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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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
Suggested positions of operation team members and equipment (Comprehensive review of vascular and endovascular surgery, 2004) 545
Several steps in the introduction of a stent graft (Comprehensive review of vascular and endovascular surgery, 2004) 546
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) 1.1 3.8 NS May J J Vasc Surg(1998) 5.6 5.6 NS Zarins CK J Vasc Surg(1999) 2.6 0 NS De Virgilio C Arch Surg(1999) 3.6 4.7 NS Beebe HG J Vasc Surg(2001) 1.5 3.1 NS May J J Vasc Surg(2001) 2.7 5.9 NS Zarins CK Proceedings(2001) 0.5 3.5 0.05 547
Classification of endoleak (Comprehensive review of vascular and endovascular surgery, 2004) 548
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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