Transcript VISCERAL HYBRIDS - Society of Interventional Radiology

SIR 2009
Less Invasive Interventional treatment
can be recommended as 1st line
treatment for “Silent Killer”, AAA
Guy’s & St. Thomas’ Hospital, London, UK
TARUN SABHARWAL
MD FSIR FCIRSE
K Konstantinos, S.Black, S.Thomas, R.Salter, J.Reidy, C.Sandhu, R.Bell,
M.Waltham, T.Carrel, P.Taylor
Abdominal Aortic Aneurysm
• Weakened area in the aorta
• Natural history of AAA is of slow expansion and
rupture with catastrophic consequence
Role of IR in AAA
• The goal is to prevent aneurysms from
rupturing
AAA Silent Killer
• AAA occurs in 5-7% population older than 60yrs
• Affects 2.7m Americans and is the 13th death
• Risk factors : age, smoking, male sex and family
history
• Asymptomatic in majority
• Back pain, abdominal pain
Rupture
• Manifest with unheralded rupture and death
• Prognosis after rupture is grim with community based
mortality as high as 79%
• 59-83% AAA die before reaching hospital
• Operative mortality rates are 40%
• Leaving at best 10-25% discharge
EVAR compared with Open
Repair
• Mortality rate for elective surgical repair of
nonruptured AAAs is 5%
• EVAR is associated with periprocedural
mortality benefit compared with open
repair (relative risk reduction 3.1)
• ↓ periprocedural complications
• Benefit of reduced aneurysm related
mortality at 4yrs (4% vrs 7%)
DREAM and EVAR 1 trials
EVAR offers a less invasive alternative to
conventional open repair
Benefits of EVAR over Open
repair in rAAA
• Local anesthesia
• Maintenance of abdominal wall and
muscle tone
• Decreased aortic occlusion time
• Diminished blood loss
• Better thermoregulation
Common perceptions of
EVAR
• High late complication rate
• High rate of secondary interventions
• Long term surveillance required:
more expensive and risk of radiation
cancers
Secondary Intervention rates
Endoluminal repair
 RETA (Thomas EJVES 2005 n=1823)
38% at 5 y
 EUROSTAR (Laheij BJS 2000 n=1023)
38% at 4y
 EVAR 1 (Lancet 2005 n=543 EVAR)
20% at 4 y
 EVAR 2 (Lancet 2005 n=166 EVAR)
26% at 4 y
 Greenberg (JVS 2008 n=739)
20% at 5 y
 Sampram (JVS 2002 n=703)
35% at 3 y
EVAR 1 Open repair cohort: 6% at 4 y
Aim of our Study
• Analyze the treatment of patients with
AAA with EVAR
• Assess rate of secondary interventions
• Assess need for intense CT surveillance
Method
 Prospective database
 453 patients
 2000 – 2008
 Male/female = 11/1
 Follow up
 Age
 Aneurysm diameter
 Elective
 Urgent
 Emergency
30 months (2-90)
76 (40 – 93)
6.1 (5.3 – 11)
406 (89.8%)
17 (3.6%)
30 (6.6%)
Results
30-day mortality: 15/453 (3.3%)
Technical Success: 451/453 (99.6%)
Open conversion: 1 urgent : 1 emergent
Secondary Interventions: 33/453 (7.2%)
of which 6/453 (1.3%) from surveillance
Conclusion
 Low secondary intervention rate for EVAR
 Secondary interventions are effective
 Surveillance with intensive CT scanning identifies few
complications
 Questionable benefit of intensive CT surveillance
protocols
 Suggested current protocol: 3/12 CT and yearly
duplex thereafter
Conclusions
•  durability and
effectiveness of EVAR
• EVAR ↓ risks of
surgery, amount of
pain, large incisions,
hospital stay and much
shorter recovery time