9th Current Trends in Aortic & Cardiovascular Surgery & Interventions Justin Galovich, MD Carlos Donayre, MD John Lin, MD Irwin Walot, MD Rodney A. White, MD
Presented at the 9th Current Trends in Aortic and Cardiovascular Surgery and Interventions Conference; Houston, 26–27 April 2013. Section Editor: Joseph S. Coselli, MD Key words: Abdominal compartment syndrome; aortic aneurysm, abdominal; aortic rupture; blood vessel prosthesis implantation; endovascular procedures; stent graft; treatment outcome From: Department of Surgery, Division of Vascular and Endovascular Surgery, Harbor-UCLA Medical Center, Torrance, California 90502 Address for reprints: Rodney A. White, MD, Division of Vascular and Endovascular Surgery, Harbor-UCLA Medical Center, 1000 W. Carson St., Box 11, Torrance, CA 90502 E-mail: [email protected] © 2013 by the Texas Heart ® Institute, Houston
Texas Heart Institute Journal
Endovascular Repair First for Ruptured Abdominal Aortic Aneurysms
E
ndovascular aneurysm repair (EVAR) has provided a minimally invasive treatment option for elective aneurysm repair, with lower short-term morbidity and mortality rates, but it requires continuous postoperative monitoring. As physicians’ comfort and confidence with the technique have increased, EVAR has become the preferred treatment for ruptured infrarenal abdominal aortic aneurysms (AAA). Since its inception by Volodos in 1988,1 endovascular repair of the aorta has been transformed. What began as an experimental procedure now accounts for most elective AAA repair. Ruptured endovascular aneurysm repair (rEVAR) has become the preferred treatment for many ruptured AAAs in centers that have hybrid interventional rooms, which can accommodate expedient open or endovascular repair. In comparison with open repair, rEVAR has shown superior 30-day and 5-year mortality rates.2 Patients with ruptured AAA who are transferred for a higher level of care have superior clinical outcomes when treated with rEVAR, compared with open repair.3 One of the main arguments for performing rEVAR first is the high 30-day mortality rate associated with open repair (consistently near 50%, versus around 25% for rEVAR).2 Even the 5-year survival rate for rEVAR is better than that for open repair (37% versus 26%).4 Although rEVAR has superior mortality rates in comparison with open repair, significant morbidity leaves room for improvement—especially with regard to the prevention and management of abdominal compartment syndrome. The principles for rEVAR remain the same as those for open repair; however, the stent choice might vary from that for elective EVAR. After either femoral artery cutdown or percutaneous access, wire access is attained and a long sheath is placed to secure the position of a supraceliac aortic occlusion balloon, in case it should be needed. The balloon should be inflated only for the purpose of providing hemodynamic stability, because the use of aortic occlusion balloons is associated with abdominal compartment syndrome.5 Next, intravascular ultrasound (IVUS) is used to evaluate the anatomy of the aneurysm’s neck and the access route for rEVAR. The IVUS can be used to confirm computed tomographic (CT) findings or as the primary imaging technique, in the absence of a preoperative CT scan. Although it makes intuitive sense to use the EVAR graft with which you are most familiar, bear in mind that contralateral gate cannulation can prolong graft deployment—which should not be delayed. In rEVAR, a unibody graft has the advantage in cases with difficult gate cannulation (see Patient 1) of no contralateral gate to cannulate. Patient 1. An 85-year-old woman presenting with lower abdominal pain that radiated to her groin was found upon CT scanning to have a contained rupture of an AAA. After transfer to our hospital for a higher level of care, she underwent endovascular repair of the aneurysm with a unibody Endologix endograft (Endologix, Inc.; Irvine, Calif ) (Fig. 1). Another expedient option is the use of aorto/uni-iliac prostheses (see Patient 2), which have shown long-term durability. Patient 2. An 87-year-old man with a history, 12 years earlier, of aorto/bifemoral bypass for a ruptured AAA presented with abdominal pain and was found to have a contained rupture of a para-anastamotic aortic aneurysm at the proximal suture line. The ruptured para-anastomic aneurysm was repaired by creating an aorto uniiliac configuration—that is, a Talent ® Converter stent-graft system (Medtronic, Inc.; Minneapolis, Minn) combined with an Endurant® aortic cuff (Medtronic)—followed by a left-to-right femorofemoral bypass. No re-intervention has been required in the subsequent 2-year follow-up (Fig. 2). EVAR First for Ruptured AAAs
553
B
A
C
Fig. 1 Patient 1. A) M2S reconstruction and corresponding axial images show the aneurysm at its maximal diameter (upper arrow) and the narrow distal aorta (lower arrow). B) Intravascular ultrasonographic reconstructions are compared with an intraoperative angiogram for determination of the aneurysm’s neck anatomy. (In the absence of a preoperative computed tomographic scan, intravascular ultrasound can be used to evaluate neck anatomy and access.) C) Final aortogram after placement of the endograft.
A
B
C
D E
Fig. 2 Patient 2. A) M2S reconstruction shows a ruptured para-anastamotic aneurysm. B) Intravascular ultrasonographic evaluation of the aneurysm shows a contained rupture and a disrupted aortic graft lacking a secure seal and a fixation zone. Angiograms show C) placement of the Talent ® converter stent-graft (arrow) and D) proximal extension with Endurant ® aortic cuff (arrow) by means of a suprarenal open stent to achieve a secure fixation zone. E) Completion angiogram and M2S reconstruction of the postoperative computed tomographic angiogram show exclusion of the ruptured para-anastomotic aneurysm.
Endovascular repair of ruptured aneurysms has a reintervention rate of up to 20%, with type 2 endoleaks being the most common indication.6 Many studies that compare rEVAR results with those of open repair for ruptured AAA might have selection bias (that is, more favorable anatomy in the rEVAR groups).6 554
EVAR First for Ruptured AAAs
In consideration of the high mortality rate for open repair, we might conclude that many lives could be saved by adopting an “EVAR first” program. In order to reduce morbidity and mortality rates in association with endovascular treatment of ruptured AAA, improvements in EVAR should focus on abdominal Volume 40, Number 5, 2013
compartment syndrome and on the development of standard algorithms for efficient transport of patients and mobilization of the acute aortic team.5 Now that most AAAs are treated with EVAR, the obvious question arises: Will morbidity and mortality rates remain the same for open AAA repair, or will they become worse as the open procedure is performed less often— especially by current vascular surgery residents?
References 1. Volodos’ NL, Karpovich IP, Shekhanin VE, Troian VI, Iako venko LF. A case of distant transfemoral endoprosthesis of the thoracic artery using a self-fixing synthetic prosthesis in traumatic aneurysm [in Russian]. Grudn Khir 1988;(6)84-6. 2. Eefting D, Ultee KH, Von Meijenfeldt GC, Hoeks SE, ten Raa S, Hendriks JM, et al. Ruptured AAA: state of the art management. J Cardiovasc Surg (Torino) 2013;54(1 Suppl 1):47-53. 3. Mandawat A, Mandawat A, Sosa JA, Muhs BE, Indes JE. Endovascular repair is associated with superior clinical outcomes in patients transferred for treatment of ruptured abdominal aortic aneurysms. J Endovasc Ther 2012;19(1):88-95. 4. Mehta M, Byrne J, Darling RC 3rd, Paty PS, Roddy SP, Kreienberg PB, et al. Endovascular repair of ruptured infrarenal abdominal aortic aneurysm is associated with lower 30-day mortality and better 5-year survival rates than open surgical repair. J Vasc Surg 2013;57(2):368-75. 5. Mehta M, Hnath JC. Lessons learned in offering EVAR for ruptured aneurysms. Endovasc Today 2013;Feb:37-44. 6. Ten Bosch JA, Cuypers PW, van Sambeek M, Teijink JA. Current insights in endovascular repair of ruptured abdominal aortic aneurysms. EuroIntervention 2011;7(7):852-8.
Texas Heart Institute Journal
EVAR First for Ruptured AAAs
555
Presented at the 9th Current Trends in Aortic and Cardiovascular Surgery and Interventions Conference; Houston, 26–27 April 2013. Section Editor: Joseph S. Coselli, MD Key words: Abdominal compartment syndrome; aortic aneurysm, abdominal; aortic rupture; blood vessel prosthesis implantation; endovascular procedures; stent graft; treatment outcome From: Department of Surgery, Division of Vascular and Endovascular Surgery, Harbor-UCLA Medical Center, Torrance, California 90502 Address for reprints: Rodney A. White, MD, Division of Vascular and Endovascular Surgery, Harbor-UCLA Medical Center, 1000 W. Carson St., Box 11, Torrance, CA 90502 E-mail: [email protected] © 2013 by the Texas Heart ® Institute, Houston
Texas Heart Institute Journal
Endovascular Repair First for Ruptured Abdominal Aortic Aneurysms
E
ndovascular aneurysm repair (EVAR) has provided a minimally invasive treatment option for elective aneurysm repair, with lower short-term morbidity and mortality rates, but it requires continuous postoperative monitoring. As physicians’ comfort and confidence with the technique have increased, EVAR has become the preferred treatment for ruptured infrarenal abdominal aortic aneurysms (AAA). Since its inception by Volodos in 1988,1 endovascular repair of the aorta has been transformed. What began as an experimental procedure now accounts for most elective AAA repair. Ruptured endovascular aneurysm repair (rEVAR) has become the preferred treatment for many ruptured AAAs in centers that have hybrid interventional rooms, which can accommodate expedient open or endovascular repair. In comparison with open repair, rEVAR has shown superior 30-day and 5-year mortality rates.2 Patients with ruptured AAA who are transferred for a higher level of care have superior clinical outcomes when treated with rEVAR, compared with open repair.3 One of the main arguments for performing rEVAR first is the high 30-day mortality rate associated with open repair (consistently near 50%, versus around 25% for rEVAR).2 Even the 5-year survival rate for rEVAR is better than that for open repair (37% versus 26%).4 Although rEVAR has superior mortality rates in comparison with open repair, significant morbidity leaves room for improvement—especially with regard to the prevention and management of abdominal compartment syndrome. The principles for rEVAR remain the same as those for open repair; however, the stent choice might vary from that for elective EVAR. After either femoral artery cutdown or percutaneous access, wire access is attained and a long sheath is placed to secure the position of a supraceliac aortic occlusion balloon, in case it should be needed. The balloon should be inflated only for the purpose of providing hemodynamic stability, because the use of aortic occlusion balloons is associated with abdominal compartment syndrome.5 Next, intravascular ultrasound (IVUS) is used to evaluate the anatomy of the aneurysm’s neck and the access route for rEVAR. The IVUS can be used to confirm computed tomographic (CT) findings or as the primary imaging technique, in the absence of a preoperative CT scan. Although it makes intuitive sense to use the EVAR graft with which you are most familiar, bear in mind that contralateral gate cannulation can prolong graft deployment—which should not be delayed. In rEVAR, a unibody graft has the advantage in cases with difficult gate cannulation (see Patient 1) of no contralateral gate to cannulate. Patient 1. An 85-year-old woman presenting with lower abdominal pain that radiated to her groin was found upon CT scanning to have a contained rupture of an AAA. After transfer to our hospital for a higher level of care, she underwent endovascular repair of the aneurysm with a unibody Endologix endograft (Endologix, Inc.; Irvine, Calif ) (Fig. 1). Another expedient option is the use of aorto/uni-iliac prostheses (see Patient 2), which have shown long-term durability. Patient 2. An 87-year-old man with a history, 12 years earlier, of aorto/bifemoral bypass for a ruptured AAA presented with abdominal pain and was found to have a contained rupture of a para-anastamotic aortic aneurysm at the proximal suture line. The ruptured para-anastomic aneurysm was repaired by creating an aorto uniiliac configuration—that is, a Talent ® Converter stent-graft system (Medtronic, Inc.; Minneapolis, Minn) combined with an Endurant® aortic cuff (Medtronic)—followed by a left-to-right femorofemoral bypass. No re-intervention has been required in the subsequent 2-year follow-up (Fig. 2). EVAR First for Ruptured AAAs
553
B
A
C
Fig. 1 Patient 1. A) M2S reconstruction and corresponding axial images show the aneurysm at its maximal diameter (upper arrow) and the narrow distal aorta (lower arrow). B) Intravascular ultrasonographic reconstructions are compared with an intraoperative angiogram for determination of the aneurysm’s neck anatomy. (In the absence of a preoperative computed tomographic scan, intravascular ultrasound can be used to evaluate neck anatomy and access.) C) Final aortogram after placement of the endograft.
A
B
C
D E
Fig. 2 Patient 2. A) M2S reconstruction shows a ruptured para-anastamotic aneurysm. B) Intravascular ultrasonographic evaluation of the aneurysm shows a contained rupture and a disrupted aortic graft lacking a secure seal and a fixation zone. Angiograms show C) placement of the Talent ® converter stent-graft (arrow) and D) proximal extension with Endurant ® aortic cuff (arrow) by means of a suprarenal open stent to achieve a secure fixation zone. E) Completion angiogram and M2S reconstruction of the postoperative computed tomographic angiogram show exclusion of the ruptured para-anastomotic aneurysm.
Endovascular repair of ruptured aneurysms has a reintervention rate of up to 20%, with type 2 endoleaks being the most common indication.6 Many studies that compare rEVAR results with those of open repair for ruptured AAA might have selection bias (that is, more favorable anatomy in the rEVAR groups).6 554
EVAR First for Ruptured AAAs
In consideration of the high mortality rate for open repair, we might conclude that many lives could be saved by adopting an “EVAR first” program. In order to reduce morbidity and mortality rates in association with endovascular treatment of ruptured AAA, improvements in EVAR should focus on abdominal Volume 40, Number 5, 2013
compartment syndrome and on the development of standard algorithms for efficient transport of patients and mobilization of the acute aortic team.5 Now that most AAAs are treated with EVAR, the obvious question arises: Will morbidity and mortality rates remain the same for open AAA repair, or will they become worse as the open procedure is performed less often— especially by current vascular surgery residents?
References 1. Volodos’ NL, Karpovich IP, Shekhanin VE, Troian VI, Iako venko LF. A case of distant transfemoral endoprosthesis of the thoracic artery using a self-fixing synthetic prosthesis in traumatic aneurysm [in Russian]. Grudn Khir 1988;(6)84-6. 2. Eefting D, Ultee KH, Von Meijenfeldt GC, Hoeks SE, ten Raa S, Hendriks JM, et al. Ruptured AAA: state of the art management. J Cardiovasc Surg (Torino) 2013;54(1 Suppl 1):47-53. 3. Mandawat A, Mandawat A, Sosa JA, Muhs BE, Indes JE. Endovascular repair is associated with superior clinical outcomes in patients transferred for treatment of ruptured abdominal aortic aneurysms. J Endovasc Ther 2012;19(1):88-95. 4. Mehta M, Byrne J, Darling RC 3rd, Paty PS, Roddy SP, Kreienberg PB, et al. Endovascular repair of ruptured infrarenal abdominal aortic aneurysm is associated with lower 30-day mortality and better 5-year survival rates than open surgical repair. J Vasc Surg 2013;57(2):368-75. 5. Mehta M, Hnath JC. Lessons learned in offering EVAR for ruptured aneurysms. Endovasc Today 2013;Feb:37-44. 6. Ten Bosch JA, Cuypers PW, van Sambeek M, Teijink JA. Current insights in endovascular repair of ruptured abdominal aortic aneurysms. EuroIntervention 2011;7(7):852-8.
Texas Heart Institute Journal
EVAR First for Ruptured AAAs
555
