Management of Vascular Disease Weighing Natural History Against Outcomes after Interventions Scott Berceli, MD PhD Associate Professor of Surgery
Jan 13, 2015
Management of Vascular Disease
Weighing Natural History Against
Outcomes after Interventions
Scott Berceli, MD PhD
Associate Professor of Surgery
CarotidStenosis
Carotid Endarterectomy
100%
AorticAneurysm
Open AAARepair100%
LegIschemia
Lower ExtremityBypass100%
Disease:
Treatment:
Standard Vascular Surgical Practice(circa. 2000)
CarotidStenosis
Carotid Endarterectomy
60%+
Carotid Stenting40%
AorticAneurysm
Open AAARepair20%
+Endograft AAA
Repair80%
LegIschemia
Lower ExtremityBypass
80%+
SFA StentingTibial Angioplasty
20%
Disease:
Treatment:
Standard Vascular Surgical Practice(circa. 2007)
Abdominal Aortic Aneurysms
Incidence • Found in 2-5% of individuals > 65 year old • Accounts for 1.2% of deaths in > 65 age group• 13th leading cause of death in U.S.
Risk Factors • Hypertension• Smoking• Family History (20% first degree relatives) • Male sex (4:1 M:F ratio)• Advancing age (rare in patients < 50 y.o.)
Rupture Risk
1960’s to 1990’s
2%
5%
10%
20%
0%
5%
10%
15%
20%
3.0 4.0 5.0 6.0 7.0 8.0
Size (cm)
Year
ly ri
sk o
f AA
A ru
ptur
e
Adapted from Szilagyi, Ann Surg, 1966
2004
ADAMs TrialUK Small Aneurysm
Patients with 4.0 to 5.5 cm AAA randomized to repair or observation
• no difference in AAA related mortality• 5.0-5.5 cm rupture risk 2% per year
]
VA Large AneurysmLongitudinal study of high risk patients with > 6.0 AAA
• 5.5 - 5.9 cm 9.2% per year• 6.0 - 6.4 cm 10.5 % per year• 6.5 - 6.9 cm 19.1% per year• > 7.0 cm 32.5% per year
]Determined from abd films
and physical exam
0%
5%
10%
15%
20%
3.0 4.0 5.0 6.0 7.0 8.0
Size (cm)
Year
ly ri
sk o
f AAA
rupt
ure
Revised
Previous
Timing of elective AAA Repair
• Repair vs. continued observation offered for AAA 5.0-5.5 cm• Repair recommended for AAA 5.5 cm (good risk patients)
+Operative Mortality
(open and endovascular) 2-4%
=
Presentation of Patients with Ruptured AAA
Classic Triad• Abdominal or back pain• Pulsatile abdominal mass• Hypotension
• 95% of all patients with rupture have at least 1 of 3 signs
• < 50% of patient with rupture have all 3 signs
Treatment is immediate operative repair within minutes
Symptomatic AAA
• Acute presentation of back or abdominal pain in a patient with a AAA (4.0 cm or greater) without other identifiable etiology
• Often accompanied by a tender aneurysm on exam
• Hemodynamically stable, with no evidence of rupture on CT scan
• Natural history his poorly known, felt to represent impending rupture (hours to day to weeks?)
• Warrants emergent vascular surgery evaluation, usually leading to urgent operative repair within hours
Symptomatic AAA = Ruptured AAA
Methods of AAA Repair
• Open• Endovascular
Open operative repair
Endovascular repair
• Material Components– Graft: woven polyester– Stent: nitinol (nickel-titanium)
exoskeleton• Thermal shape memory
– Non-absorbable polyester sutures• >2000 hand-sewn suture/stent graft
Primary Bifurcated Module Delivery Catheter
Infrarenal Placement
Completed Primary Deployment
Contralateral Limb Delivery Catheter Access
Contralateral Limb Deployment
Completed Repair
Carotid Artery Stenosis
Pathophysiology
50% or less due to disease of the carotid bifurcation
Risk Factors
• TIA’s
• Hypertension
• Cigarette smoking
• Hyperlipidemia
• Age, male sex, race, heredity
• Diabetes
History of carotid endarterectomy in the U.S.
Design a clinical trial
NASCETDesign
3000 patients randomized to medical or surgical therapy and followed for a minimum of 5 years
50 selected centers (<6% peri op stroke/death rate), sxs within 3 months, <80 yo; specific angio criteria
NASCET
2 year estimate by life table of ipsilateral stroke 26% for medical, 9% for surgical (70-99%)
18 mo mortality risk reduction 58%, stroke risk reduction 71%
NASCET
2 yr Estimate of Ipsilateral Stroke
Failure Rate NNT
Stenosis Medical Surgical
70-99% 26.1% 12.9% 8
50-69% 22.2% 15.7% 15
<50% 18.7% 14.9% 26
ACAS
• 39 centers, 17 credentialed surgeons (<3% for asymptomatic)
• <80 yo
• 1662 patients with >60% stenosis by angio
ACAS
Operative and angio stroke morbidity/mortality 2.3% (1.2% angio)
Surgery No Surgery
Projected 5 yr 5.1% 11%
stroke event rate
Stroke risk reduction 55% (only 17% for females)
ACAS
• Stroke risk reduces from 2%/yr to 1%/yr, or 5% at 5 yrs
• One stroke prevented for every 20 CEAs done in asymptomatic patients