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Week 2 – Case 1
68ys screen detected AAA male with a past history of hypertension and prostate cancer stage 3 under hormonal treatment for 4ys with stable PSA. No other significant medical conditions.
Fit and active walks 5 miles 3-times a week
Aneurysm now 5.7 on CTA and it was found to be anatomically suitable for EVAR.
Assume you assessed him clinically
1- What investigations you would like to request?
2- Patient read about both modalities of repair and asks for your advice, what would you recommend?
3- Taking your advice, he is more inclined towards OSR, do you agree or disagree and why?
4- He asks about recovery, possible risks ,follow up protocol of OSR and the likelihood of needing further interventions compared to standard infra-renal EVAR?
5- Could you please give comment on available evidence that you may use to make your decision?
routine labs, pre-op investigations including, echo, cardiac perfusion scan, cardiopulmonary fittness scan
there are no contraindications in given histormfor open repair, i have no clinical data to favour endo/open, i would explain general principles, endo being less invasive, less demanding with more quick recovery times and return to normal activity, however, open repair is more durable, less incidence of 2ry interventions.
Given anatomical suitabilty for EVAR i would personally recommend it, however patient preference should be respected.
- routine labs, pre-op investigations including, echo, cardiac perfusion scan, cardiopulmonary fittness scan
- there are no contraindications in given histormfor open repair, i have no clinical data to favour endo/open, i would explain general principles, endo being less invasive, less demanding with more quick recovery times and return to normal activity, however, open repair is more durable, less incidence of 2ry interventions.
- Given anatomical suitabilty for EVAR i would personally recommend it, however patient preference should be respected.
1- What investigations you would like to request?
- I will request full bloods, including FBC, renal and liver function, coagulation screening
- serum albumin and nutrition status (recommendation 39 class I level C)
- ECG, Echo, pulmonary function tests (recommendation 34 class IIa level C) or CPET
2- Patient read about both modalities of repair and asks for your advice, what would you recommend?
patient is relatively young and fit, so I will recommend open repair
(NICE guidlines Offer open surgical repair for people with unruptured AAAs meeting the criteria in recommendation 1.5.1, unless it is contraindicated because of their abdominal copathology, anaesthetic risks, and/or medical comorbidities).
3- Taking your advice, he is more inclined towards OSR, do you agree or disagree and why?
I agree, because it meets the NICE guidlines as mentioned above, taking in consideration his prostate cancer is stable, not on chemo, no METs
4- He asks about recovery, possible risks ,follow up protocol of OSR and the likelihood of needing further interventions compared to standard infra-renal EVAR
recovery is longer with OSR with ICU admission after theatre for advancing monitoring
it caries the risks of Cardiac events, mortality 5% which more than EVAR, also other complication of infection, bleeding, chest infection, bowel ischemia, VTE, but it is more durable and less likely to need further intervention.
Q1:,
Lab investigation; CBC, bleeding profile, KFTs,LFTs,CRP,S.ALBUMIN
CARDIOPULMONARY FITNESS;(CEPT if available ) ECG,ECHO,PULMONARY FUNCTION TEST
Q2:
OSR is preferred as long as the patient is fit due to less need for reintervention and prolonged patency rate
Q3 :
if the patient is fit for osr, I will agree
Q4:
according to OSR
Prolonged hospital stay and recovery
Possible need for ICU admission
Need for rehabilitation 3 : 6 months
According To F.U (neurological , cardiac , bowel ischemia and LL perfusion)reintervention is higher for EVAR
Possible complications ;infection, 2 ry Hemorrhage, cardiac complications,pulmonary complications, renal failure ,acute limb ischemia, bowel ischemia, aortoenteric fistula ,anastomosis aneurysms
Q1) : I would order:
* 18F-FCH PET/CT ( for proper cancer Staging).
Ferda, J., Baxa, J., Ferdova, E., Kucera, R., Topolcan, O., & Molacek, J. (2019). Abdominal aortic aneurysm in prostate cancer patients: the “road map” from incidental detection to advanced predictive, preventive, and personalized approach utilizing common follow-up for both pathologies. EPMA Journal, 10, 415-423.
* Other investigation and pre-operative labs: CBC, Coagulation profile, lipid profile, ECG, ECHO, lung function test, Renal function test, Hepatic function test, Albumin level.
Q 2-3) I will discuss with urologist & oncologist about cancer stage & life expectancy.
If the patient has stage 3: 5-year life expectancy around 95% (cancer research UK)
So, I recommend repair of AAA over conservative ttt and according to ESVS (Guidelines 2023 – recommendation 119), the best ttt is EVAR to allow ttt of malignancy with minimal delay.
Also, if the patient is not need any surgery, chemo or radiotherapy for 6 mouths post AAA repair, i recommend OSR as he is fit for surgery.
Q4)
A recovery is faster with EVAR than OSR.
Their are many complecations that are most common with OSR as:
– surgical site infection
– surgical hernia.
– Renal impairment .
– Cardiac & Pulmonary complications.
– Intestinal ischemia.
– Anaesthesia complications.
– Stroke.
About Follow of OSR: re-imaging at 3-5 years.
But, after EVAR: Lifelong surveillance at 6-12 M intervals.
Q5) According to ESVS (2023)
For decision also,
Q1
First abdominal U/s to make sure from the size of aneurysm
Lab investigations KFTs,CBC, bleeding profile,LFTs
Cardiopulmonary fitness:ECG ,ECho, Pulmonary function tests ,CPET
Q2
I advise him with EVAR as patient in stage 3 prostatic cancer on hormonal therapy since 4years so he has reasonable life expectancy.
the life expectancy in stage 3:
Around 95 out of every 100 men (around 95%) will survive their cancer for 5 years or more after diagnosis.
Q3
I disagree
As the patient has reasonable life expectancy
Q4
According to open surgical repair
Postoperative ICU admission, prolonged hospital stay ,
Infection,bowel ischemia, Acute limb ischemia,aortoenteric fistula
Thanks for your reply
Do you think the patient needs further USS , knowing he is coming as referral from screening program where his surveillance tool is USS
What would be the evidence to support EVAR over OSR in such patient please?
Q1:, LAB investigation; CBC,BLEEDING profile, KFTs,LFTs,CRP,S.ALBUMIN
CARDIOPULMONARY FITNESS; ECG,ECHO,PULMONARY FUNCTION TEST
Q2:i’d prefer OSR if pt is surgically fit due its long term patency
Q3 : i’ll agree
Q4:according to OSR LONGER HOSPITAL STAY AND Icu admission post Operative may be indicated
Accordingto F.U and reintervention is higher for EVAR
POSSIBLE complications ;infection, cardiac complications,pulmonary complications, renal failure ,acute limb ischemia
Aortocavalfistula, aortoenteric fistula ,anastomosis aneurysms
Good answer, can you please give some evidence to support it
Q1: Full labs, ECG, Echo and CPET
aortic US with inner to inner diameter to ensure the size as the US is more accurate in sizing
Q2: i will recommend EVAR as ESVS recommend For most patients with suitable anatomy and reasonable life expectancy, endovascular repair should be considered the preferred treatment modality for elective abdominal aortic aneurysm repair ( Class IIa level B)
Q3: i will agree for OSR as the patient is fit and well with good life expectancy as a patient with stage 3 prostatic cancer (around 95% for 5 years or more)
Q4: Prolonged hospital stay, infection, bowel ischemia, arterial occlusion, MI, renal insuffciency and pulmonary complications
Q5: For most patients with suitable anatomy and reasonable life expectancy, endovascular repair should be considered the preferred treatment modality for elective abdominal aortic aneurysm repair
(ESVS class IIa level B)
Can you expand your evidence to support the decision, I mean is there any key trial ,systematic review or meta analysis to support the guidelines? thanks
Week 2 case 1
1. Basic full labs including albumin level , libid profile . Cardio pulmonary fitness by : ECG ,ECHO , CPET
2. If the patient fit and all investigations are normal : i recommend open repair.
3. I agree . Because OSR has better patency rate than EVAR .. without need for regular follow up as EVAR .
4. Regarding OSR : longer hospital stay, longer recovery time than EVAR . ITU admission post op.
Possible risks : MI , infection, bowel ischmia, stroke, renal failure, peripheral ischmia , any organ damage
Routine Follow up visits for the wound till complete healing
No need for further interventions
5. According to NICE guidelines 2020 : OSR is the 1st line of ttt in fit patients
Good answer thanks
Q1.
full lab investigations , PSA, CPET, echocardiogram , pulmonary function test
PET\CT after oncology consultation.
Q2.
after oncology consultation and confirmation of the stage of the cancer
i will discuss with patient both intervention modalities and the risk of each one
i will recommend open surgical repair provided that he has high survival rate and shows good fittness on CPET
Q3.
i will agree with the patient as open surgery has less reintervention rate
Q4.
open repair has more recovery time but on long term standard EVAR shows high reintervention rate and long follow up plan with ct
Q5.
EVES 2024 recommendations
Good answer
Can I ask which trial is supporting your answer and what is the reported mortality risk in both modalities and if possible brief about long term results please
EVAR 1 trial showed higher perioperative survival rate after EVAR vs OSR (1.
7% vs 7.4 %)
EVAR1 trial showed also higher reintervention rate after EVAR
also showed higher mortality rate on the long term after EVAR
ACE trial showed insignificant perioperative mortality risk difference
but also showed higher reintervention rate after EVAR
Thanks for your answer
I would like to have your answer regarding what possible complications to be mentioned with OSR please
complications include :
myocardial ischemia and infarction
acute kidney injury
bowel ischemia and infarction
respiratory faliure
organ damage
hypovolemia and blood loss
Thanks for your answer
1- full labs, ECG, ECocardiography ,chest assessment, metastatic work up for cancer prostate.
2- i advise for open repair
3- agree as patient is fit and patency rate is better than EVAR, no need for routine follow up and imaging like EVAR
4- consent should be obtained including complications that can occur like MI, renal injury, mesenteric ischemia, wound infection , burst abdomen or wound dehiscence and need for ICU admission post operative
5-
In patients with long life expectancy, open abdominal aortic aneurysm repair should be considered as the preferred treatment modality.
Esvs IIb
Thank you all for your active participation and valuable comments.
1- CBC, Liver function , Kidney function , Coagulation profile , PSA , Echo and CPET.
2- I will discuss both modalities with the patient
open repair has advantage of being more durable less required re-intervention and less financial cost
EVAR is a less invasive procedure that could be done per-cutaneous and has much faster returning to daily activity but has more risk for re-intervention.
3- I would agree if the patient is “fit and well” for surgery, has no hostile Abdomen,no horse shoe kidney, no previous history of exploratory incisions, and accepting the long rehabilitation journey.
4- about recovery patient will need ICU admission for 2-3 days then will need to start rehabilitation program for up to 6 months before returning to daily activity
possible risk include risk of hemorrhage- surgical site infection-surgical site hernia- acute kidney insult – graft thrombosis- intestinal ischemia- buttock claudication- sexual dysfunction-death.
follow up protocol include follow up in the clinic for surgical site care follow up U/S to detect any possible hematoma, checking for peripheral pulsation to exclude limb ischemia.
there is less risk of re-intervention in OSR compared to EVAR.
5-Becquemin JP. The ACE trial: a randomized comparison of open versus endovascular repair in good risk patients with abdominal aortic aneurysm. J Vasc Surg. 2009 Jul;50(1):222-4; discussion 224. doi: 10.1016/j.jvs.2009.04.074. PMID: 19563976.
Thanks Mina and well done, your answer is very comprehensive. OSR is to be considered if he’s deemed anesthetically fit. I would also mention the anesthetic risk as well like MI and CVS. if patient considers EVAR, he has to comply with regular US and accepting possible interventions in the future.
Q1
Full labs
ECG
Chest X-ray
Abdominal US to confirm measured size 5.7cm by CTA ( inner-to-inner maximum anterior-posterior aortic diameter)
Pulmonary Function Tests
CPET
18F-fluoromethylcholine PET/CT ( Staging, follow-up, restaging of PCa)
Q2
EVAR
Q3
Disagree
EVAR less invasive procedure does not involve a laparotomy.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3087962
Q4
With EVAR patients recover quickly and in most cases would be able to undergo the cancer surgery within 2 weeks if required.
Lower hospital mortality with EVAR compared to OSR 1
Long-term aneurysm-related mortality, re-intervention rates, and rupture rates were higher after EVAR than after OSR. 2
1.Antoniou GA, Antoniou SA, Torella F. Editor’s choice – endovascular vs. open repair for abdominal aortic aneurysm: systematic review and meta-analysis of updated peri-operative and long term data of randomised controlled trials. Eur J Vasc Endovasc Surg. 2020;59:385–397. doi: 10.1016/j.ejvs.2019.11.030
2 Li B, Khan S, Salata K, Hussain MA, de Mestral C, Greco E, Aljabri BA, Forbes TL, Verma S, Al-Omran M. A systematic review and meta-analysis of the long-term outcomes of endovascular versus open repair of abdominal aortic aneurysm. J Vasc Surg. 2019;70:954–969.e30. doi:
10.1016/j.jvs.2019.01.076.
Q5
ESVS 2024
Recommendation 152
Patients with a large or symptomatic abdominal aorticaneurysm with an indication for repair and concomitant malignancy should be considered for a staged surgical approach, with endovascular repair first, to allow fortreatment of the malignancy with minimal delay.
Thanks Saeed, good answers.
A1: why do you want US? Patients get referred from the AAA screening program to vascular surgeons based on US so you proceed to CT straightaway.
Do you think PET is needed if he’s PSA is stable?
Respect your advice about EVAR (especially your reference article) but I wouldn’t exclude OSR completely.
It sounds like you are placing the patient in EVAR-2 category which is not exactly the case here. Prostate Ca has one of the best long term prognosis so I wouldn’t categorise it in the same way as other abdominal malignancies.
Q1 full labs
Ecg ECHO pulmponary function test or CEPT if available
Q2 EVAR
Q3 yes agree because the choice of surgical technique should be discussed between the treating clinician and the patient and multiple factors should be considered when individualising a patient treatment plan. These include (1) anatomical suitability for EVAR, (2) physiological reserves and fitness for surgery, (3) life expectancy, (4) patient preferences, and (5) needs and exepectations, including the importance of sexual function, and anticipated compliance with frequent lifelong surveillance and follow up
Q4
OSR need long recovery period with mortality higher than EVAR and more complication but is no need for long period followup nor reintervevtions compared to EVAR according to EVAR 1 DREAM OVER and ACE trials
Q5
For most patients with suitable anatomy and reasonable life expectancy, endovascular repair should be considered the preferred treatment modality for elective abdominal aortic aneurysm repair claas IIa level B ESVS 2024
Thanks Abdullah for the clear answers. Totally agree with your justifications for OSR.
it depends mainly on discussion with urology team regarding his life expectancy. if long, OSR is the best because his age still young.
if life expectancy is short, EVAR will be better for him.
also his preoperative evaluation ( general labs, echo and CPET), is major factor besides the patient decision.
Well done Esmail, life expectancy is a pivotal factor (may be for “SHORT” life expectancy, repair might not be indicated at all).
What about Q3, Q4 and Q5?
Q2:
In just major cases, discussion with patient must be open and frank.
Firstly, we should inform patient about benefits and risks of each type of intervention.
I think have to talk to oncology consultant about patient’s life expectancy before recommend one type of intervention over the other.
Patient’s anatomy is suitable for EVAR, so we can mainly depend on life expectancy to choose the optimal method for intervention.
Based on European Society for Vascular Surgery (ESVS) 2024
.
Thanks Ahmed, so what would YOU him knowing that prostate cancer stage 3 carries 95% survival at 5 yrs.?
What about Q3,Q4 and Q5?
Q1: Investigations:
- echo
- labs (cbc, urea, creat,..
- bone scan to detect any metastasis
Q2: i would recommend open surgery
Q3: i agree, because patient is fit & cancer stage 3 which has 5 year survival of 95%
Q4: possible complications: bowel ischemia, sexual dysfunction, buttock claudication
Thanks Remon, concise and to the point. well done
Anesthetic risks of MI,pulmonary and Cerebrovascular have to be discussed as well
Surgical risks includes as organ damage, acute kidney injury and limb loss must be highlighted clearly.
RCT
Esvs
Thanks for the case
1- would request full lab investigation
Especially Kidney function ,PSA.
*Echocardiogram
*Pulmonary function test
*I would consult urology if PET scan is needed to assess cancer status and life expectancy of the patient.
2-if patient has long life expectancy i would recommend OSR.(ESVS lla)
3-agree because patient is fit EVAR advantage decreases on long term and need for re intervention.
5-ESVS recommendations.
Thanks Muhamed. Totally agree with your answers, I assume Oncology rather than urology will answer your question.