Chapter 72 - Aortoiliac aneurysm - endovascular treatment

Question 1

Volodos 1986

Answer 1

first description of EVAR

Question 2

Parodi 1990

Answer 2

First EVAR

Question 3

When was EVAR first approved in Europe and US

Answer 3

Europe 1996 US 1999

Question 4

Early models of EVAR grafts

Answer 4

AneuRx (Medtronic) - low profile, high migration Vanguard (Boston) - fabric tears and perf Excluder (Gore) - Type IV due to pores Talent - spring fractures and C-bar breaks AFX - passive fixation and sits at aortic bifurcation Aorfix - only graft with IFU 90 degree angulated necks

Question 5

Perclose IFU size recommendations

Answer 5

1 perclose: 5-8F 2 percloses: - 8.5-21F

Question 6

EVAR1 key points

Answer 6

1) UK study 2) 1082 patients fit for open 3) 1999-2003 4) 30d mortality 1.7 vs 4.7% 5) secondary intervention 9.8 vs 5.8%

Question 7

DREAM key points

Answer 7

1) Multicenter 2) 345 patients 3) 2000-2003 4) Mortality 1.2 vs 4.6% 5) mortality and morbidity 4.7 vs 9.8% (mostly pulmonary)

Question 8

OVER key points

Answer 8

1) 42 veteran affairs centres 2) 881 patients 3) mortality 0.5 vs 3% 4) 2 year mortality 7.0 vs 9.8%

Question 9

FRENCH study on EVAR vs OPEN

Answer 9

in low to moderate risk patients there’s no difference between EVAR and open

Question 10

EVAR1 long term outcome

Answer 10

1) 6 year no difference but only 24% had follow up 2) Initial benefit lost in 2 years 3) Higher graft-related complication needing reintervention at 4 years in EVAR

Question 11

DREAM long term results

Answer 11

1) 2 year 2.1 vs 5.7% aneurysm-related mortality 2) all mortality same 3) higher reintervention at 6 year in EVAR 30 vs 19.1

Question 12

OVER long term results

Answer 12

3 years EVAR and open converge in outcome

Question 13

EUROSTAR registration on reintervention and rupture in EVAR

Answer 13

5% reintervention Rupture 1%/year

Question 14

MEDICARE on follow up post EVAR

Answer 14

50% lost to f/u at 5 year

Question 15

Difference in MEDICARE 2001-2004 vs 2003-2007

Answer 15

2001-2004: EVAR increases reintervention, rupture, long term mortality 2003-2007: sustained benefit at 5.7 years of EVAR

Question 16

EVAR 2 key points

Answer 16

1) EVAR vs medical management 2) 338 patients 3) no difference in mortality…possible reasons: a) patients died waiting EVAR b) 25% medical group crossed to EVAR Conclusion: EVAR not indicated in high risk patients

Question 17

EUROSTAR on different grafts (Aneurx, talent, zeneth, exluder)

Answer 17

Aneurx and Talent: higher migration and endoleak (I and III) Zeneth: higher sac shrinkage, limb occlusion; lowest migration Excluder: least limb occlusion

Question 18

Forces required to migrate different grafts

Answer 18

Sewn on grafts: 150N Zenith: 24N Ancure: 12.5N Vanguard 9N Talent 4.5N

Question 19

Patency of Aortouni with fem-fem bypass

Answer 19

90.9% at 54 months 97.7% primary patency at 66 months 100% secondary patency at 66 months

Question 20

Rate of type 2 endoleak on post-op CT

Answer 20

10-20%

Question 21

Type 2 endoleak natural course

Answer 21

80% resolve in 12 months no correlation with rupture based on EUROSTAR

Question 22

Options/approach to treating type 2 endoleak

Answer 22

1) Transarterial 2) Translumbar

Question 23

Type III endoleak rate

Answer 23

0-1.5%

Question 24

Duplex sensitivity for endoleaks

Answer 24

67%

Question 25

Migration causes of endografts

Answer 25

1) Neck dilatation 2) Sac shrinkage + shortenings 3) external compression

Question 26

AneuRx migration risk

Answer 26

8.4%

Question 27

Stent limb occlusion rates

Answer 27

3-7% at 4 year most occur in first 6 months

Question 28

Risks of stent limb occlusions

Answer 28

1) Aortoiliac occlusive disease 2) Small aorta < 14 mm 3) Tortuous iliacs 4) landing in EIA

Question 29

Are neck dilatations over time related to radial force of endografts

Answer 29

No unless it’s 1) AneuRx 2) >30% oversized

Question 30

Infection rate of EVAR

Answer 30

0.2-0.7%

Question 31

Current mortality rate of EVAR

Answer 31

3.6%

Question 32

Pelvic ischemia symptoms

Answer 32

1) Butt claudication/necrosis 2) spinal cord ischemia 3) colorectal ischemia 4) erectile dysfunction

Question 33

Unilateral and bilateral IIA embolize risk of butt claudication

Answer 33

52% and 63%

Question 34

Natural course of IIA embolize induced butt claudication

Answer 34

2/3 improve in 1 year

Question 35

Unilateral and bilateral IIA embolize risk of ED

Answer 35

17% and 24%

Question 36

Risk of colonic ischemia in EVAR

Answer 36

1.7%

Question 37

Risk of spinal cord ischemia with bilateral IIA occlusion

Answer 37

3% paraparesis

Question 38

SVS guideline for follow up post CT

Answer 38

CTA 1 month and 12 month if endoleak then repeat in 6 months if no leak then duplex annually

Question 39

What are CardioMEMS

Answer 39

30x5x1.5 mm sensory placed in sac at time of EVAR to measure endotension

Question 40

Reintervention rates for zenith and talent at 4 year

Answer 40

7% Zenith 9.4% Talent

Question 41

Rate of endoleak at 5 years

Answer 41

12-15%

Question 42

Largest treatable CIA aneurysm

Answer 42

25mm with Endurant 28mm graft

Question 43

In hospital cost of EVAR

Answer 43

$20000 USD

Question 44

OVER trial on cost

Answer 44

EVAR cheaper initially but converges at 2 years

Question 45

Surveillance strategy following endovascular aneurysm repair

Answer 45

Question 46

Timeline for Endovascular Aneurysm Repair Development

Answer 46

Question 47

Device Characteristics of Current Stent Grafts

Answer 47