared with 0.07 cm/year
The larger the aorta becomes, the faster it grows

19. Symptoms and Signs Most asymptomatic - detected fortuitously
When symptomatic
deep visceral pain
not usually ppted by exertion nor relieved by rest/NTG
often constant-not influ by body motion/position
Rupture of thoracic aneu - excruciating pain, profound dyspnea and quickly shock
A large asc Ao aneu – occ dysphagia/stridor/bone pain

26. “SilverLining” in Ascending Aneurysm Disease: Protection From Arteriosclerosis

27. New pts, for whom only one size data point is available- imaging at short intervals until the behavior of aorta is understood (3-6/12)
Compare present scan with the pt's first scan, not with the last prior scan
Stable, asymptomatic pts- imaging every 2 yrs (aneu Ao grows at ≈1 mm/yr)
New onset of sympts- imaging should be done promptly, regardless of the interval

28. Current Risks of Thoracic Ao Surgery

29. Elective sx- survival rate very similar to N population
Once the aorta has dissected- prognosis is thereafter adversely affected
Pts who required emergency sx- higher rate of early mortality & survival curve poor
Even after sx replacement of portions of Ao, the remainder will forever remain dissected
Ao wall was deficient to start with, after dissection- more vulnerable to enlargement & rupture
Elective sx- survival rate very similar to N population

31. Aneu evaluated using a 3-dimensional reconstruction from CTA/MRA or aortography with a calibrated catheter
Access arteries are measured- FA –retroperitoneal access to iliacs or aorta entertained
Iliac A assessed for tortuosity & calcification

38. Bifurcated supported endograft

39. Endovascular Repair Of AAA
older
substantial comorbidities (renal, respiratory, & cardiac dysfunction)
Females & those with a smallerbody habitus -↑ EVAR abortion rate – smaller access arteries

40. Anatomic requirements for endovascular repair of TAA
A proximal neck at least 15 to 25mm from the origin of the left subclavian artery
A distal neck at least 15 to 25mm proximal to the origin of the celiac artery
Adequate vascular access—absence of severe tortuosity,calcification,or atherosclerotic plaque burden involving the aortic or pelvic vasculature
The transverse diameter of the proximal and distal neck should be within the range that available devices can appropriately accommodate

42. Endovascular repair of thoracic aneurysms

43. Multilayered stents

46. EVAR Complications Access-related Deployment-related Systemic
Hematoma
Lymphocele
Infection
Embolization
Ischemic limb
Deployment-related
Failed deployment
Arterial rupture
Dissection
Device-related
Structural failure
Implant-related
Endoleaks
Limb occlusion
Stent graft kink
Sac enlargement
Proximal neck dilatation
Stent migration
AAA rupture
Infection
Buttock/leg claudication
Systemic
Cardiac
Pulmonary
Renal insufficiency
Cerebrovascular
Deep vein thrombosis
Pulmonary embolism
Coagulopathy
Bowel ischemia
Spinal cord ischemia
Erectile dysfunction

49. Treatment of Endoleaks
Methods employed- coil embolization, placement of stent-graft cuffs and extensions, laparoscopic ligation of inferior mesenteric and lumbar arteries, open surgical repair, and EVAR redo procedures
Type I and III - urgent intervention- blood flow & sac pressure will continue to ↑→ rupture
Type IV - resolve on their own
Type II – controversial
Some of them will thrombose on their own while others will lead to sac enlargement
Challenge - when to intervene
One approach - monitor with a 6/12 post-procedure CT scan- If aneu has increased- plan intervention
3 approaches : transarterial, translumbar embolization, laparoscopic ligation

50. EUROSTAR
Secondary interventions following endovascular AAA repair using endografts
2846 pts- In 8.7% 2⁰procedure at some time
Annual rate of 2⁰ intv- 4.6%
proximal type I endoleak evident on completion angio- predictive of later 2⁰ intv
Mortality rate 2⁰ intv -15% >peri-op mortality aft elect open repair
Aneurysm expansion -17%pts 2⁰ intv
Continuing need for surveillance for device-related compli- necessary
J vasc Surg 2006;43:

51. EVAR trial 1
Comparison of endovascular aneu repair with open repair in AAA
1082 elect- EVAR(n=543) /open repair(n=539)
30-d mortality- EVAR (1·7%-9/531) v/s (4·7%-24/516) in open gp
2⁰ intv more in EVAR (9·8% vs 5·8%, p=0·02)
In large AAAs, EVAR reduced 30-d operative mortality by two-thirds compared with open repair
Long term- EVAR 1 - 3% lower initial mortality for EVAR, with a persistent ↓ in aneu-related death at 4 ys- Improvement in overall late survival was not demonstrated
Lancet 2004; 364: 843–48

52. EVAR trial 2
Endovasc aneu repair and outcome in pts unfit for open repair of AAA
338 pts- EVAR (n=166) /no intrv (n=172)
30-day op mortality in EVAR- 9% (13/150)
No intrv rupture rate- 9·0/100 person years
overall mortality aft 4 yrs- 64%
No signi diff betw EVAR v/s no intrv for all-cause mortality (hazard ratio 1·21, p=0·25)
No diff in aneu-related mortality
EVAR did not improve survival over no intrv, asso with a need for continued surveillance & reintrv, at substantially ↑ cost
Lancet 2005; 365: 2187–92

53. Data From the EVAR-2 Trial Showing No Benefit of Stent Therapy of Abdominal Aneurysm Over Medical Therapy

54. DREAM Comparing conventional and endovascular repair of AAA
345 patients-30 d
Combined- op mortality + severe compli- 9.8% (open) v/s 4.7% (EVAR)- risk ratio- 2.1
EVAR preferable to open AAA at least 5 cm
Two-year outcomes
Cum survival rates- 89.6% open v/s 89.7% EVAR
The perioperative survival adv with EVAR- not sustained aft 1st post-op year
N Engl J Med Oct 14;351(16):1677-9
N Engl J Med. 2005 Jun 9;352(23):

55. CAESAR
Comparison of Surveillance Versus EVAR for Small Aneurysm Repair
AAA  cm - imm EVAR v/s surveillance by USG &CT →repair aft defined threshold (D≥5.5 cm, enlargement >1 cm/y, sympts)
360 pts (early EVAR = 182; surv = 178)
At 54/12- no significant difference
Mortality & rupture rates in AAA <5.5 cm are low and no clear adv shown betw early or delayed EVAR strategy
<36/12- 3/5 small aneu under surveillance might grow to require repair
Eur J Vasc Endovasc Surg. 2010 Sep 23

56. The PIVOTAL study: a randomized comparison of endovascular repair versus surveillance in patients with smaller abdominal aortic aneurysms
The ACE trial: a randomized comparison of open versus endovascular repair in good risk patients with abdominal aortic aneurysm

57. Death at 2-3Yrs for TEVAR v/s Open Surgery

58. Stroke for TEVAR v/s Open Surgery

59. Paraplegia or
Pareparesis
for
TEVAR
v/s
Open Surgery

60. AAA
Class I 1. Pts with infrarenal/juxtarenal AAAs ≥5.5 cm should undergo repair to eliminate risk of rupture. ( B) 2. Pts with infrarenal/juxtarenal AAAs cm should be monitored by USG/CT every 6 -12/12 to detect expansion. ( A) Class IIa 1. Repair can be beneficial in infrarenal/juxtarenal AAAs cm. (B) 2. Repair is probably indicated in pts with suprarenal/type IV thoracoabdominal AA 5.5 to 6.0 cm. (B) 3. In pts with AAAs <4.0 cm, monitoring by USG every 2-3 yrs is reasonable. (B)
ACC/AHA 2005 Practice Guidelines

61. Class I 1. In pts with the clinical triad of abd and/or back pain, a pulsatile abdominal mass, and hypotension, imm surgical evaluation is indicated. (B) 2. In pts with symptomatic AA, repair is indicated regardless of diameter. (C)
ACC/AHA 2005 Practice Guidelines

62. Th AA
Class I 1. Asympt degenerative thoracic aneu , who are otherwise suitable candidates and for whom the asc aorta or aortic sinus diameter is ≥5.5 cm should be evaluated for surgical repair. (C) 2. Marfan syndrome or other genetically mediated disorders (vascular EDS,Turner , BAV, or familial thoracic AA) should undergo elective Sx at smaller diameters (4.0 to 5.0cm) (C) 3. Pts with a growth rate >0.5 cm/y in an aorta <5.5 cm should be considered for Sx. (C) 4. Pts undergoing AV repair/replacement and who have an asc aorta or aortic root >4.5 cm should be considered for concomitant repair of Ao root or replacement of asc Ao. (C)
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines

63. Desc Th Ao and Thoracoabd AA
Class I 1. Desc tho Ao >5.5cm, saccular aneurysms, or postoperative pseudoaneurysms, endovascular stent grafting should be strongly considered when feasible.(B) 2. Thoracoabd A, in whom EVAR options are limited and surgical morbidity is elevated, elective sx recommended if the Ao >6.0 cm, or less if Marfan (C)
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines

64. Evaluation of Family Members
A CT scan recommended for adult males & females beyond childbearing age
For children & females of childbearing age, echo of the asc Ao & abd Ao recommended