Introduction

The treatment of aortic aneurysms with stent

grafts was first introduced in 1991
1
as a less
invasive surgery. Initially it was used on
high-risk patients
2
possibly where a co-
morbidity increased the risks of open repair
3
,
however EVAR did not become widely
known until around 1999 and it is now
reported that up to 50% of elective
abdominal aortic aneurysms are treated
using an EVAR technique
4
.

A limiting factor of the EVAR technique is the
dependence on the vascular anatomy of the
patient
5
. Other complications associated
with EVAR include graft migration and
dislocation, endo-leaks, limb occlusion and
rupture
6
.

The Abdominal Aortic Aneurysm Quality
Improvement Programme (AAAQIP) of
Great Britain and Ireland aimed to reduce
mortality rates associated with elective infra-
renal aneurysm procedures to be <3.5% by
2013
7
. Local standards have also been set
for radiation dosage and duration of the
EVAR procedure
8
. On completion of the
database I will audit the findings with these
aims to discover if they have been met.


Method
Using a previous database that detailed follow-up time for EVAR patients I identified the 59 patients who had
the procedure from 2008 when it was first introduced to RGH to 2014. Using the Welsh Clinical Portal
Database and the National Vascular Registry (NVR) records I was able to collect data under specific
headings. One limitation associated with the population used was the sample size as it is small in
comparison to other studies. The database will continue to be updated and prospectively audited on a
regular basis.

Using the databases mentioned above, I recorded the size of the aneurysm, radiation dose during the
procedure, volume of contrast used and the duration of the procedure. Unfortunately these variables were
not always recorded on the databases available and therefore there are some data sets missing.

The levels of urea, creatinine and haemoglobin were collected before and after the procedure to enable the
investigation of kidney function and blood loss. In an attempt to standardise the data set, I recorded the
results 24 hours before the operation and 24 hours after the operation. One limitation associated with this
data set included the retrospective aspect of the data, as tests were not always undertaken within the 24
hours. In these cases I recorded the closest test to 24 hours.

Acknowledgments
I declare that this project is my own work.
Information taken from other sources has
been cited and referenced.

Many thanks to my tutor Mr Rocker and the
vascular team at Royal Glamorgan for their
kind help during this project.
Results
Of the 59 patients, 91.6% were male and 8.4% were female.
Within the sample size of 59 patients there was 1.7% mortality (n=1) from the EVAR procedure.
Using classification from the NVR the indication for EVAR were 83% elective operations where as 7% were non-elective
ruptures, and 10% were non-elective non-ruptured.
The average size of the aneurysm was 5.7cm with a range throughout the data set of +/- 5.2cm.
The average radiation dose was 17,210cGy/cm2 with a range of 166,680cGy/cm2. The average volume of contrast used during
the procedure was 115mls with a range of 280mls and an average screening time of 17.4 minutes with a range of 32.34 minutes.
A normal range for urea is between 2.5mmol/l and 6.7mmol/l. The average pre-operative urea was 7.2mmol/l and the average
post-operative urea level was 6.5mmol/l. The largest difference was 8.2mmol/l and the average difference between pre and
post-operative urea concentration was +/- 1.8mmol/l.
A normal range for creatinine is between 79mol/l and 118mol/l. The average pre-operative creatinine was 112.4mol/l and the
average post-operative creatinine was 108.4mol/l. The largest difference between pre and post-operative creatinine was
100mol/l and the average range was +/- 17.6mol/l.
A normal range for haemoglobin is between 13.5g/dl and 18g/dl. The average pre-operative Hb was 13.0g/dl and the average
post-operative Hb level was 11.4g/dl. The largest difference between pre and post-operative Hb was 5.9g/dl with an average
range of +/- 1.9g/dl.


Conclusions
The AAAQIP set a target of <3.5% mortality in procedures by 2013
7
, the mortality rate for the EVAR procedures of the
59 patients investigated was 1.7%, satisfying the aim of the AAAQIP.

When investigating the target dose and screening time there was no national threshold level however, there was a
local target guidance of 23,841.9 cGy/cm2
8
, the average radiation dose of the 59 patients investigated was 17,210
cGy/cm2. Again, this result is well below the targeted value. A similar local target for screening time was set at 24.2
minutes
8
. Average screening time was found at 17.4 minutes however there was a large range from 8.0 to 40.3
minutes with 17% of the data set found above the suggested screening time.

Although the dosage and screening times are below the stated figures, the value is calculated partially from the data
set I looked at, as it is a local figure. To ensure that the radiation dose and screening time are of a true standard, a
national target would need to be set but as of yet this does not exist.

When looking into kidney function the averages of pre-operative creatinine and post-operative creatinine are within
the reference ranges. Looking at the average range between the results pre and post operatively suggests that in the
majority of cases kidney function was preserved despite the use of contrast. A complication of EVAR is nephrotoxicity
from radiological contrast. These results are reassuring in that no patient suffered any major deterioration in renal
function requiring renal replacement therapy.

To develop this study, I would like to create a similar database for the open procedures and compare the variables
between the two. The results of this could then be compared to similar papers consisting of different patients from
different locations. In conclusion, the creation on the EVAR database has shown that the mortality rate, within this
data set has reached the target set by the NVR. The radiation dosage and screening time has also met local targets.
No national levels have been established yet.

Alice Bolton

Literature cited
PARODI, J. PALMAZ, J. &
BARONE, H. (1991).
Transfemoral Intraluminal
Graft Implantation for
Abdominal Aortic
Aneurysms. Annals of
Vascular Surgery. 5, 491-
499.

PARODI, J. MARTIN, M.
VEITH, J. Transfemoral
endovascular stented graft
repair of an abnormal aortic
aneurysm. Arch Curg 1995;
130:549.

BEARD, J. D., LOFTUS, I.,
& GAINES, P. A. (2014).
Vascular and endovascular
surgery. Edinburgh,
Saunders Elsevier.

LEE,W. CARTER,J.
UPCHURCH, G. et al.
Perioperative outcomes
after open and endovascular
repair of intact abdominal
aortic repair aneurysms in
the United States during
2001. J Vasc Surg 2004;
39:491.

WOLF, Y. FOGARTY, T.
OLCOTT, C. et al.
Endovascular repair of
abdominal aortic
aneurysms: eligibility rate
and impact on the rate of
open repair. J Vasc Surg
2000; 32:519-23.

STERNBERGH,W.
MONEY,S. GREENBERG,R.
et al. Influence of the
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An Audit Of Endovascular Aneurysm Repair Of Infrarenal Abdominal
Aortic Aneurysms at
The Royal Glamorgan Hospital

Objective

To Audit Endovascular Aneurysm Repair
(EVAR) since its introduction at Royal
Glamorgan Hospital (RGH), by means of
creating a database and comparing findings
with available National and Local guidelines.