ENDOVASCULAR THERAPY FOR EMERGENT THORACICAND ABDOMINAL AORTIC SITUATIONSE. Aslım¹, T. H. Akay¹, S. Özkan¹, A. Harman², F. Boyvat²,S. Aslamaci¹¹ Başkent Üniversity Faculty of Medicine Department of CardiovascularSurgery, Ankara² Başkent Üniversity Faculty of Medicine Department of Radiology, Ankara
ENDOVASCULAR THERAPY FOR AORTIC EMERGENCIESEndovascular Stent graft Indications;Elective; Thoracic aortic aneurysms,Abdominal aortic aneurysms,, Stanford type B dissections(J.C. Parodi,Transfemoral intraluminal graft implantationfor abdominal aortic aneurysm, Ann Vasc Surg1991)
ENDOVASCULAR THERAPY FOR AORTIC EMERGENCIESIt is generally accepted that the mortality in elective aorticsurgery is about 5% however this percentage is about80-90% in ruptured aortic aneurysmsEven in patients who survived and had the chance toreach the operating rooms, the mortality rate is over50%- Johansen K, et al. Ruptured abdominal aortic aneurysm: the Harborview experience. J Vasc Surg. 1991- Ouriel K, et al. Factors determining survival after ruptured aortic aneurysm: the hospital, the surgeon, and thepatient. J Vasc Surg. 1990;11:493-6.- Lee WA, et al.Perioperative outcomes after open and endovascular repair of intact abdominal aorticaneurysms in the United States during 2001. J Vasc Surg 2004; 39:491-6.
ENDOVASCULAR THERAPY FOR AORTIC EMERGENCIESEndovascular stent grafting of a ruptured aortic aneurysm was firstreported in 1994 by Nottingham groupOhki and colleagues has reported the endovascular repair of 12ruptured aortic anurysms with a mortality of 16 %- S.W. Yusuf et al, Emergency endovascular repair of leaking aortic aneurysm [letter] . Lancet344 (1994)- T. Ohki, et al, Endovascular graft repair of ruptured aortoiliac aneurysms. J Am Coll Surg 189(1999)
Conventional Surgery‣ Increased systemic inflammatory response leading tomultiple organ dysfunction‣ preoperative hypotension‣ the damage of collateral vascular structures duringsurgical dissection‣ Ischemia reperfusion injury related with aortic crossclamping‣ Secondary hypothermia‣ Coagulopathy related with massive transfusionM.J. Bown, et all. The systemic inflammatory response syndrome, organ failure, andmortality after abdominal aortic aneurysm repair. J Vasc Surg 37 (2003)
Endovascular Repair‣ No aortic clamp‣ less bleeding and less transfusion‣ Less damage to collateral vessels‣ protecting the body heatAim; to decrease the mortality and morbidity inperioperative and long term, besides decreasing thehospital stay time and procedure related costsEndovascular aneurysm repair decreases the hospital staytime with a percentage of 60-65 % and reduces theblood loss 25 to 40 % when compared to open surgeryZarins, et all. AneuRx stent graft versus open surgical repair of abdominal aorticaneurysms:Multicenter prospective clinical trial. J Vasc Surg1999 ;29:292-308
ComplicationsEndovascular treatment;- Iliac artery laseration- microemboli- Stenosis or occlusion in the branches of the graft- Endoleak (11 – 44 %)Convantional Surgery;- bleeding- Distortion of the anatomical structures- iatrojenic damage to duodenum, left renal vein, venacava inferior and iliac veins
Acute aortic dissections Stanford type B aortic dissection is one of the mostcatastrophic events that effect aorta! The treatment is usually medical when the situation isnot complicated and did not effect the ascending aorta In uncomplicated Stanford type B aortic dissectionsaneurysmal dilatation occurs in the 20% of the patientsdespite the maximum antihypertensive therapy. Mortality is more than 50% when the situation iscomplicated with the end organ ischemia The aim in the endovascular stent graf procedures is tostick the intimal layer to the false lumen and prevent apossible aortic rupture.
ENDOVASCULAR THERAPY FOR AORTIC EMERGENCIES Endovascular Stent graft Implantations in acute thoracic aorticsyndromes and other emergent situations is used in recent yearswith an increasing popularity.Slonim, et al., Aortic dissection: percutaneous management of ischemic complications withendovascular stents and balloon fenestration. J Vasc Surg 1996.23Nienaber, et al., Nonsurgical reconstruction of thoracic aortic dissection by stent-graftplacement. N Engl J Med 1999Dake et al., Endovascular stent-graft placement for the treatment of acute aortic dissection. NEngl J Med 1999Amabile et al. Surgical versus endovascular treatment of traumatic thoracic aortic rupture.JVasc Surg. 2004 ;40(5):873-9Aslim E, et al. Endovascular Management of Aortic Arch Injury After Blunt ThoracicTrauma EJVES Extra 2005 Lawlor et al. Endovascular management of traumatic thoracic aortic injuries. Can J Surg. 2005Pratesi et al. Acute traumatic rupture of the descending thoracic aorta: endovasculartreatment. Am J Surg. 2006Caronno et al. Emergency endovascular stent-graft treatment for acute thoracic aorticsyndromes. Surgery. 2006
ENDOVASCULAR THERAPY FOR AORTIC EMERGENCIES08/2004 – 03/2007Age: 61.4 ± 16.3 ( 38-86)Male/Female 13/3ASA II: 2ASA III: 10ASA IV: 4Anesthesia:General;1, Local Anesthesia +sedation;13,Epidural;2Technical Success: % 100Aorto uniiliac grafting + femoro - femoral cross overbypass: 1Mortality 16/3 (MI, Multi organ failure, intraabdominalabundant bleeeding)Morbidity;16/1 paresia in right lower exstremity30-Day Mortality:%18,75 (n=3)Convertion: % 0 (n=0)Leak: Type I %7.5 (n=1)Type II %15 (n=2)
ENDOVASCULAR THERAPY FOR AORTIC EMERGENCIESLocation;Thoracic aorta 8 Abdominal Aorta 8Lesion Type ;The Rupture of Abdominal Aortic Aneurysm 7Abdominal Aortic plaque rupture 1The Rupture of ThoracicAortic Aneurysm 2Blunt ThoracicAortic Trauma 4( pseudo aneurysm , traumatic aortic dissection and subtotal aortic rupture )AcuteTypeB dissection 2Graft Type n tube bifurcationMedtronicTalent/Valiant 8 7 1Gore Excluder/ TAG 8 2 616 9 7
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ENDOVASCULAR THERAPY FOR AORTIC EMERGENCIES• Mortality morbidity rates are significantly low• Keeping the patient in a stable condition, a sufficient graftbank and a trained team to perform the procedure underemergent conditions are the major requirements for thefeasibility of this treatment.• In the future, performing this procedure in the selectedcenters will help to reduce mortality in these lifethreatening situations
ENDOVASCULAR THERAPY FOR AORTICEMERGENCIESRight and Safe Treatment Option in SelectedPatients