Polling Station

Poll 13/04/2018 – 30/06/2018

Topic: Asymptomatic juxta- and pararenal aortic aneurysms

Patient’s characteristics

Gender: Female
Age: 75 years old
Comorbidity: Arterial hypertension, hypercholesterinemia, previous aortocoronary bypass grafting, previous myocardial infarction, previous smoker, peripheral arterial disease, atrial fibrillation
Symptoms: None
Previous operations: None

Aneurysm characteristics:

Max. aneurysm diameter: 54 mm

Length of proximal infrarenal neck: 0 mm

Distance between SMA and LRA: 20 mm

Diameter of renal arteries: RRA: 5,3 mm, LRA: 6 mm

Suprarenal angulation: 60°

Diameter of distal neck: 30 mm

Minimum diameter of common iliac arteries: R: 11 mm, L:9 mm

Maximum diameter of common iliac arteries: R: 11 mm, L: 14 mm

Minimum diameter of external iliac arteries: R: 7 mm, L: 6,2 mm

Question #1

Treatment strategy

What would be your treatment strategy in this case?

Open surgical repair
fEVAR
chEVAR
Branched endografting
Conservative treatment and follow-up

The expert: Giovanni Torsello

As to this specific case and according to the Protagoras study (2) the best solution would be a chimney endografting (chEVAR) using a low-profile, flexible nitinol stent-graft for the aorta and balloon expandable covered stents for both renal arteries. The distance between SMA and left renal artery is ideal to achieve a new landing zone of 20mm. The upward orientation of the right renal artery could be, however, challenging during the chEVAR procedure.

Question #2

Diameter

Which diameter is an indication for the open or endovascular treatment of a juxta- or pararenal AAA in your daily practice?

≥50mm
≥55mm
≥60mm

The expert: Giovanni Torsello

According to the German national guidelines (in press), a maximum diameter of >50 mm is recommended as an indication for treatment. According to NICE guidelines rupture is more likely to occur in women than in men (3). For this reason, I would treat female patients with juxtarenal AAA already at a diameter of 50mm.

Question #3

Criterion to decide between fEVAR and chEVAR

Which criterion is the most important to decide between fEVAR and chEVAR in a patient with an asymptomatic juxta- or pararenal AAA and appropriate anatomy for both procedures?

Comorbidity
Age
Costs
If fEVAR is feasible, chEVAR should not be used in asymptomatic patients

The expert: Giovanni Torsello

We have a long positive experience with fEVAR. ChEVAR is probably a better solution only in case with involvement of one renal artery. Multiple parallel grafts increase the risk of gutter-related type Ia endoleak and should be avoided, when possible (4). Thus, I would vote that if fEVAR is feasible, chEVAR should not be used in asymptomatic patients.

Question #4

VQI perioperative mortality risk score

Do you use the Vascular Quality Initiative (VQI) perioperative mortality risk score in your daily practice?

Yes
No
I am not familiar with the VQI risk score

The expert: Giovanni Torsello

The risk scores are of great importance. However, there are several clinical and anatomic scenarios, that are playing an important role in our daily practice and are not reflected in such risk scores. Thus, my decision making is not always based on risk scores.

Question #5

Percentage of chEVAR procedures

Which is approximately the percentage of chEVAR procedures for asymptomatic juxta-/suprarenal aortic aneurysms in your daily practice?

I am not familiar with the chEVAR technique
< 10%
10-40%
40-70%
> 70%

Question #6

Percentage of fEVAR procedures

Which is approximately the percentage of fEVAR procedures for asymptomatic juxta-/suprarenal aortic aneurysms in your daily practice?

I am not familiar with the fEVAR technique
< 10%
10-40%
40-70%
> 70%

Question #7

Percentage of open surgery

Which is approximately the percentage of open surgery for asymptomatic juxta-/suprarenal aortic aneurysms in your daily practice?

I am not a surgeon and I am not referring patients to vascular surgeons
< 10%
10-40%
40-70%
> 70%