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Less Invasive Interventional treatment can be recommended as 1 st line treatment for “Silent Killer”, AAA

SIR 2009. Less Invasive Interventional treatment can be recommended as 1 st line treatment for “Silent Killer”, AAA. Guy’s & St. Thomas’ Hospital, London, UK TARUN SABHARWAL MD FSIR FCIRSE

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Less Invasive Interventional treatment can be recommended as 1 st line treatment for “Silent Killer”, AAA

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  1. SIR 2009 Less Invasive Interventional treatment can be recommended as 1st line treatment for “Silent Killer”, AAA Guy’s & St. Thomas’ Hospital, London, UK TARUN SABHARWAL MD FSIR FCIRSE K Konstantinos, S.Black, S.Thomas, R.Salter, J.Reidy, C.Sandhu, R.Bell, M.Waltham, T.Carrel, P.Taylor

  2. Abdominal Aortic Aneurysm • Weakened area in the aorta • Natural history of AAA is of slow expansion and rupture with catastrophic consequence

  3. Role of IR in AAA • The goal is to prevent aneurysms from rupturing

  4. AAA Silent Killer • AAA occurs in 5-7% population older than 60yrs • Affects 2.7m Americans and is the 13th death • Risk factors : age, smoking, male sex and family history • Asymptomatic in majority • Back pain, abdominal pain

  5. Rupture • Manifest with unheralded rupture and death • Prognosis after rupture is grim with community based mortality as high as 79% • 59-83% AAA die before reaching hospital • Operative mortality rates are 40% • Leaving at best 10-25% discharge

  6. EVAR compared with Open Repair • Mortality rate for elective surgical repair of nonruptured AAAs is 5% • EVAR is associated with periprocedural mortality benefit compared with open repair (relative risk reduction 3.1) • ↓ periprocedural complications • Benefit of reduced aneurysm related mortality at 4yrs (4% vrs 7%) DREAM and EVAR 1 trials

  7. EVAR offers a less invasive alternative to conventional open repair

  8. Benefits of EVAR over Open repair in rAAA • Local anesthesia • Maintenance of abdominal wall and muscle tone • Decreased aortic occlusion time • Diminished blood loss • Better thermoregulation

  9. Common perceptions of EVAR • High late complication rate • High rate of secondary interventions • Long term surveillance required: more expensive and risk of radiation cancers

  10. Secondary Intervention rates Endoluminal repair • RETA (Thomas EJVES 2005 n=1823) 38% at 5 y • EUROSTAR (Laheij BJS 2000 n=1023) 38% at 4y • EVAR 1 (Lancet 2005 n=543 EVAR) 20% at 4 y • EVAR 2 (Lancet 2005 n=166 EVAR) 26% at 4 y • Greenberg (JVS 2008 n=739) 20% at 5 y • Sampram (JVS 2002 n=703) 35% at 3 y EVAR 1 Open repair cohort: 6% at 4 y

  11. Aim of our Study • Analyze the treatment of patients with AAA with EVAR • Assess rate of secondary interventions • Assess need for intense CT surveillance

  12. Method • Prospective database • 453 patients • 2000 – 2008 • Male/female = 11/1 • Follow up 30 months (2-90) • Age 76 (40 – 93) • Aneurysm diameter 6.1 (5.3 – 11) • Elective 406 (89.8%) • Urgent 17 (3.6%) • Emergency 30 (6.6%)

  13. Results • 30-day mortality: 15/453 (3.3%) • Technical Success: 451/453 (99.6%) • Open conversion: 1 urgent : 1 emergent • Secondary Interventions: 33/453 (7.2%) of which 6/453 (1.3%) from surveillance

  14. Conclusion • Low secondary intervention rate for EVAR • Secondary interventions are effective • Surveillance with intensive CT scanning identifies few complications • Questionable benefit of intensive CT surveillance protocols • Suggested current protocol: 3/12 CT and yearly duplex thereafter

  15. Conclusions •  durability and effectiveness of EVAR • EVAR ↓ risks of surgery, amount of pain, large incisions, hospital stay and much shorter recovery time

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