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EndoVascular Aortic Aneurysm Repair (EVAR)

EndoVascular Aortic Aneurysm Repair (EVAR). Dr. Thomas Lam PYNEH. Definition of an Aneurysm. Focal arterial dilatation based upon absolute measurements of diameter A localized dilatation of an artery with an increase in diameter of 50% or more than that of the non-dilated adjacent vessel

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EndoVascular Aortic Aneurysm Repair (EVAR)

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  1. EndoVascular Aortic Aneurysm Repair (EVAR) Dr. Thomas Lam PYNEH

  2. Definition of an Aneurysm • Focal arterial dilatation based upon absolute measurements of diameter • A localized dilatation of an artery with an increase in diameter of 50% or more than that of the non-dilated adjacent vessel Johnston KW, Rutherford RB, Tilson MD et al. Suggested standards for reporting on arterial aneurysm. Subcommittee on reporting standards for arterial aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 1991;13:452-8

  3. Abdominal Aortic Aneurysm (AAA) • Most common is the infra-renal aorta • ~75% are found incidentally and are asymptomatic • Natural history • expansion at a rate of ~0.5cm a year and eventually rupture • Rupture of these aneurysms had mortality rate of 80% Norwood MG. Lloyd GM. Bown MJ. Fishwick G. London NJ. Sayers RD. Endovascular abdominal aortic aneurysm repair. Postgraduate Medical Journal. 83(975):21-7, 2007 Jan.

  4. Laplace’s Law

  5. Epidemiology • The annual incidence of AAA in Hong Kong • 13.7 per 100,000 population • 105 per 100,000 for those aged 65 and above. • mean age 74 years of age • 84% of them age> 65. • ~10% of the AAAs that presented were ruptured • The operative repair rate for AAAs • 8% for intact aneurysms • 54% for ruptured ones • Overall, 45% of all aneurysm repairs were performed for a ruptured AAA. Cheng SW, Ting AC, Tsang SH. Epidemiology and outcome of aortic aneurysms in Hong Kong. World J Surg. 2003 Feb;27(2):241-5

  6. What is our treatment strategy ?

  7. The UK small aneurysm trial The U.K. Small Aneurysm Trial: design, methods and progress. The UK Small Aneurysm Trial participants. European Journal of Vascular & Endovascular Surgery. 9(1):42-8, 1995 Jan. Powell JT. Brown LC. Forbes JF. Fowkes FG. Greenhalgh RM. Ruckley CV. Thompson SG. Final 12-year follow-up of surgery versus surveillance in the UK Small Aneurysm Trial. British Journal of Surgery. 94(6):702-8, 2007 Jun.

  8. The UK small aneurysm trial

  9. Elective AAA repair • The operative technique of open AAA repair was first described by Dubost in 1951 C Dubost, M Allary and N Oeconomos, Treatment of aortic aneurysms; removal of the aneurysm; re-establishment of continuity by grafts of preserved human aorta. Mem Acad Chir (Paris) 77 (1951), pp. 381–383. • Elective open AAA repair is a complex procedure with a 30 day mortality of ~5% and a major complication rate of 15-30% Ernst CB. Abdominal aortic aneurysm. N Engl J Med 1993;328:1167–72. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm. Part II. Variables predicting morbidity and mortality. J Vasc Surg 1989;9:437–47. • The major risks during open elective repair are perioperative cardiac events, but respiratory and renal failure are also common Blankensteijn JD, Lindenburg FP, Van der Graaf Y, et al. Influence of study design on reported mortality and morbidity rates after abdominal aortic aneurysm repair. Br J Surg 1998;85:1624–30.

  10. Is there any less invasive means of treatment ?

  11. Endovascular aortic aneurysm repair (EVAR)

  12. EVAR • EVAR was first described in humans by Parodi et al in 1991 Parodi JC. Palmaz JC. Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Annals of Vascular Surgery. 5(6):491-9, 1991 Nov.

  13. The UK Registry for Endovascular Treatment of Aneurysms (RETA) was started in 1996 the European EUROSTAR was initiative in 1999 These sources have suggested that the initial operative mortality of EVAR was comparable to that of open AAA repair but has consistently fallen and may now be as low as 1% Harris PL, Buth J, Mialhe C, et al. The need for clinical trials of endovascular abdominal aortic aneurysm stent-graft repair: the EUROSTAR Project. EUROpean collaborators on Stent-graft Techniques for abdominal aortic Aneurysm Repair. J Endovasc Surg 1997;4:72–7. Harris PL, Vallabhaneni SR, Desgranges P, et al. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. European Collaborators on Stent/graft techniques for aortic aneurysm repair. J Vasc Surg 2000;32:739–49.

  14. EndoVascular Aneurysm Repair EVAR trial 1 Brown LC. Epstein D. Manca A. Beard JD. Powell JT. Greenhalgh RM. The UK Endovascular Aneurysm Repair (EVAR) trials: design, methodology and progress. European Journal of Vascular & Endovascular Surgery. 27(4):372-81, 2004 Apr R M Greenhalgh, L C Brown, G P S Kwong, J T Powell, S G Thompson. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. The Lancet:Sep4-Sep10,2004;364,9437;843-8 R M Greenhalgh, L C Brown, D Epstein, G P S Kwong et al. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trail 1): randomised controlled trial. The Lancet:Jun25-Jul1,2005;365,9478;2179-2186

  15. Dutch Randomised Endovascular Aneurysm Management (DREAM) trial Prinssen M. Buskens E. Blankensteijn JD. The Dutch Randomised Endovascular Aneurysm Management (DREAM) trial. Background, design and methods. Journal of Cardiovascular Surgery. 43(3):379-84, 2002 Jun Prinssen M. Verhoeven EL. Buth J. Cuypers PW. van Sambeek MR. Balm R. Buskens E. Grobbee DE. Blankensteijn JD. Dutch Randomized Endovascular Aneurysm Management (DREAM)Trial Group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. New England Journal of Medicine. 351(16):1607-18, 2004 Oct 14 Blankensteijn JD. de Jong SE. Prinssen M. van der Ham AC. Buth J. van Sterkenburg SM. Verhagen HJ. Buskens E. Grobbee DE. Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. New England Journal of Medicine. 352(23):2398-405, 2005 Jun 9

  16. Is endovascular repair superior to open repair ?

  17. EVAR 1 trial

  18. DREAM trial

  19. Ongoing trials • the United States Open versus Endovascular Repair (OVER) Trial for Abdominal Aortic Aneurysms • the French Anévrisme de l’aorte abdominale: Chirurgie versus Endoprothèse (ACE) trial

  20. What is the usefulness of EVAR in medically unfit patient ?

  21. EndoVascular Aneurysm Repair EVAR trial 2 EVAR trial participants. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2): randomised controlled trial. The Lancet. 365(9478):2187-92, 2005 Jun 25-Jul 1

  22. EVAR trial 2

  23. Graft-specific problems • Endoleak • Graft migration • Continued surveillance • Reintervention • Cost Wain RA, Marin ML, Ohki T, et al. Endoleaks after endovascular graft treatment of aortic aneurysms: classification, risk factors, and outcome. J Vasc Surg 1998;27:69–78. White GH, Yu W, May J, et al. Endoleak as a complication of endoluminal grafting of abdominal aortic aneurysms: classification, incidence, diagnosis, and management. J Endovasc Surg 1997;4:152–68.

  24. EVAR in ruptured AAA • The first report was in 1994 that ruptured AAA can be successfully treated with EVAR Yusuf SW, Whitaker SC, Chuter TA, et al. Emergency endovascular repair of leaking aneurysm. Lancet 1994;344:1645. • Reports showed encouraging results Ohki T, Veith FJ, Sanchez LA, et al. Endovascular grafts and other image-guided catheter-based adjuncts to improve the treatment of ruptured aortoiliac aneurysms. Ann Surg 2000;232:466–79. Lee WA, Hirneise CM, Tayyarah M, et al. Impact of endovascular repair on early outcomes of ruptured abdominal aortic aneurysms. J Vasc Surg 2004;40:211–15.

  25. Conclusion • EVAR is a new AAA repair approach • no need for laparotomy • less post-operative pain • shorter hospital stay • EVAR is associated with lower operative mortality • EVAR got similar mid-term all-cause mortality and quality of life • EVAR showed no survival benefit compared with no intervention in medically unfit patient • EVAR is associated with higher reintervention rate, graft-specific problem and unknown long-term outcomes

  26. Albert Einstein (1879 – 1955)

  27. Thank you

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