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Vascular and Endovascular Surgery DivisionUniversity of Florence www.chirvasc-unifi.it

Ateromasia emboligena Ateromasia emboligena dell’aorta toracicadell’aorta toracica

R. PULLI

Ateromasia emboligena dell’aorta toracicaAteromasia emboligena dell’aorta toracica

Patologia spontanea

In corso di procedure invasive

•Trattamento endovascolare

•Tronchi epiaortici•Aorta toracica

Ateromasia emboligena dell’aorta toracicaAteromasia emboligena dell’aorta toracica

Patologia spontanea– Stroke– Embolia periferica– Embolia viscerale

In corso di procedure invasive– Stroke– Paraplegia

Embolia periferica o viscerale…Embolia periferica o viscerale…

…is a rare clinical syndrome requiring a high index of suspicion.

Ateromasia emboligena dell’aorta toracicaAteromasia emboligena dell’aorta toracica

IMPORTANZA DELLO STUDIO CON TEE

Trattamento endovascolareTronchi epiaortici

Trattamento endovascolareTronchi epiaortici

Volume 331:1729-1734 December 29, 1994 Number 26

Transluminal Placement of Endovascular Stent-Grafts for the Treatment of Descending

Thoracic Aortic Aneurysms

Michael D. Dake, D. Craig Miller, Charles P. Semba, R. Scott Mitchell, Philip J. Walker, and Robert P. Liddell

Trattamento degli aneurismi toracici ESPERIENZA EUROPEA

Registro Italiano di Chirurgia VascolareSICVEREG

Aneurismi toraciciDissecazioni di tipo B (acute e croniche)Rotture traumatiche dell’aortaPseudoaneurismiUlcere penetrantiFistole (aorto-bronchiali, aorto-esofagee)

Trattamento endovascolare:spettro di applicabilità

Permette una rapida diagnosi differenziale Permette una rapida diagnosi differenziale con l’IMA, il tamponamento cardiaco e con l’IMA, il tamponamento cardiaco e l’embolia polmonarel’embolia polmonare

Può essere eseguito al letto del paziente e Può essere eseguito al letto del paziente e non richiede più di 15 minutinon richiede più di 15 minuti

Operatore dipendente; lunga learning curveOperatore dipendente; lunga learning curve

Specificità elevata; sensibilità minoreSpecificità elevata; sensibilità minore

Erbel L et al., Lancet 1989

“ “TEE is the study of choice in non trauma patients TEE is the study of choice in non trauma patients with possible aortic abnormalities”with possible aortic abnormalities”

Ecocardiografia transesofagea

Department of Vascular SurgeryDepartment of Vascular Surgery University of FlorenceUniversity of Florence

ENDOVASCULAR TREATMENT OF THORACIC ENDOVASCULAR TREATMENT OF THORACIC AORTAAORTA

(2000 – 2007)(2000 – 2007)

100 cases100 cases100 cases100 casesAtherosclerotic Atherosclerotic aneurysmaneurysm

57 57 (56,6%)(56,6%)

Type B chronic Type B chronic dissectiondissection

21 21 (21,3%)(21,3%)

Type B acute dissectionType B acute dissection 3 (3%)3 (3%)Traumatic aortic ruptureTraumatic aortic rupture 14 14

(14,1%)(14,1%)Penetrating aortic ulcerPenetrating aortic ulcer 3 (3%)3 (3%)Intramural haematomaIntramural haematoma 2 (2%)2 (2%)

36 cases36 cases36 cases36 cases

Aortic arch pathologiesAortic arch pathologies 1313

Thoracoabdominal aortic Thoracoabdominal aortic aneurysmaneurysm

1010

Multilevel aortic diseaseMultilevel aortic disease 1313

36 males; mean age 73 years 36 males; mean age 73 years (range 65-81)(range 65-81)

Department of Vascular SurgeryDepartment of Vascular Surgery University of University of FlorenceFlorence

COMPLEX LESIONSCOMPLEX LESIONS(2000 – 2008)(2000 – 2008)

5 cases5 casesCarotid to subclavian Carotid to subclavian

artery bypassartery bypass

1 case1 caseSubclavian artery Subclavian artery

transpositiontransposition

Zone 23 case3 case

Ascending aorta to Ascending aorta to innominate and left innominate and left

common carotid artery common carotid artery bypass + carotid to bypass + carotid to

subclavian artery bypasssubclavian artery bypass

Zone 0

Zone 1

1 case1 case Ascending aorta to left common carotid Ascending aorta to left common carotid andand

subclavian artery bypasssubclavian artery bypass1 case1 case Subclavian to subclavian artery bypassSubclavian to subclavian artery bypass

with carotid transpositionwith carotid transposition2 case2 case Carotid to carotid to subclavian artery Carotid to carotid to subclavian artery bypassesbypasses

HYBRID TREATMENT OFHYBRID TREATMENT OFAORTIC ARCHAORTIC ARCH

Ishimaru S, 2002

HYBRID TREATMENTHYBRID TREATMENTOF AORTIC ARCHOF AORTIC ARCH

HYBRID TREATMENTHYBRID TREATMENTOF AORTIC ARCHOF AORTIC ARCH

HYBRID TREATMENT OFHYBRID TREATMENT OFAORTIC ARCH: RESULTS AORTIC ARCH: RESULTS

(N=13)(N=13)

Mortality: 1 (7.5%)Stroke: -Complications:

- frenic nerve paralisis 1 (7.5%)Endoleak:

- type II 1 (7.5%)Secondary procedures: -

Follow-up [mean (range)]: 12 months (1-24)

HYBRID PROCEDURESHYBRID PROCEDURESFOR AORTIC ARCHFOR AORTIC ARCH

Author NComplete

debranching

Earlystroke/death

Earlyneuroeven

ts

Survival(%)

Kieffer, 200516

8 31% 25% 56 at 2y

Schumacher, 2006

25

9 20% 4% 76 at 2y

Zhou, 200616

13 6% - 92 at 1.3y

Bergeron, 200625

15 12% -92 at 1.2y

Inglese, 200615

15 - -93 at 1.5y

Melissano, 200737

14 16% 11%89 at 1.5y

Spinal cord angiogram

HYBRID TREATMENT OF HYBRID TREATMENT OF THORACOABDOMINAL AORTA:THORACOABDOMINAL AORTA:

Spinal angio-MRI evaluationSpinal angio-MRI evaluation

HYBRID TREATMENT OFHYBRID TREATMENT OFTHORACOABDOMINAL AORTATHORACOABDOMINAL AORTA

HYBRID TREATMENT OFHYBRID TREATMENT OFTHORACOABDOMINAL AORTATHORACOABDOMINAL AORTA

HYBRID TREATMENT OFHYBRID TREATMENT OFTHORACOABDOMINAL AORTATHORACOABDOMINAL AORTA

HYBRID TREATMENT OFHYBRID TREATMENT OFTHORACOABDOMINAL AORTA: RESULTS (N=10)THORACOABDOMINAL AORTA: RESULTS (N=10)

Mortality:Mortality:- perioperative (MOF, 2 bleeding)- perioperative (MOF, 2 bleeding) 3 (30%)3 (30%)

- follow-up (MI)- follow-up (MI) 11

Endoleak:Endoleak:- type II- type II 11

Secondary procedures:Secondary procedures: -- Paraplegia:Paraplegia: -- Renal insufficiency:Renal insufficiency: -- Bypass graft patency:Bypass graft patency: 96%96%

Follow-up [mean (range)]: 9 months (1-21)

HYBRID PROCEDURESHYBRID PROCEDURESFOR THORACOABDOMINAL FOR THORACOABDOMINAL

AORTAAORTA

Author N Completedebranchi

ng

Early mortali

ty

Paraplegia

Endoleak

Bypass

patency

Fulton, 2005 2 1 - - - 100%

Resch, 200613

4 23% 30% 23%

Black, 200626

21 23% - 23% 98%

Zhou, 200615

10 7% - - 95%

Gawenda, 2007

6 2 - - - 100%

Conclusioni

L’ateromasia emboligena dell’aorta toracica è una evenienza non frequente, ma con conseguenze spesso disastroseLa diagnostica deve far uso di metodiche ultrasonografiche (TEE) in associazione ad angio-TC o angio-RMIl trattamento è controverso, comprendendo l’anticoagulazione, la terapia trombolitica o trattamenti più invasivi, chirurgico od endovascolare

Conclusioni

L’impiego sempre più diffuso di metodiche endovascolari ha contribuito all’aumento di incidenza di complicanze emboliche in presenza di aorta toracica ateromasicaIn questo caso il riconoscimento di tale complicanza è più difficile ed il trattamento più complessoLa prevenzione rimane il punto cruciale da sviluppare ulteriormente