1. Abdominal Aortic Aneurysm and Peripheral Disease 순천향대학교 부천병원 흉부외과학교실 원 용 순

2. Contents AAA  General consideration  Randomized Control Trials Comparing EVAR and Open AAA repair (OAR)  Patient selection criteria for EVAR  EVAR procedure  Complications of EVAR ; endoleak  Experience of SCHBC Peripheral Disease  ACA/AHA Practice Guideline  Classification of peripheral arterial disease (PAD)  Endovascular procedure  Experience of SCHBC Conclusions

3. Endovascular Treatment of AAA ; EndoVascular Aneurymal Repair : EVAR Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:491-499

4. Stent-graft design incorporating both limited and adjustable dimensional variability for maximum versatility. The fixed attachment points on the left have limited linear variability, whereas the adjustable fixation points on the right result in increased adaptability Modular endovascular bifurcation prosthesis including main bifurcation segment (A), contralateral leg (B), proximal aortic cuff (C), iliac cuff (D), and bifurcated (E) or straight (F) extenders. CTA, computed tomography- angiography; DSA, digital subtraction angiography

5. Dutch Randomized Endovascular Aneurysm Management (DREAM) trial Between Nov. 2000 and Dec.2003, Netherlands 351 patients ( > 5cm AAA, suitable for both OSR and EVAR ) OSR = 174 pts vs. EVAR = 171 pts Primary end point – operative mortality & moderate or severe complications NEJM 2004;351:1607-1618

6. DREAM trial NEJM 2004;351:1607-1618

7. DREAM trial NEJM 2004;351:1607-1618

8. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1) : randomised controlled trial Sept. 1999 ~ Dec. 2003, UK 1082 patients  > 60 years, > 5.5cm AAA  AAA was regarded as anatomically suitable for EVAR  OSR = 539 pts vs. EVAR = 543 pts to assess long term survival, generalisability, graft durability, health-related quality of life (HRQL), and hospital costs associated with both EVAR and OSR Lancet 2005 ; 365 :2179 - 86

9. EVAR trial 1 Lancet 2005 ; 365 :2179 - 86

10. EVAR trial 1 Lancet 2005 ; 365 :2179 - 86

11. Patient selection criteria for EVAR Fusiform AAA ≥ 5 ~ 5.5cm in diameter Saccular AAA Suggested aortic morphology  Proximal neck length ≥ 1.5 cm  Neck diameter ≤ 2.8 cm  Neck angulation ≤ 60 degrees  Preservation of critical side branches  Iliofemoral arteries of sufficient diameter for sheath access  No severe iliac artery or aortic tortuosity No hereditary connective tissue disorder Anesthesia clearance for possible conversion to open repair if necessary

12. Proximal neck length ≥ 1.5 cm Neck angulation ≤ 60 degrees Fusiform AAA ≥ 5 ~ 5.5cm in diameter or Saccular AAA Preservation of critical side branches Iliofemoral arteries of sufficient diameter for sheath access Patient selection criteria for EVAR No severe iliac artery or aortic tortuosity

13. EVAR procedure Preop. CT angiography

14. EVAR procedure

15. Postop. CT angiography

16. Endoleak Type I, II, III, IV, V Migration Kink, Stenosis, and Occlusion Graft infection Rupture Complications of EVAR

17. Endoleak Type I : a leak between the stent-graft and the proximal or distal arterial wall attachment site Type II : back-bleeding into the aneurysm sac from a patent inferior mesenteric (IMA), lumbar, internal iliac, accessory renal or gonadal artery

18. Type III : between stent-graft components (e.g. the junction between the main body and limb of a device) or through a hole in the fabric of the graft Type IV : excessive graft porosity Type V (endotension) : when the sac increases in size without a detectable endoleak Endoleak

19. Types of Endoleaks II III I I IV

20. Result of Endoleak 1. Many type II endoleaks undergo resolution by spontaneous thrombosis 2. Frank J. Veith et al. J Vasc Surg 2002;35:1029-35 Nature and significance of endoleaks and endotension: Summary of opinions expressed at an international conference Christopher K. Zarins et al. J Vasc Surg 2000;32:90-107 Endoleak as a predictor of outcome after endovascular aneurysm repair: AneuRx multicenter clinical trial

21. Result of Endoleak Timothy Resch et al. J Vasc Surg 1998;28:242-9 Persistent collateral perfusion of abdominal aortic aneurysm after endovascular repair d oes not lead to progressive change in aneury sm diameter

22. Experience of SCHBC - EVAR for AAA Feb, 2008 to May, 2009 13 patients (M : F = 11 : 1) Mean age : 70.54 (54 – 82) Aneurysm size : 56.23mm (32-76.3mm)  Ruptured : 1  Impending rupture : 2  unruptured : 10

23. ComplicationOREVAR Wound problem3/15(20%)1/13(8%) Pulmonary Cx.2/15(13%)0/13(0%) G-I complication1/15(6%)1/13(8%) Acute thromboembolism 1/15(6%)0/13(0%) Mortality : 2/15(13%) in OR 1/13(8%) in EVAR EVAR and OR in SCHBC P<0.05

24. Experience of SCHBC - Endoleak Endoleak : 6/13 (46%)  type I : 2 ( Ia, Ib)  type II : 2  type III : 2 Result of endoleaks  type II & type III : improved, 2wks, 3mths  Other loss : 1 Follow up : 2 Mortality : 1 (type Ia endoleak)

25. Peripheral Arterial Disease(PAD) ACA/AHA Practice Guideline

26. Iliac lesion TransAtlantic Inter-Society Consensus (TASC) Working Group

27. Femoral popliteal lesion TransAtlantic Inter-Society Consensus (TASC) Working Group

28. ACA/AHA Practice Guideline – Endovascular treatment for Claudication Recommandations  Endovascular procedure is the treatment of choice for type A lesions in iliac or femoral popliteal lesions  More evidence is needed to make firm recommendations about the type B and C lesions  Primary stent placement is not recommended in the femoral, popliteal or tibial arteries

29. Subintimal Angioplasty (SI-PTA) (A) The occlusion is approached away from a collateral (B) The catheter/guidewire is advanced through the subintimal space, enabling it to take the path of least resistance (C) The catheter is retracted back and the guidewire is manipulated into a wide loop (D) The loop is advanced forward until it re-enters the true lumen A schematic diagram to show the subintimal recanalization procedure Semin Vasc Surg1995;8:253-264

30. Endovascular procedure

32. Experience of SCHBC July, 2007 to May, 2009 16 patients (M : F = 14 : 2) not suitable for bypass surgery  Anesthesia, poor run off or more peripheral lesion Mean age : 65.2 (47 – 77) Lesions  Iliac : 6  Femoropopliteal : 7  Combine : 3 Stent insertion : 14

33. Experience of SCHBC ABI follow up (POD # 7)  Pre PTA (mean) : Post PTA = 0.44 : 0.94 Post PTA amputation of extremities  2 pts (2 nd toe Rt., BK amputation both) P =0.009

34. Conclusions EVAR is a effective and feasible procedure in patients at low surgical risk as well as at high risk In randomized studies, EVAR is superior to the open repair at short-term and midterm results In SCHBC experience, perioperative results in EVAR are more acceptable than them of open repair

35. Conclusions Endovascular procedure is an another option in treatment methods of patient with PAD Endovascular procedure, especially, is more effective and feasible in PAD patients with high surgical risk, poor run off and more peripheral lesions More research is needed to make sure of the effects of endovascular procedure for patients with PAD

36. Thank you for your attention!