Latest / European Society for Vascular Surgery / Sac shrinkage after EVAR: a true marker of success or a misleading signal? with K. Mani

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Sac shrinkage after EVAR: a true marker of success or a misleading signal? with K. Mani · European Society for Vascular Surgery

• 0:14
  Welcome to the ESVS podcast. I'm Rosalinda D
• 0:17
  'Amico, one of the new voices of the ESVS podcast
• 0:20
  and I work as a vascular surgeon in Switzerland.
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  Today we will discuss one of the most debated
• 0:26
  topics in surveillance after standard evil. aneurysm
• 0:30
  sac shrinkage and what it should actually mean
• 0:32
  for our follow -up decisions. I'm delighted to
• 0:35
  be joined by Professor Kevin Mani, Head of Department
• 0:38
  of the Vascular Surgery at Uppsala University
• 0:40
  Hospital and an internationally recognized expert
• 0:43
  in IVAR outcomes and follow -up strategies. Thank
• 0:47
  you Rosalinda for the opportunity to be part
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  of this. Before we dive in, let me briefly frame
• 0:54
  where the field stands. Current ESVS clinical
• 0:58
  practice guidelines on management of abdominal
• 1:00
  aorto -ailiac aneurysm support early post -EVAR
• 1:05
  imaging, commonly around 30 days, followed by
• 1:08
  a re -stratified surveillance strategy based
• 1:11
  on anatomy, seal, endolyx, and suck behavior,
• 1:14
  with the ongoing debate being how far we can
• 1:17
  safely de -escalate imaging in patients who look
• 1:20
  low -risk. At the same time, an international
• 1:23
  Delphi consensus recently proposed was a pragmatic
• 1:26
  definition of sacro -aggression, a decrease in
• 1:30
  maximum sac diameter of at least 5 mm compared
• 1:33
  with baseline, and it emphasized that sacro -aggression
• 1:36
  should be assessed routinely and considered an
• 1:39
  important indicator of EVAR success. Professor
• 1:42
  Mani, let's start at the beginning. In the Delphi
• 1:45
  consensus, sacro -aggression is defined as 5
• 1:48
  mm reduction in maximum diameter. In your view,
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  is this 5 mm threshold primarily a pragmatic
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  or does it truly reflect a biological meaningful
• 1:59
  change? Well, I think the 5 mm threshold is really
• 2:05
  based on the measurement error. of an aortic
• 2:10
  diameter, both on CT and ultrasound scans. So
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  if you do an intra -observer or intra -observer
• 2:16
  studies, you will notice that in an aneurysm
• 2:19
  that's around five and a half centimeters or
• 2:21
  larger, there is a margin of error of around
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  two, three millimeters in measurement or slightly
• 2:26
  even more sometimes. To have a significant shrinkage,
• 2:31
  you need to make sure that you are kind of beyond
• 2:33
  that margin of error and that's where. the 5
• 2:35
  mm threshold is a pragmatic one in my mind. How
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  important is timing? If sacrogression is generally
• 2:42
  expected within the first two years, does shrinkage
• 2:46
  at 12 months carry a different prognostic value
• 2:49
  compared with shrinkage that appears much later,
• 2:52
  say 4 or 5 years? It's a good point. I think
• 2:56
  if you have a... shrinkage early on you're likely
• 3:02
  to have a continued shrinkage over time sometimes
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  you have a persistent type 2 endolic early on
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  that disappears over time and then the shrinkage
• 3:10
  starts later i don't believe this has a great
• 3:14
  impact other than the fact that you know the
• 3:17
  guideline the guidelines recommend imaging every
• 3:20
  five years and if you have sac shrinkage and
• 3:24
  good seal you can delay your next imaging to
• 3:27
  five years which means that if you only at one
• 3:30
  year achieve a sac shrinkage you can actually
• 3:33
  then delay and don't do no scans four years while
• 3:36
  if you achieve this at year three or four you
• 3:39
  still do a five -year scan so that is the way
• 3:41
  we practice it The consensus also proposed that
• 3:45
  changes within 4 .9 mm represent sac stability.
• 3:49
  In daily practice, do you consider sac stability
• 3:52
  equivalent to treatment success, or in absence
• 3:55
  of regression, even without expansion, a subtle
• 3:58
  warning that something may not be completely
• 4:00
  resolved? Very good question. I think it's reasonable
• 4:05
  to say that sac stability is a successful treatment.
• 4:09
  Most importantly... we should be careful about
• 4:12
  making our patients anxious by, for example,
• 4:16
  stating that sac stability is a warning sign.
• 4:19
  I don't think that's correct. We know that patients
• 4:21
  with sac stability have a slightly different
• 4:23
  course than patients with sac shrinkage. So there
• 4:26
  are several studies that show that if you have
• 4:28
  a significant sac shrinkage, your risk for intervention
• 4:31
  or any aortic events is much lower than if you
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  have sac stability and, of course, than if you
• 4:36
  have sac expansion. So patients with sac stability,
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  have continued follow -up imaging annually. If
• 4:42
  there is, for example, a type 2 endolic, yeah,
• 4:44
  that's sextability. But I wouldn't regard it
• 4:47
  as a warning sign or as a failed treat. it is
• 4:50
  still a successful ortic tree. The literature
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  reports several predictors of absent regression
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  like older age, thrombus characteristic and anticoagulation
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  among others. In your practice, do these factors
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  meaningfully influence how stringent your follow
• 5:07
  -up is or are they too weak to justify individualised
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  surveillance? To be honest, we don't actively
• 5:15
  use these parameters in individualising surveillance.
• 5:19
  We do individualized surveillance after EVAR
• 5:22
  based on ceiling zone length, based on aortic
• 5:26
  and islet diameters, and based on presence of
• 5:28
  endoleaks and sac regression. Variables such
• 5:30
  as anticoagulation and thrombus characteristics
• 5:33
  do affect sac regression, but I think sac regression
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  is a much more tangible and pragmatic... endpoint
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  to use for individualizing your surveillance
• 5:44
  strategy. Do device design and proximal fixation,
• 5:47
  for example, suprarenal versus infrarenal influence
• 5:51
  sac behavior in a clinically meaningful way?
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  And more practically, are there specific device
• 5:57
  anatomy combinations where you would maintain
• 5:59
  tightness or surveillance even in absence of
• 6:02
  sac expansion? The most important part, I think,
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  is the diameter of the landing zones and obviously
• 6:09
  the length of the landing zone. So if you have
• 6:11
  a significant seal zone, more than one centimetre
• 6:15
  on both ends, that is important. It doesn't matter
• 6:18
  to me if it's suprarenal or infernal fixation
• 6:21
  devices, but it needs to be adequate and with
• 6:23
  wall opposition of the stent graft against the
• 6:26
  wall. And if the landing zone is dilated to start
• 6:31
  with, so if the proximal landing zone is more
• 6:33
  than 30 millimetres or the distal landing zone
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  is more than 20 millimetres, I think that affects
• 6:40
  our practice in terms of follow -up which means
• 6:43
  in practice that if the device diameter device
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  used was 32 or 34 36 for the proximal end and
• 6:52
  a bell bottom device in the iliac that situation
• 6:56
  would affect how we would follow the patient
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  Another strong message from the DELPHI process
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  was that comparison of two CTAs, baseline and
• 7:07
  follow -up, is considered the most accurate way
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  to detect sacro -regression. At the same time,
• 7:13
  duplex ultrasound is widely used in the routine
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  surveillance. Given the complex three -dimensional
• 7:18
  nature of IVAR anatomy, do you have concerns
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  that duplex may occasionally misinterpret sac
• 7:24
  dynamics, for example suggesting shrinkage that
• 7:27
  might not be confirmed on orthogonal CTA measurements?
• 7:31
  And practically speaking, does your confidence
• 7:33
  in sacroaggression depend on imaging modality
• 7:36
  used? So the most important aspect of measuring
• 7:39
  sac dynamics is that it should be measured with
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  the same modality. So duplex ultrasound should
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  be compared to duplex ultrasound and CT scan
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  should be compared to CT scan, which means that
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  if you have a practice of following patients
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  with ultrasound and you have a baseline ultrasound
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  and you have a certified lab that does ascrotomy,
• 7:59
  ultrasound. To me, that is then safe to follow
• 8:01
  that, leave our follow -up with the ultrasound
• 8:03
  scans, also in measuring diameters. And if you
• 8:06
  have a practice of following CTs, obviously you
• 8:08
  should do the follow -up measurements and comparisons
• 8:11
  with CTs. That is one aspect. The other aspect
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  that I think we sometimes misinterpret or maybe
• 8:16
  cheat with is that we compare the latest scan
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  with the scan from one year before. So if the
• 8:22
  patient is at year four of follow -up, you scan
• 8:24
  the four -year scan, either ultrasound or duplex
• 8:26
  with a three -year scan. And actually, it's important
• 8:29
  to underline that the guidelines and also this
• 8:31
  Delphi consensus is underlining that you should
• 8:34
  compare your follow -up scan with the baseline
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  first imaging after EVAR diameter. So a sac regression
• 8:41
  or sac expansion may occur later on, but the
• 8:44
  comparison should be done with the first one.
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  So it can be that the sac regression is two millimeters
• 8:50
  per year, which means that if you compare between
• 8:53
  two years it's not significant but if you go
• 8:55
  back four years it is a significant segregation.
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  So using the same modality from baseline versus
• 9:01
  follow -up and comparing always your latest scan
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  with the baseline scan are two important aspects.
• 9:07
  this, I think. What is your interpretation of
• 9:09
  patient to shrink early and then later re -expand?
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  How does that affect your confidence in sac shrinkage
• 9:16
  as a marker of durable procedural success? This
• 9:19
  is not a very common situation. And the most
• 9:23
  likely situation where this happens is when you
• 9:27
  lose seal. If there is, for example, a dilatation
• 9:30
  of the iliacs resulting in a type 1B endoleak,
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  that's a classic situation where you can have
• 9:35
  had a sac shrinkage. and all of a sudden you
• 9:37
  have a sac expansion. So I think it's dangerous
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  when that happens, but that definitely is a sign
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  of warning. And it can probably be avoided to
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  miss such situations by not only following sac
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  regression, yes or no, as a dichotomous variable
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  that decides your follow -up, but also being
• 9:54
  aware of the importance of adequate ceiling length,
• 9:58
  ceiling zone length, proximal distillery, and
• 10:00
  the diameter of the landing zone. So if the patient
• 10:04
  has a a large diameter iliac or a compromised
• 10:07
  ceiling length, even in the presence of sac regression,
• 10:11
  I think that patient should have a follow -up
• 10:13
  scan. Let's move to what I think is the most
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  challenging area in daily practice. A patient
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  with a stable sac, no obvious type 1, 3 endolics,
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  maybe a small type 2, or sometimes no visible
• 10:26
  endolic at all. How do you approach patients
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  who don't shrink? Does your follow -up modality
• 10:31
  and interval change in this scenario? Do you
• 10:35
  see sac non -regression as a failure of treatment
• 10:38
  or just a different biological trajectory? So
• 10:41
  this comes back to your previous question. I
• 10:44
  don't think lack of sac regression or sac stability
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  is a failure. And I again want to underline that
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  our patients worry. So if we start talking about
• 10:52
  failures in this situation, we create a lot of
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  anxiety among patients that is not justified,
• 10:58
  to be honest, in terms of what happens over time
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  with this. The approach in this situation is
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  that the patient obviously needs continued follow
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  -up to detect any sac expansion or development
• 11:10
  of new endoleaks, but this situation does not
• 11:12
  motivate any re -interventions. How important
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  are the assessment of quality and length of proximal
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  and distal ceiling zone in a sac that shrink?
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  Is the evaluation of these factors downplayed
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  when shrinkage is present, or should it be? I
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  don't think it should be downplayed. I think
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  that the ceiling zone is really what an E -bar
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  depends on for its success. And if you have an
• 11:39
  adequate ceiling zone of more than one centimeters
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  proximally distally, we know based on previous
• 11:45
  studies that that is a very important marker
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  for a successful E -bar over time. Even if there
• 11:51
  is sag shrinkage, I mean, obviously these things
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  often happen at the same time. So if you have
• 11:56
  a good ceiling zone, a good ceiling zone length
• 12:00
  you are also much more likely to have sac shrinkage
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  but theoretically you can have sac shrinkage
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  with minimal ceiling zone or with a ceiling loan
• 12:08
  that's compromised because it's a 24 millimeters
• 12:11
  iliac with the 28 millimeter landed standcraft
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  and in that situation I think it is important
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  to continue with annual imaging follow -up of
• 12:21
  those patients, while if you have sac shrinkage
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  and excellent ceiling zone, you can be much more
• 12:26
  relaxed with less frequent follow -up. Now another
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  dilemma. Persistent type 2 endoleak in presence
• 12:32
  of sac shrinkage. Does shrinkage in this context
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  influence your follow -up interval or imaging
• 12:39
  modality in these patients? That's very interesting.
• 12:42
  I think if you have a persistent type 2 endoleak,
• 12:44
  and significant sac shrinkage. That shows that
• 12:47
  this type 2 endolic is something you see on a
• 12:50
  scan on either ultrasound or CT, but it's not
• 12:52
  physiologically important. So I would be happy
• 12:55
  to follow that patient up. less frequently. And
• 12:59
  this is also what the current ESVS guidelines
• 13:01
  suggest. Finally, volumetric assessment is becoming
• 13:04
  easier and AI -based segmentation may soon allow
• 13:08
  rapid and reproducible 3D sac measurements. The
• 13:12
  Delphi panel showed cautious but not unanimous
• 13:15
  agreement that this tool may become useful adjunct
• 13:18
  in the future. Do you see this as a potential
• 13:21
  game changer not only for research but for clinical
• 13:24
  surveillance and early detection of adverse sac
• 13:28
  dynamic? Absolutely. I think this is really an
• 13:31
  exciting development. Honestly, it has taken
• 13:34
  more time than I would have expected for us to
• 13:36
  be able to shift to 3D volume measurements, but
• 13:40
  I'm sure this is going to come and this is going
• 13:43
  to replace the less stringent sac diameter measurements
• 13:47
  that we currently run. Based on the available
• 13:50
  evidence and your experience, is sack shrinkage
• 13:53
  best described as a marker of success or imperfect
• 13:57
  surrogate that can sometimes mislead the follow
• 14:00
  -up decision? And if you have to leave our listeners
• 14:04
  with a practical take -home message, what would
• 14:07
  it be? This is exciting. I think sack shrinkage
• 14:12
  is a marker of success. But the important part
• 14:15
  to me is that if our follow -up is not a decision
• 14:18
  that you should take only on one marker, such
• 14:21
  as sac shrinkage. We should be stringent in how
• 14:24
  we evaluate follow -up scans, really comparing
• 14:27
  it to the baseline scan, having a good understanding
• 14:31
  of ceiling zones that we have achieved, as well
• 14:34
  as sac shrinkage. So in combination, ceiling
• 14:38
  zone, endolic presence, and sac shrinkage, that
• 14:40
  is how you can decide on your follow -up of the
• 14:43
  patient. Avoid having... unexpected events and
• 14:47
  treat patients that need treatment at the right
• 14:50
  time. Professor Mani, thank you very much for
• 14:51
  joining us and for such a clear and open discussion.
• 14:55
  And thanks to our listeners for tuning into the
• 14:57
  ESVS podcast. Please follow the ESVS social to
• 15:01
  get updated on new releases. Talk to you soon.
• 15:04
  Bye. Thank you very much.