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1 Endovascular Aneurysm Repair Kee Chun Hong, M.D. Jang Yong Kim, M.D. Yong Sun Jeon M.D. Department of Surgery Radiology* Inha University College of Medicine & Hospital E mail : keechong@inha.ac.kr Abstract In recent years, the interest in minimally invasive surgery has grown, and the same trend is observed in vascular surgery and interventional radiology, leading to what is called endovascular surgery. Since the first use of a stent graft for the endovascular exclusion of an abdominal aortic aneurysm (AAA), endovascular aneurysm repair (EVAR) has greatly expanded, and more than 50,000 devices have been implanted until now. The endovascular graft can be implanted from a remote access site in the groin with a less anesthetic requirement. The endovascular graft is advanced over guidewires up the femoral and iliac arteries. Once in position, the graft is deployed immediately distal from the renal arteries. The aorta is not clamped and the blood loss is less than with open surgery. EVAR for AAA offers an important new alternative to open surgical procedure. The mortality rates after EVAR are reported between 0~5%. Long term follow up reports are not available, but mid term follow up of EVAR reveals an incidence of re intervention between 10~20% and a rate of late rupture of between 0.5~1.5% per year. The problems of endoleaks and graft failure continue to be the challenges that require technological innovations. Based on the currently available evidence, EVAR is an appropriate treatment for selected patients, especially those at high risk for open surgical repair. Keywords : Abdominal aortic aneurysm; Stent; EVAR 542

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3 Available endovascular grafts Name(Company) Graft material Stent material Introducer size Device (OD) composition Expansion Fixation Ancure(Guidant) Polyester Elgiloy 22F Unibody Self expanding Hooks AneuRx(Medtronic AVE) Polyester Nitinol 22F Modular Self expanding Friction Talent(Medtronic AVE) Polyester Nitinol 18~22F Modular Self expanding Friction + juxta renal bare stent Excluder(WL Gore) PTFE Nitinol 18F Modular Self expanding Friction + hooks Zenith(Cook) Polyester Stainless steel 22F Modular Self expanding Hooks + juxta renal bare stent LifePath(Edwards Lifesc) Polyester Elgiloy 22F Modular Balloon expandable Friction +crimps Powerlink(Endologix) PTFE Stainless steel 18~20F Unibody Self expanding Friction Quantum LP(Cordis) Polyester Nitinol 22F Modular Self expanding Hooks + juxta renal bare stent 544

4 Suggested positions of operation team members and equipment (Comprehensive review of vascular and endovascular surgery, 2004) 545

5 Several steps in the introduction of a stent graft (Comprehensive review of vascular and endovascular surgery, 2004) 546

6 Comparative results after EVAR and conventional open repair Author Journal (year) EVAR mortality (%) Open repair mortality (%) P Brewster DC J Vasc Surg(1998) 0 0 NS Goldstone J Proceedings(1998) NS May J J Vasc Surg(1998) NS Zarins CK J Vasc Surg(1999) NS De Virgilio C Arch Surg(1999) NS Beebe HG J Vasc Surg(2001) NS May J J Vasc Surg(2001) NS Zarins CK Proceedings(2001)

7 Classification of endoleak (Comprehensive review of vascular and endovascular surgery, 2004) 548

8 Is EVAR cost effective? Author Journal (year) Holzenbein J Eur J Vasc Endovasc Surg(1997) Yes Ceelen W Acta Chir Beig(1999) Equal Patel SW J Vasc Surg(1999) Yes Selwert AJ Am J Surg(1999) Equal Quinones WJ J Vasc Surg(1999) No Stenbergh WC J Vasc Surg(2000) No Clair DG J Vasc Surg(2000) No Birch SE Aus NZJ Surg(2000) No Turnipseed W J Vasc Surg(2001) No Bosch JL Radiology(2001) No 549

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10 1. Dos Santos JC. Sur La des obstruction des thrombose arterielle anciennes. Med Acad Chir 1947; Vollmar J. Rekonstrukive chirurgie der arterien. Stuttgart 1967; 24-27: Sternburgh WC III, Carter G, York JW. Aortic neck angulation predicts adverse outcome with endovascular abdominal aortic aneurysm repair. J Vasc Surg 2002; 35: Stanely BM, Semmens JB, Mai Q. Evaluation of patient selection guidelines for endoluminal AAA repair with the Zenith stent graft: the Australian experience. J Endovasc Ther 2001; 8: Beebe HG. Imaging modalities for aortic endografting. J Endovasc Surg 1997; 4: Broeders IAMJ, Blankensteijn JD. A simple technique to improve the accuracy of proximal AAA endograft deployment. J Endovasc Ther 2000; 7: May J, White GH. Endovascular treatment of aortic aneurysm. In: Rutherford R, ed. Vascular surgery, 5th ed. Philadelphia: WB Saunders, 1999: Brewster DC, Geller CS, Kaufmann JA. Initial experience with endovascular aneurysm repair: comparison of early results with outcome of conventional open repair. J vasc Surg 1998; 27: De Virgilio C, Bui H, Donayre C. Endovascularvs open abdominal aortic aneurysm repair. Arch Surg 1999; 134: Beebe HG, Cronewett JL, Katzen BT. Results of an aortic endograft trial: impact of device failure beyond 12 months. J Vasc Surg 2001; 33: S White GH, Yu W, May J. Endoleaks as a complication of endo- 551

11 luminal grafting of abdominal aortic aneurysm: classification, incidence, diagnosis and management. J Endovasc Surg 1997; 4: White GH, May J, Waugh R. Type I and type II endoleak: a more useful classification for reporting results of endoluminal repair of AAA. J Endoivasc Surg 1998; 5: Schrink GW, Aarts N, Wilde J. Endoleakage after stent graft treatment of abdominal aneurysms: implications on pressure and imaging: an in vitro study. J Vasc Surg1998; 28: Faries PL, Sanchez LA, Martin ML. An experimental model for the acute and chronic evaluation of intra aneurysmal pressure. J Endovasc Surg 1997; 4: Moore WS, Rutherford RB, for the EVT Investigators. Transfemoral endovascular repair of abdominal aortic aneurysm: results of the North American EVT phase 1 trial. J Vasc Surg 1996; 23: Blum U, Voshage G, Lammer J. Endoluminal stent grafts for infrarenal abdominal aneurysms. N Engl J Med 1997; 336: Schlensak C, Doenst T, Moreno JB, et al. Serious complications requiring surgical interventions after endoluminal stent graft placement for the treatment of infrarenal aortic aneurysms. J Vasc Surg 2001; 34: Sonesson B, Lanne T, Hansen F, Sandgren T. Infrarenal aortic diameter in the healthy person. Eur J Vasc Surg 1994; 8: Zarins CK, White RA, Moll FL. Aneurysm rupture after endovascular repair using the AneuRx stent graft. J Vasc Surg 2000; 31: Makaroun MS. The Ancure endografting system: an update. J Vasc Surg 2001; 33: S Sato DT, Goff CD, Gregory RT, et al. Endoleak after aortic stent graft repair: diagnosis by color duplex ultrasound versus computed tomography. J Vasc Surg 1998; 28: Cuypers PW, Laheij RJ, Buth J. Which factors increase the risk of conversion to open surgery following endovascular abdominal aortic aneurysm repair? The EUROSTAR collaborators. Eur J Vasc Surg 2000; 20: : 21; 10-5 Peer Reviewer Commentary 552

Original Articles Korean Circulation J 1999;29 9 : Bifurcated Stent-Graft Vanguard 를이용한 복부대동맥류의경관적치료 심원흠 1 최동훈 1 윤영섭 1 이도연 2 장병철 3 Bifurcated S

Original Articles Korean Circulation J 1999;299:907-912 Bifurcated Stent-GraftVanguard 를이용한 복부대동맥류의경관적치료 심원흠 1 최동훈 1 윤영섭 1 이도연 2 장병철 3 Bifurcated Stent-GraftVanguard for the Endovascular Treatment of Abdominal