ABDOMINAL AORTIC ANEURYSM IMAGING SURGICAL AND PERCUTANEOUS SELECTION
ABDOMINAL AORTIC ANEURYSM IMAGING SURGICAL AND PERCUTANEOUS SELECTION
Abdul R. Halabi, MD, FACC Cardiology and Vascular Associates, P.C. Intervention...
ABDOMINAL AORTIC ANEURYSM IMAGING SURGICAL AND PERCUTANEOUS SELECTION
Abdul R. Halabi, MD, FACC Cardiology and Vascular Associates, P.C. Interventional Cardiology, Beaumont Health System Assistant Professor of Medicine, Oakland University William Beaumont School of Medicine
No disclosures.
OUTLINE
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NATURAL HISTORY
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ANATOMICAL FEATURES
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IMAGING MODALITIES
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ROLE OF IMAGING • OPEN VS ENDO REPAIR • POST REPAIR SURVEILLANCE
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CHALLENGING CASES
AAA DISEASE
“The natural history of an abdom inal aortic aneurysm is to enlarge and rupture”.
MOST AAAS ARE ASYMPTOMATIC Many patients are not diagnosed prior to symptoms and fatal rupture
SCREENING •
The USPSTF recommends a one-time screening for abdominal aortic aneurysm by ultrasonography in men aged 65 to 75 who have ever smoked (Grade B).
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The USPSTF recommends against routine screening for AAA in women (Grade D).
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The SVS recommends screening for men & women with a family history of AAA at age 55 & 65 years, respectively.
EPIDEMIOLOGY
Increasing incidence with age Increasing prevalence over past 30
years Likelihood of having an aneurysm is 1 in 10 among 75 year old men
CLASSIFICATION
NOTABLE INDIVIDUALS WITH RUPTURED AAA
Albert Einstein
Lucille Ball
Conway Twitty
Roy Rogers
George C. Scott
Only Roy Rogers survived a ruptured AAA…
Albert Einstein
1948 underwent cellophane wrap of his AAA 1955 aneursym ruptured and Einstein refused further treatment (he wanted to die with "dignity”) Dubost did first open surgical repair in 1951 – Open surgery becomes standard of care for AAA
Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:491-9
DIAMETER AND RISK OF RUPTURE
Diameter
Annual Risk of Rupture
< 4 cm
0%
4 - 5 cm
0.5 - 5 %
5 - 6 cm
3 - 15 %
6 - 7 cm
10 - 20 %
7 - 8 cm
20 - 40 %
> 8 cm
30 - 50 %
J Vasc Surg 2003;37:1106-17
OUTLINE
•
NATURAL HISTORY
•
ANATOMICAL FEATURES
•
IMAGING MODALITIES
•
ROLE OF IMAGING • OPEN VS ENDO REPAIR • POST REPAIR SURVEILLANCE
•
CHALLENGING CASES
HIGH RISK FEATURES
AAA > 4 cm AAA 4 to 5 cm with increase in size of > 5mm past 6 months AAA size twice the size of infrarenal neck Saccular
J Vasc Surg 2001;33:S135-45
ROLE OF IMAGING IN OPEN VERSUS ENDO REPAIR PLANNING •
ANATOMICAL CONSIDERATIONS • AAA and Iliac Size • Angulation and Tortuosity • Infra-Renal Neck • Thrombus
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PROCEDURAL PLANNING • Side Branches
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POST REPAIR SURVEILLANCE • Endoleaks and Re-intervention Planning • Device Migration
ANATOMICAL CONSIDERATIONS
Proximal aortic neck – Diameter of device oversized 10-20% – Length ≥ 1.5 cm for all FDA approved devices
Angulation/tortuosity – Short angulated necks, short wide necks, & severe AAA tortuosity can lead to suboptimal outcomes
Iliac access – Large enough to accommodate 16F-24F delivery systems (7-8mm for bifurcated devices)
ANGULATION
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Defined as the angle formed between the vertical plane and a line that transects the long axis of either the neck or the aneurysm. An angle of 60º or more leads to difficulties in implantation, kinking, leakage, and the possibility of downward migration of the device. Relative contra-indication to EVAR.
