aneurysm - SFAV

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aneurysm - SFAV

Aneurysms

Miltos Lazarides, Dierk Vorwerk


To explain the possible mechanisms

of formation of aneurysms

To explain the differences between

aneurysms, pseudo-aneurysms,

false aneurysms


TERMINOLOGY I

• The diagnosis “aneurysm” refers to

dilated segments of angioaccess,

whose diameter exceeds 1.5 to 2-fold 2

the diameter of the adjusted normal

non-dilated vein or graft

• In case of total dilatation of the entire

cannulable vein the preferred term is

“ectasia”


TERMINOLOGY II

• True aneurysms

• False aneurysms

(or pseudoaneurysms)

• Anastomotic aneurysms


Pathogenetic mechanism of AAA

creation. Is it the same in access

related aneurysms?

MMP’s

MMP’s: Matrix metalloproteinases


Perigraft hematoma

False

(no vessel wall

in the

dilatation)

Upper limb vein aneurysms in

association with a vascular access

True (vein

enlargement)

post-stenotic

turbulence

pre-stenotic

pressure increase


Τypes of arterial injuries


“One-site-itis”


Anastomotic aneurysm and

ectasia


Indications for intervention in

access-related aneurysms

FISTULAS

GRAFTS

Only if they involve the anastomosis

Involvement of the overlying skin

Shortness of potential cannulation area

Rapid expansion

Size exceeding twice the diameter of the

graft

Involvement of the overlying skin

Signs of infection

Shortness of potential cannulation area

DOQI 2006


Aneurysms per

se do not

necessarily

require

surgical or

endovascular

intervention


When to treat aneurysms?

• Urgently in ruptured aneurysms

• In the next available theatre

session in erosions and rapid

expansions

• Programmed reconstruction in all

other cases

• Staged procedure in special

situations (e.g. tandem aneurysms)


How to treat aneurysms?

1. Surgical repair

2. Endovascular repair

3. Hybrid repair

4. Other (thrombin injection etc)


Surgical repair of access

related aneurysms

1. Autologous repair

end to end repair

new anastomosis

aneurysmorraphy

2. Repair using synthetic graft


Surgical techniques (autologous)

kinking

Resection of the

involved segment

and primary repair

anastomotic aneurysm

Resection of the

aneurysm and

new anastomosis


Surgical techniques (synthetic)

stenosis

Resection of the involved

segment & interposition

of a new graft

skin erosion, bleeding)

Aneurysm ligation and

bypass of the

aneurysmal area


Aneurysmorrhaphy I

From Balaz et al, J Vasc Access, 2008


The management of an infected false

(or potentially infected) aneurysm


Treatment options

1. Total graft excision (optional vein patching)

2. Subtotal graft excision (oversewing of a

small stump left at the anastomosis)

3. Partial excision of the involved segment

(interposition of a new graft through an

uncontaminated field by a new route)


Total graft excision


Brachial artery ligation is

generally well-tolerated

tolerated*

A potential disadvantage associated

with brachial a. ligation is that it may limit

a future ipsilateral access procedure

Padberg et al 1992, Schanzer 2008


Subtotal graft removal


Partial graft excision


Case 1: is partial graft excision

feasible?


Partial graft excisionŁfeasible


Case 2: is partial graft excision

feasible?


Skin breakdown and cuff protrusion!! Ł

following subtotal graft removal


Treatment options for graft infections

used by different authors

1.6% 29%

19%


Case 3: Is partial graft excision

feasible


Case 4: Infected pseudoaneurysm

of an AV upper thigh loop graft.

What is the suggested mode of

treatment?


Subtotal excision of the infected

graft was performed


Case series of upper thigh AV grafts

n

1-year

patency

2-year

patency

Infection

rate

Ischemia rate

Tashijan 73 83% 83% 22% 1%

Khadrra 74 77% 62% 16% 3%

Bhandari 46 85% 77% 35%

Taylor 45 18% 16%

Cull 116 68% 54% 41% 11%

Miller 63 62% 39% 11% 0%

Englesbe 30 41% 26% 27% 3%

Korzets 37 73% 65% 5% 11%

Vogel 134 62% 20%

Slater 22 80% 9%

Hazinedaroglou 17 24% 18%


The infection rate in upper

thigh AV grafts is

unacceptably high with a

mean value of 23% *

*Results from 11 published studies

(150 out of 657 patients)


Gradman et al 2003


Case 5: false aneurysm and proximal true

aneurysm in a brachiocephalic AV fistula.

What is the suggested way of treatment?


Trapdoor technique I


Trapdoor technique II


Case 6: Anastomotic Case aneurysm in a radial-

cephalic AV fistula. What is the best way of

treatment?


Case 7: false and

anastomotic aneurysms


Case 8: cephalic vein true aneurysm (ectasia)


Case 9:

multiple previous

AV grafts

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