Abdominal Aortic Aneurysm Medical Slides

Present the trial evolution: EVAR-1 (2004): EVAR had lower 30-day mortality (1.6% vs 4.7%). However, 15-year follow-up (2020): no difference in overall survival, EVAR had higher reintervention rate (26% vs 11%), and late AAA-related mortality was higher with EVAR (due to endoleak-related ruptures and reinterventions). OVER trial (2019, 14-year follow-up): similar findings — early EVAR advantage lost by 3 years, no long-term survival benefit. DREAM trial (2017): confirmed no survival benefit at 12 years. Teaching message: EVAR reduces early mortality but requires lifelong surveillance CT and has higher reintervention rates. Open repair is more durable. Patient selection should consider age, fitness, and ability to comply with long-term surveillance.

Present the five types with management: Type I (attachment site leak — proximal Ia or distal Ib) — high pressure, mandates immediate repair (extension cuff, conversion). Type II (retrograde flow from branch vessels — lumbar, IMA) — most common, low pressure, usually benign, observe if sac is stable; intervene if sac growth >5 mm. Type III (graft defect — fabric tear or modular disconnection) — high pressure, requires repair. Type IV (graft porosity) — transient, self-limiting, observed post-implantation. Type V (endotension — sac expansion without identifiable leak) — controversial, manage on case-by-case basis. Surveillance: CT angiography at 1 month, 6 months, then annually post-EVAR.

Present the emergency protocol: (1) Permissive hypotension — target SBP 70-90 mmHg (maintain consciousness), avoid aggressive fluid resuscitation (dislodges retroperitoneal tamponade). (2) Emergency imaging — unstable patients with known AAA → OR immediately. Hemodynamically responsive → CT angiography to assess EVAR suitability. (3) Repair strategy: IMPROVE trial (2014) showed emergency EVAR (when anatomically suitable) versus open repair had similar 30-day mortality (~35% overall), but EVAR had shorter ICU stay and lower cost at 3 years. Approximately 60% of ruptured AAA are anatomically suitable for EVAR. (4) Damage control: if no EVAR capability, aortic balloon occlusion (REBOA) or supraceliac clamp, infrarenal tube graft, damage control if coagulopathic.