Transcript Pre-operative evaluation of cardiac morbidity

ΠΑΥΛΟΣ Γ. ΒΑΚΑΛΟΠΟΥΛΟΣ
ΑΓΓΕΙΟΧΕΙΡΟΥΡΓΟΣ
ΑΝΑΠΛΗΡΩΤΗΣ ΔΙΕΥΘΥΝΤΗΣ ΑΓΓΕΙΟΧΕΙΡΟΥΡΓΙΚΗΣ
ΚΛΙΝΙΚΗΣ ΝΑΥΤΙΚΟΥ ΝΟΣΟΚΟΜΕΙΟΥ ΑΘΗΝΩΝ
-------------------------------------------------------------------ΕΘΝΙΚΟ ΚΑΙ ΚΑΠΟΔΙΣΤΡΙΑΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΑΘΗΝΩΝ
ΙΑΤΡΙΚΗ ΣΧΟΛΗ
ΠΑΝΕΠΙΣΤΗΜΙΟ MILANO-BICOCCA
ΔΙΑΚΡΑΤΙΚΟ ΜΕΤΑΠΤΥΧΙΑΚΟ ΠΡΟΓΡΑΜΜΑ ΣΠΟΥΔΩΝ
«ΕΝΔΑΓΓΕΙΑΚΕΣ ΤΕΧΝΙΚΕΣ»
20/09/2014
Planning
RCTs
ESVS Guidelines
Discussion
RCTs
 EVAR 1 & 2
 DREAM
 OVER
 ADAM
 CEASAR
 PIVOTAL
EVAR 1 &2
1 : fit pts for OR
 ELECTIVE EVAR VERSUS OR
2: unfit pts for OR
EVAR versus NO
 38 to 41 hospitals UK, 60 yrs, 5.5 cm, C/T scan, 1999-2004
Target:
 primary outcome was mortality (operative, all-cause and
AAA related).
 Secondary outcomes were graft-related complications
and reinterventions, adverse events, renal function,
health-related quality of life and costs
EVAR 1 results
 Follow-up 5 yrs
 Very little loss to follow-
up (1%)
 EVAR trial 1, 30-day
operative mortalities were
1.8% and 4.3% in the
EVAR and open-repair
groups
 there was no significant
difference between the
groups in terms of allcause mortality
 The EVAR group did
demonstrate an early
advantage in terms of
AAA-related mortality,
which was sustained for
the first few years, but
lost by the end of the
study, primarily due to
fatal endograft ruptures
EVAR 2 results
 The 30-day operative mortality was 7.3% in the EVAR
group
 this group after 4 years demonstrated a significant
advantage in terms of AAA-related mortality
 this advantage did not result in any benefit in terms of
all-cause mortality
EVAR 1 & 2 conclusions
 EVAR offers a clear operative mortality benefit over
open repair in patients fit for both procedures, but this
early benefit is not translated into a long-term survival
advantage. Among patients unfit for open repair, EVAR
is associated with a significant longterm reduction in
AAA-related mortality but this does not appear to
influence all-cause mortality.
DREAM
 351 patients, 5 cm in diameter, suitable candidates for
both techniques
Target:
 better outcome EVAR in the first month after the
procedure
is sustained beyond the perioperative period.
DREAM results 2yrs after
 survival rates were 89.6 % for OR and 89.7% for EVAR
 aneurysm-related death were 5.7 % for OR and 2.1%
for EVAR
 This advantage in the perioperative period
no significant difference in subsequent aneurysmrelated mortality
 survival free of moderate or severe complications was
also similar in the two groups at two years
DREAM conclusions
 The perioperative survival advantage with
endovascular repair as compared with open
repair is not sustained after the first
postoperative year.
OVER
Target:
 To compare postoperative outcomes up to 2 years after
endovascular or open repair of AAA in a planned
interim report of a 9-year trial.
 Procedure failure, secondary therapeutic procedures,
length of stay, quality of life, erectile dysfunction,
major morbidity and mortality.
 881 pts, 9-year trial, 2 yrs follow up
OVER results
 Perioperative mortality was lower for endovascular
repair (0.5% vs 3.0%), but there was no significant
difference in mortality at 2 years (7.0% vs 9.8%).
 Patients in the endovascular repair group had reduced
median procedure time, blood loss, transfusion
requirement, duration of mechanical ventilation,
hospital stay and intensive care unit stay, but required
substantial exposure to fluoroscopy and contrast.
OVER conclusions
 The early advantage of endovascular repair
was not offset by increased morbidity or
mortality in the first 2 years after repair
ADAM
Target:
 elective surgical repair of small abdominal aortic
aneurysms improves survival
 50 to 79 yrs, 4.0 to 5.4 cm, Follow-up ranged from 3.5
to 8.0 years (mean, 4.9), 569 patients were randomly
assigned to immediate repair and 567 to surveillance
 By the end of the study, aneurysm repair had been
performed in 92.6 percent of the patients in the
immediate-repair group and 61.6 percent of those in
the surveillance group.
ADAM results
 The rate of death from any cause, the primary
outcome, was not significantly different in the two
groups
 a low total operative mortality of 2.7% in the
immediate-repair group.
 no reduction in the rate of death related to abdominal
aortic aneurysm in the immediate-repair group (3.0%)
as compared with the surveillance group (2.6%).
 Eleven patients in the surveillance group had rupture
of abdominal aortic aneurysms (0.6% per year),
resulting in seven deaths.
ADAM conclusions
 Survival is not improved by elective repair of
abdominal aortic aneurysms smaller than
5.5 cm, even when operative mortality is low.
PIVOTAL
 4 to 5 cm, AneuRx/Talent, 1050-patient, 525 in each
group,
Primary targets:
aneurysm rupture
AAA-related death up to 3 years
Secondary targets:
All-cause and AAA-related mortality in
smokers vs nonsmokers;
conversion to open surgical repair
PIVOTAL debate
 Smaller AAAs can be more favorable for EVAR as a
result of suitable aortic anatomy
 longer necks, less angulation, less tortuosity, and
longer iliac landing zones
 With each 1-cm increase in diameter, anatomic
suitability for EVAR decreased fivefold.
 increased risks of OR at a time when the patients are
older and less fit for EVAR
Welborn MB, Yau FS, Modrall JG, Lopez JA, Floyd S, Valentine RJ, et al.
Endovascular repair of small abdominal aortic aneurysms: a paradigm shift?
Vasc Endovasc Surg 2005;39:381-91.
PIVOTAL early results
 perioperative mortality was only 0.6%, and the 3-year
rate of rupture or aneurysm-related mortality was near
zero
 early EVAR would be of benefit in preventing rupture
 both appear to be safe alternatives for patients with
small aneurysms of 4.0 to 5.0
Ouriel K, Clair DG, Kent KC, Zarins CK; Positive Impact of Endovascular Options
for treating Aneurysms Early (PIVOTAL) Investigators J Vasc Surg. 2010
May;51(5):1081-7. doi: 10.1016/j.jvs.2009.10.113. Epub 2010 Mar 20. Endovascular
repair compared with surveillance for patients with small abdominal aortic
aneurysms..Division of Vascular Surgery, Columbia University and NewYorkPresbyterian Hospital, New York, NY, USA. [email protected]
CAESAR
Target :
 endovascular aortic aneurysm repair (EVAR) or
surveillance in AAA<5.5 cm.
 all-cause mortality
follow-up of 32.4 months
 4.1-5.4 cm, 360 patients
 One perioperative death after EVAR and two late
ruptures (both in the surveillance group) occurred
CAESAR estimations
 all-cause mortality of 14.5% in the EVAR and 10.1% in
the surveillance group.
 Aneurysm-related mortality, aneurysm rupture and
major morbidity rates were similar
 For aneurysms under surveillance, the probability of
delayed repair was 59.7% at 36 months (84.5% at 54
months).
 The probability of receiving OR at 36 months for EVAR
feasibility loss was 16.4%.
 no clear advantage was shown between early or
delayed EVAR strategy
 3 to 5 small aneurysms require repair and 1 to 6 might
lose feasibility for EVAR.
ESVS GUIDELINES
• Randomised
controlled
trials,
large
registries and singlecenter series comparing
EVAR with OR have shown that the
minimally invasive approach has lower
early morbidity and mortality
 low incidence of primary conversion to OR
after EVAR, between 0.9 and 5.9%
(1.8% on RCTs)
Pre-operative evaluation of cardiac
morbidity
Regardless of the type of surgery, coronary
artery disease (CAD) is the leading cause of
early and late mortality after AAA repair
Cardiac disease
 Before the planned endovascular procedure, a
detailed cardiac history should therefore be
obtained, and patients should be screened for all
cardiovascular risk factors.
Level 2, Recommendation B.
 Cardiac stress testing prior to EVAR is
recommended in patients with three or more
clinical factors for cardiac disease.
 Level 2b, Recommendation B
Pulmonary disease
 A recent retrospective study conducted by
Jonker293 found that patients with AAA and
chronic obstructive pulmonary disease had
improved outcomes after EVAR compared to those
undergoing open repair. In-hospital death and
major complications occurred in 30% of patients
after open repair compared with 12% after EVAR.
Jonker FH, Schlosser FJ, Dewan M, Huddle M, Sergi M, Dardik A, et al. Patients
with abdominal aortic aneurysm and chronic obstructive pulmonary disease have
improved outcomes with endovascular aneurysm repair compared with open
repair. Vascular 2009 NoveDec;17(6):316e24.
Renal protection strategies
The REMEDIAL trial suggested that
the strategy of volume supplementation by sodium
bicarbonate plus NAC
seems to be superior
to the combination of normal saline with NAC
alone in preventing CIN in patients at medium to
high risk
Briguori C, Airoldi F, D’Andrea D, Bonizzoni E, Morici N, Focaccio A, et al.
Renal insufficiency following contrast media administration trial
(REMEDIAL): a randomised comparison of 3 preventive strategies.
Circulation 2007 Mar 13;115(10): 1211e7 [Epub 2007 Feb 19].
Suprarenal fixation did not seem to increase
the likelihood of postoperative renal
impairment.
Furthermore,
suprarenal
fixation may be responsible for progressively
significant proteinuria.
Kouvelos GN, Boletis I, Papa N, Kallinteri A, Peroulis M, Matsagkas MI.
Analysis of effects of fixation type on renal function after endovascular aneurysm
repair. Department of Surgery, Vascular Surgery Unit, Medical School, University
of Ioannina, Greece. J Endovasc Ther. 2013 Jun;20(3):334-44. doi: 10.1583/124177MR.1.
Graft Type
 The RETA Registry reported that all in-
hospital complications, reinterventions,
conversions, and technical failure were
significantly more frequent in the AUI
group.
Thomas SM, Beard JD, Ireland M, Ayers S, on behalf of the Vascular Society of Great Bitain
and Ireland and the British Society of Interventional Radiology. Results from theprospective
registry of endovascular treatment of abdominal aortic aneurysm (RETA): midterm results
to five years. Eur J Vasc Endovasc Surg 2005;29:563e70.
Noorani A, Cooper DG, Walsh SR, Sadat U, Varty K, Boyle JR, Hayes PD. Cambridge Vascular
Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust,
Cambridge, UK. Comparison of aortomonoiliac Endovascular aneurysm repair versus a
bifurcated stent-graft: analysis of perioperative morbidity and mortality. J Endovasc Ther.
2009 Jun;16(3):295-301. doi: 10.1583/08-2645.1.
Type of anaesthesia
The preferential use of local anaesthesia for EVAR,
restricting regional anaesthesia or general anaesthesia
only to those with predefined contraindications, is
feasible and appears to be well tolerated.
Level 3b, Recommendation B.
Percutaneous access
Percutaneous approach for EVAR may
provide a less invasive aortic access and can
facilitate shorter hospital stay in selected
patients.
Level 3, Recommendation D.
Management of accessory renal
arteries
Most often the occlusion of accessory renal
arteries during EVAR is not associated with
clinically significant signs or symptoms of
renal infarct, does not contribute to any
increase in endoleak rate and should not be
embolised preoperatively.
Level 4, Recommendation C.
Management of concomitant iliac
aneurysms
Preservation of flow to at least one hypogastric artery is
recommended in standard risk patients.
Level 2c, Recommendation B.
Hypogastric embolisation is usually preferred over simple
coverage of its ostium by the endograft to prevent the
risk of Type 2 endoleak, but coils should be placed as
proximal as possible to spare collateral circulation.
Level 4, Recommendation C.
The use of an IBD in maintaining antegrade
flow to at least one hypogastric artery for
aortoiliac aneurysm repair was shown to be
feasible and safe in some preliminary clinical
series
Malina M, Dirven M, Sonesson B, Resch T, Dias N, Ivancev K. Feasibility of a branched stentgraft in common iliac artery aneurysms. J Endovasc Ther 2006;13:496e500.
Tielliu IF, Bos WT, Zeebregts CJ, Prins TR, Van Den Dungen JJ, Verhoeven EL. The role of
branched endografts in preserving internal iliac arteries. J Cardiovasc Surg (Torino)
2009;50(2):213e8.
Ziegler P, Avgerinos ED, Umscheid T, Perdikides T, Erz K, Stelter WJ. Branched iliac bifurcation:
6 years experience with endovascular preservation of internal iliac artery flow. J Vasc Surg
2007;46(2):204e10.
Verzini F, Parlani G, Romano L, De Rango P, Panuccio G, Cao P. Endovascular treatment of iliac
aneurysm: concurrent comparison of side branch endograft versus hypogastric
exclusion. J Vasc Surg 2009;49(5):1154e61.
Pararenal aneurysms: fenestrated
grafts
In case of short or diseased neck the use of
endografts with fenestrations shows promising
results but should be performed with
appropriate training and in centers with
extensive experience in EVAR.
Level 3, Recommendation C.
early mortality of the procedure resulted
ranging between 0% and 8.5%, with a
reintervention rate of 7.9-24%.
Monahan TS, Schneider DB. Fenestrated and branched stent
grafts for repair of complex aortic aneurysms. Semin Vasc Surg
2009;22:132e9.
Endovascular repair of ruptured
AAA
EVAR should be considered as a treatment
option for ruptured AAA, provided that anatomy
is suitable, and the centre is appropriately
equipped and the team experienced in emergency
endovascular aneurysm procedures.
Level 2b, Recommendation B.
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