Endovascular Aneurysm Repair Late Failure After EVAR: Disclosure: Cook, Inc. Is the Incidence Increasing? • Patents How is it Treated? • Consulting Tim Chuter, DM • Research Support Division of Vascular Surgery, UCSF UCSF UCSF Endovascular Aneurysm Repair Endovascular Aneurysm Repair Increasing Late Failure? Perfusion • Rising failure rate of old devices Pressure • Patients living longer Dilatation • Higher failure rate of new devices Rupture – What are the failure modes? – What are the predisposing factors? – Which devices are likely to fail and how? UCSF UCSF 1
Endovascular Aneurysm Repair Endovascular Aneurysm Repair Unstable Repair 1990-1991 Parodi et al • Structure • Position • Function UCSF UCSF Endovascular Aneurysm Repair Endovascular Aneurysm Repair AneuRx: Kaplan-Meier plot of freedom Flow Related from migration (>5mm) Pressure Related Sternbergh WC, III. J Vasc Surg 2003;37:916-917 UCSF UCSF 2
Endovascular Aneurysm Repair Endovascular Aneurysm Repair Suprarenal Stent UCSF UCSF Endovascular Aneurysm Repair Endovascular Aneurysm Repair Fabric failure Nitinol Corrosion Side of stent Apex of stent Beebe et al JVS 2001;33:S55-S63 Heintz C. et al. J Endovasc Ther 2001;8:248-53 UCSF UCSF 3
Endovascular Aneurysm Repair Endovascular Aneurysm Repair Fabric failure AneuRx “Microleak” J. Matsumura Northwestern University Zenith AneuRx LifePath UCSF UCSF Endovascular Aneurysm Repair Endovascular Aneurysm Repair Aneurysm Dilatation Extension of Disease Schanzer et al., Circulation, 2011 • Neck dilatation – Limited only by the graft itself • 41% at 5yr • Common iliac artery dilatation • More in later cohort – Rarely forms an aneurysm • More in elderly, bad anatomy, endoleak – Often causes loss of contact without leak UCSF UCSF 4
Endovascular Aneurysm Repair Endovascular Aneurysm Repair Aneurysm Dilatation Re-intervention Schanzer et al., Circulation, 2011 • 30% at 5 yr (DREAM) • Unknown time from preop CT to treatment • 20% at 5 yr (EVAR1, Nordon et al 2009) • No device-specific data • Many were for type II endoleak • Selection bias (M2S database) • Most interventions were trans-catheter UCSF UCSF Endovascular Aneurysm Repair Endovascular Aneurysm Repair New Devices Convergent Evolution • Everything is device-specific • Barbed uncovered proximal stent • Pre-clinical testing is of little value • Polished Nitinol stents • Late-occurring failure appears long after a • Tightly woven Dacron fabric new device is introduced • Short widely spaced Z-stents • Mechanical and biological factors UCSF UCSF 5
Endovascular Aneurysm Repair Endovascular Aneurysm Repair Endurant Zenith LP UCSF UCSF Endovascular Aneurysm Repair Endovascular Aneurysm Repair Incraft Anaconda UCSF UCSF 6
Endovascular Aneurysm Repair Endovascular Aneurysm Repair Aptus Trivascular UCSF UCSF Endovascular Aneurysm Repair Endovascular Aneurysm Repair Nellix What to do? • Follow-up – Before catastrophic failure • Re-intervention UCSF UCSF 7
Endovascular Aneurysm Repair Endovascular Aneurysm Repair Follow-Up Conversion vs. Re-intervention • Depends on device-specific failure mode • Infection • CT for endoleak and aneurysm size • Everything else • Ultrasound for endoleak and aneurysm size • Plain film for fracture, component separation or migration • Pressure measurements? UCSF UCSF Endovascular Aneurysm Repair Endovascular Aneurysm Repair How to Manage Late Failure How to Manage Late Failure • Type I Endoleak • Type II Endoleak – Migration – IMA – Implantation site degeneration – Lumbar UCSF UCSF 8
Endovascular Aneurysm Repair Endovascular Aneurysm Repair How to Manage Late Failure How to Manage Late Failure • Type III Endoleak • Endotension – Relining – Relining: Complete vs. Multi-component – Uniiliac vs. bifurcated UCSF UCSF Endovascular Aneurysm Repair Endovascular Aneurysm Repair How to Manage Late Failure Conclusions – Migration • Young patients need durable repair – Implantation site degeneration • Unhealthy implantation sites are unstable • New devices are unpredictable: – May eliminate current failure modes – May also introduce new ones • Old devices (like old operations) are at least predictable UCSF UCSF 9
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