•82 Male is referred to you with incidental finding of 6.6 cm AAA detected in CT abdomen for an attack of diverticular disease 2/12.
•
•He has a back ground of: HPN, DM and diverticular disease, he is an ex smoker. He underwent laparotomy after trauma 15 years undergoing splenectomy and small bowel repair . He has no family history of aneurysms . He is leading a sedentary life and uses his car for most of commutes. He can walk 300 meters before he gets short of breath.
•Regular meds Ca channel blocker and metformin .
•Examination : BMI 38 ,mid line laparotomy scar . Palpable non tender aneurysm palpable distal pulses . No popliteal aneurysms bilaterally.
•The CT is a portal phase Ct from level of diaphragm to Groins.
•Bloods: Hb 14, eGFR 70 HBA1c 7
•Echo showed reduced EF of 45 % with left ventricular strain and normal valves
•CPET AT 13 mlO2/kg/min with peak AT 18 mlO2/kg/min
•Spirometry – FEV1 (80%)
•Rockwood Clinical Frailty Score: 3
•reviewed by vascular anaesthetist : Fit for intervention (endovascular ) High risk of open.
| Thoracic Aorta | normal thoracic aorta | Patent subclavian artery bilaterally | ||
| Abdominal aorta | Proximal Landing zone 24 mm l . 25 mm above CA Aortic bifurcation 28 mm | Distal Rt CIA landing zone 16 mm ( 2 cm length) | Distal Lt CIA landing zone 12 mm ( 2 cm length)L | |
| Access | RT CFA 8 mm . Mild post wall atheroma | Rt EIA 9 mm minimal tortuosity | LT CFA 8 mm .moderate post wall atheroma 9 (60 % stenosis) | Lt EIA 9 mm minimal tortuosity |
| L | IVD | CLOCK | ||
| CA | 0 | 24 | 12 | 6 mm |
| SMA | 19 | 26 | 1230 | 7 mm |
| RRA | 24 | 28 | 1030 | 6 mm single artery |
| LRA | 27 | 28 | 0300 | 5 mm single artery |
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•Q1: The patient is with you in the clinic now, explain the key history and examination points
•Q2: What are your next steps and explain he rationale for each step ?
. 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 .
•Q4: Explain with evidence your approach and plan
•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 ?
key history, controlled DM, HTN, mild renal impairment, hostile abdomen, obesity, limited mobility but managing well
examination,
I will do completer vascular examination to exclude the Prescence of peripheral aneurysm or peripheral ischemia
also I will do abdominal examination for tenderness
Q2:
I will request an urgent CTA whole aorta for accurate measurements and proper planning as the previously done CT was only abdominal.
I will also refer the patient to the anesthetist for preoperative assessment
I will mention that I will discuss the management plan with the patient after the CTA and anesthetic assessment
Q3: I will explain to the patient the risk of rupture now is higher than the risk of intervention especially with availability of endovascular treatment modality based on SAT
and based on EVAR 2 trial intervention has better long term survival rate than BMT
also I will do a clarified explanation of the possible complication of intervention
Q4: the patient is not fit for SOR based on anesthetic assessment and hostile abdomen
also, not suitable for infrarenal EVAR due to juxta renal AAA
so I will go for FEVAR with suprarenal extension with proper planning and MDT discussion to see which branches going to be involved
Q5:
6.5 cm JRAAA needs repair (recommendation 22 class 1 level A)
FEVAR as first option (recommendation 96 class IIa level C)
parallel graft techniques as an alternative in emergency or FEVAR not available (recommendation 97 class IIB level C)
A1;
Previous extensive abdominal operations, High BMI, hostile abdomen, will make open approach difficult.
A2;
Plan for FEVAR , 3D cta of entire aorta, planning fenestration sites, Angles
A3;
Fevar , open or US guided percutanous bilat. CFA access, pitail, initial imaging to confirm plan, wire through aorta up to ascending, exchange for stiff-wire, pass main device, confirm placement, angle, fenestration sites, deploy main device, wire through fenestrations, insert and deploy the iliac limbs, confirm placement, patency, absence of ebdoleaks, proglide for closure, goodbye
A5;
FEVAR
Q1:
key history, controlled DM, HTN, mild renal impairment, hostile abdomen, obesity, limited mobility but managing well
examination,
I will do completer vascular examination to exclude the Prescence of peripheral aneurysm or peripheral ischemia
also I will do abdominal examination for tenderness
Q2:
I will request an urgent CTA whole aorta for accurate measurements and proper planning as the previously done CT was only abdominal.
I will also refer the patient to the anesthetist for preoperative assessment
I will mention that I will discuss the management plan with the patient after the CTA and anesthetic assessment
Q3: I will explain to the patient the risk of rupture now is higher than the risk of intervention especially with availability of endovascular treatment modality based on SAT
and based on EVAR 2 trial intervention has better long term survival rate than BMT
also I will do a clarified explanation of the possible complication of intervention
Q4: the patient is not fit for SOR based on anesthetic assessment and hostile abdomen
also, not suitable for infrarenal EVAR due to juxta renal AAA
so I will go for FEVAR with suprarenal extension with proper planning and MDT discussion to see which branches going to be involved
Q5:
6.5 cm JRAAA needs repair (recommendation 22 class 1 level A)
FEVAR as first option (recommendation 96 class IIa level C)
parallel graft techniques as an alternative in emergency or FEVAR not available (recommendation 97 class IIB level C)
Q1: The patient is with you in the clinic now, explain the key history and examination points
I’ll begin by introducing myself to the patient ask the patient about
1- full personal history (name, age, sex, occupation, marital status, special habits, offsprings)
2- Medical history ( Dm, HTN, Cardiac, renal, allergy, any other chronic disease,hospital admission )
3-Surgical history (any previous operation : time, type, complications )
4- Medication ( any regular medications)
5- symptoms related to lower limb ischemia (distance walked before claudication, trophic changes in the foots)
I’ll then ask the patient for verbal consent for abdominal examination to detect the aneurysm any tenderness any back pain or tenderness
Examine both lower limbs for peripheral pulsations and bilateral popliteal possible aneurysm.
•Q2: What are your next steps and explain he rationale for each step ?
I’ll ask for complete laboratory investigation Echo cardiogram and assessment by the cardiologist, pulmonary function test , and anesthesia consultation
I’ll also ask for complete CTA from the root of the aorta till the foot for proper assessment.
. 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
.I think the best modality for this patient is FEVAR which is endovascular procedure to treat Abdominal aortic aneurysm with fenestration to keep both renal arteries and SMA patent also the pateint may need extended stent graft if any type of endoleak appeared.
•Q4: Explain with evidence your approach and plan
Fenestrated or Branched Endovascular versus Open Repair for Complex Aortic Aneurysms: Meta-Analysis of Time to Event Propensity Score Matched DataEuropean Journal of Vascular and Endovascular Surgery
Volume 61, Issue 2, February 2021, Pages 228-237
European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms
Eur J Vasc Endovasc Surg (2024) 67, 192e331
•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 ?
FEVAR is the best modality for this patient
Chimney vs. Fenestrated Endovascular vs. Open Repair for Juxta/Pararenal Abdominal Aortic Aneurysms: Systematic Review and Network Meta-Analysis of the Medium-Term Resultsby Petar Zlatanovic 1,*,Aleksa Jovanovic 2,Paolo Tripodi 3 andLazar Davidovic 1,4
J. Clin. Med. 2022, 11(22), 6779
Well done Dr Mina.
Family history is important as well.
Why is FEVAR the option for this patient?
Can you clarify what is metaanalysis of time to event propensity score and what are the out ones of this paper?
Any other upto date papers more focused on juxtarenal aneurysms?
Dr. Amr can I Ask about Lt. CIA it seen anurysmal and its landing zone about 12.
My qution we need of IBD for this or is enough and no risk of endoleak??
And lt CFA Post. Wall atheroma 60% we do endartectomy or not if not when we insert the device ther is risk of detachment of atheroma??
Well spotted . You are right I would usually do an endarterectomy simultaneously if the CFA is diseased to decrease risk of developing ALI in the peri operative period 2nd to thrombosis. These procedures will require a big sheath or multiple sheath diminishing flow intra operatively
Thank you Dr Abdullah. The distal landing zone is 12 mm in diameter and 20 mm long so IBD is not required
Can you tell me the indications and size criteria for using IBD and when would you choose to go for IBD versus embolization of the IIA and extension to the EIA
Q1 hx of symptoms related to AAA back and abd. Pain bowel habits fever ll pain or claudication risk factors HTN DM cardiac pulmonary Smoking hx familly and drug hx
General ex. BP HR Temp. RR vascular( pulses and exclude other aneurysum Pop) and neurological examination abd. Examination tenderness pulsatile swelling bruit focus on scar of previous operation no signs of infection fitulas or sinus.
Q2 next step full labs ( cbc KFT LFT PT INR albumin electrolyte GFR blood group)
Cardiac, pulmonary, anesthiae, geriatric medicine, nutrional medicine and to assess the fitness of pt and to improve risk factors also help to reduce complication.
Also discuss with gasteroenterologist about diverticular disease what the risk and plan?
CTA is for arterial tree for planning and exclude other pathology.
Q3
So. Pt has complex AAA ( juxtarenal) There are no data available on rupture risk
and natural history specifically for complex AAAs. But pt has diameter 6.6 is indication for intervention Patients with complex abdominal aortic aneurysms may be considered for elective repair at a diameter of ‡ 55 mm in men and ‡ 50 mm in women, taking into account fitness for repair, aneurysm anatomy, and patient preferences class IIb C.
So we have 2 options open or endo for repair but we considrerd the fitness and other teams consultation that pth high risk for open also pt has previous operation in abd increase risk of complication and infection.
Also the claming in complex AAA Repair incresed mortality and renal dysfunction
Either intervention we will discuis complication
Q4.
For patients with a complex abdominal aortic aneurysm and high surgical risk, endovascular repair with fenestrated and branched technologies should be considered as first line therapy. IIa c ESVS 2024
Q5.
Fenestrations are preferable in cases where the aortic wall will be close to the endograft, e.g., in short neck AAAs and juxta and pararenal.
Branches are preferable when the aortic wall will be further from the endograft which typically occurs in some type IV TAAA. Scallops are sometimes included to increase the total seal of the repair without increasing its complexity
There are no direct comparisons between the outcomes of OSR and f/bEVAR, and available data are limited by selection and publication bias. Furthermore, the lack of independent long term follow up data makes it difficult to evaluate the durability of both techniques.
Can you quote the references for this information
ESVS 2024
ESVS
Well done Dr Abdullah .
Geriatian involvement in these cases can be helpful in selected cases.
There is some studies demonstrating the importance of nutritional optimisation in the perioperative period so having a multidisciplinary team including a dietician is ideal
Well done appropriate quality imaging is imperative for planning these cases.
Any recent studies published this year that supports one approach in comparison to the other published in 2024
Q4,5:
My plan and approach;
This is a juxtarenal aneurysm
So classic EVAR will not be the suitable option.
According to the CTA sizing measures, we need to clarify two important points;
1. Is the visceral segment aneurysmal or not?
2. Is there enough proximal landing zone above the CA (20 mm)
Accordingly; the suitable options we can choose from are: FEVAR and chimney.
T-Branch is not a good option in such case
Well done Dr Remon.
By definition A JRAAA the visceral segment is not aneurysmal.
Can you explain what do you mean by enough proximal landing zone?
How durable is using CHEVAR IN elective scenarios?
Any publications or guidelines to support the different approaches
according to the esvs 2024, patency numbers were 93, 92, 90% at 3, 4, 5 years.
yet they still do not recommend chimney unless as an emergency or a bailout procedure
recommendation 122
Exactly ChEvar should only be considered as a bailout technique were no other option is available as the likelihood of type 1a endoleak is high
i mean a minimum of 2 cm of healthy parallel aorta for the proximal seal zone.
Well done
Q3:
Discussion with the patient will include the following:
1. Clarification of his condition and risks of aneurysm rupture.
2. Available options as open surgery and EVAR
3. Potential hazards of open surgery as his condition necessitates a Supra-renal clamping, specifically in the presence of his cardiac condition.
4. Available endovascular intervention options
Well done Dr Remon.
Are there any publications/guidelines to support one method over the other?
Can you elaborate on the risks in a bit more details ?
yes sure:
the hazards of OSR in such case include the following:
according to the esvs 2024, they recommend endovascular option over OSR
What about risks of complex endovascular repair?
Q1: key points in history and exam
1. Risk factors like DM,HTN, smoking
2. History of previous abdominal surgery and attacks of diverticulitis (hostile abdomen)
3. Cardiac status
3. Any signs of impending rupture (pain, tenderness )
Q2: next steps
* First: justification for intervention: aneurysm is 6.6 cm
* Second: determining kind of intervention according to local factors (hostile abdomen) and cardiac comorbidity,, it’s preferable to do EVAR
* Third: determining what kind of EVAR (chimney/ fenestrated/ t- branch)
* Fourth: patient assessment and optimization of cardiac condition (Echo)
Well done . Q1. It is important to inquire about the general fitness as part of history taking as it gives you an initial overview of the patient fitness.
Q2: well done. Next step also include having appropriate imaging. For example ; if the initial CT did not provide adequate information for planning (thick cuts or inappropriate contrast phase )
Optimization of cardiac condition is usually done in specific scenarios as cardiologists only intervene of they think it will change the risk profile significantly. Also some intervention for example DES might increase risk of intervention initially.