abdominal aortic aneurysm
DESCRIPTION
TRANSCRIPT
Sean Tierney,
Consultant Vascular Surgeon
Adelaide & Meath National Children’s Hospital,
Tallaght
http://www.perfuse.netVascular surgery @ Tallaght
The problemThe problem
• Population survey (n=7887)
• Chichester, UK• Aneurysm >3cmScott et al. Br J Surg 1995
Age Men Women65 5.9 0
66-70 5.9 171-75 9 1.876-80 9.2 1.6
Total (>65y) 7.6 1.3
% prevalence
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PrevalencePrevalence
Prevalence • all 65-80 yo = 4%1
• elderly males = 5-9%2
• only 40% reach criteria for surgery
Mortality• Males = 1.4% of all death >55 years• Females = 0.5% >55 yearsNetherlands 19903
1 Scott BJS 1991
2 Hak EJVES 1996
3 Pleumeekers EJVS 1994
http://www.perfuse.netVascular surgery @ Tallaght
PrognosisPrognosis
Szilagyi 1966
0
10
20
30
40
50
60
70
<6cm >6cm
Aneurysm size
Surgery
Observation
% 5 year survival
http://www.perfuse.netVascular surgery @ Tallaght
Law of Laplace (sphere) P =2T/R
0
20
40
60
80
<5cm 5.0-5.9cm >6.0-6.0cm >7.0cm
5 year risk of rupture
Aneurysm size
RisksRisks
http://www.perfuse.netVascular surgery @ Tallaght
Presentation - rupturePresentation - rupture
Blood loss
Blood Pressure
Minutes…
http://www.perfuse.netVascular surgery @ Tallaght
Presentation - rupturePresentation - rupture
Blood loss
Blood Pressure
Hours
Retroperitoneal irritation Collapse
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Rupture - outcomeRupture - outcome
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Other presentationsOther presentations
incidental
symptomatic
embolisation
http://www.perfuse.netVascular surgery @ Tallaght
Conventional repairConventional repair
http://www.perfuse.netVascular surgery @ Tallaght
Conventional repairConventional repair
http://www.perfuse.netVascular surgery @ Tallaght
Conventional repairConventional repair
http://www.perfuse.netVascular surgery @ Tallaght
Aortic Aneurysm repairAortic Aneurysm repair
• DuBost – first homograft repair 1951
• Modern graft materials 1953
Postoperative• 5 year survival = 63-84% disease matched control
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Problem solved?Problem solved?
%Mortality 4.9Cardiac 0.0
MI 5.3LVF 6.2
Renal 5.7Respiratory 6.9Others 4.0
Rutherford Vascular Surgery 1995
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New technologyNew technology
Parodi et al Ann Vasc 1991
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EVAREVAR
http://www.perfuse.netVascular surgery @ Tallaght
ProblemsProblems
• Implantation– microembolism– blood loss– endoleak
• Device related– kinking– migration– stent fracture– graft failure/porosity
• Endoleak
http://www.perfuse.netVascular surgery @ Tallaght
EVAR - 1 EVAR - 1 OutcomesOutcomes
****
Lancet 2004; 364: 843–48
http://www.perfuse.netVascular surgery @ Tallaght
EVAR - 1 EVAR - 1 OutcomesOutcomes
Lancet 2004; 364: 843–48
http://www.perfuse.netVascular surgery @ Tallaght
DurabilityDurability
0
20
40
60
80
100
0 1 2 3 4 5
Years
Fre
edo
m f
rom
rei
nte
rven
tio
n
Eurostar BJS 2000
Cumulative reintervention rate > 10% per year
http://www.perfuse.netVascular surgery @ Tallaght
EVAR - 2 EVAR - 2 OutcomesOutcomes
Lancet 2005; 365: 2187–92
http://www.perfuse.netVascular surgery @ Tallaght
Technical limitations (EVAR)Technical limitations (EVAR)
• Neck– length– diameter– thrombus– angulation
• Iliac artery– size– tortuosity– aneurysms (esp bilateral)
At least 1/3 (33%) anatomically unsuitable
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Place for EVARPlace for EVAR
IndicationsIndications• still unresolved issues• anatomical suitability• older vs younger• ? high risk patient• significant costs
• Complement rather than replaces open surgery
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ScreeningScreening
Screened ControlTotalUptake 80%AAA 5%>5.5cm 0.60%
AAA mortality 3.3/1000 1.9/1000OR
33400
0.58 (0.42-0.78)* *p<0.001
Screened ControlTotalUptake 80%AAA 5%>5.5cm 0.60%
AAA mortality 3.3/1000 1.9/1000OR
33400
0.58 (0.42-0.78)* *p<0.001
Lancet 2002; 360: 1531–39
http://www.perfuse.netVascular surgery @ Tallaght
Cost effectiveCost effective
• Cost of screening £63 per patient
• Cost-effectiveness ratio:– £28,400 per life year gained (4
years)– c£8,000 (10 years).
Lancet 2002; 360: 1531–39