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Wave 2: Module 3: Aortic Week 6 – Case 2
•68 Male is referred to you from the regional screening program with AAA > 5.5 cm on US
•Q1: The patient is with you in the clinic now, explain the key history and examination points.
•He has a back ground of: HPN otherwise fit and well. He is a current smoker. He has no family history of aneurysms . He is still working asa project manager and he is quite active playing golf every weekend.
•Regular meds; Ca channel blocker.
•Examination : BMI 29 , Abdominal examination NAD. Palpable non tender aneurysm palpable distal pulses . You can feel prominent popliteal pulse on the left side.
Q2: What are your next steps and explain he rationale for each step.
•Bloods: Hb 14, eGFR >90 HBA1c 5
•Echo normal
•CPET AT 15 mlO2/kg/min with peak AT 20 mlO2/kg/min
•Spirometry – FEV1 (70%)
•Rockwood Clinical Frailty Score: 1
•reviewed by vascular anaesthetist : Fit for intervention (endovascular /open).
•CTA of the whole aorta showed 65 mm Type 2 TAAA extending to Aortic bifurcation.
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•Left pop artery aneurysm 2.5 cm with no thrombus and 3 vessel run off.
| Thoracic Aorta | Aneurysmal beyond the LSCA. Normal arch Proximal landing zone is as described | Patent subclavian artery bilaterally | ||
| Abdominal aorta | Aortic bifurcation 24 mm | Distal Rt CIA landing zone 18 mm ( 2 cm length) | Distal Lt CIA landing zone 20 mm ( 2 cm length)L | |
| Access | RT CFA 8 mm . Mild post wall atheroma | Rt EIA 11 mm minimal tortuosity | LT CFA 8 no atheroma | Lt EIA 10 mm minimal tortuosity |
| L | IVD | CLOCK | ||
| CA | 0 | 42 | 12 | 6 mm |
| SMA | 22 | 40 | 1245 | 7 mm |
| RRA | 28 | 35 | 1000 | 6 mm single artery |
| LRA | 29 31 | 35 35 | 0330 0400 | 5 mm 3 mm supplying lower pole |
•Q3 : The patient came back to see you after undergoing the tests . Based on the data and the imaging finding explain your discussion with the patient regarding options and what evidence you have to support your decision making .
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•Q4: Explain with evidence your approach and plan
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•Q 5 :what is your plan for device and why (open/ FEVAR, BEVAR , T branch , ChEVAR). Any evidence to choose one approach versus the other ?
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•Q6 : The patient came back after considering the options and decided to undergo endovascular approach . Ellaborate on your consent process .
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•Q7: What is your approach towards the popliteal aneurysm?
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•Q8: In a similar scenario the popliteal aneurysm was 3.5 cm with large thrombus burden and a single vessel run off. What is your plan of management ?
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A1:key hx and ex
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A2: next steps
For investigations,
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A3:options and decision making
it’s a TAAA more than 6.5 cm or an AAA above 5.5 cm, then it clearly needs intervention.
both open and endovascular repair are possible.
ADAM and UK SMALL ANEURYSM trials that recommend repair of aneurysms more than 5.5 cm in diameter
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A4:approach and plan
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A5: evidence for approach advised
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A6:consent process
expected post op complications need to be clear and to be cosented like ….
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Q7:approach to current pop aneurysm
Both options are valid — either covered stent or open surgery on elective base
Depends on presenting symptoms, the anatomy, the team experience, and the patient’s general condition.
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Q8:approach to pop aneurysm with 3,5 cm and thrombus
on urgent base
If there’s rupture or symptomatic aneurysm, then I’d go for open evacuation of the aneurysm sac and repair the artery with short exclusion bypass
if there is no rupture or symptoms ,then I’d go for EPAR by covera stent.
Q1:
I’d start by asking about smoking, lifestyle, how active he is. Also past history of hypertension or diabetes. Then I’d ask if he had any previous abdominal surgeries. Family history is important too, especially if there’s any aneurysms or sudden deaths. Presenting symptoms matter — like abdominal pain, any GI bleeding, or pressure symptoms like lower limb issues or renal signs.
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Q2:
On exam I’d check vital signs first, then do an abdominal exam to look for any pulsatile mass, check peripheral pulses, and also do a chest exam.
For investigations, I’d request CTA with 0.5 mm cuts from the aortic root to the feet, sagittal views included. I’d also do an echo, and maybe stress echo or CPET depending on the patient’s general condition.
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Q3:
If it’s a TAAA more than 6.5 cm or an AAA above 5.5 cm, then it clearly needs intervention. If the patient is generally fit, both open and endovascular repair are possible. But in older patients or those with higher peri-op risk, we usually prefer the endovascular option. And if the inner diameter is large, like more than 40 mm, then BEVAR might be the better choice.
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Q4:
In this case I’d go for a staged endovascular approach. First stage would be placing a covered stent for the thoracic part, maybe with carotid-subclavian bypass if needed. Then second stage would be BEVAR to manage the abdominal aneurysm and preserve the visceral branches.
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Q7:
Both options are valid — either covered stent or open surgery. Depends on the anatomy, the team experience, and the patient’s general condition.
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Q8:
If there’s rupture or symptomatic aneurysm, then I’d go for open evacuation of the aneurysm sac and repair the artery with a stent graft if possible.
Q1
History :
Personal history of smoking, activity, lifestyle
Past H of DM, htn
Surgical H of any abd operation
Family H of aneurysm
Present H of abd pain, git bleeding, pressure manifestation
Q2
Examination
General : vital signs
Local : Ăbď examination, peripheral, respiratory system exam
Investigation
CTA multislice with ,5 mm cut sections saggital view from aortic root till foot
Echo
Stress echo
CPET
Q3
TAAA > 6.5
Need rapid intervention
AAA > 5.5
Need intervention
Both OSR and EV are possible as pt fit
But old age with increased perioperative morbidity has favor for Endo vascular
BEVAR is suitable as large inner vascular diameter > 40 mm
Q4
Stagged endovascular approach
1 st covered stent for TAAA with carotid subclavian bypass
2 nd stage is BEVAR for abdominal aortic aneurysm and saving visceral branches
Q7
Covered stent or open
Both of them is proper for this pt
Q8
Open evacuation of aneurysm and stent graft repair of artery
A1:
Full history medical surgical medications and allergy as discovered during screening with no symptoms
Social and family history
A2:
CTA from aorta to feet as long as prominant pop pulsation to confirm pop a aneurysm
Echo
Pulm function tests
Labs
A3,4,5and 6:
Assess the patient fitness for intervention
Evaluate the CTA data regarding the access site the proximal and distal landing zones the size of aneurysm the visceral and renal brr inflow and outflow vv and ptn preferences to take the decision
According to the data available the ptn is fit for both OSR and EV but clamping would be very proximal with increase in mortality and morbidity peri procedural and the ptn has a successful job so delayed recovery with prolonged hospital stay is to be cosidered so EV option is preferred
BEVAR in this situation is better than FFEVAR according to the IVD more than 40 mm at visceral segments with the ChEVAR is not an option according to EVES guidelines 2024
Staged procedures for the type II TAAA with TEVAR first then BEVAR as a stage 2 procedure
SCI is a great risk to be explained clearly to the ptn and csf dainage and staged procedures to be done for sp cord protection
Endoleak with progressive sac expansion
AKI
Rupture
Thrombosis of brr or limbs
distal embolization
are expected post op complications to be cosented
A7:
Pop art 2.5 with no thrombosis and 3 vv run off is to be done later either OSR exclusion bypass vein graft med approach or EPAR stent graft VBX
A8:
3.5 pop art aneurysm with mural thrombus and singl run off vessel is for urgent reconstruction for the fear of rupture or thrombosis with ALI up to amputation before the BEVAR procedure and preferably bu exclusion and distal run of vv ebmbolectomy and by pass graft med approach better for tibial vv exploration
Well done. Any evidence to help you choose open versus endovascular repair in Q7
for a patient with discovered AAA during survey the main history important points are
Medical history of .. HTN, DM, Hyperlipidemia
Smoking history
Level of daily activities
Family history especially first degree relatives of AAA
Any previous abdominal surgery
For examination
General examination for patient vital signs are very important in case of suspected rupture AAA
Local examination of palpable abdominal masses , abdominal tenderness, distal pulsations
Pulsation of any associated femoral or popliteal aneurysm
Q2 answer
Next step will be CTA of entire aorta all the way down to the feet
Then asking for investigations to assess patient general condition as CPET, ECHO, CBC, KFT, and LFT
Q3 ANSWER
For that patient I will explain that he has a TAAA. With a diameter or 6.5 cm that need to be repaired to avoid risk of rupture according to ADAM and UK SMALL ANEURYSM trials that recommend repaire of aneutysms nore than 5.5 cm in diameter
He has a complex TAAA that require extra maneuvers during repair either open or endovascular which both fit the patient but with lower peri operative risks for the endovascular root with potentially higher reintervention rate and more spinal cord ischemic events
And the surgical root is more durable with lower reintervention rate and more peri-operative morbidity
That is supported by UK COMPASS TRIAL and several recent meta-analysis
Answer q4 and q5
My approach will be staged endovascular aneurysm repair starting from the thorathic segment at first with using femoral arteries as access sites the landing zones will be zone two and that will require LT SCA. Revascularization
The used graft will be most probably BEVAR graft due to the large inner vessel diameter at the visceral branches take off .a size that is large enough to allow branched EVAR grafts to be used as cannulation sites for visceral branches stentgrafting
Then after 6 to 8 weeks I wi ll go back to repair the rest of infra renal aorta to to allow time for spinal blood flow to increase by collateral circulation
Q6 answer
I will concent the patient of possible intra operative complications as
Rupture aneurysm and possibility for open conversion if the situation cannot be solved by endovascular means , myocardial ischemia
Access sites complications as hematoma ,pseudoaneurysm formation , vessel rupture, dissection , and distal embolization of atheromatous plaqes
Post operative complications as endoleak and possible reintervention, bowel ischemia, spinal cord ischemia and possible paraplegia, acute renal failure, and abdominal compartmental syndrome
Late complications as graft migration, separation, thrombosis ,and infection
Q7
2.5 cm popliteal aneurysm is a large enough to warrent intervention and I will use endovascular exclusion by stent graft
Q8 in that scenario with fear from showering and occluding the resedual patent vessel open exclusion bypass is a more suitable choice
Well done.
Is the risk of spinal cord ischemia higher in endovascukar versus open surgery ?
Why did you choose endovascular option in Q7
In general SCI incidence is higher in OSR than in endovascular repair ,I meant the incidence I high in that particular case scenario as coverage of entire thoracoabdominal aorta will. Carry a higher risk in OSR reimplantation of artery of adamkeiwitz may reduce the incidence
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I chooses it as it is more rapid than open surgery to decrease the burden over the patient