Aneurysm Repair Where are we now? - Jefferson Health · 2017-04-24 · Best case scenario rare !...
Transcript of Aneurysm Repair Where are we now? - Jefferson Health · 2017-04-24 · Best case scenario rare !...
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Aneurysm Repair Where are we now?
Richard Parsons M.D. FACS
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Endovascular treatment of aortic disease
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Anatomy
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Indications for repair of AAA
• Size > than 5cm
• Expansion greater than 0.2-.4 cm/year
• Symptomatic aneurysm
• Rupture
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Endovascular stent graft repair of Abdominal Aortic Aneurysm(EVAR)
• First performed in the US in 1994
• Has become the most common way to repair AAA 90+% at Abington Hospital
• From 2014-2016 we have performed 83 EVARs
• Length of stay is usually 1 night
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Endovascular repair of Abdominal Aortic Aneurysm
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Technically challenging features of endovascular aneurysm repair
Inverted funnel
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Technically challenging features of endovascular repair
Thrombus
thrombus
neck Accessory rena artery
Angulated neck
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Complications of repair
• Renal failure
• Colonic ischemia
• Aortic rupture
• Endoleaks
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Bowel ischemia Bowel ischemia
Colon ischemia
Renal ischemia
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CAUTION—Investigational device. Limited by Federal (or United States) law to investigational use.
Juxtarenal: AAA
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Post treatment leaks
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Endoleak classification types I-V
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Type I endoleak
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Type II endoleak from IMA retrograde flow
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Thoracic aneurysm
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Endovascular thoracic aortic aneurysm repair
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Endovascular vs open Thoracic Aneurysm Repair
• Repair when 6cm or greater • Less painful • Shorter length of stay • Less morbidity and mortality
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Complications of TAA repair
• Endoleak • Graft migration • Stent fracture • Delayed rupture • Infection • Paraplegia
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Best case scenario rare ! • Left subclavian artery not involved • Does not extend below diaphragm • Spinal ischemia risk diminished
LSCA
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Risk factors for paraplegia
• Long thoracic segment coverage
• Previous abdominal aortic repair
• Intra or postoperative hypotension
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Mechanisms to decrease paraplegia risk
• Avoid hypotension • Stage thoracic and abdominal repair
– 3-6 months apart • CSF catheter drainage to decrease spinal cord
pressures to be below 10mm • Evoked potential monitoring using balloon
occlusion • Temporarily creating an endoleak that is later
closed
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Thoracic dissection
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Treatment of type B dissection
• 90 % can be treated with BP control and pain medication
• Continued pain or aortic rupture requires immediate repair
• Invasive treatment is reserved for nonperfused vascular beds
–Mesenteric –Renal –Lower extremity –Late aneurysmal degeneration
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Treatment strategies
• Open fenestration • Endovascular fenestration • Proximal endograft placement to
open the true lumen and close the false lumen
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Risks of treatment
• Aortic rupture • Stroke • Spinal cord ischemia( paraplegia) • Ischemia of branch vessels( renal,
mesenteric,extremeties)
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Dissection Endovascular Stents
STABLE I Trial Enrollment • 83 pts. enrolled • US and OUS centers
CAUTION—Investigational device. Limited by Federal (or United States) law to investigational use.
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Remodeling of the aorta after dissection flap is closed
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Treatment of asymptomatic aortic dissection
• Prevention of late aneurysm dilatation • Aortic remodeling occurs in 90% of treated
patients • Only 70% of untreated patients remodeled
30% have aneurysmal dilatation • Unclear if treatment of all asymptomatic
dissections is justified
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Traumatic aortic dissection
• High speed deceleration injury • The aorta is tethered at the
ligamentum arteriosum dissection occurs just distal to subclavian
• Wide mediastinum on chest X-ray • CTA confirms dissection
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Thank you!
Richard Parsons MD