•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 ?
Q7: follow up with antiplatelet
For selected patients at higher clinical risk, repair can be deferred until the PAA has become >30 mm, especially in the absence of thrombus. Level of recommendation: grade 2 (weak); quality of evidence: C (low) (J Vasc Surg2022;75:109S-20S.)
Q8: it depends on priority if it is acute or critical limb I will repair the POP A first, if it is thrombosed but still asymptomatic I will repair the TAAA first and then the POP A
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
Q2 next step full labs ( cbc KFT LFT PT INR albumin electrolyte GFR)
Pt reached the threshold for repair so CTA of thoracic and abd aorta involving LL to exclude associated pathology and anatomy of aorta to plan and to make appropriate descion.
Cardiac and pulmonary assessment
Anestheia consult
Q3 pt has TAAA type 2 and lt pop artery aneurysm 2.5 cm asymptomatic .
Regarding TAAA Open or endovascular repair should be considered for patients at low to moderate surgical risk, with an atherosclerotic or degenerative thoraco-abdominal aortic neurysm of 60 mm or larger diameter, rapid aneurysm enlargement (>10 mm/year), or aneurysm related symptom. Class IIa c
Pt indicated for repair and we should discus the open and endo and coplication of each procedure also clarify the risk of rupture
Also the complication of open repair like mortality stroke MI pulmonary renal injury. Ll ischemia and SCI.
discus needed of extra corporeal techniques and CSF drainage .
In open type I, II, and III thoraco-abdominal aortic aneurysm surgery, extra-corporeal techniques allowing distal aortic and organ perfusion should be considered to reduce ischaemic complications, especially in extensive aneurysms requiring prolonged cross clamping. Class IIa C.
also explain endo complication like SCI due to long covered of aorta also endoleaks carfiac pulmonary renal and bowel ischemia
Q4. I go for open Pt is fit for both procedure unless the tht pt prefer endo
For thoraco-abdominal aneurysm repair, in patients unfit for open repair, an endovascular procedure should be considered IIa C
Q5 proximal landing Zone Is 1cm revasculraziation of subclavian is needed so I do carotid subclavian bypass then BEVAR/FEVAR
Q6.
Informed consent for complex high-risk surgeries for lifethreatening diseases is a difficult and nuanced process that should give the patient a realistic understanding of what you face as the surgeon and what they face as the patient, which must include the worst case scenario along with the best if the patient is to make a decision consistent with his goals in treatment. Especially because of the risks of mortality paraplegia, stroke, and renal failure SCI upper limb iscemia MI LL ischemia POPA thrombosis bowel ischemia in addition to possible ventilator dependence in marginal patients facing TAAA surgery, the consent conversation has to be a realistic discussion of probability and uncertainty surrounding surgery and what life will be like if the surgical effort fails to return the patient to his preoperative functional status.
Q7. Its contrversial descion
Although it is generally accepted that all symptomatic PAAs and those 2.0 cm or more in diameter should be considered for treatment in medically suitable candidates, some controversy exists.treating asymptomatic patients with PAAs 2.0 cm or larger may be justified, given the associated 30% to 40% risk for development of acute ischemic complications and the subsequent high risk of limb loss. Some writers suggest that all popliteal aneurysms should be repaired once found, regardless of size, because of the high complication and limb loss rates.
Other writers advocate that some asymptomatic PAAs can be safely observed. Galland et al. evaluated 95 popliteal PAAs. Of those that were asymptomatic, less than 3 cm, and without distortion, none became thrombosed.
Q8 OPEN repair by saphenous if possible before repair of TAAA
Q7: follow up with antiplatelet
For selected patients at higher clinical risk, repair can be deferred until the PAA has become >30 mm, especially in the absence of thrombus. Level of recommendation: grade 2 (weak); quality of evidence: C (low) (J Vasc Surg2022;75:109S-20S.)
Q8: it depends on priority if it is acute or critical limb I will repair the POP A first, if it is thrombosed but still asymptomatic I will repair the TAAA first and then the POP A
Q1:
key history,
family history, smoking, HTN
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
and to evaluate the POP artery aneurysm and the run off vessels (recommendation
9 class I level c), (recommendation 26 class IIa level c), (recommendation 27
class IIa level c)
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: according
to CTA the maximum diameter is 64mm this indication for intervention as the
risk of rupture is greater than the risk of intervention (recommendation 116 class IIb
level c)
as the patient is fit for both
OSR and ENDO, I will have a detailed discussion with the patient about both
procedures, possible complications and follow up plan (recommendation 120 class IIa level c)
Q4: as I mentioned
above patient is fit for both so the decision here depends on anatomy and
patient preference
In terms of anatomy, it is suitable for FEVAR with carotid subclavian bypass to have an acceptable proximal seal at zone 2
For open repair it needs thoraco abdominal approach with debranching of renal and visceral vessels
Patient preference, I will give him enough time and explanation and let him decide
Q5:
open or endo I have discussed it before
FEVAR is the best one for this case (recommendation 122 class IIa level c) using parallel graft techniques should only be considered as an option in the emergency setting, or as a bailout, and ideally be restricted to 2 chimneys or less
Q6: I will consent the patient for all the possible complication, including risk of paraplegia, renal failure and possibility of staged intervention and reintervention in case of any abnormality detected in the follow up plan
•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.
Full lab
CTA on the aorta from the root till the feet
Cardiology consultation
Anesthesia consltation
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
TEVAR is a less invasive approach in comparison to OSR in terms of morbidity and mortality and decreased hospital stay.
Walsh SR, Tang TY, Sadat U, Naik J, Gaunt ME, Boyle JR, et al. Endovascular stenting versus OR for thoracic aortic disease: systematic review and meta-analysis of peri-operative results. J Vasc Surg 2008;47:1094e8
Goodney PP, Travis L, Lucas FL, Fillinger MF, Goodman DC, Cronenwett JL, Stone DH. Survival after open versus endovascular thoracic aortic aneurysm repair in an observational study of the Medicare population. Circulation. 2011 Dec 13;124(24):2661-9. doi: 10.1161/CIRCULATIONAHA.111.033944. Epub 2011 Nov 21. PMID: 22104552; PMCID: PMC3281563.
Management of Descending Thoracic Aorta Diseases Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)
Eur J Vasc Endovasc Surg (2017) 53, 4e52
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 better with staged procedure if there’s available distal landing zone to decrease the incidence of Spinal cord ischemia
Q6 : The patient came back after considering the options and decided to undergo endovascular approach . Ellaborate on your consent process
Consent should include high risk for possible complications include SCI, Renal impairment, Ruptured aneurysm, possible re intervention due to endoleak , Death.
•Q7: What is your approach towards the popliteal aneurysm?
open repair with reversed saphenous vein bypass is recommended as the diameter is more than 2 mm provided that there’s good saphenous vein and life expectancy more than 5 years to prevent distal thrombosis
Popliteal Artery Aneurysms: The Risk of Nonoperative Management
Annals of Vascular Surgery
Volume 8, Issue 1, January 1994, Pages 14-23
The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysmsCLINICAL PRACTICE GUIDELINES| VOLUME 75, ISSUE 1, SUPPLEMENT , 109S-120S, JANUARY 2022
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 ?
according to the severity of ischemia symptoms if it’s critical revascularization should be added to open surgical repair of the PAA
Well done Dr Mina
TEVAR looking at the measurements above where is your proximal landing zone ?
Q 5 : why is FEVAR better with staged procedure ?
Q6 : other possible risks?
•Q7:Q8
Should you repair it before, simultaneously or after the aneurysm
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