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shown to be 6% at 4 years in the EVAR1 trial (vs 20% for EVAR) but the outcome of these was much worse, as implied by the 3% advantage in aneurysm-related mortality for the endovascular group. Further results from on-going trials and registries are expected to support the trend for less re-intervention and lower aneurysm-related mortality (and hence improved long-term results) for EVAR. [Q14: B]
3.2
Case Analysis Quiz
A number of pre and postoperative imaging examples are shown in pictures 8–12. Determine the favorable and unfavorable features shown regarding EVAR adequacy, planning and follow-up (Figs. 3.8–3.12).
Fig. 3.8 Aortic angiogram showing a very favorable anatomy for endovascular repair: the neck is straight and long, without irregular features of the wall. In addition, the aneurysm sac is straight, and both iliac arteries are non-aneurismal and relatively straight. Notice duplication of the renal arteries, a frequent finding. In long necks, coverage of a polar renal artery is unnecessary and may result in serious morbidity. Efforts should be made to identify the lowest renal artery and cover only below that
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Fig. 3.9 Axial CTA slice of the aneurysm neck. After center-lumen line reconstruction, it is clear that true diameter can differ significantly from that measured in the axial plane, due to vessel tortuosity. Sizing using a workstation is more precise and therefore advisable. Volume-rendering reconstructions are luminograms and thus do not reveal the true diameter of vessels. These should be used for appreciation of the anatomy but for not assessing true aneurysm size
Fig. 3.10 The iliac arteries show severe angulation. This feature is unfavorable for access of the deployment sheaths and is associated with a higher risk of distal type I endoleak. The wide patent lumen and patent IMA are also a risk factor for type II endoleaks, although its significance is not yet fully understood. These two features (iliac angulation and wide patent AAA lumen) will make cannulation of the contra-lateral limb more challenging. An alternative is to canulate in a reversed fashion from the main-body (cross-over technique) or from a brachial access and snare the guide wire
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Fig. 3.11 The aneurysm neck is severely angulated and short. These features have been recognized as risk factors for proximal type I endoleak and migration. Newer and more flexible stent-grafts adapt to adverse neck anatomy and seem to reduce this risk. Advances in planning and deployment precision allow treatment for short necks, as the entire possible length of seal is used
Fig. 3.12 Axial slice of a follow-up CTA – a fenestrated endograft with renal balloon-expandable stents is in situ. In fenestrations, stenting of branch vessels is advised in order to guarantee early patency and preserve flow over time. A small portion (3–4 mm) of the stents should protrude into the luminal side of the aorta, while a minimum of 15 mm should prolong onto the treated artery. Notice the flaring of the intra-aortic segment of the stents, creating a desired “rivet” configuration. This is achieved by partially dilating the stent with an oversized angioplasty balloon and subsequently adjusting the flare with a compliant aortic balloon
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References
1. Lederle FA, et al. The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. Arch Intern Med. 2000;160(10):1425-1430.
2. Ashton HA, Buxton MJ, Day NE, et al. Multicentre Aneurysm Screening Study Group. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomized controlled trial. Lancet. 2002 (Nov 16); 360(9345):1531-1539.
3. Melton LJ 3rd, Bickerstaff LK, Hollier LH, et al. Changing incidence of abdominal aortic aneurysms: a population-based study. Am J Epidemiol. 1984;120:379-386.
4. Diehm N, Kickuth R, Gahl B, et al. Intraobserver and interobserver variability of 64-row computed tomography abdominal aortic aneurysm neck measurements. J Vasc Surg. 2007 (Feb);45(2):263-268.
5. HigashiuraW,SakaguchiS,TabayashiN,TaniguchiS,KichikawaK.Impactof3-dimensional- computed tomography workstation for precise planning of endovascular aneurysm repair. Circ J. 2008 (Dec);72(12):2028-2034.
6. The UK. Small Aneurysm Trial Participants. Mortality results for randomized controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet. 1998;352(9141):1649-1655.
7. Lederle FA, Wilson SE, et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med. 2002;346(19):1437-1444.
8. Schermerhorn ML, Cronenwett JL. Natural history and decision making for abdominal aortic aneurysms. In: Zelenock GB, ed. Mastery of Vascular and Endovascular Surgery. 1st ed. Philadelphia: Lippincott Williams & Wilkins; 2006:71-78.
9. Cao P, CAESAR Trial Collaborators. Comparison of surveillance vs Aortic Endografting for Small Aneurysm Repair (CAESAR) trial: study design and progress. Eur J Vasc Endovasc
Surg. 2005 (Sept);30(3):245-251.
10.Ouriel K. The PIVOTAL study: a randomized comparison of endovascular repair versus surveillance in patients with smaller abdominal aortic aneurysms. J Vasc Surg. 2009 (Jan);49(1):266-269.
11.Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg. 1999 (Sep);230(3):289-296.
12.Abedi NN, Davenport DL, Xenos E, Sorial E, Minion DJ, Endean ED. Gender and 30-day outcome in patients undergoing endovascular aneurysm repair (EVAR): an analysis using the ACS NSQIP dataset. J Vasc Surg. 2009 (Sep);50(3):486-491. 491.e1-4.
13.Egorova N, Giacovelli JK, Gelijns A, et al. Defining high-risk patients for endovascular aneurysm repair. J Vasc Surg. 2009 (Dec);50(6):1271-1279. e1.
14.Greenhalgh RM, Brown LL, Kwong GP, Powell JJ, THompson SG. Comparison of endovascular repair with open repair in patients with AAA (EVAR trial 1) 30 day operative mortality results: randomised controlled trial. Lancet. 2004;364:843-848.
15.Prinssen M, Verhoeven ELG, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004;351:1607-1618.
16.Lederle FA, Freischlag JA, Kyriakides TC, et al.; Open Versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009 (Oct) 14;302(14):1535-1542.
17.Abbruzzese TA, Kwolek CJ, Brewster DC, et al. Outcomes following endovascular abdominal aortic aneurysm repair (EVAR): an anatomic and device-specific analysis. J Vasc Surg. 2008 (July);48(1):19-28.
42 |
F.M.V.B. Gonçalves et al. |
|
|
18.vanPrehnJ,SchlosserFJ,VerhagenHJM,et al.Oversizingofaorticstentgraftsforabdominal aneurysm repair: a systematic review of the benefits and risks. Eur J Vasc Endovasc Surg. 2009;38(1):42-53.
19.Sampaio SM, Panneton JM, et al. Aortic neck dilation after endovascular abdominal aortic aneurysm repair: should oversizing be blamed? Ann Vasc Surg. 2006;20(3):338-345.
20.Black SA, Wolfe JH, Clark M, Hamady M, Cheshire NJ, Jenkins MP. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. J Vasc Surg. 2006 (Jun);43(6):1081-1089.
21.Biasi L, Ali T, Loosemore T, Morgan R, Loftus I, Thompson M. Hybrid repair of complex thoracoabdominal aortic aneurysms using applied endovascular strategies combined with visceral and renal revascularization. J Thorac Cardiovasc Surg. 2009 (Dec);138(6):1331-1338.
22.Greenberg RK, Sternbergh WC, Makaroun M, et al. Fenestrated Investigators. Intermediate results of a United States multicenter trial of fenestrated endograft repair for juxtarenal abdominal aortic aneurysms. J Vasc Surg. 2009 (Oct);50(4):730-737. e1.
23.Verhoeven EL, Vourliotakis G, Bos WT, Tielliu IF, Zeebregts CJ, Prins TR, Bracale UM, van den Dungen JJ. Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: an 8-year single-centre experience. Eur J Vasc Endovasc Surg. 2010 (Mar 2) [Epub ahead of print].
24.Hobo R, Sybrandy JE, et al. Endovascular repair of abdominal aortic aneurysms with concomitant common iliac artery aneurysm: outcome analysis of the EUROSTAR experience. J Endovasc Ther. 2008;15(1):12-22.
25.ChaerRA,etal.Duplexultrasoundasthesolelong-termsurveillancemethodpost-endovascular aneurysm repair: a safe alternative for stable aneurysms. J Vasc Surg. 2009;49(4):845-849.
26.Beeman BR, et al. Duplex ultrasound imaging alone is sufficient for midterm endovascular aneurysm repair surveillance: a cost analysis study and prospective comparison with computed tomography scan. J Vasc Surg. 2009;50(5):1019-1024.
27.Badri H, et al. Duplex ultrasound scanning (DUS) versus computed tomography angiography (CTA) in the follow-up after EVAR. Angiology. 2010;61(2):131-136.
28.Hobo R, Buth J. Secondary interventions following endovascular abdominal aortic aneurysm repair using current endografts. A EUROSTAR report. J Vasc Surg. 2006;43(5):896-902.
29.Nordon I, Karthikesalingam A, Hinchliffe R, Holt P, Loftus I, Thompson M. Secondary interventions following endovascular aneurysm repair (EVAR) and the enduring value of graft surveillance. Eur J Vasc Endovasc Surg. 2009 (Nov 23) [Epub ahead of print].