3. Epidemiology Age: 5-7% of population 60+yrs age US: reported incidence of 5-7% Mean age 70-75yrs Sex: M:F = 1.6-4.5:1 Race: White M > Blacks M White F = Black F Mortality/Morbidity: Grows ~0.4 cm/year 75% mortality (upon rupture) 13 th leading cause of death in the US (~15,000 deaths per year) Overall mortality 0.9%-5% after repair Rupture is based on size

4. Pathophysiology & Risk Factors Atherosclerosis Elastin Wall Structure Genetics Smoking Brady AR, Thompson SG, Greenhalgh RM, et al. Br J Surg 90:492, 2003. 90% had smoking history Others: HTN, infection, trauma, arteritis, cystic medial necrosis, Marfan Syndrome, Ehlers-Danlos Syndrome

5. Symptoms and Signs Asymptomatic Inflammatory AAA may cause back pain Pulsatile abdominal mass Mid-abdomen just above and left of the umbilicus Lederle FA, Wilson SE, Johnson GR, et al. N Engl J Med 346:1437, 2002. Ruptured AAA Triad (50%): 1. Sudden onset abdominal pain 2. Pulsatile mass 3. Hypotension

6. Imaging Incidental, ultrasound, CT angiogram and angiogram

7. Diagnosis Physical exam ◦ Firm, pulsatile abdominal mass ◦ Overall sensitivity of 52%  Sensitivity increases with diameter  29% for 3.0 to 3.9cm  50% for 4.0-4.9 cm  76% for > 5.0 cm ◦ Extension into iliac arteries is not appreciated X-ray ◦ About 70% of cases ◦ Characteristic eggshell pattern of calcification ◦ Accurate determination of size difficult ◦ Negative AXR does NOT rule out diagnosis Ultrasound ◦ Most widely used noninvasive test ◦ Provides structural detail of vessel wall ◦ Can accurately measure the size in longitudinal and cross sectional directions ◦ Advantages  Noninvasive, low cost, wide availability  Good for initial evaluation or pts, screening and surveillance

8. Diagnosis CT ◦ Most precise test for imaging AAA ◦ Can identify  Proximal and distal extent of aneurysm, including thoracic portion  Occlusive aneurysmal disease  Presence of multiple and accessory renal arteries  Seize of aortic lumen, amount of thrombus, and presence of calcific disease MRI ◦ Imaging of choice for patients with renal insufficiency ◦ High quality images of aorta ◦ However, less sensitive in identifying accessory renal arteries or renal artery stenosis Arteriography ◦ Reliable information on size of aortic lumen and branch vessel disease ◦ However, due to thrombus, aortic lumen is near normal in size so inaccurate assessment of size or aneurysm ◦ Helpful for assessment of associated arterial disease in pre-op eval

9. Screening SVMB/SVS/AAVS (2004) Kent KC, Zwolak RM et al: Screening for abdominal aortic aneurysm: a consensus statement. J Vasc Surg 39(1):267, 2004 Men: Recommends for screening in all men age 60-85 years Women: Recommends for screening in women age 60-85 years with a family history of AAA USPSTF (2005) Men: Recommends for screening in men age 65-75 years who have ever smoked. Recommends against screening in men age 65-75 years who have never smoked Women: Recommends against screening in all women ACC/AHA (2006) Men: Recommends for screening in men age 65 years or older who have ever smoked. Recommends for screening in men age 60 or older with a family history of AAA Women: None

10. Screening for Aneurysms 4 randomized trials of AAA screening have been performed ◦ Reduction in AAA related mortality ranging from 21-68% ◦ Reduction in AAA rupture ranging from 45-49% Multicentre Aneurysm Screening Study ◦ >70,000 men screened between ages of 65-74 ◦ Aneurysms >5.5 cm referred for repair ◦ After 4 years there was 42% reduction in AAA related deaths in the screened group Society for Vascular Surgery screening recommendations ◦ Baseline ultrasound screening for AAA in  Men 60-85  Women 60-85 with cardiovascular risk factors  Men and women older than 50 with a family history of AAA ◦ Yearly ultrasound for AAA 4.0-4.5cm ◦ Ultrasound every 6 months for AAA larger than 4.5cm

11. AAA Expansion and Rupture Average growth rate: ~0.4cm per year Factors: BP, size at detection, COPD Size is the best determinant of rupture 40% of untreated aneurysms 5.5-6cm or larger will rupture within 5 years Average survival without treatment: 17 months Lederle FA et al. JAMA 2002;287:2968.

14. Rupture Repair – EVAR is superior 30 day mortality EVAR 19%, Open 47% LOS EVAR 6, Open 18.5 D/C to home EVAR 55%, open 20% Major complication EVAR 36%, Open 80% OR time EVAR 3 hours, Open 4.5 hours Blood loss EVAR 200 cc, Open 4 liters

15. Treatment Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery (Brewster DC, Cronenwett JL, Hallett JW, et al. Vasc Surg 37:1106, 2003) 1. The arbitrary setting of a single threshold diameter for elective AAA repair that is applicable to all patients is not appropriate, as the decision for repair must be individualized in each case. 2. Randomized trials have shown that the risk of rupture of small ( 1 cm/y) or symptoms develop. However, early surgery is comparable to surveillance with later surgery, so patient preference is important, especially for AAAs 4.5 to 5.5 cm in diameter. 3. Based upon the best available current evidence, a diameter of 5.5 cm appears to be an appropriate threshold for repair in an "average" patient. However, subsets of younger, low-risk patients with long projected life expectancy may prefer early repair. If the surgeon's personal documented operative mortality rate is low, repair may be indicated at smaller sizes (4.5 to 5.5 cm) if that is the patient's preference.

16. 4. For women, or AAAs with greater-than-average rupture risk, 4.5 to 5.0 cm is an appropriate threshold for elective repair. 5. For high-risk patients, delay in repair until larger diameter is warranted, especially if endovascular aortic repair (EVAR) is not possible. 6. In view of its uncertain long-term durability and effectiveness, as well as the increased surveillance burden, EVAR is most appropriate for patients at increased risk for conventional open aneurysm repair. 7. EVAR may be the preferred treatment method if anatomy is appropriate for older, high- risk patients, those with "hostile" abdomens, or other clinical circumstances likely to increase the risk of conventional open repair. 8. Use of EVAR in patients with unsuitable anatomy markedly increases the risk of adverse outcomes, the need for conversion to open repair, or AAA rupture. 9. At present, there does not appear to be any justification that EVAR should change the accepted size thresholds for intervention in most patients. 10. In choosing between open repair and EVAR, patient preference is of great importance. It is essential that the patients be well informed to make such choices.

17. Surgery Open repair with synthetic graft 35% of current cases Primarily for poor anatomy Ocassionally young age Endovascular aneurysm repair (EVAR) 65% of current cases

18. Anatomic Requirements for EVAR Anatomic Criteria Length, angulation, and diameter of infrarenal neck > 60° neck angulation – 70% complication rate Minimum adequate length is 8 mm Desireable length is 1.5 cm Iliac artery diameter Large enough to accommodate device (7 mm) Small enough to allow device to seal (1.5 cm) Concurrent common or internal iliac artery aneurysm Can be difficult to manage Absence of thrombus at aortic neck Thrombus does not allow for a good neck seal

19. Standard Open Repair

20. Complications of Open Repair Mortality rate less than 5% in good risk pts ◦ Most frequent cause of death is ischemic myocardial injury Complications following elective open repair occur in 10-30% of cases ◦ Most frequent complication is nonfatal MI (avg. 6.9%) usually within first 48 hours post-op ◦ Renal failure (6%) ◦ Pneumonia (5%) ◦ Bleeding ◦ Ileus ◦ Ischemia of left colon and rectum ◦ Lower extremity ischemia from embolization of thrombus or atherosclerotic plaque ◦ Ischemic injury to lumbosacral plexus or to the spinal cord ◦ Post-op sexual dysfunction from injury to autonomic nerves during dissection (up to 25% of patients) ◦ DVT in as many as 18% of patients

21. Complications of Open Repair Late complications after successful repair are rare ◦ Only occurs in about 7% of patients, but Late complications more common in repair of rupture (17%) ◦ Complications include:  Anastomic pseudoaneurysm (3%)  Graft thrombosis (2%)  Graft-enteric erosion or fistula (1.6%)  Graft infection (1.3%)  Anastomotic hemorrhage (1.3%)  Colonic ischemia (0.7%)  Atheroembolism (0.3%)

22. Endovascular Aneurysm Repair (EVAR)

33. Potential Drawbacks of EVAR Need for frequent CT scans/follow up 1 month, 3 months, 6 months, one year and every year thereafter 90 % efficacious at 6 year mark Need for conversion Late rupture rate Up to 25% of patients need reintervention within the first year

34. Complication of EVAR: Endoleaks Type I: Lack of complete seal between stent graft and vessel wall at attachment sites Type II: Back filling of the aneurysm sac via such branch vessels as the lumbar of inferior mesenteric arteries Type III: Leaks at connections of modular components, device disruption, fabric tears Type IV: Extravasation of contrast material through interstices in the grafted artery White GH, May J, Waugh RC, et al. J Endovasc Surg 1998;5:189–193.

35. Open vs. EVAR StudyPatients Follow up (yrs) 30d Mortality Total Death Mayo Clinic AAA (Open) 30736 57.6 Canadian AAA (Open) 68065.45.8 AneuRx I–III (EVAR) 119241.92.4 EUROSTAR (EVAR) 295541.72.5

36. Time 01 mo.6 mo.1 year2 years3 years Persistent endoleak rate 21%5.9%7.5%10.1%8.5% New endoleak rate -5.9%4.3%2.5%2.8% Total endoleak rate 21%11.8% 12.6%11.4% Migration rate -4%1.0% 1.2%1.4% 0% Aortic size5.4 cm5.3 cm5.1 cm4.8 cm4.5 cm4.0 cm Reinterventi on rates -.83%2.0% 0%2.8% 0% St Luke’s- Roosevelt Last Evaluated 124 case – Endoleak and rate and aneurysm follow up data

37. Trials EVAR (Greenlagh, R) DREAM (Blankensteijn, J) ACE (Becquemin, J) OVER (Lederle, F)

38. DREAM (Dutch Randomized Endovascular Aneurysm Management) Prinssen M, Verhoeven EL, Buth J, et al. N Engl J Med 2004;351:1607–1618. Open vs. EVAR Radomized controlled trial of 345 patients with AAA >5cm EVAR operative mortality 1.2% Open repair operative mortality 4.6% Blankensteijn JD, de Jong SE, Prinssen M, et al. N Engl J Med 2005;352:2398–2405. Evaluation of perioperative period Cumulative survival rate were similar (89.6% vs. 89.7%) EVAR had lower aneurysm-related death (2.1% vs. 5.7%)

39. Dutch Randomized Endovascular Management Trial (DREAM) 30 day mortality was better in EVAR group (1.2% vs.. 4.6%) EVAR group showed less operative mortality and post- op complications (4.7% vs.. 9.8%) No overall survival difference at 2 years Aneurysm related death less in EVAR group (2.1% vs.. 5.7%)

40. Endovascular Aneurysm Repair Trial -1 (EVAR-1) Short term survival benefit of EVAR 30 day mortality rate 1.7% vs.. 4.7% At 4 years, no difference in mortality Aneurysm related death less in EVAR group (4% vs.. 7%) Greater post-op complications over 4 year follow-up in the EVAR group (41% vs. 9%) No difference in quality of life Hospital costs higher in EVAR group

41. EVAR-2 Trial Looked at effectiveness of EVAR in high risk patients Compared EVAR to observation No benefit of EVAR over observation 30 day mortality rate after EVAR was 9% 4 year mortality rate in EVAR group 64% No difference in late overall mortality No difference in aneurysm related mortality Higher hospital costs in EVAR group No health-related quality of life benefit to EVAR

42. Where are we going next? Suprarenal fixation Including renal stent grafts Branched grafts Including visceral artery stent graft More skills? Less access? More cost? More morbidity?

43. Questions?