DR IMRAN JAVED,

MBBS, FCPS Surgery.

INTERNATIONAL FELLOW

DR IMRAN JAVED,

MBBS, FCPS Surgery.

INTERNATIONAL FELLOW

JOURNAL CLUB July 2010

JOURNAL CLUB July 2010

Long-term Follow-up of Secondary Interventions After Endovascular Aneurysm Repair

With the AneuRx Endoprosthesis:

A Single-Center Experience

Long-term Follow-up of Secondary Interventions After Endovascular Aneurysm Repair

With the AneuRx Endoprosthesis:

A Single-Center Experience

Department of Vascular Surgery St. Antonius Hospital, Nieuwegein,

and, University Medical Center Utrecht, The Netherlands.

Department of Vascular Surgery St. Antonius Hospital, Nieuwegein,

and, University Medical Center Utrecht, The Netherlands.

Guus W. van Lammeren, MD,Bram Fioole, MD, PhD, Evert J. Waasdorp, MD,Frans L. Moll, MD, PhD,Joost A. van Herwaarden, MD, PhDJean-Paul P. M. de Vries, MD, PhD

Guus W. van Lammeren, MD,Bram Fioole, MD, PhD, Evert J. Waasdorp, MD,Frans L. Moll, MD, PhD,Joost A. van Herwaarden, MD, PhDJean-Paul P. M. de Vries, MD, PhD

AIM OF THE STUDYAIM OF THE STUDYTo report short and long-term

results of secondary interventions, including renewed endo-vascular and open reconstructions, occuring in a single center cohort of EVAR patients treated with an AneuRx stent-graft endoprosthesis.

To report short and long-term results of secondary interventions, including renewed endo-vascular and open reconstructions, occuring in a single center cohort of EVAR patients treated with an AneuRx stent-graft endoprosthesis.

MethodsMethodsBetween 1996 and 2003, an AneuRx device

was used primarily in 212 patients (197 men; mean age 71±7.0 years).

Sixty-two (29%) patients (58 men; mean age 73±7.2 years) required a secondary intervention (percutaneous, endovascular, or open repair) after EVAR and were prospectively followed after their secondary interventions.

Data were analyzed retrospectively.

Between 1996 and 2003, an AneuRx device was used primarily in 212 patients (197 men; mean age 71±7.0 years).

Sixty-two (29%) patients (58 men; mean age 73±7.2 years) required a secondary intervention (percutaneous, endovascular, or open repair) after EVAR and were prospectively followed after their secondary interventions.

Data were analyzed retrospectively.

AGE (YEARS) 73+-7.2

MEN 58 (95%)

HYPERTENSION 19 (31%)

DIABTES MELLITUS 2 (3%)

HYPERCHOLESTROLEMIA 19 (31%)

HYPERHOMOCYSTEINEMIA 1 (2%)

HISTORY OF M.I. 25 (40%)

HISTORY OF STROKE 6 (10 %)

COPD 15 (24%)

DEMOGRAPHICS OF 62 PATIENTSDEMOGRAPHICS OF 62 PATIENTS

Complications after EVARComplications after EVAR

AneuRx EVAR(n=212)

Type Ia(n=28)

Type Ib(n=6)

Type II(n=8)

Type III(n=17)

Obstruction(n=3)

Secondary intervention

(n=62)

No secondary Intervention

(n=150)

MANAGEMENT OF TYPE I ENDOLEAK

MANAGEMENT OF TYPE I ENDOLEAK

Type Ia= 28

Cuff=23Aorto-monoiliac graft

=4Open=1

Type Ib=6

Cuff =6

MANAGEMENT OF TYPE II & III ENDOLEAK

MANAGEMENT OF TYPE II & III ENDOLEAK

Type III=17

Cuff=9Aorto-monoiliac

Graft=7Open=1

Type II

Embolization=8

ENDOGRAFT OBSTRUCTIONENDOGRAFT OBSTRUCTIONLYSIS

(n=1)

LYSIS

(n=1)

OPEN

(n=2)

OPEN

(n=2)

INDICATIONS FOR EVARINDICATIONS FOR EVARInfra-renal AAA >5.5

cm.

Isolated Iliac Artery Aneurysm >3.5cm.

Combined Aorto-iliac anerysmal disease.

Infra-renal AAA >5.5 cm.

Isolated Iliac Artery Aneurysm >3.5cm.

Combined Aorto-iliac anerysmal disease.

FOLLOW-UP PATIENTSFOLLOW-UP PATIENTS• BY CT-

ANGIOGRAPHY (CTA)

1- BEFORE DISCHARGE.

2- AT 3 MONTHS.

3- AT 12 MONTHS.

4- THEN YEARLY CTA.

• BY CT-ANGIOGRAPHY (CTA)

1- BEFORE DISCHARGE.

2- AT 3 MONTHS.

3- AT 12 MONTHS.

4- THEN YEARLY CTA.

DEFINITIONSDEFINITIONSTECHNICAL SUCCESS is

defined as successful access to the arterial system using a remote site; successful deployment of graft, with secure proximal & distal fixation and no Type I or Type III endoleak; and a patent graft without significant twist, kinks, or obstruction.

TECHNICAL SUCCESS is defined as successful access to the arterial system using a remote site; successful deployment of graft, with secure proximal & distal fixation and no Type I or Type III endoleak; and a patent graft without significant twist, kinks, or obstruction.

CLINICAL SUCCESS is defined as successful deployment of endovascular device at the intended location with death as a results of aneurysm-related treatment, Type I or Type III endoleak, graft infection or thrombosis, aneurysm expansion (5mm diameter or 5% volume), aneurysm rupture or conversion to open repair.

CLINICAL SUCCESS is defined as successful deployment of endovascular device at the intended location with death as a results of aneurysm-related treatment, Type I or Type III endoleak, graft infection or thrombosis, aneurysm expansion (5mm diameter or 5% volume), aneurysm rupture or conversion to open repair.

OUTCOME OF SECONDARY INTERVENTIONOUTCOME OF SECONDARY INTERVENTIONINDICATION TECHNICAL SUCCESS CLINICAL SUCCESS

TYPE Ia=28

EXTENSION CUFF=23

AORTOMONOILIAC GRAFT=4

OPEN REPAIR=1

22 (96%)

4 (100%)

1 (100%)

12 (52%)

3 (75%)

1 (100%)

TYPE Ib=6

EXTENSION CUFF=6 5 (83%) 6 (100%)

TYPE II=8

EMBOLIZATION

7 (88%) 7 (88%)

TYPE III=17

INTERPOSITION CUFF=9

AOERTOMONOILIAC GRAFT=7

OPEN REPAIR=1

9 (100%)

7 (100%)

1 (100%)

6 (67%)

6 (86%)

1 (100%)

OBSTRUCTION=3

LYSIS=1

OPEN REPAIR=2

1 (100%)

2 (100%)

0 (0%)

0 (0%)

TOTAL=62 59 (95%) 42 (68%)

Results ResultsOf the 212 AneuRx patients, 59 (28%) required

secondary interventions for endoleaks (28 type Ia, 6 type Ib, 8 type II, and 17 type III) and 3 (1%) for obstruction of the endoprosthesis.

The mean interval between primary EVAR and secondary intervention was 39±30 months.

The yearly risk of requiring a secondary intervention after receiving a primary AneuRx graft was 3.7%.

Of the 212 AneuRx patients, 59 (28%) required secondary interventions for endoleaks (28 type Ia, 6 type Ib, 8 type II, and 17 type III) and 3 (1%) for obstruction of the endoprosthesis.

The mean interval between primary EVAR and secondary intervention was 39±30 months.

The yearly risk of requiring a secondary intervention after receiving a primary AneuRx graft was 3.7%.

ResultsResultsOverall 30-day morbidity after a secondary

intervention was 18% (11/62); the 30-day mortality was 5% (3/62). Short endovascular extender cuffs were used for type Ia endoleaks in 23 of 28 patients.

Over a mean follow-up of 81±34 months after the secondary intervention, the success of short endovascular cuffs for treatment of type Ia endoleak was 52% (12/23); the remaining 11 (48%) patients required additional reinterventions for recurrent endoleak or persistent aneurysm growth.

Overall 30-day morbidity after a secondary intervention was 18% (11/62); the 30-day mortality was 5% (3/62). Short endovascular extender cuffs were used for type Ia endoleaks in 23 of 28 patients.

Over a mean follow-up of 81±34 months after the secondary intervention, the success of short endovascular cuffs for treatment of type Ia endoleak was 52% (12/23); the remaining 11 (48%) patients required additional reinterventions for recurrent endoleak or persistent aneurysm growth.

Patients with a primary AneuRx stent-graft had an acceptable yearly risk of requiring a secondary intervention following EVAR, but 30-day morbidity and mortality rates were significant and must be taken into account during primary decision making for endovascular or open repair.

Proximal extender cuffs may not be a durable treatment for type Ia endoleak.

Patients with a primary AneuRx stent-graft had an acceptable yearly risk of requiring a secondary intervention following EVAR, but 30-day morbidity and mortality rates were significant and must be taken into account during primary decision making for endovascular or open repair.

Proximal extender cuffs may not be a durable treatment for type Ia endoleak.

CONCLUSIONCONCLUSION