Is EVAR The Treatment of Choice For Inflammatory AAAs by itlpw9937


									  Is EVAR The Treatment of Choice For Inflammatory AAAs?

                                                Jaap Buth

Two to 10% of abdominal aortic aneurysms                     or less previous cardiac events (p=.0272) and        Notes
have an inflammatory component (IAAA),                       less pulmonary disease (p=.0032) in the IAAA
characterized by a white glistening fibrotic sur-            group. Regarding existing anatomy no differ-
face, a thickened aneurysm wall and adhesions                ences were observed in angulation in the aneu-
to neighbour structures. The thickened wall can              rysm neck (p=.12), the aneurysm itself (p=.18)
be observed on CT and is usually in the range                or the iliac arteries (p=.08). The infrarenal neck
of 0.5–3 cm. Histologically, the muscular and                was similar with regard to diameter (p=.87) and
elastic structures of the media are replaced                 length (p=.11) in the two study groups. The
by fibrotic tissue. Abundant lymphocytes and                 aneurysm had comparable diameters (p=.78)
plasma cells are present. Patients with IAAA                 and patency of iliac and hypogastric arteries.
often have symptoms of abdominal or back
pain. General symptoms like fatigue and weight               Device or limb stenosis during the procedure
loss are also common. The erythrocyte sedimen-               occurred almost 18 times more frequently in the
tation rate (ESR) and C-reactive protein (CRP)               group with IAAA (p=.0005). Device migration
are usually higher than in patients with abdomi-             as observed on the intraoperative angiogram did
nal aortic aneurysm without fibrosis.1, 2, 3 The             not occur in any of the patients with IAAA and
fibrotic changes may represent a difficulty dur-             in 40 of the patients with non-IAAA (1.1%). No
ing open surgery. This is reflected by a longer              differences were observed with regard to length
operating time, a higher mortality and morbidity             of stay in hospital, prevalence of endoleak or
and a greater need for blood transfusions when               the incidence of primary conversion to open
compared to non-inflammatory aneurysm.4, 5,                  surgery. Only blocking of one iliac artery was
  Theoretically, therefore, endovascular repair              significantly different in the two study groups.
(EVAR) could be an option in the treatment of                Thirteen (25%) occurred in IAAA (nine inten-
IAAA, however, variation in outcome has been                 tional and four inadvertently) and 488 (13.5%)
reported. In some cases, a successful result                 in non-IAAA, p=.0100.
with shrinking of the aneurysmal sack has been
                                                             The first-month mortality in the entire cohort
observed.7, 8, 9, 10 In contrast, others have reported
                                                             was 2.2% (82 patients). There was no signifi-
an increased inflammatory response following
                                                             cant difference between the groups with IAAA
EVAR in these patients (Fig. 1).11, 12
                                                             and atherosclerotic AAA. Arterial thrombosis
In this proceedings we summarize the out-                    occurred only in the group of patients with non-
come in patients with IAAA treated by EVAR                   IAAA (0.8%). An increased periaortic inflam-
as reported to the EUROSTAR register.13 The                  matory response was observed in 12% and a
results were compared with EVAR performed in                 decreased periaortic inflammation in 17% of the
patients with non-inflammatory aortic aneurysm               patients with IAAA (ns).
reported to the same register. In addition the out-
                                                             During follow-up there were no differences in the
come of open surgical repair (OSR) in IAAA as
                                                             incidence of type I, II and III endoleaks. Device
detailed in a recent systematic review of the lit-
                                                             migration, kinking, stenosis or thrombosis was
erature by a group from Manchester, UK14 , was
                                                             comparable in both groups. No differences were
compared to the EUROSTAR data.
                                                             observed with regard to all-cause death, aneu-
Results                                                      rysm-related death, rupture and conversion to
                                                             open repair. Of 47 patients with IAAA, diameter
The mean age in patients with IAAA (52                       measurements were recorded during follow-up.
patients) was approximately 6 years less than in             A regression of the aneurysm was observed in
the control group ( 3613 non-IAAA patients, p<               41 (87%, p=.0001). With regard to aneurysm
.0001). Other significant differences in patient             shrinkage, no difference was observed between
characteristics included a higher incidence of               patients with and without IAAA.
smoking (p=.0175), and lower incidence of
hypertension (p=.0133), better cardiac condition

Detailed information on 11 patients with IAAA             While exclusion of the aneurysm seems to be            Notes
was obtained by questionnaire. At presenta-               obtained by EVAR in most cases, the effect on
tion hydronephrosis was present in five patients          the fibrosis itself is less clear. Postoperatively
(45%). Previous ureteric procedures had been              both increased and decreased periaortic inflam-
performed in four patients (36%). Worsening               mation was observed on follow-up CT-scans.
of renal function in this subgroup was observed           An obvious decrease was observed in 55%
in the early postoperative period in 9% and in            and a significant increase was only observed
the late postoperative period in 27%. Postop-             in six patients in the EUROSTAR series. The
erative ureteric stenting or ureterolysis was             cause of this variable reaction regarding the
performed in two (18%) of these patients. No              fibrosis remains unknown. It is possible that
patients needed dialysis early or late postop-            the increased fibrosis in some cases could be
eratively. Serum concentration of urea and cre-           related to the so-called ‘post implantation reac-
atinine decreased in these 11 patients, although          tion’ occasionally seen in patients treated with
not significantly. The ESR decreased during the           EVAR. Following open operation, the fibrosis
early postoperative period. However, later it             is decreasing in about 75% of the cases.14-16
increased again to preoperative levels. The CRP           Although rare, increased fibrosis has also been
levels decreased in the late postoperative phase          reported following open surgery.14, 17, 18
compared to the preoperative phase. Aneurysm
wall thickness decreased in the 11 patients with          Even if the preoperative anatomy was similar
detailed information from 21 mm preopera-                 in the two EUROSTAR groups, there was an
tively to 17 mm early and 13 mm late postop-              increased rate of graft limb stenosis in the IAAA
eratively. Ureteric entrapment was observed in            group. As there were no significant anatomical
45% of the patients preoperatively, decreasing            differences between the two groups, the higher
to 27% after the procedure. In one patient the            incidence of graft limb stenosis-occlusion may
ureteric obstruction which was present preop-             be related to the distal landing zone in the exter-
eratively remained troublesome after operation            nal iliac artery. This finding is associated with
with continued requirement for ureteric stenting.         the more frequent overlapping of the hypo-
                                                          gastric artery by the device limb in the IAAA
In the recently published review on outcomes              group. It is possible that the iliac arteries where
of different treatments in IAAA, 999 patients             encapsulated by fibrotic tissue and that the arte-
with OSR and 121 with EVAR, all with IAAA                 rial wall as well as the aneurysm wall was stiffer
were included.14 In these study groups the                than in patients with non-inflammatory aneu-
30-day mortality was 6% and 2%, respectively              rysms. Thus, modelling of the endoprosthesis
(ns). However, the one-year all-cause mortal-             with a balloon catheter after deployment could
ity after OSR was 14% compared to 2% after                become more difficult. It is also possible that
EVAR (p=.02). In these study groups preopera-             IAAA is a separate disease entity with genetic
tive hydronefrosis regressed postoperatively in           risk factors,19 a higher incidence of autoimmune
69% versus 38%, respectively (p= .01). There              diseases20 and a higher metabolic activity than
were no differences in new onset hydronefrosis.           non-inflammatory AAA.21 However, although
                                                          statistically significant, the total number of graft
Discussion                                                limb obstructions was small and further investi-
                                                          gation of this particular phenomenon is neces-
Taking into consideration that open surgery
for IAAA is often challenging from a technical
point of view with reported higher mortality and          Hydronephrosis with or without ureteric proce-
complication rate,2, 4, 5 the present investigation       dures were frequently observed in patients with
indicates that with respect to exclusion of the           IAAA treated by EVAR (approximately 40% in
aneurysm from the circulation, EVAR is a fea-             EUROSTAR and the Review data). Late post-
sible method with promising early and midterm             operative worsening of renal function was pres-
results. The British literature review observed           ent in 27%. These findings suggest that EVAR
a lower perioperative mortality with EVAR                 alone may not be the optimal treatment for all
(ns) and significantly lower one-year all-cause           patients with IAAA. Possibly some patients
mortality. The reason for this latter difference is       with IAAA and ureteral stenosis might need
not known since there were insufficient data on           post-EVAR ureterolysis, omental wrapping of
comorbidities.                                            the ureters or perhaps corticosteroid therapy,
                                                          although this has not usually been considered
                                                          necessary following open surgery. On the basis

of the present analysis EVAR may especially               6.   Boyle JR, Thompson MM, Nasim A, Say-           Notes
be considered in patients with IAAA who have                   ers RD, Holmes M, Bell PRF. Endovascular
a high risk for open repair or in those who do                 repair of an inflammatory aortic aneurysm.
not have ureteral stenosis. However, more stud-                Eur J Vasc Endovasc Surg. 1997;13:328–
ies are needed to determine whether EVAR is                    329.
also the first-choice in the treatment of good-risk
patients with IAAA.                                       7.   Chuter T, Ivancev K, Malina M, Lind-
                                                               blad B, Brunkwall J, Risberg B. Inflam-
In conclusion, the results following EVAR of                   matory aneurysm treated by means of
patients with IAAA and patients with non-IAAA                  transfemoral endovascular graft insertion. J
were largely similar with regard to early and                  Vasc Interv Radiol. 1997;8:39–41.
mid-term results. EVAR is a feasible method to
exclude IAAA from the circulation. Perianeu-              8.   Deleersnijder R, Daenens K, Fourneau I,
rysmal fibrosis did not regress in a proportion of             Maleux G, Nevelsteen A. Endovascular
patients, however, clinical outcome was favour-                repair of inflammatory abdominal aortic
able. In open surgical repair the operatieve mor-              aneurysms with special reference to con-
tality risk seems higher which may apply in                    comitant ureteric obstruction. Eur J Vasc
the first place in patients with a compromised                 Endovasc Surg. 2002;24:146–149.
health. Because regression of hydronefrosis
                                                          9.   Hinchliffe RJ, Macierewicz JA, Hopkin-
is higher after OSR (even when patients with
                                                               son BR. Endovascular repair of inflam-
simultaneous ureterolysis are accounted for) this
                                                               matory abdominal aortic aneurysms. J
treatment may be considered in patients in good
                                                               Endovasc Ther. 2002;9:277–281.
medical condition.
                                                          10. Vallabhaneni SR, Mc Williams RG,
                                                              Anbarasu A, Rowlands PC, Brennan JA,
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