Side effects of TEVAR andEVAR on the heart:

Myth or reality ?Christos D. Liapis, MD, FACS, FRCS, FEBVS

Professor (Em) of Vascular SurgeryNational & Kapodistrian University of AthensDirector Vascular & Endovascular Clinic

Athens Medical Center7/12/2018

NO DISCLOSURES RELATED TO THE TOPIC

C. Liapis

• A non-significant tendency toward cardiovascular

deaths was apparent in the EVAR trials in the

endovascular group during the 24-month interval.

• Cardiovascular mortality was primarily due to

the required secondary interventions.

1. Brown LC, et al. EVAR trial participants. Does EVAR alter the rate of cardiovascular events in patients withAAA considered unfit for open repair? Results from the randomized EVAR trial 2. EJVES 2010

2. Brown LC, et al. EVAR trial participants. Incidence of cardiovascular events and death after open orendovascular repair of abdominal aortic aneurysm in the randomized EVAR trial 1. Br J Surg. 2011

EVAR and cardiovascular Outcome

C. Liapis

ACE Study 2007 Survival free of reinterventions

Courtesy J.P Becquemin, IMAD Sept. 2018 C. Liapis

Courtesy J.P Becquemin, IMAD Sept. 2018

French Endurant Registry (REF) 2017 Survival free of reinterventions

C. Liapis

Courtesy J.P Becquemin, IMAD Sept. 2018

ACE Study 2007: Survival at 4 years

C. Liapis

French Endurant Registry (REF) 2017 Survival at 4 years

Courtesy J.P Becquemin, IMAD Sept. 2018 C. Liapis

Short-term vs. long-term MI following EVAR and Open AAA Repair

b

Stather et.al British Journal of Surgery 2013; 100: 863–872 C. Liapis

Arterial Stiffness

Liao J et al Curr Ather Reports 2014 C. Liapis

Arterial stiffening results in increased pulse pressure, left ventricular hypertrophy, subendocardial ischemia,

endothelial dysfunction and cardiac fibrosis

Pulse wave velocity (PWV) andarterial stiffness

Pulse wave velocity (PWV): the gold standard methodof arterial stiffness measurement and a strongindependent predictor of cardiovascular morbidityand mortality.

Cavalcante JL et al JACC 2011; Ben-Shlomo Y et al JACC 2013

CARDIOVASCULAR SURVIVAL

months

Blacher J. et al Circulation. 1999;99:2434-2439C. Liapis

Arterial stiffness, circulating vascular calcification inhibitors and inflammatory mediators in pts with AAA

• PWV and hsCRP, WBC, IL-6, Osteoprotegerin were significantly upregulatedin pts with AAA.

• Independent association of PWV with mean blood pressure, OPG and AAAdiameter

Kadoglou NP, Liapis CD et al. Arterial stiffness and novel biomarkers in patients with abdominal aortic aneurysms. Regul Pept. 2012

C. Liapis

Changes in arterial stiffness in patients undergoing EVAR and TEVAR

Computational Fluid Dynamics

C. Liapis

Magnetic resonance elastography (MRE) is a phase‐contrast magnetic resonance imaging technique that measures tissue

stiffness non‐invasively.

Khan S. et.al NMR in Biomedicine. 2017

Cardiovascular magnetic resonance elastography

C. Liapis

Schäfer et al J Vasc Surg 2018 C. Liapis

4D MRI and aortic stiffness

Changes in arterial stiffness in patients undergoing AAA repair

EVAR (n=48) was associatedwith significant increase inPWV at 6 months

Open repair (n=39) of AAA induced modest increase of PWV

• Lantelme P et al J Hypertens 2009• Kadoglou NP, Moulakakis KG, Liapis CD. Changes in aortic pulse wave velocity of patients undergoing

endovascular repair of abdominal aortic aneurysms. J Endovasc Ther. 2012C. Liapis

Differential effects of stent-graft fabrics on arterial stiffness in patients undergoing EVAR

Values of PWV and novel biomarkers at baseline and after 12 months

N=118 pts

PWV, OPG and IL-8 increase was more pronounced in Polyester Woven groupcompared to PTFE group (p=0.033, p=0.048, p<0.001 respectively)

Kadoglou NP, Moulakakis KG, Liapis CD. Differential effects of stent-graft fabrics on arterialstiffness in patients undergoing endovascular aneurysm repair. J Endovasc Ther. 2014

C. Liapis

• Three abdominal aortic endoprostheses (AFX, Endurant II, Nellix)• Identical silicone aneurysm models. One model was left

untreated, and another model contained an aortic tube graft (Gelweave).

• The models were placed in an in vitro flow set‐up that mimics physiological flow.

Results: aPWV was significantly lower for the control compared to the AFX, Endurant, Nellix and tube graft models (P  <  0.05). Structural stiffness of the AFX model was significant lower compared to the control model (P  <  0.001), whereas all other models showed higher structural stiffness.

Effect of abdominal aortic endoprostheses on arterial pulse wave velocity in an in vitro abdominal aortic flow model

Noort K. et.al Physiological Measurement 2018, Volume 39, Number 10 C. Liapis

Takeda Y. et al Circ J 2014;78:322-328

7-day cardiac effects of EVAR

C. Liapis

Positive correlation between PWV and LV massTakeda Y. et al Circ J 2014;78:322-328

7-day cardiac effects of EVAR

C. Liapis

increased baPWV

induced left ventricular

hypertrophy, left atrium

enlargement and

impaired diastolic

function

EVAR alters cardiac structure and function 1 year post op

Takeda Y et al Circ J 2014C. Liapis

PRE-OP LV COMPLIANCE

CHANGE IN PWV

CHANGE IN LEFT ATRIAL VOL

Takeda Y. et al Circ J 2014;78:322-328

Pre and 1 year post op exercise tolerance

C. Liapis

Non-invasive Determination of Aortic Mechanical Propertiesand Their Effects on Left Ventricular Function Following EVAR

The stiffer endograft does not appear to acutely increase aortic impedance, though it does alter the timing of reflected

waves which may have negative effects on LV function.

Gregory A. et.al Journal of Medical and Biological Engineering 2018

Pre‐EVAR Post‐EVAR

C. Liapis

Arterial stiffness and thoracic endografts

M, 79y, Symptomatic8cm TAAMedtronicVALIANT Thoracic40X40, 46X46

C. Liapis

PWV and NT-proBNP changes in pts following TEVAR

Endovascular treatment of descending thoracic aortic aneurysms was associated withsignificantly increased NT-proBNP levels and arterial stiffness.

An increased cardiac risk for patients with already impaired cardiac compensatory mechanism ?

Moulakakis K., Liapis CD et.al. Ann Vasc Surg 2017 C. Liapis

• TEVAR and EVAR are associated with lowerperioperative mortality and morbidity ratescompared to open surgical repair BUT thisadvantage is blunted at long term, mainly due toan increase in cardiovascular complications.

• Arterial stiffening together with adverse cardiacfunction after stent graft implantation mayexplain this change in the long-term outcome

Conclusions (I)

C. Liapis

• There is evidence of increased arterial stiffnessafter EVAR related to graft type (polyester morethan PTFE).

• Arterial stiffness should be taken intoconsideration by the industry when designing newendografts. In the meantime patients afterendovascular treatment of aneurysms are in needof intensive cardiac follow up.

Conclusions (II)

C. Liapis

• Examine changes in proximal aorticimpedance, ascending aortic compliance, pulsewave analysis, PWV, LV load, and LVsystolic/diastolic function pre and post op,including long term, for aortic arch, TEVAR andEVAR cases.

• Examine differences in cardiac effects betweengraft material, length of the covered aorta,diabetics and chronic renal failure patients.

Future studies

C. Liapis

Thank you for your attention