Endovascular repair of traumatic aortic transection six years of experience

ENDOVASCULAR REPAIR OF ENDOVASCULAR REPAIR OF RUPTURED ABDOMINAL RUPTURED ABDOMINAL

AORTIC ANEURYSMSAORTIC ANEURYSMS

G. TrellopoulosClinic of Cardiovascular Surgery

General Hospital “G. Papanikolaou”, Thessaloniki

3ο VASCULAR SYMPOSIUM

ADVANCES & CONTROVERSIES IN VASCULAR DISEASES

University of Thessaly

23-25 MAY 2008

Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysmsBackgroundBackground

OOpen pen RRepairepair for rAAA for rAAA representsrepresents::

High MortalityHigh Mortality 48.4%(25.4 –69.3)*48.4%(25.4 –69.3)*

High MorbidityHigh Morbidity 30-50%30-50%

*Bown MJ, Sutton AJ: Br J Surg 2002; 89:714-30. *Bown MJ, Sutton AJ: Br J Surg 2002; 89:714-30.


ENDOVASCULAR REPAIRENDOVASCULAR REPAIR

Avoidance of general anesthesiaAvoidance of general anesthesiaAvoidance of aortic clamping and de-clampingAvoidance of aortic clamping and de-clampingLess blood lossLess blood loss

Potential less Mortality and MorbidityPotential less Mortality and Morbidity


The first reported e-EVAR...The first reported e-EVAR...

Lancet 344:1645, 1994

Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysms Studies and trialsStudies and trials

Since 2006, 28 studies were published. A total of 857 patients with ruptured AAA repaired with EVAR

Treatment of ruptured aortic aneurysms Treatment of ruptured aortic aneurysms Studies and trialsStudies and trials

Systematic Review

EVAREVAR(n=148)(n=148)

OROR(n=330)(n=330)

30 day 30 day mortalitymortality

22%22% 38%38%

Systemic Systemic complicationscomplications

28%28% 56%56%

10 non RCT

Visser et al, Radiology,2007

E-EVARE-EVAR OROR

Early Early MortalityMortality

18%18% 34%34%

E-EVAR E-EVAR suitabilitysuitability

67% (34-67% (34-100)100)

NaNa

Harkin et al, EJVES, 2007

33 non-RCT + 1 RCT (876 pts)

Between EVAR & OR :Heterogeneity was found in patients's hemodynamic condition at their presence at the hospital

Treatment of ruptured aortic aneurysmsLiterature Review

Randomized trials

Hinchliffe et al EJVES, 2006

E-EVARE-EVARn=15n=15

OR OR n=17n=17

P valueP value

30-day 30-day mortalitymortality

53%53% 53%53% NSNS

MorbidityMorbidity 77%77% 80%80% NSNS

Treatment of ruptured aortic aneurysmsAn international multicenter study

EVAREVAR OROR

MortalityMortality 35%35% 39%39%

CT CT examinationexamination

87%87% 87%87%

Unstable Unstable patientpatient

43%43%

Time admision Time admision to operationto operation

90 min90 min 60min60min

Suitability for EVAR 52%

Hemodynamic instability precluded EVAR in 14%

The principal reason to preclude EVAR was an adverse configuration of the neck

Peppelenboch N et al, J Vasc Surg 2006

Critical issues for successful EVAR

1.1. Clinical condition of patient (criteria)Clinical condition of patient (criteria)

2. 2. CT imaging (anatomic criteria)CT imaging (anatomic criteria)

3. 3. Type of anesthesiaType of anesthesia

4. 4. Stent graft configurationStent graft configuration

5. 5. Use of intraaortic occlusion balloonUse of intraaortic occlusion balloon

Critical issue ICritical issue I

Presentation of patient with ruptured AAAPresentation of patient with ruptured AAA

Which method is selected:Which method is selected:

Criteria and requirements Criteria and requirements

EVAR? EVAR? OR?OR?

Critical issue ICritical issue IClinical and anatomic criteriaClinical and anatomic criteria

Clinical criteriaClinical criteriaStable patient >100mmHgStable patient >100mmHg

Moderate instability Moderate instability >60mmHg without episode >60mmHg without episode of cardiac arestof cardiac arest

Severe instability <60mmHg Severe instability <60mmHg with episode of loss of with episode of loss of consciousnessconsciousness

Anatomic criteriaAnatomic criteria

Infrarenal neck: length > 10mmInfrarenal neck: length > 10mm diameter < 32mmdiameter < 32mm angulation < 85angulation < 8500

External iliac: diameter > 7mm External iliac: diameter > 7mm

Peppelenboch N et al, J Vasc Surg 2006; 43:1111-1122

A French group believes that the limit is A French group believes that the limit is 80mmHg80mmHg for cardiac, splahnic, renal and brain for cardiac, splahnic, renal and brain perfusion perfusion Alsac JM et al, Acta Chir Belg 2005

The Monefiore group prefer even lower limit The Monefiore group prefer even lower limit at at 50mmHg50mmHg to gain to gain “hypotensive “hypotensive hemostasis”hemostasis” Veith FJ et al, JCardiovasc Surg 2002

Critical issue ICritical issue I

Requirements: Requirements:

appropriate training of medical and appropriate training of medical and paramedical personnel, available in out-of paramedical personnel, available in out-of hours callhours call

availability of wide range of endograftsavailability of wide range of endografts

Our experience: EVAR is preferred when blood pressure is > 80mmHg without loss of consciousness

Diameter of proximal neck: 29mmAngulation of proximal neck: 400

Length of proximal neck: 8mmDiameter of aneurysm: 7cmDiameter of EIA: 11.5mm

Critical issue II – Anatomic criteriaCritical issue II – Anatomic criteria

Talent 34 x16x 155



Length of proximal neck: 20mmDiameter of aneurysm: 9.9cmDiameter of EIA: 10mm

Talent 30x16x155


Diameter of proximal neck: 22mm

Angulation of proximal neck: 900

Length of proximal neck: 12mm

Diameter of aneurysm: 11cm

Diameter of EIA: 9mm

Excluder 26x14x160



Length of proximal neck: 12mmDiameter of aneurysm: 11,3cmDiameter of EIA: 5mm

Critical issue IIICritical issue IIIType of anesthesiaType of anesthesia

One third of patients that are reported in the One third of patients that are reported in the literature have been operated under local literature have been operated under local anesthesiaanesthesia

26% started as local and were converted to 26% started as local and were converted to general anesthesia general anesthesia

Our experience: 62,5% of patients have been operated under local anesthesia

Branchereau A et al, “Endovascular Aortic Repair: The state of the art”

Critical issue IVTreatment of ruptured aortic aneurysms BF vs AUI

Anatomical and Technical requirements

1. Two healthy iliac access

2. More measurements

3. Contralateral cannulation

4. Bigger stock

5. Local anesthesia

1. One healthy iliac access

2. Less measurements

3. Fem-Fem bypass

4. Smaller Stock

5. General anesthesia

Critical issue IVCritical issue IVStent graft configurationStent graft configuration

Decision depends on:Decision depends on:1.1. ExpertiseExpertise2.2. AvailabilityAvailability3.3. Anatomic characteristicsAnatomic characteristics

Bifurcated

45%

Aortouniiliac

52%

Our experience: 9/16 (56%): Bifurcated

3/16 (19%): Aortouniiliac

4/16: Other (2 proximal cuff, 1 iliac extender,

1 thoracic)

Branchereau A et al, “Endovascular Aortic Repair: The state of the art”

Critical issue VCritical issue VUse of intraaortic occlusion balloonUse of intraaortic occlusion balloon

10 centers 10 centers in hemodynamically in hemodynamically unstable patientsunstable patients

7 centers 7 centers never used a balloon never used a balloon

1 center 1 center always a balloon is used always a balloon is usedBranchereau A et al, “Endovascular Aortic Repair: The state of the art”

From 18 studies in 18 centers:From 18 studies in 18 centers:

Via branchial artery (Montefiory group)

Via femoral artery (Malmo group, Zurich group)

17% of 369 patients required balloon occlusion

Our experience: in 2/16 (12.5%) cases an occlusion balloon was used

30 day mortality30 day mortalityVeith et al reported a 30-day mortality in 18% (48 centers on

442 RAAAs)

Meta-analysis:1. Harkin et al reported 18% mortality2. Visser et al reported 22% mortality

Randomized trials:Hinchliffe et al: 52% (EJVES, 2006)

International multicenter study:

Peppelenboch N et al: 35% (J Vasc Surg 2006)

Our experience: 37.5% in-hospital mortality (6/16)

30 day mortality30 day mortalityExplanations for different results:Explanations for different results:1. The different percentage of suitability of EVAR in 1. The different percentage of suitability of EVAR in

diverse centersdiverse centersGreco G et al, J Vasc Surg 2006: Greco G et al, J Vasc Surg 2006: 6% 6% patients with RAAA were repaired patients with RAAA were repaired

EVARlyEVARly

Peppelenboch N et al, J Vasc Surg 2006: 52% patients with RAAA were repaired EVARly

Dalainas et al, Word J Surg 2006: 93% patients with RAAA were repaired EVARly

2. Operator’s experience

Greco G et al, J Vasc Surg 2006:Greco G et al, J Vasc Surg 2006:

centers with >25 cases / year, for 4 years (elective and nonelective)

mortality: 26%

centers with <25 cases / year

mortality: 46%

Follow-upFollow-upArya N et al, J Endovasc Ther 2004: Arya N et al, J Endovasc Ther 2004: 73%73% of patients demonstrated of patients demonstrated

significantly decreased (>5mm) diameter of aneurysm compared significantly decreased (>5mm) diameter of aneurysm compared with 43% elective serieswith 43% elective series

Hechelhammer L et al, J Vasc Surg 2005: The risk of secondary Hechelhammer L et al, J Vasc Surg 2005: The risk of secondary interventions in 2 years isinterventions in 2 years is 35%.35%. Late conversionLate conversion 9%9%

Visser JJ et al, J Vasc Surg 2006: Mortality and complications was Visser JJ et al, J Vasc Surg 2006: Mortality and complications was similar in patients similar in patients after endovascular repair compared with those after endovascular repair compared with those after open surgery after open surgery

Our experience: in meanly 2-years follow-up 2/10 survivors presented with proximal migration. The one was treated endovascularly and the other with open surgery. One patient died due to myocardiac infraction.

Preoperative: 25mm 1 year: 28mm 4 years: 28mm

Preoperative: 9,9cm 1 year: 6,8cm 4 years: 6,5cm

Preoperative: 25mm After 6 months: 27mm 2 years: 27mm

Preoperative: 9cm After 6 months: 7.5mm 2 years: 7.5cm

Preoperative: 28mm 1 year: 28mm 2 years: 28mm

Preoperative: 8cm 1 year: 6,1cm 2 years: 5cm

Conclusions1.1. EVAR for RAAA is feasible in selected patients EVAR for RAAA is feasible in selected patients

in institution with experiencein institution with experience2.2. The mortality after EVAR for RAAA is The mortality after EVAR for RAAA is

influenced from operator’s experience and the influenced from operator’s experience and the “suitability of patients” in different centers“suitability of patients” in different centers

3.3. The risk of reintervention after EVAR is high The risk of reintervention after EVAR is high and strict follow-up is necessary and strict follow-up is necessary

4.4. Long term data are needed to assist if EVAR is Long term data are needed to assist if EVAR is durable treatment in relation to Endoleak and durable treatment in relation to Endoleak and ruptured risk.ruptured risk.

5.5. The debate for the future would be not which The debate for the future would be not which technique is superior, but to define exactly the technique is superior, but to define exactly the role of endovascular repair as an additional role of endovascular repair as an additional therapeutic option for RAAAs.therapeutic option for RAAAs.

EFKARISTO!

Endovascular repair of traumatic aortic transection six years of experience

Healthcare

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