Tim Ryan Gillian Lieberman, MD January 2002 Gray Hair & Back Pain (aka Abdominal Aortic Aneurysm) Tim Ryan, HMS III Gillian Lieberman, MD Tim Ryan Gillian Lieberman, MD Patient Presentation Mrs. M. is a 62 year old woman with surgical Hx of Appy, Thoracic outlet, Lumbar laminectomy, Thyroidectomy with 10 yr history of LBP, now presents with acute LBP, L>R. 2 Tim Ryan Gillian Lieberman, MD LBP Partial DDx ie. VAST MUSCULAR LOW BACK PAIN INTERVERTEBRAL DISC RUPTURE, LUMBAR REITER SYNDROME SPONDYLITIS, ANKYLOSING LUMBAR SPINAL STENOSIS ANEURYSM, AORTA, ABDOMINAL COCCYX, FRACTURE BURSITIS, TROCHANTERIC PUERPERAL INFECTION FALLOPIAN TUBE, OCCLUSION COCCYDYNIA COLITIS, ULCERATIVE COLITIS, STAPHYLOCOCCAL COLON, CARCINOMA IRRITABLE BOWEL DISEASE CYST, PILONIDAL CYSTITIS, ACUTE DIVERTICULITIS DYSMENORRHEA, PRIMARY ENDOMETRIOSIS ENDOMETRIUM, CARCINOMA ENTERITIS, REGIONAL ENTEROCOLITIS, PSEUDOMEMBRANOUS, ACUTE GENERALIZED ANXIETY DISORDER GRANULOMATOUS COLITIS PREGNANCY, INTRAUTERINE PROSTATE, CALCULUS HERPES ZOSTER HYDRAMNIOS HYPERPARATHYROIDISM, PRIMARY SPINAL CORD, COMPRESSION INFLUENZA SPONDYLOLISTHESIS KIDNEY, CALCULUS KIDNEY, CYST, SOLITARY KIDNEY, FAILURE, CHRONIC KIDNEY, PERINEPHRIC ABSCESS KIDNEY, POLYCYSTIC DISEASE URETHRA, DIVERTICULUM UTERUS, ADENOMYOMA MYELOMA, MULTIPLE IDIOPATHIC SCIATIC NEUROPATHY NEUROPATHY, SCIATIC OOPHORITIS OSTEOARTHRITIS OSTEOPOROSIS PANCREATITIS, ACUTE PREGNANCY, TUBAL, RUPTURED PROSTATE, CARCINOMA PROSTATITIS, ACUTE PROSTATITIS, CHRONIC RECTUM, ADENOCARCINOMA PELVIC INFLAMMATORY DISEASE, ACUTE PELVIC INFLAMMATORY DISEASE, CHRONIC HIP FRACTURE URETHRITIS, FEMALE UTERINE CERVIX, CARCINOMA UTERUS, LEIOMYOMA UTERUS, PROLAPSE ENDOGENOUS DEPRESSION REACTIVE DEPRESSION ACUTE NECROTIZING PANCREATITIS 3 Tim Ryan Gillian Lieberman, MD Serious LBP DDx ANEURYSM, AORTA, ABDOMINAL COCCYX, FRACTURE PUERPERAL INFECTION FALLOPIAN TUBE, OCCLUSION COLITIS, ULCERATIVE COLITIS, STAPHYLOCOCCAL COLON, CARCINOMA CYSTITIS, ACUTE DIVERTICULITIS ENDOMETRIOSIS ENDOMETRIUM, CARCINOMA ENTERITIS, REGIONAL (CROHNS DISEASE) ENTEROCOLITIS, PSEUDOMEMBRANOUS, ACUTE HERPES PREGNANCY, INTRAUTERINE HERPES HYPERPARATHYROIDISM, PRIMARY INFLUENZA KIDNEY, FAILURE, CHRONIC KIDNEY, PERINEPHRIC ABSCESS KIDNEY, POLYCYSTIC DISEASE URETHRA, DIVERTICULUM UTERUS, ADENOMYOMA MYELOMA, MULTIPLE OOPHORITIS OSTEOPOROSIS PANCREATITIS, ACUTE PREGNANCY, TUBAL, RUPTURED PROSTATE, CARCINOMA RECTUM, ADENOCARCINOMA PELVIC INFLAMMATORY DISEASE, ACUTE PELVIC INFLAMMATORY DISEASE, CHRONIC HIP FRACTURE UTERINE CERVIX, CARCINOMA ACUTE NECROTIZING PANCREATITIS 4 Tim Ryan Gillian Lieberman, MD Life threatening LBP DDx ANEURYSM, AORTA, ABDOMINAL COCCYX, FRACTURE PUERPERAL INFECTION COLON, CARCINOMA, Other Obstruction PREGNANCY, TUBAL, RUPTURED HIP FRACTURE PELVIC FRACTURE ACUTE NECROTIZING PANCREATITIS 5 Tim Ryan Gillian Lieberman, MD Mrs. M Work-Up Lumbar AP Plain Film 6 Tim Ryan Gillian Lieberman, MD Mrs. M Work-Up Lumbar AP Plain Film “Eggshell sign” 7 Tim Ryan Gillian Lieberman, MD Mrs. M Work-Up Pelvic/Lumbar AP Plain Film 8 Tim Ryan Gillian Lieberman, MD Mrs. M Work-Up Pelvic/Lumbar AP Plain Film “Eggshell sign” 9 Tim Ryan Gillian Lieberman, MD Mrs. M Work-Up Lateral Lumbar Plain Film 10 Tim Ryan Gillian Lieberman, MD Mrs. M Work-Up Lateral Lumbar Plain Film “Eggshell sign” 11 Tim Ryan Gillian Lieberman, MD Presentation of AAA • Incidental finding (30%) • Abdominal mass • Low back pain • Shock (rupture) 12 Tim Ryan Gillian Lieberman, MD AAA Pt. Work-Up • • • • • Plain films ~ 15% detectable US- surveillance CT pre-op planning Angio/DSA pre-op/intra-op MRI- rarely 13 Tim Ryan Gillian Lieberman, MD Mrs. M Work-Up • Plains films show calcified aorta, ?AAA>>U/S •U/S showed aneurysmal aorta,~3.0cm •Follow with serial U/S @ 6mo •Intervene for 5.0 cm or 0.5 cm growth/6 mo 14 Tim Ryan Gillian Lieberman, MD Mrs. M. Surveillance • Follow up U/S 28 moths later. 15 Tim Ryan Gillian Lieberman, MD Surveillance • Follow up U/S 28 moths later. 16 Tim Ryan Gillian Lieberman, MD Surveillance • Follow up U/S 28 moths later. Relatively Hypoechoic lumen 17 Tim Ryan Gillian Lieberman, MD Surveillance • Doppler shows thrombus w/ small lumen. 18 Tim Ryan Gillian Lieberman, MD Surveillance • Sag. U/S shows thrombus w/ small lumen. 19 Tim Ryan Gillian Lieberman, MD Surveillance • Sag. Doppler U/S 20 Tim Ryan Gillian Lieberman, MD Pre-Op Work-Up •CT w/ contrast showed: No obvious leak Peri-renal dilatation Thrombus in aortic lumen @ level of renal artery 21 Tim Ryan Gillian Lieberman, MD Treatment Options • Open surgical repair • Endovascular repair • Do nothing 22 Tim Ryan Gillian Lieberman, MD Endovascular AAA Repair • First clinical use by Parodi, 1990 • Available in U.S. since 1999 23 Tim Ryan Gillian Lieberman, MD Endo AAA * Aneurx Endograft 7 Open Repair 0.9 3.5 Hosp. Days 3.4 9.3 Blood Loss (cc) 544 1617 Major Morbidity (%) ICU days 15 24 *AneuRx clinical trial Phases I-III PMA Annual Report, Jan 2001 Tim Ryan Gillian Lieberman, MD Endo AAA Limitations • Proximal neck for stent attachment • Common femoral/ external iliac vessels must be large, non-tortuous • Unknown long term course 25 Tim Ryan Gillian Lieberman, MD Endo AAA Complications •Endoleaks •Late Rupture •Graft migration 26 Tim Ryan Gillian Lieberman, MD Endo AAA- One System • Main body • Proximal extender • Contralateral Iliac limb • Iliac Extender 27 Tim Ryan Gillian Lieberman, MD Endo AAA- One System • Bullet tip w/ guidewire lumen • Retractable sleeve • Runners 28 Tim Ryan Gillian Lieberman, MD Endo AAA- One System • Tantalum markers • NiTi stent • Woven Dacron graft 29 Tim Ryan Gillian Lieberman, MD Endo AAA- The Repair • • • • Delivery catheter tip Angiography catheter External marker L. Renal Artery 30 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA- The Repair • Proximal Stent • Tantalum markers 31 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA- The Repair • Digital subtraction Angiogram 32 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA- The Repair • Tip of retractable sheath 33 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA- The Repair • Both limbs in place • Unrepaired common iliac aneurysm on left 34 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA- The Repair • No Endoleaks • Rt. Internal iliac a. 35 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endoleaks 36 Tim Ryan Gillian Lieberman, MD Endoleaks 37 Tim Ryan Gillian Lieberman, MD Endoleak? •Early caval filling, c/w tricuspid insufficiency 38 Tim Ryan Gillian Lieberman, MD Endo AAA- Endoleak • Unibody bifurcated graf • Stented only at ends • Occluded L. iliac limb 39 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA- Endoleak • Communcating artery of Drummond • Patent IMA 40 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA- Endoleak • Catheterization of Drummond to IMA. 41 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA- Endoleak • Contrast in Aneurysm, outside of of graft. 42 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA- Endoleak • Occluding coil deployed in IMA 43 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA- Endoleak • Occluding coil deployed in IMA • Type II endoleak repaired 44 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA- Endoleak • Reconstitution of L. iliac by collaterals. 45 Source: BIDMC-pacs Tim Ryan Gillian Lieberman, MD Endo AAA-Migration • 87 yo man, s/p endovascular repair 24 months prior • Limb markers are too far apart; suggests disarticulation of limb. 46 Source: http://www.ctvstexas.com/a_aneurx.html, see also J Vasc Surg, Mar 2000 Tim Ryan Gillian Lieberman, MD Endo AAA-Migration 47 Source: http://www.ctvstexas.com/a_aneurx.html, Endo AAAMigration with rupture Tim Ryan Gillian Lieberman, MD 48 Source: http://www.ctvstexas.com/a_aneurx.html, Tim Ryan Gillian Lieberman, MD Endo AAARupture • 88 yo man w/ multiple medical problems. •s/p endograft repair of AAA 23 months ago, presents w/ severe abdominal and back pain, SBP 76mmHg. •Known endoleak from accessory renal a., treatment for which had been refused by pt. 49 Source: http://www.ctvstexas.com/a_aneurx.html, Tim Ryan Gillian Lieberman, MD Endo AAA Mid-term results • 1192 pt’s in clinical trial of modular device • 10 aneurysm ruptures post-repair at 3 yr. • 6/174 ruptures with 1st generation device •4/1018 ruptures with second generation device • 93, 88, 86 % survival at 1,2 & 3 yr overall. •14,000+ implants with one modular system to date. • Endovascular sutures/staples coming soon 50 Tim Ryan Gillian Lieberman, MD Acknowledgements • • • • • Michelle Swire, MD Maria-Candida Albano, MD Pamela Lepkowski Larry Barbaras and Cara Lyn D’amour Gillian Lieberman, MD 51 Tim Ryan Gillian Lieberman, MD References • • • • Arko FR, Lee WA, Hill BB, Cipriano P, Fogarty TJ, Zarins CK. Increased flexibility of AneuRx stent-graft reduces need for secondary intervention following endovascular aneurysm repair. J Endovasc Ther. 2001 Dec;8(6):583-91. Zarins CK, White RA, Moll FL, Crabtree T, Bloch DA, Hodgson KJ, Fillinger MF, Fogarty TJ. The AneuRx stent graft: four-year results and worldwide experience 2000. J Vasc Surg. 2001 Feb;33(2 Suppl):S135-45. Review. White RA, Donayre CE, Walot I, Woody J, Kim N, Kopchok GE. Computed tomography assessment of abdominal aortic aneurysm morphology after endograft exclusion. J Vasc Surg. 2001 Feb;33(2 Suppl):S1-10. White RA, Donayre C, Walot I, Stewart M. Abdominal aortic aneurysm rupture following endoluminal graft deployment: report of a predictable event. J Endovasc Ther. 2000 Aug;7(4):257-62. • Zarins CK, White RA, Hodgson KJ, Schwarten D, Fogarty TJ. Endoleak as a predictor of outcome after endovascular aneurysm repair: AneuRx multicenter clinical trial. J Vasc Surg. 2000 Jul;32(1):90-107. • Zarins CK, White RA, Fogarty TJ. Aneurysm rupture after endovascular repair using the AneuRx stent graft. J Vasc Surg. 2000 May;31(5):960-70. • Politz JK, Newman VS, Stewart MT. Late abdominal aortic aneurysm rupture after AneuRx repair: a report of three cases. J Vasc Surg. 2000 Mar;31(3):599-606. • http://www.ctvstexas.com/a_aneurx.html, • http://www.aneurx,com 52