Mortality ConferenceJuly 26, 2007

Makati Medical Center

Jumel V. Bornilla, MD

Josephine M. Deveza, MD

Objectives

• To present a case of asymptomatic abdominal aortic aneurysm.

• To discuss the current guidelines/recommendations in abdominal aortic aneurysm.

• To discuss its prognosis and management.

Clinical Date

• 72 year old

• Male

• Came in for coronary angiogram

History of Present Illness

• About 2 weeks PTA– elevated PSA

• 14.55 NG/ML (0 – 4 NG/ML)

– ultrasound of the whole abdomen • Abdominal aortic aneurysm probably infrarenal

(5.4 x 4.1x 3.7cm), fusiform.• Right renal mass• Mild prostate gland enlargement

History of Present Illness– CT scan of the whole abdomen

• Atherosclerotic infrarenal abdominal aortic aneurysm about 5.6cm with accompanying large thrombus formation.

• Abdominal aortic calcification of the suprarenal abdominal aorta as well as common iliac, internal and external iliac branches.

• Large thrombus formation noted medial and posterior in the right common iliac artery measures 4.4cm greatest axial diameter. Saccular aneurysmal dilation with thrombus formation in the right common iliac.

• Antero-lateral right renal cortical nodule measuring 2.0 x 2.0 x 2.0cm main consideration is renal cell Ca stage II

• Advised surgery• Admitted for further work up

Review of Systems

• (-) headache, (-)dizziness, (-) BOV• (-) cough and colds, (-)nasal congestion,

(-) dyspnea• (-) chest pain, (-) palpitations, (-) orthopnea,

(-) PND• (-) heartburn, (-) changes in bowel movement,

(-) hematemesis, (-) hematochezia, (-) melena, (-) weight loss

• (-) hematuria, (-) dysuria• (-) edema

Past Medical History

• Hypertensive for 30 years with good BP control, maintained on Amlodipine 5mg tab OD, Nifedipine 5mg tab SL prn

• History of bronchial asthma

• Dyslipidemic on Rosuvastatin 10mg tab OD HS

• No diabetes mellitus

• No history of ischemic heart disease

Family History

• (+) Hypertension – siblings• (+) Diabetes Mellitus – siblings, mother• (+) Bronchial Asthma • (+) Lung Cancer – uncle• (+) Prostate Cancer - brother• No history of coronary artery disease, • No cerebrovascular disease

Personal and Social History

• Non smoker

• Non alcohol beverage drinker

• Allergy to Aspirin and Penicillin

Physical Examination

Gen. Survey: conscious, coherent, not in respiratory distress

Vital Signs:

BP:140/70 mmHg CR:80 bpm RR:18 cpm To:37.1C

Height: 158cm Weight:~ 63.5kg BMI: 25.4 kg/m2

HEENT: pinkish palpebral conjunctivae, anicteric sclerae, flat neck veins, no palpable thyroid, (-) neck masses, (-) carotid bruits, (-) lymphadenopathies

Chest: symmetrical chest expansion, (-) intercostal retractions, (-) rales, (-) wheezes

Cardiac: Adynamic Precordium, regular S1S2, apex beat at 5th ICS LMCL, (-) S3S4, (-) murmurs, (-) thrills

Abdomen: Globular, NABS, (-) bruits, normo-tympanic, (-) tenderness (-) organomegaly

Extremities: well-developed, (-) cyanosis, (-) erythema, (-) femoral bruits, unequal peripheral pulses (Left femoral, popliteal, dorsalis pedis > Right femoral, popliteal, dorsalis pedis)

Physical Examination

Admitting Impression

• Abdominal aortic aneurysm, Infrarenal

• Hypertensive atherosclerotic cardiovascular disease

• Benign Prostatic Hypertrophy

• T/C Consider Renal Cell Ca, Right

Course in the ward

• On admission:

• Coronary angiogram with aortogram Single vessel coronary artery disease

involving the LADInfra-renal aortic aneurysm

Course in the ward

• Nephrology service impression:– CRI prob 2’ to Hypertensive Nephropathy– Hypertensive Atherosclerotic Cardiovascular

Disease– T/C Renal Cell Ca, Right

Intra-operative Course

• Patient underwent coronary artery bypass graft –LIMA-LAD

• Acute aortic dissection developed in the ascending aorta

• Repair was done under profound hypothermic condition

Intraoperative course

• Massive blood loss (9.1L)

Blood Tranfusions

Triple vasopressors

• Hypotension

Post-operative Course

• Unresponsive, pupils fixed dilated (initially)

• (~8hrs) Referred Neurologist

• Stable vital signs

• Improvement of neurologic status

• Lethargic, pupils 2-3mm sluggishly reactive to light, can follow command

• Reoperation: repair of bleeders and removal of clots

(~34hrs) Post-operative course

• Continuous Renal Replacement Therapy

• Hypotensive and bradycardia

(3rd post-op day) cardiopulmonary arrest

Final Diagnosis

• S/P CABG – LIMA --> LAD• S/P Repair of acute aortic aneurysm, ascending aorta

under profound hypothermic circulatory arrest• S/P control of bleeders • Acute renal failure• Hypoxic Ischemic Encephalopathy 2’ to brainstem infarct• Abdominal aortic aneurysm (infrarenal and right common

iliac)• Right renal cortical nodule T/C Renal cell carcinoma• Benign Prostate Hypertrophy• Systemic Arterial Hypertension• Dyslipidemia

Abdominal Aortic Aneurysms

AAA Basics: What is it?

• Most common between renal arteries and bifurcation

• Infrarenal Aorta is

between 1.4 and

3.0cm

• Average Aorta size

is 2.0cm

AAA Basics: What is it?

• Most aortas less than 5cm in diameter do not rupture

• Transverse 3rd vertebrae diameter is a good baseline for minimal rupture size

AAA Basics: How Often?

• ADAM study showed prevalence of AAA of 4 cm in 1.4% of vets 50-79

• Men affected 4x more

• 2x more common in whites

• Average age 69 year for men, 78 years for women

ADAM – Aneurysm Detection and Management

Abdominal Aortic Aneurysm

• AAA is common and becoming more common

• 2.3 to 3.2 million Americans >60 yrs have AAA

• 200,000 new diagnosis each year• 15,000 die each year from rupture• 13th leading cause of death in US, 3rd

leading cause of sudden death in men >60• 75% are asymptomatic until they rupture

AAA Basics: Mortality

• 15,000 lives per year taken due to rupture (13th leading cause of death)

• 40% of 5.5-6cm AAAs will rupture in 5 years

• Average survival if untreated is 17 months

AAA Basics: Mortality

• Small Aneurysms carry much less risk, 0.5% of 4-5.5 cm rupture

• Therefore small AAAs can be monitored with ultrasound

AAA Basics: Risks?

• Smoking increases risk 8x in ADAM

• HTN present in 40% of patients• Family history and

presence of COPD are also cofactors

• Cholesterol may play a role

Rupture Risk of Untreated Aneurysms

• High mortality due to rapid circulatory collapse

• Up to 50% of patients with untreated aneurysms >5.5 cm will die of rupture in  5-year period

• 50% of emergent cases arrive in ER alive– 50% of this group survives surgical

conversion

Mitchell, MD, Rutherford RB, Krupski WC. “Infrarenal Aortic Aneurysm” in Vascular Surgery (4th Ed. Vol. Il ) W.B. Saunders Company., Philadelphia, PA 1995

AAA Diagnosis

• An intact AAA produces only minimal symptoms, if any

• Most patients may know of painless, throbbing mass

• Back pain is rare, due to pressure on nerves, vertebral erosion

AAA Imaging

• Ultrasound is most useful and least expensive mode of diagnosis

• Best used to assess progression of AAA size

• Average expansion of 0.4 cm/year

Longitudinal Section of 2cm Aorta

AAA Imaging• CT and CTA are also

very effective tools to outline size and shape of AAA

• Because of CT and MRI, aortograms are not performed as frequently

AAA: Assessment

Management of abdominal aortic aneuryms. CT indicates computed tomography; MR, magnetic resonance imaging.

Management of abdominal aortic aneuryms. CT indicates computed tomography; MR, magnetic resonance imaging.

AAA Surgery• Performed because of natural history of AAA expansion and risk of

death• There is also morbidity due to arterial thromboembolism to legs• Therefore surgery is recommended in AAA over 5.5 cm• 2002 study showed no benefit to operate on small (4-5.5) aneurysms

ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral

Arterial Disease (Lower Extremity, Renal, Mesenteric, andAbdominal Aortic)

Class I

1. Patients with infrarenal or juxtarenal AAAs measuring 5.5 cm or larger should undergo repair to eliminate the risk of rupture. (Level of Evidence: B)

2. Patients with infrarenal or juxtarenal AAAs measuring 4.0 to 5.4 cm in diameter should be monitored by ultrasound or computed tomographic scans every 6 to 12 months to detect expansion. (Level of Evidence: A)

ACC/AHA 2005 Practice Guidelines for the Management of Patients With

Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, andAbdominal Aortic)

Class IIa

1. Repair can be beneficial in patients with infrarenal or juxtarenal AAAs 5.0 to 5.4 cm in diameter. (Level of Evidence: B)

2. Repair is probably indicated in patients with suprarenal or type IV thoracoabdominal aortic aneurysms larger than 5.5 to 6.0 cm. (Level of Evidence: B)

3. In patients with AAAs smaller than 4.0 cm in diameter, monitoring by ultrasound examination every 2 to 3 years is reasonable. (Level of Evidence: B)

ACC/AHA 2005 Practice Guidelines for the Management of Patients With

Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, andAbdominal Aortic)

Class III

• Intervention is not recommended for asymptomatic infrarenal or juxtarenal AAAs if they measure less than 5.0 cm in diameter in men or less than 4.5 cm in diameter in women. (Level of Evidence: A)

Medical Management of Asymptomatic Aneurysms

• Aggressive blood pressure control, with beta blockers being part of the regimen in an attempt to slow aneurysm growth.

• Surveillance for the development of signs and symptoms that may be associated with the aneurysm.

• Serial imaging of the aneurysm to evaluate growth and structure.

Surgical Therapy: Indications

• The presence of symptoms

• A diameter of 5 to 6 cm for an ascending aortic aneurysm and 6 to 7 cm for a descending aortic aneurysm; often 7 cm in high risk patients

• Accelerated growth rate (1 cm per year) in aneurysms less than 5 cm in diameter

• Evidence of dissection

Surgical Outcome

• The subsets of aortic arch and Crawford type II (proximal descending to infrarenal aorta) aneurysms have the highest morbidity and mortality rates

• The incidence of postoperative acute renal failure severe enough to require dialysis was 7 percent

• The long term mortality and morbidity were related to other cardiovascular events, such as aneurysm in other areas, MI, and stroke

AAA Repair

Two types of repair performed

OPEN ENDOVASCULAR

First performed 1951•Now involves placement of Dacron or PTFE graft•2-4% operative death rate, 5-10% complication rate

First performed 1991• Less invasive, done through femoral vessels• Only certain types of AAA can be repaired

Open vs. Endovascular

Anatomic Criteria

• Proximal neck length >15 mm diameter <28 mm

• Tube graft: distal cuff length >10 mm diameter <28 mm

• Iliac artery diameter >7 mm and < 15 mm– Minimal to moderate tortuosity

• No mural thrombus at attachment sites• Minimal calcification

• No associated mesenteric occlusive disease

Potential Complications

• Blood Clots Requiring Reoperation

• Reaction to Blood Transfusion

• Bowel Dysfunction• Impotence• Paraplegia due to

loss of Spinal Artery

DeathBreathing Problems

PneumoniaAirway SpasmVentilatory Failure

Kidney FailureBleeding

Indications for Endovascular Repair

• High risk patients—excessive morbidity and mortality

• Parodi—initially used endografts only in patients deemed not surgical candidates– Advanced age– FEV1 < 800cc– Renal insufficiency– Multiple previous abdominal operations

Open Repair: Drawbacks 

• Significant incision in the abdomen

• 30–90 minute cross-clamp

• Up to 4-hour procedure

• Contraindicated in many patients

• 1–2 days intensive care, 7–14 days hospitalization, 4–6 weeks recovery time

Open Repair: Drawbacks 

• Many patients considered “unfit” – High anesthesia risk– Significant cardiac comorbidities – Previous abdominal surgery/hostile abdomen

• Difficult recovery for patient– Risks losing independence– Reoperation risk– Risk of impotence

J Vasc Surg 2001; 33:913–20Ann Vasc Surg 2000; 14:13 – 19

Patient Risk during Elective Transabdominal AAA Repair 

(Canadian Prospective Study, 666 patients)

• Cardiac event 15.1%• Congestive Heart Failure 8.9%• Arrhythmia 10.5%• Myocardial Infarction 5.2% • Prolonged ileus 11.0%• Respiratory failure 8.4%• Renal damage 5.4%• Mortality 4.8% • Limb ischemia 3.5%  

K.W. Johnston, J VASC SURG 1989; 9:437-47

Tube Endograft Placement

Katzen, et al

Uniiliac Endograft Placement

Semba, et al

Bifurcated Endograft Placement

Katzen, et al

AneuRx • Medtronic• Modular bifurcated

with extension cuffs• Graft—thin walled

polyester• Stent—outer self

expanding Nitinol stents

• Delivery—25F introducer sheath– Mechanical deployment

handle

May, et al

Benefits• Theoretical

– Reduced complications and mortality– Decreased hospitalization– Decreased cost

• Realized– Same number of complications but different types

• Less systemic complications, same mortality• Shorter respiratory support

– Decreased ICU and hospital stay– Decreased blood loss– Cost?

Results of Endovascular Repair

• Several initial studies in small groups of patients showed no mortality benefit to endovascular repair (Blum et. al. 1997, May et. al 1997)

• Follow up study by Treharne in 1999 showed modest improvement using physiologic assessments

• Many questions in literature regarding efficacy of EAAA repair (Collin and Murie 2001 “A Failed Experiment”)

Costs of EAAA repair

• Claire in 2000 studied 139 patients– Determined that average savings of EAAA

was approx 6,000 pounds before graft cost• 9 days in hospital vs. 3 days

– To break even, grafts need to become cheaper, original devices were custom-made and expensive ($10,000+)

– Some thought the procedure was not worth extra cost and complications

• Lifelong CT follow-up to detect leaks is expensive!

Endovascular Approach: Simulates Surgical Placement

Documented Benefits:

• Shorter hospital stay

• Less blood loss during operation

• Fewer postoperative complications involving respiratory system and heart

• Less patient discomfort and shorter recovery time

Benefits of Endovascular Repair 

                           Endograft    Open Repair• Blood loss (ml)           641 1596• Blood replaced (units)        0.3 1.6 • Extubation time (days)        0.1 0.9• ICU time (days)            0.9 2.5• Hospital LOS (days)          3.4 9.4• Ambulate w/o   •     assistance (days)           1.5 4.0• Regular diet (days)          1.4 5.1

p<0.05 in all cases 

Vasc Surg 1999; 29:292–308

Endografts: Summary of Clinical Results 

• Reduced morbidity and equal mortality compared to open repair

• High technical success• Acceptable incidence of secondary procedures• Low incidence of surgical conversion, early and

late• Effective in preventing rupture in majority of

patients 

J Vasc Surg 2001; 33:S135–45

Endovascular Repair: Drawbacks 

• New, evolving therapy

• Limited long-term data

• More intense patient follow-up with surveillance CT exam

Complications of EAAA repair

• Systemic– MI, CHF, arrhythmias, respiratory failure, renal failure

• Procedure related– Dissection, malpositioning, renal infarction,

thromboembolizaton, ischemic colitis– Groin hematoma, wound infection

• Device related– Migration, detachment, rupture, stenosis, kinking,

endoleak

Endoleaks

• Coined by White, et al, 1996– Leak around proximal or distal attachment

sites• Persistent flow in aneurysm sac• Incomplete exclusion

• Rates– 0 to 44%

• Risks– Expansion– Rupture

Endoleak Classification• Type I—perigraft

– Persistent flow at proximal or distal attachment sites

• Type II—retrograde flow from side branches– Inferior mesenteric or lumbar arteries– Subgroup A: inflow only; B: in and outflow

• Type III—graft defect

• Type IV—graft porosity

• Primary or secondary

Changes in Aortic Morphology

• Aneurysm diameter– Growth in size associated with persistent endoleak

• Neck size– Annual expansion 0.7mm 1st year, 0.9mm 2nd year– May lead to migration and late endoleaks

• Aneurysm length– Shortens >5mm in 68% patients at 12mos– Associated with kinking and dislocation

EAAA in 2004

• There are many new grafts available, now they are ‘Second Generation’– Data from EUROSTAR (4000+ patients)– Newer grafts have better 3-year mortality– Fewer secondary interventions– Fewer conversions of open repair– Fewer graft rupture– Shorter hospital stay

Torella et. al. 2004

Projected Impact of AAA   Screening Program 

• Americans with AAA age >60: 2.3–3.2 million (5–7%)

• Annual deaths from AAA rupture: 15, 000• Lives saved annually from screening: 10,000• Annual savings in direct health care costs from 

AAA screening: $50 million

 The Interventionalist 2001; 1:4

Deaths in Controlled Screening Trial of Men Aged 64 to 81 

Eur J Vasc Endovasc Surg 2001; 21:535-40 

• Screening identifies the most clinically significant aneurysms in one session and may reduce mortality nearly 70%

Screening for AAA 

Who to screen– Older patients (>55 yr), particularly men and

Caucasians– Patients with risk factors:

• Smoking• Hypertension• Atherosclerosis

How to screen– Ultrasound– Palpation

Summary• Endograft AAA repair is still a developing

field with promise– Certain patient populations may benefit– Long term trials are ongoing– Lot of Baby-Boomers will need AAA repair

Current Therapy: Open Surgical Repair

Aneurysm opened, graft sewn in, aorta wrapped and closed around graft

• Established procedure  (>40 years)

• Excludes aneurysm and prevents sac growth• Proven, long-term results• Considered the “gold standard”• Operative mortality

– 1% to 5% (elective repair)

Open Repair and Graft

Thank you all for your attention and participation.