Late Failure After EVAR: Disclosure: Cook, Inc. Is the Incidence - - PowerPoint PPT Presentation

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Late Failure After EVAR: Disclosure: Cook, Inc. Is the Incidence - - PowerPoint PPT Presentation

May 04, 2023 26 likes •121 views

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

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UCSF

Late Failure After EVAR:

Is the Incidence Increasing? How is it Treated?

Tim Chuter, DM Division of Vascular Surgery, UCSF

UCSF Endovascular Aneurysm Repair

Disclosure: Cook, Inc.

  • Patents
  • Consulting
  • Research Support

UCSF Endovascular Aneurysm Repair

Perfusion Pressure Dilatation Rupture

UCSF Endovascular Aneurysm Repair

Increasing Late Failure?

  • Rising failure rate of old devices
  • Patients living longer
  • Higher failure rate of new devices

– What are the failure modes? – What are the predisposing factors? – Which devices are likely to fail and how?

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UCSF Endovascular Aneurysm Repair

Unstable Repair

  • Structure
  • Position
  • Function

UCSF Endovascular Aneurysm Repair

1990-1991 Parodi et al

UCSF Endovascular Aneurysm Repair Flow Related Pressure Related UCSF Endovascular Aneurysm Repair

AneuRx: Kaplan-Meier plot of freedom from migration (>5mm)

Sternbergh WC, III. J Vasc Surg 2003;37:916-917

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UCSF Endovascular Aneurysm Repair UCSF Endovascular Aneurysm Repair

Suprarenal Stent

UCSF Endovascular Aneurysm Repair

Fabric failure

Side of stent Apex of stent Beebe et al JVS 2001;33:S55-S63 UCSF Endovascular Aneurysm Repair

Nitinol Corrosion

Heintz C. et al. J Endovasc Ther 2001;8:248-53

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UCSF Endovascular Aneurysm Repair AneuRx LifePath Zenith UCSF Endovascular Aneurysm Repair

Fabric failure

AneuRx “Microleak”

  • J. Matsumura

Northwestern University UCSF Endovascular Aneurysm Repair

Extension of Disease

  • Neck dilatation

– Limited only by the graft itself

  • Common iliac artery dilatation

– Rarely forms an aneurysm – Often causes loss of contact without leak

UCSF Endovascular Aneurysm Repair

Aneurysm Dilatation

Schanzer et al., Circulation, 2011

  • 41% at 5yr
  • More in later cohort
  • More in elderly, bad anatomy, endoleak
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UCSF Endovascular Aneurysm Repair

Aneurysm Dilatation

Schanzer et al., Circulation, 2011

  • Unknown time from preop CT to treatment
  • No device-specific data
  • Selection bias (M2S database)

UCSF Endovascular Aneurysm Repair

Re-intervention

  • 30% at 5 yr (DREAM)
  • 20% at 5 yr (EVAR1, Nordon et al 2009)
  • Many were for type II endoleak
  • Most interventions were trans-catheter

UCSF Endovascular Aneurysm Repair

New Devices

  • Everything is device-specific
  • Pre-clinical testing is of little value
  • Late-occurring failure appears long after a

new device is introduced

  • Mechanical and biological factors

UCSF Endovascular Aneurysm Repair

Convergent Evolution

  • Barbed uncovered proximal stent
  • Polished Nitinol stents
  • Tightly woven Dacron fabric
  • Short widely spaced Z-stents
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UCSF Endovascular Aneurysm Repair

Endurant

UCSF Endovascular Aneurysm Repair

Zenith LP

UCSF Endovascular Aneurysm Repair

Incraft

UCSF Endovascular Aneurysm Repair

Anaconda

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UCSF Endovascular Aneurysm Repair

Aptus

UCSF Endovascular Aneurysm Repair

Trivascular

UCSF Endovascular Aneurysm Repair

Nellix

UCSF Endovascular Aneurysm Repair

What to do?

  • Follow-up

– Before catastrophic failure

  • Re-intervention
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UCSF Endovascular Aneurysm Repair

Follow-Up

  • Depends on device-specific failure mode
  • CT for endoleak and aneurysm size
  • Ultrasound for endoleak and aneurysm size
  • Plain film for fracture, component

separation or migration

  • Pressure measurements?

UCSF Endovascular Aneurysm Repair

Conversion vs. Re-intervention

  • Infection
  • Everything else

UCSF Endovascular Aneurysm Repair

How to Manage Late Failure

  • Type I Endoleak

– Migration – Implantation site degeneration

UCSF Endovascular Aneurysm Repair

How to Manage Late Failure

  • Type II Endoleak

– IMA – Lumbar

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UCSF Endovascular Aneurysm Repair

How to Manage Late Failure

  • Type III Endoleak

– Relining – Uniiliac vs. bifurcated

UCSF Endovascular Aneurysm Repair

How to Manage Late Failure

  • Endotension

– Relining: Complete vs. Multi-component

UCSF Endovascular Aneurysm Repair

How to Manage Late Failure

– Migration – Implantation site degeneration

UCSF Endovascular Aneurysm Repair

Conclusions

  • Young patients need durable repair
  • 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