doença oclusiva em terrritório aorto ilíaco

REVASCULARIZAÇÃOREVASCULARIZAÇÃOEM TERRITÓRIO EM TERRITÓRIO

AORTOILÍACOAORTOILÍACOTRATAMENTO CIRÚRGICO TRATAMENTO CIRÚRGICO

ABERTOABERTO

INTRODUÇÃOINTRODUÇÃO

1/3 PACIENTES COM ATEROSCLEROSE 1/3 PACIENTES COM ATEROSCLEROSE OBLITERANTEOBLITERANTE

POPULAÇÃO – 39-65 ANOS 1-2%POPULAÇÃO – 39-65 ANOS 1-2% ACIMA DOS 70 ANOS 6%ACIMA DOS 70 ANOS 6% SUCESSO INICIAL DE 96%SUCESSO INICIAL DE 96% PERVIEDADE - 5 ANOS – 91%PERVIEDADE - 5 ANOS – 91% MORBIDADE – 8,3%MORBIDADE – 8,3% MORTALIDADE – 3,3% MORTALIDADE – 3,3%

HISTÓRICOHISTÓRICO

Sushuruta – Índia – 2500 AC – controle do Sushuruta – Índia – 2500 AC – controle do sangramentosangramento

Hipócrates - bandagensHipócrates - bandagens Galeno – excisão – 15 séculos atrásGaleno – excisão – 15 séculos atrás Hallowel – 1759 – reconstrução vascularHallowel – 1759 – reconstrução vascular John Murphy – 1897John Murphy – 1897 Alexis Carrel – Nobel 1912 Alexis Carrel – Nobel 1912 Dos Santos - EndarterectomiaDos Santos - Endarterectomia


DeBakey – 1953 – endarterectomia carotídeaDeBakey – 1953 – endarterectomia carotídea Arthur Voorhees – prótese vascularArthur Voorhees – prótese vascular Dotter – Angioplastia - 1964Dotter – Angioplastia - 1964 Campos de Batalha – 1536 – Ambroise ParéCampos de Batalha – 1536 – Ambroise Paré

2° Guerra – Walter Reed Army Hospital Group – 2° Guerra – Walter Reed Army Hospital Group – reparo no campo.reparo no campo.

MASH – CoréiaMASH – Coréia

19231923 CLAUDICAÇÃOCLAUDICAÇÃO

BILATERALBILATERAL AUSÊNCIA DE PULSOSAUSÊNCIA DE PULSOS IMPOTÊNCIAIMPOTÊNCIA

1947 - 1947 - TROMBOENDARTERECTOMIATROMBOENDARTERECTOMIA

1952 - Wylie1952 - Wylie

ANATOMIAANATOMIA

TASC II Classification of Aortoiliac ‐TASC II Classification of Aortoiliac ‐DiseaseDisease

Tipo ATipo A Estenose unilateral ou bilateral da artéria ilíaca Estenose unilateral ou bilateral da artéria ilíaca

comumcomum Estenose curta unilateral ou bilateral da artéria Estenose curta unilateral ou bilateral da artéria

ilíaca externa (<3cm)ilíaca externa (<3cm)


Tipo BTipo B Estenose curta aorta da infra-renal (<3cm)Estenose curta aorta da infra-renal (<3cm) Oclusão unilateral da artéria ilíaca comumOclusão unilateral da artéria ilíaca comum Uma ou várias estenoses - 3 10cm envolvendo ‐Uma ou várias estenoses - 3 10cm envolvendo ‐

a artéria ilíaca externa sem se extender para a a artéria ilíaca externa sem se extender para a femoral comum.femoral comum.

Oclusão unilateral da artéria ilíaca externa sem Oclusão unilateral da artéria ilíaca externa sem envolver a origem da ilíaca interna ou femoral envolver a origem da ilíaca interna ou femoral comumcomum


Tipo CTipo C Oclusão da artéria ilíaca comum - bilateral Oclusão da artéria ilíaca comum - bilateral Artéria Ilíaca Externa – bilateral - estenose - 3 10cm sem ‐Artéria Ilíaca Externa – bilateral - estenose - 3 10cm sem ‐

envolver a artéria femoral comumenvolver a artéria femoral comum Estenose unilateral da artéria ilíaca externa envolvendo a artéria Estenose unilateral da artéria ilíaca externa envolvendo a artéria

femoral comum femoral comum Estenose unilateral da artéria ilíaca externa envolvendo a artéria Estenose unilateral da artéria ilíaca externa envolvendo a artéria

femoral comum e a origem da artéria ilíaca internafemoral comum e a origem da artéria ilíaca interna Oclusão unilateral da artéria ilíaca externa (calcificada) sem Oclusão unilateral da artéria ilíaca externa (calcificada) sem

envolver a artéria femoral comum e a origem da artéria ilíaca envolver a artéria femoral comum e a origem da artéria ilíaca internainterna


Tipo DTipo D Oclusão aórtica infra-renal Oclusão aórtica infra-renal Doença difusa da aorta envolvendo ambas as ilíacasDoença difusa da aorta envolvendo ambas as ilíacas Múltiplas estenoses das artérias artéria ilíaca comum, Múltiplas estenoses das artérias artéria ilíaca comum,

interna e femoral comuminterna e femoral comum Oclusão unilateral da artéria da artéria ilíaca comum e Oclusão unilateral da artéria da artéria ilíaca comum e

ilíaca externailíaca externa Oclusão bilateral da artéria ilíaca externaOclusão bilateral da artéria ilíaca externa Estenose ilíaca associada AAAEstenose ilíaca associada AAA

TÉCNICA OPERATÓRIATÉCNICA OPERATÓRIA

EndarterectomiaEndarterectomia

Reservado para o Tipo I Reservado para o Tipo I Não pode ser realizada em pacientes com Não pode ser realizada em pacientes com

Aneurisma Aneurisma Perviedade Perviedade

Cirurgião DependenteCirurgião Dependente

60 94% em 5 anos‐60 94% em 5 anos‐

Bypass AnatômicoBypass Anatômico

Aortofemoral Aortofemoral Transabdominal ou Retroperitoneal Transabdominal ou Retroperitoneal Anastomoses : Termino-terminal ou Termino-Anastomoses : Termino-terminal ou Termino-

laterallateral PTFE ou DacronPTFE ou Dacron

Bypass Extra-AnatômicoBypass Extra-Anatômico

ABDÔMEN HOSTILABDÔMEN HOSTIL CONDIÇÕES CLÍNICASCONDIÇÕES CLÍNICAS

1.1. AXILO-FEMORALAXILO-FEMORAL

2.2. AXILO-BIFEMORALAXILO-BIFEMORAL

3.3. FEMORO-FEMORAL (CRUZADO)FEMORO-FEMORAL (CRUZADO)

INDICAÇÕES PARA O INDICAÇÕES PARA O PROCEDIMENTO CIRÚRGICOPROCEDIMENTO CIRÚRGICO

Recommendation 36Recommendation 36. Treatment of aortoiliac lesions. Treatment of aortoiliac lesions

· TASC A and D lesions: Endovascular therapy is the treatment of · TASC A and D lesions: Endovascular therapy is the treatment of choice for type A lesions and surgery is the treatment of choice choice for type A lesions and surgery is the treatment of choice for type D lesions [C].for type D lesions [C].

· TASC B and C lesions: Endovascular treatment is the preferred · TASC B and C lesions: Endovascular treatment is the preferred treatment for type B lesions and surgery is the preferred treatment for type B lesions and surgery is the preferred treatment for good-risk patients with type C lesions. The treatment for good-risk patients with type C lesions. The patient’s co-morbidities, fully informed patient preference and patient’s co-morbidities, fully informed patient preference and the local operator’s long-term success rates must be considered the local operator’s long-term success rates must be considered when making treatment recommendations for type B and type C when making treatment recommendations for type B and type C lesions [C].lesions [C].

BYPASS AORTOFEMORALBYPASS AORTOFEMORAL

PERVIEDADEPERVIEDADE

5a perviedade % 10a perviedade % 5a perviedade % 10a perviedade %

INDICAÇÃO CLAUDICAÇÃO ISQUÊMIA CRÍTICA CLAUDICAÇÃO ISQUÊMIA CRÍTICAINDICAÇÃO CLAUDICAÇÃO ISQUÊMIA CRÍTICA CLAUDICAÇÃO ISQUÊMIA CRÍTICA

Membros Membros 91 (90 94)‐91 (90 94)‐ 87 (80 88)‐87 (80 88)‐ 86 (85 92)‐86 (85 92)‐ 81 (78‐81 (78‐83)83)

Pacientes 85 (85 89)‐Pacientes 85 (85 89)‐ 80 (72 82)‐80 (72 82)‐ 79 (70 85)‐79 (70 85)‐ 72 (61‐72 (61‐76)76)

de Vries S, Hunink M. Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta-de Vries S, Hunink M. Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta-analysis. J Vasc Surg 1997;26(4):558-569.analysis. J Vasc Surg 1997;26(4):558-569.

Bypass ExtranatômicoBypass Extranatômico

PERVIEDADEPERVIEDADE

Procedimento 5a perviedade %Procedimento 5a perviedade %

Axilo femoral bypassAxilo femoral bypass 51 (44 79)‐51 (44 79)‐Axilo bi femoral bypassAxilo bi femoral bypass 71 (50 76)‐71 (50 76)‐Femoral femoral bypassFemoral femoral bypass 75 (55 92)‐75 (55 92)‐

Objective: Objective: Aortobifemoral bypass (ABF) grafting has been the traditional treatment for extensive aortoiliac occlusiveAortobifemoral bypass (ABF) grafting has been the traditional treatment for extensive aortoiliac occlusivedisease (AIOD). This retrospective study compared the outcomes and durability of recanalization, percutaneousdisease (AIOD). This retrospective study compared the outcomes and durability of recanalization, percutaneoustransluminal angioplasty, and stenting (R/PTAS) vs ABF for severe AIOD.transluminal angioplasty, and stenting (R/PTAS) vs ABF for severe AIOD.

Methods: Methods: Between 1998 and 2004, 86 patients (161 limbs) underwent ABF (n Between 1998 and 2004, 86 patients (161 limbs) underwent ABF (n _ _ 75) or iliofemoral bypass (n 75) or iliofemoral bypass (n _ _ 11), and11), and83 patients (127 limbs) underwent R/PTAS. All patients had severe symptomatic AIOD (claudication, 53%; rest pain,83 patients (127 limbs) underwent R/PTAS. All patients had severe symptomatic AIOD (claudication, 53%; rest pain,28%; tissue loss, 12%; acute limb ischemia, 7%). The analyses excluded patients treated for aneurysms, extra-anatomic28%; tissue loss, 12%; acute limb ischemia, 7%). The analyses excluded patients treated for aneurysms, extra-anatomicprocedures, and endovascular treatment of iliac stenoses. Original angiographic imaging, medical records, and procedures, and endovascular treatment of iliac stenoses. Original angiographic imaging, medical records, and

noninvasive testing were reviewed. Kaplan-Meier estimates for patency and survival were calculated and univariate noninvasive testing were reviewed. Kaplan-Meier estimates for patency and survival were calculated and univariate analyses performed. Mortality was verified by the Social Security database.analyses performed. Mortality was verified by the Social Security database.

Results: Results: The ABF patients were younger than the R/PTAS patients (60 vs 65 years; The ABF patients were younger than the R/PTAS patients (60 vs 65 years; P P _ _ .003) and had higher rates of.003) and had higher rates ofhyperlipidemia (hyperlipidemia (P P _ _ .009) and smoking (.009) and smoking (P P < .001). All other clinical variables, including cardiac status, diabetes,< .001). All other clinical variables, including cardiac status, diabetes,symptoms at presentation, TransAtlantic Inter-Society Consensus stratification, and presence of poor outflow weresymptoms at presentation, TransAtlantic Inter-Society Consensus stratification, and presence of poor outflow weresimilar between the two groups. Patients underwent ABF with general anesthesia (96%), often with concomitantsimilar between the two groups. Patients underwent ABF with general anesthesia (96%), often with concomitanttreatment of femoral or infrainguinal disease (61% endarterectomy, profundaplasty, or distal bypass). Technical successtreatment of femoral or infrainguinal disease (61% endarterectomy, profundaplasty, or distal bypass). Technical successwas universal, with marked improvement in ankle-brachial indices (0.48 to 0.84, was universal, with marked improvement in ankle-brachial indices (0.48 to 0.84, PP<.001). Patients underwent R/PTAS<.001). Patients underwent R/PTASwith local anesthesia/sedation (78%), with a 96% technical success rate and similar hemodynamic improvement (0.36 towith local anesthesia/sedation (78%), with a 96% technical success rate and similar hemodynamic improvement (0.36 to0.82, 0.82, P P < .001). At the time of R/PTAS, 21% of patients underwent femoral endarterectomy/profundaplasty or bypass< .001). At the time of R/PTAS, 21% of patients underwent femoral endarterectomy/profundaplasty or bypass(n (n _ _ 5) for concomitant infrainguinal disease. 5) for concomitant infrainguinal disease. Limb-based primary patency at 3 years was significantly higher for Limb-based primary patency at 3 years was significantly higher for ABFABFthan for R/PTAS (93% vs 74%, than for R/PTAS (93% vs 74%, P P _ _ .002). Secondary patency rates (97% vs 95%), limb salvage (98% vs. 98%), and long-.002). Secondary patency rates (97% vs 95%), limb salvage (98% vs. 98%), and long-

term survival (80% vs 80%) were similar.term survival (80% vs 80%) were similar. Diabetes mellitus and the requirement of distal bypass were associated Diabetes mellitus and the requirement of distal bypass were associated with decreased patency (with decreased patency (P P < .001). Critical limb ischemia at presentation (tissue loss, hazard ratio [HR], 8.1; < .001). Critical limb ischemia at presentation (tissue loss, hazard ratio [HR], 8.1; P P < .< .001), poor outflow (HR, 2; 001), poor outflow (HR, 2; P P _ _ .023), and renal failure (HR, 2.5; .023), and renal failure (HR, 2.5; P P _ _ .02) were associated with decreased survival..02) were associated with decreased survival.

Conclusion: Conclusion: R/PTAS is a suitable, less invasive alternative to ABF for the treatment of severe AIOD. Repair of theR/PTAS is a suitable, less invasive alternative to ABF for the treatment of severe AIOD. Repair of theconcomitant femoral occlusive disease is often needed regardless of open or endovascular treatment. Infrainguinal concomitant femoral occlusive disease is often needed regardless of open or endovascular treatment. Infrainguinal

disease negatively affects the durability of the procedure and patient survival. ( J Vasc Surg 2008;48:1451-57.)disease negatively affects the durability of the procedure and patient survival. ( J Vasc Surg 2008;48:1451-57.)

CONCLUSÃOCONCLUSÃO

OPÇÃO DO TRATAMENTO CIRÚRGICOOPÇÃO DO TRATAMENTO CIRÚRGICO

CONDIÇÕES ANATÔMICASCONDIÇÕES ANATÔMICAS CONDIÇÕES CLÍNICAS DO PACIENTECONDIÇÕES CLÍNICAS DO PACIENTE RISCO DO PROCEDIMENTORISCO DO PROCEDIMENTO INTERVENÇÕES PRÉVIASINTERVENÇÕES PRÉVIAS EXPECTATIVA DE VIDAEXPECTATIVA DE VIDA

doença oclusiva em terrritório aorto ilíaco

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