In most cases EVAR substituted conventional repair for ruptured

AAA

Why?

Antalya, 27/30-10-2011

Medical School Twente

EVAR team Medisch Spectrum TwenteEnschede, the Netherlands

Why think of EVAR?• Gut feeling: great difference rEVAR vs

open*

• Reduced peri-operative mortality in elective AAA repair- EVAR 1: EVAR 1.7% vs open 4.7%

- EVAR 2: 9% for unfit patients

• Less blood loss

• Less use of ICU

• Shorter length of hospital stay

• Less major morbidity

• Shorter recovery timeAntalya, 27/30-10-2011

Medical School Twente

Influence of EVAR on (r)AAA outcome

05

101520253035

In hospital mortality per vascular area per year(R)AAAaortic-iliac oblitfem-distal oblitcerebrovasc oblit

%

6194 arterial interventions MST 1997-2007

Medical School Twente

Antalya, 27/30-10-2011

Why think of EVAR?• Gut feeling: great difference rEVAR vs

open

• Reduced peri-operative mortality in elective AAA repair- EVAR 1: EVAR 1.7% vs open 4.7%

- EVAR 2: 9% for unfit patients

• Less blood loss

• Less use of ICU

• Shorter length of hospital stay

• Less major morbidity

• Shorter recovery timeAntalya, 27/30-10-2011

Medical School Twente

Advantages of rEVAR• Less invasive

- No laparotomy required- No retroperitoneal dissection- Local anaesthesia• Intact vascular resistance and muscular tone

abdominal wall- Reduced blood loss- Less hemodynamic disturbance

– No aortic cross clamping required• Less ischemia and reperfusion of lower body and

visceral organs- Reduced inflammatory response, cytokines →

MOFAntalya, 27/30-10-2011

Medical School Twente

Advantages of rEVAR

• Less effect on- Cardial function- Respiratory function- Renal function

• Fewer systemic complications

• Faster recovery

Antalya, 27/30-10-2011

Medical School Twente

Ruptured AAA: Evidence

• > 400 papers mentioning rEVAR– Open vs rEVAR minimum of 5 patients in

each group • 17 single center studies• 1 multicentre study• 1 single center RCT• 2 database analysis

Antalya, 27/30-10-2011

Medical School Twente

Ruptured AAA: Evidence• Analysis

– Heterogenicity of studies– Lack of standardized reporting– Small numbers– Small percentage treated with rEVAR (15-50%)– Devices: AUI vs Bifurcation vs Tube– Percentage unstable patients rEVAR 33-73% vs

open 35-68%• Definition of “unstable” varied

– Local anaesthesia 0-97%

• Mean short term mortality 25% rEVAR vs 42% open

Antalya, 27/30-10-2011

Medical School Twente

Ruptured AAA: Evidence

• Cochrane review 2008– No RCT – Heterogenicity studies– Reduction mortality rate, ICU stay and

blood loss encouraging

Antalya, 27/30-10-2011

Medical School Twente

Ruptured AAA: MST experience

• No treatment• Open procedure (MST 30% 30-day

mortality)• rEVAR?

Antalya, 27/30-10-2011

Medical School Twente

Ruptured AAArEVAR• Aortic Unilateral device

+Straight forward procedure+Small stockage– Fem-fem needed– On long term proximal migration and

type 1 endoleak• Bifurcated devices

– Enormeous stockage on the shelves needed

– Contralateral access unpredictable

Antalya, 27/30-10-2011

Medical School Twente

ANACONDA Contralateral access facilitated by

magnet system Body repositionable Device also applicable in complex

anatomy

Ruptured AAATAAR (TransAbdominal Aneurysm

Repair)• Mortality and morbidity high and

unchanged last decades (40-90%)

EVAR• Aortic Unilateral device

– Straight forward procedure– Small stockage– Fem-fem needed– On long term angulation, proximal

migration and type 1 endoleak are not negligible

• Bifurcated devices – Enormeous stockage on the shelves

needed – Contralateral access unpredictable

Antalya, 27/30-10-2011

Medical School Twente

Ruptured Aortic Aneurysm Study with the Anaconda

• Feasibility study• Single center• Prospective• Intension to treat• From April 2006 until April

2010• Consecutive patients

Antalya, 27/30-10-2011

Medical School Twente

Ruptured AAA MST

9%

61%

3%1%

24%

162 ruptured infrarenal aneurysms31 not treated89 open procedures4 Talent AUI4 Endurant (1 AUI)34 Anaconda

Antalya, 27/30-10-2011

Medical School Twente

RASA (N= 34)

Patient characteristicsGender

MaleFemale

304

AgeMean (range) 73 (58-87) years

Follow upMean (range) 25 (7-55) months

Lost to follow up 0

Antalya, 27/30-10-2011

Medical School Twente

RASA (N= 34)

Highlights anatomy

Antalya, 27/30-10-2011

Medical School Twente

Mean range

Diameter infrarenal neck

D2a (mm)D2b (mm)D2c (mm)

2223 23

16-3117-2816-30

Body sizeOversizing %

2924

21-3414-47

Neckshape Parallel || Conical \ /Rev.-conical / \Bell ( )

28231

Length infrarenal neck mm 25 9-55

Circumferential thrombus

% <10 0-25

Circumferential calcification

% <10 0-50

Angulation neck aneurysm

degrees 41 0-100

Aneurysm diameter (D3) mm 76 33-125

OR-timeX-ray time

146 min (70-300 min) 12 min (3-50 min)

ContrastPacked cells

140 cc (25-360 cc)5 (0-21)

Endoleak at “end” operation 1x Type I? (conversion, re-relap, prox inlay)7x Type II, at discharge 2, 30-day onward 0

Occlusion renal artery 2 times intentional (accessory renal artery)

IC-hospitalisation 3 days (0-15)17x < 24 hours

Conversion 3x

RASA (N=34) Peri-operative results

Antalya, 27/30-10-2011

Medical School Twente

Conversions free rupture during procedure † free rupture, balloon, thrombosis aorta † ongoing instable patient, missed type I

endoleak?final angio: no endoleakclamp infrarenal “on prosthesis”conventional suturing proximal

2 x decompression abdomen

RASA (N=34) Intra-operative techniques

Antalya, 27/30-10-2011

Medical School Twente

Cannulation contralateral gate

-straight forward-with tricks-not cannulated

28x4x2x*

Body repositioning 5x

Renal stents 1x, renal arteries in valleys of body

Local anaesthesia 30x

*Cannulation not possible? free rupture during cannulation

procedure free rupture, balloon, no time for

cannulation procedure, to introduce balloon body needed to be released, thrombosis aorta

RASA (N=34) Intra-operative techniques

Antalya, 27/30-10-2011

Medical School Twente

Cannulation contralateral gate

-straight forward-with tricks-cannulation not possible

28x4x2x*

Body repositioning 5x

Renal stents 1x, renal arteries in valleys of body

Local anaesthesia 30x

Antalya, 27/30-10-2011

Medical School Twente

D3 98mmSevere iliac angulation

Body repositioning

Antalya, 27/30-10-2011

Medical School Twente

Antalya, 27/30-10-2011

Medical School Twente

Magnet system “downstream”Repositioning mainbody

RASA (N=34) Mortality

Antalya, 27/30-10-2011

Medical School Twente

period cause total

Intra-operative 2 1x cardiac arrest1x thrombosis aorta and visceral arteries

2

In hospital 3 mof, cardial, pneumonia

5 (15%)

30-day mortality 1 cardial 6 (17%)

6-months mortality

1 cardial 7

Study mortality 4 cardial 2x, malignancy, CVA

11

Aneurysm related

3

Device related 0

RASA (N=25) Re-interventions

Antalya, 27/30-10-2011

Medical School Twente

nr reason

In hospital (8) 2

2112

After conversion to aorto-bi-fem, hemicolectomy (bowel ischemia) and later rupture anastomosis left groinSigmoid resection (ischemia) and later closure abdomenStents renal arteriesOccluded leg, thrombectomy and stent flowsplitterDecompression abdomen, later suturing proximal anastomosis (type I endoleak?)

30-day (1) 1 Occluded leg, thrombectomy and kissing PTA flowsplitter

6-months 0

Study 1 After 4 yrs rupture type Ib left -> extended with leg

Conclusion RASA

• Treating a ruptured aneurysm with the Anaconda is feasible– Succesfull exclusion rAAA in 31 of 34

patients• 91% success

– 2x free rupture during operating procedure– Possible type I endoleak, converted (suturing prox.

anastomosis)

– 30 day mortality = 17%– Tricks needed, not straight forward

Antalya, 27/30-10-2011

Medical School Twente

In most cases EVAR substituted conventional repair for ruptured

AAA

Why?

Antalya, 27/30-10-2011

Medical School Twente

• Feasible• Growing evidence• Many heterogeneous studies• Lower mortality rates

• Future: • Multiple periscope and chimney

grafts for type IV TAAA or AAA

Randomised controlled trialsAJAX

IMPROVEECAR