AAA en paciente joven

AAA EN PACIENTE JOVEN (<60 AÑOS):
REPARO ABIERTO O EVAR?
ALBERTO MUÑOZ M.D.
Cirujano Vascular y Endovascular
Hospital Universitario Fundación Santafé
Director Clínica Vascular Bogotá
Profesor de Cirugía, Universidad Nacional Colombia
A perfection of means, and confusion of
aims, seems to be our main problem.
It has become appallingly obvious that our
technology has exceeded our humanity
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AAA
Ø Enfermedad con riesgo de ruptura y muerte
Ø Existe tratamiento efectivo con cirugia
abierta y endovascular
AAA
Ø Nuestra mision es escoger basado en la
evidencia el que ofrezca el mayor beneficio y
calidad de vida de acuerdo al riesgo,
anatomia, la preferencia personal del
paciente y costoefectividad.
Reparo Electivo AAA
Ø Mortalidad quirurgica (30 dias)
Abierto 3% - 4.3%- 4.6%
The United Kingdom EVAR Trial Investigators. Endovascular versus OpenRepair of abdominal
aortic aneurysm.
N Engl J Med 2010;362:1863-71.
De Bruin JL, Baas AF, Buth J, Prinssen M, Verhoeven EL, Cuypers PW,
et al. DREAM study group. Long-term outcome of open or endovascular
repair of abdominal aortic aneurysm. N Engl J Med 2010;362:
1881-9.
Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT, Matsumura JS,
Kohler TR, et al. Outcomes following endovascular vs open repair of
abdominal aortic aneurysm: a randomized trial.
JAMA 2009;302:1535-42.
Reparo Electivo AAA
Ø Mortalidad quirurgica (30 dias)
EVAR
0.5% - 1.2%- 1.8%
The United Kingdom EVAR Trial Investigators. Endovascular versus OpenRepair of abdominal
aortic aneurysm.
N Engl J Med 2010;362:1863-71.
De Bruin JL, Baas AF, Buth J, Prinssen M, Verhoeven EL, Cuypers PW,
et al. DREAM study group. Long-term outcome of open or endovascular
repair of abdominal aortic aneurysm. N Engl J Med 2010;362:
1881-9.
Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT, Matsumura JS,
Kohler TR, et al. Outcomes following endovascular vs open repair of
abdominal aortic aneurysm: a randomized trial.
JAMA 2009;302:1535-42.
The United Kingdom EVAR Trial Investigators. Endovascular versus
open repair of abdominal aortic aneurysm.
N Engl J Med 2010;362:1863-71.
Reparo Electivo AAA
Ø El reparo abierto es durable a traves del tiempo
Ø Baja tasa de complicaciones tardias, 1-2% por año
Ø Riesgo de hernias insicionales y obstruccioin intestinal
Ø No requiere controles seguidos, libre de irradiacion, endofugas,
migracion, trombosis, kinking, expansion del aneurisma y ruptura
Hallett JW Jr, Marshall DM, Petterson TM, et al. Graft-related complications after
abdominal aortic aneurysm repair: reassurance from a 36-year population-based
experience. J Vasc Surg 1997;25:277-84.
Conrad MF, Crawford RS, Pedraza JD, et al. Long-term durability of open abdominal
aortic aneurysm repair. J Vasc Surg 2007;46:669-75.
The United Kingdom EVAR Trial Investigators. Endovascular versus open
repair of abdominal aortic aneurysm.
N Engl J Med 2010;362:1863-71.
EVAR
Ø  Éxito
tecnico alto
Ø  Estancia hospitalaria y UCI cortas
Ø  Menor transfusion hemoderivados
Ø  Conversion
Ø  Nefropatia inducida
por contraste
Ø  Complicaciones locales 9-16%
Ø  Endofugas y falla de endoprotesis
Ø  Reintervencion 10% año
Ø  La ruptura secundaria 1% año
Ø  Requiere seguimiento mas cercano imagenológico
COSTOS
Ø Seguimiento a 8 años promedio total de costo
en EVAR £3,019 ($4,568) mas que en reparo
abierto.
Ø Complicaciones relacionadas con protesis,
reintervenciones mayores en EVAR y nuevas
complicaciones hasta 8 años contribuyeron a
aumento de costos.
The United Kingdom EVAR Trial Investigators. Endovascular versus open repair of
abdominal aortic aneurysm. N Engl J Med 2010;362:1863-71.
Predicting one year mortality after elective AAA repair
790 patients
11 New England hospitals
Age older than 70 years
History of chronic obstructive pulmonary disease
Serum creatinine higher than 1.8 mg/dL (159 ýmol/L)
Suprarenal clamp
Beck AW, Goodney PP, Nolan BW, et al
J Vasc Surg 2009; 4:838-843
Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT, Matsumura JS,
Kohler TR, et al.
Context Limited data are available to assess whether endovascular repair of abdominal aortic aneurysm (AAA) improves short
term outcomes compared with traditional open repair.
Objective To compare postoperative outcomes up to 2 years after endovascular or open repair of AAA in a planned interim
report of a 9-year trial.
Design, Setting, and Patients A randomized, multicenter clinical trial of 881 veterans (aged _49 years) from 42 Veterans
Affairs Medical Centers with eligible AAA who were candidates for both elective endovascular repair and open repair of AAA.
The trial is ongoing and this report describes the period between October 15, 2002,and October 15, 2008.
Intervention Elective endovascular (n=444) or open (n=437) repair of AAA.
Main Outcome Measures Procedure failure, secondary therapeutic procedures, length of stay, quality of life, erectile
dysfunction, major morbidity, and mortality.
Results Mean follow-up was 1.8 years. Perioperative mortality (30 days or inpatient) was lower for endovascular
repair (0.5% vs 3.0%; P=.004), but there was no significant difference in mortality at 2 years (7.0% vs 9.8%, P=.13).
Patients in the endovascular repair group had reduced median procedure time (2.9 vs 3.7 hours), blood loss (200 vs 1000
mL), transfusion requirement (0 vs 1.0 units), duration of mechanical ventilation (3.6 vs 5.0 hours), hospital stay (3 vs 7
days), and intensive care unit stay (1 vs 4 days), but required substantial exposure to fluoroscopy and contrast.
There were no differences between the 2 groups in major morbidity, procedure failure, secondary
therapeutic procedures, aneurysm-related hospitalizations, health-related quality of life, or erectile
function.
Conclusions In this report of short-term outcomes after elective AAA repair,
perioperative mortality was low for both procedures and lower for
endovascular thanopen repair. The early advantage of endovascular repair
was not offset by increased morbidity or mortality in the first 2 years after
repair. Longer-term outcome data are needed to fully assess the relative
merits of the 2 procedures.
JAMA 2009;302:1535-42.
A randomized controlled trial of endovascular aneurysm repair versus open surgery
for abdominal aortic aneurysms in low- to moderate-risk patients
Jean-Pierre Becquemin, MD, Jean-Chistophe Pillet, MD, François Lescalie, MD, Marc Sapoval, MD,
Yann Goueffic, MD, Patrick Lermusiaux, MD, Eric Steinmetz, MD, and Jean Marzelle, MD, for the ACE
trialists, Creteil, France
Background: Several studies, including three randomized controlled trials (RCTs), have shown that endovascular
repair (EVAR) of abdominal aortic aneurysms (AAA) offered better early results than open surgical repair
(OSR) but a similar medium-term to long-term mortality and a higher incidence of reinterventions. Thus, the
role of EVAR, most notably inlow-risk patients, remains debated.
Methods: The ACE (Anevrysme de l’aorte abdominale: Chirurgie versus Endoprothese) trial
compared mortality and major adverse events after EVAR and OSR in patients with AAA anatomically suitable
for EVAR and at low-risk or intermediate-risk for open surgery.Atotal of 316 patients with>5 cm aneurysms
were randomized in institutions with proven expertise for both treatments: 299 patients were available for
analysis, and 149 were assigned toOSRand 150 to EVAR. Patients were monitored for 5 years after treatment.
Statistical analysis was by intention to treat.
Results: With a median follow-up of 3 years (range, 0-4.8 years), there was no difference in the cumulative
survival free of death or major events rates between OSR and EVAR: 95.9% 1.6% vs 93.2% 2.1% at 1 year
and 85.1% 4.5% vs 82.4% 3.7% at 3 years, respectively (P .09). In-hospital
mortality (0.6%
vs 1.3%; P 1.0), survival, and the percentage of minor complications were not statistically different.
In the EVAR group, however, the crude percentage of reintervention was higher (2.4% vs 16%, P < .0001),
with a trend toward a higher aneurysm-related mortality (0.7% vs 4%; P .12).
Conclusions: In patients with low to intermediate risk factors, open
repair of AAA is as safe as EVAR and remains a more durable
option.
( J Vasc Surg 2011;53:1167-73.)
Quality of Life after Endovascular and Open AAA Repair. Results of a
Randomised Trial
M. Prinssen,1 E. Buskens,2 J. D. Blankensteijn3* and On behalf of the DREAM trial participants1
Aim. To compare the quality of life (QoL) in the first postoperative year after elective endovascular
abdominal aortic aneurysm repair (EVAR) and open repair (OR) in a randomised study.
Methods. In the Dutch Randomised Endovascular Aneurysm Management (DREAM) trial, patients are
randomly allocated to EVAR or OR. QoL questionnaires (SF-36 and EuroQoL-5D) were sent to all
patients preoperatively (PREOP) and at five time points in the first postoperative year (3W, 6W, 3M,
6M and 12M). Between November 1999 and August 2002, 153 patients (141 male; 12 female) were
randomised (78 EVAR and 75 OR; one crossover from OR to EVAR). The EuroQoL-5D scores and the
eight domains of the SF-36 for the two groups were compared using the Mann–Whitney test. Changes
over time were analysed using the Wilcoxon sign test.
Results. There were no statistically significant differences in baseline characteristics (age, gender and
SVS risk factors). The preoperative QoL scores of the study group were similar to the QoL scores of
the general population of the same age. After 3W the OR group showed a significant decrease on the
EuroQol-5D (p 1⁄4 0.022) and in six of the eight SF-36 domains. The EVAR group also showed a
significant decrease on the EuroQol-5D (p 1⁄4 0.004) and in 5 of the 8 domains of the SF-36. At 6W
the EuroQol-5D had recovered to baseline in the OR group and the decreased domains of the SF-36
had partially
recovered.IntheEVARgrouptheEuroQol-5DandthreeofthefivedecreasedSF-36domains,hadreturnedtobas
eline.From 6M on, the OR group reported a significantly higher score on the EuroQoL-5D than the
EVAR group (p 1⁄4 0.045 (6M) and p 1⁄4 0.001 (12M)).
Conclusion. In the early postoperative period there is a small, yet significant
QoL advantage for EVAR compared to OR. At 6 months and beyond, patients
reported better QoL after OR than after EVAR.
Eur J Vasc Endovasc Surg 27, 121–127 (2004)
Sexual Dysfunction After Conventional and Endovascular AAA Repair: Results of the DREAM Trial
Monique Prinssen, MD^; Erik Buskens, MD^; Rudolf P. Tutein Nolthenius, Steven M.M. van Sterkenburg,
MD^; Joep A.W. Teijink, MD^; and
Jan D. Blankensteijn, MD^ on behalf of the DREAM Trial Participants
Purpose: To assess sexual function in the first postoperative year after elective endovas- cular aneurysm repair
lEVAR) and open repair (OR) of abdominal aortic aneurysm (AAA). Methods: In the Dutch Randomized Endovascuiar
Aneurysm Management (DREAM) trial, 153 patients (141 men; mean age 71 years, range 53-85) were randomly
allocated to EVAR (n^77) or OR (n^76). Sexual functioning was evaluated preoperatively and at 5 times in the first
postoperative year (3, 6, 13, 26, and 52 weeks) using a questionnaire derived from the Medical Outcomes Study. The
proportions of patients reporting sexual dysfunction for any of 5 aspects (interest, pleasure, engagement, orgasm, and
erection) and any increase in the magnitude of dysfunction were compared between EVAR and OR.
Results: Preoperatively, the proportion of patients reporting sexual dysfunction in at least 1 aspect was 66% for the
OR group and 74% in the EVAR group (p = NS). Surgery had a clear impact on sexual dysfunction. The proportion of
patients reporting sexual dysfunction on at least 1 aspect increased to 79% in the OR group and 82% in the EVAR group. The magnitude of sexual
dysfunction increased in both groups on all 5 aspects at 3 weeks postoperativeiy, but this was more pronounced in the
OR group {interest: OR p^O.038 vs. EVAR p=0.071; pleasure: OR p-0.009 vs. EVAR p=0.065; engagement: OR p =
0.006 vs. EVAR p 0.054, orgasm OR p-0,023 vs. EVAR p = 0.112, and erection: OR p=0.046 vs. EVAR p^O.030). At 6
weeks, the OR group still reported a significant increase in 3 aspects (plea- sure p = 0.031, engagement p-0.010, and
orgasm p=0.003), whereas the EVAR group no longer showed a significant difference. From 3 months on, both groups
had returned to baseline.
Conclusions: EVAR and open elective AAA repair both have an impact on
sexual function in the early postoperative period. After EVAR, recovery to
preoperative levels is faster than after open repair,, but at 3 months, sexual
dysfunction levels are similar in both groups.
J Endovasc Ther 2004; 11:613-620
Endovascular Repair of Abdominal Aortic Aneurysm does not Improve Early
Survival versus Open Repair in Patients Younger than 60 Years
P.K. Gupta et al.
Multiple randomised trials have demonstrated lower perioperative mortality after endovascular
aneurysm repair (EVAR) compared to open surgical repair for infrarenal abdominal aortic aneurysms
(AAAs). However, in these trials the mortality advantage for EVAR is being lost within 2 years of repair
and the patients evaluated are relatively older with no study specifically comparing EVAR and open
repair for patients younger than 60 years of age.
A retrospective analysis of prospectively collected data.
Materials and methods
Patients younger than 60 years of age who underwent EVAR and open surgical repair for elective
infrarenal AAA were identified from the 2007–09 National Surgical Quality Improvement Program
(NSQIP) – a prospective database maintained at 237 centres across the United States. Univariate and
multivariate analyses were performed.
Results
Of the 651 patients, 369 (56.7%) underwent EVAR and 282 (43.3%) underwent
open repair. Thirty-day mortality for EVAR and open repair were 1.1% and
0.4%, respectively. This was not significantly different on univariate (P = 0.22)
as well as multivariate (P = 0.69) analysis after controlling for other co-morbidities. On
multivariate analysis, body mass index, history of stroke and bleeding disorder prior to surgery were
associated with a higher 30-day mortality after AAA repair (combined open and EVAR).
Conclusions
These contemporary results demonstrate that the 30-day mortality rate after
open repair is similar to that after EVAR in patients younger than 60 years with
infrarenal AAA.
European Journal of Vascular and Endovascular Surgery 43 (2012) 506-612
CONCLUSION
Ø  Basado
en la evidencia actual el EVAR es el
estandar de manejo del paciente con AAA.
Ø  EVAR
AAA.
Ø  Las
en muchos paises se realiza en > 60 % de
nuevas generaciones de endoprotesis y
mayor experiencia de los Cirujanos Vasculares
extienden indicaciones EVAR y mejora resultados
a corto y largo plazo.
CONCLUSION
Ø  En
pacientes jovenes con riesgo quirurgico
bajo o intermedio la Cirugia continua
siendo la mejor opcion cuando es realizada
por un Cirujano Vascular en un centro con
un equipo medico medico y tecnologia que
comprueba buenos resultados.
Ø  El
manejo endovascular es una alternativa
en pacientes jovenes de alto riesgo con
anatomia adecuada.
CONCLUSION
Ø  Los
Cirujanos Vasculares debemos
mantener entrenamiento y excelencia en el
manejo abierto y endovascular del AAA,
para poder ofrecer lo mejor a cada
paciente en su situacion individual.
Ø  En
Colombia es necesario colaboracion de
los cirujanos vasculares para evitar
sobrecostos al sistema de salud.