strategies to treat evar in short proximal necks torsello.pdf · injury were significantly less in...
TRANSCRIPT
Strategies to treat EVAR in short proximal necks
Giovanni Torsello Münster, Germany
e-mail: [email protected] home page: www.gefaesschirurgie-muenster.de
Fenestrated endografts
Therapy of AAA with short or no neck
Disadvantages of the new technologies
- Price for endograft and covered stents - Complicated implantation technique - Angiosuite - Unsuitable arterial anatomy - Delay in manufacture (acute case)
Therapy of juxtarenal aortic aneurysm
Chimney technique
Typical indication for chimney
• Old (83 y) male patient, NYHA III-IV • 6.8 cm max. aneurysm diameter • Abdominal pain • Juxtarenal aneurysm with insufficient landing zone
stainless steel endoskeleton Nitinol endoskeleton
Choice of the endograft is essential
1. Insertion of the wire into the TV 2. Advancement of catheter/sheath 3. Controll angiography 4. Insertion of the atraumatic Rosen wire
1. Deployment of the endograft 2. Insertion of the chimney graft 3. Insertion of the lining stent
Standard endovascular equipment
• Wires: Terumo, 0.014“ and Rosen 0.035“ • Catheters: Vertebral (120-150cm), MPA (125 cm) • Sheath: Shuttle (Cook); 7F and 90 cm shaft • Endograft: Endurant (Medtronic) • Chimney graft: Advanta V12 (Maquet)
Postoperative CT angiography
Postoperative monitoring
CT angiography postoperatively Duplex ultrasound at 6 months CT angiography at 12 months, annually Antiplatelet medication: ASS and Clopidogrel for 2 months ASS lifelong
Chimneys vs. F-EVAR
Pararenal aortic aneurysm
Open fenestrated- or chimney endografting?
Münster algorithm for pararenal aortic pathologies
Surgery
low surgical risk relevant polar renal arteries
Chimneys high-risk patient ≤ 2 side branches symptomatic aneurysm Severe iliac tortouosity
and calcification
f-EVAR
high-risk patient > 2 side branches
Delay in the treatment > 6 weeks
January 2008 - December 2010 Surgery: 31 pts F-EVAR: 29 pts Chimneys:
30 pts
30-day outcomes
Donas KP, Torsello G et al J Vasc Surg
Chimneys F-EVAR OR P
Mortality 0 0 2 .023
Dialysis 0 0 2 .023
ICU 0.7 1.1 5.1 .001
RBCs 0.5 0.3 3.48 .001
EL-Type I 0 0 -
EL-Type II 2 2 -
Fluoroscopy 44.8 58.4
• early mortality, blood loss, LOS and acute kidney injury were significantly less in the endovascular group than in patients undergoing OR
• both Ch-EVAR and F-EVAR offer a lower risk alternative for the management of JAAA
• long-term durability, including preservation of graft fixation, seal, and branch vessel patency remain to be determined after Ch-EVAR
Conclusions
Our algorithm for proximal necks
Proximal AAA neck
Neck > 15 mm - Any device - Higher LoE for Endurant
Neck 10-15 mm Endurant
Neck 7-10 mm Endurant
Neck < 5-7 mm fEVAR Chimney
Universitätsklinik Münster St. Franziskushospital Münster
home page: www.gefaesschirurgie-muenster.de
Thank you !
• Chimneys are a lower risk alternative for the management of JAAA and TAA
• Careful selection of patients, graft and stents for the target vessels is the key for success
• Stiff endografts and low-radial force stents should be avoided
• Long-term durability, including preservation of graft fixation, seal, and branch vessel patency after Chimneys remain to be determined
Conclusions
Fenestrated and branched grafts (1.1.2001-1.9.2011; n:131)
30-day mortality rate 1.9% Follow-up 25 months 3-year survival 77% 3-year freedom from sec proced ures 76% 3-year freedom from type I leak/migration 92%
From: Troisi N. et al. J Endovasc Ther 2011;18:146-153
1st author year No of pat
30-d mortallity (% - n)
Renal faillure(% - n)
Perm dialysis (% - n)
Endoleak T- I (% - n)
Endoleak T-II (% - n)
Endoleak T- III (% - n)
Anderson 2001 13 0.0 0 7.7 1 0.0 0 0.0 0 15.4 2 0.0 0
Greenberg 2004 32 3.1 1 18.8 6 3.1 1 0.0 0 6.3 2 0.0 0
Halak 2006 17 0.0 0 0.0 0 5.9 1 0.0 0 41.2 7 0.0 0
Muhs 2006 38 2.6 1 5.3 2 0.0 0 2.6 1 50.0 19 0.0 0
O´Neill 2006 119 0.8 1 25.2 30 2.5 3 5.9 7 1.7 2 3.4 4
Semmens 2006 58 3.4 2 6.9 4 0.0 0 6.9 4 0.0 0 0.0 0
Ziegler 2007 63 0.0 0 22.2 14 1.6 1 6.3 4 0.0 0 1.6 1
Scurr 2008 45 2.2 1 0.0 0 0.0 0 2.2 1 0.0 0 0.0 0
Bicknell 2008 15 0.0 0 6.7 1 0.0 0 0.0 0 0.0 0 0.0 0
Verhoeven 2010 100 1.0 1 25.0 25 2.0 2 0.0 0 0.0 0 0.0 0
Amiot 2010 134 2.2 3 4.5 6 1.5 2 2.2 3 9.0 12 0.7 1
Tambyraja 2011 29 0.0 0 0.0 0 0.0 0 6.9 2 6.9 2 6.9 2
663 10 89 10 22 46 8
Overall 1.5% 13.4% 1.5% 3.3% 6.9% 1.2%
Fenestrated EVAR series
1st author year No of pat
30d mortallity (% - n)
Renal faillure(% - n)
Perm dialysis (% - n)
Endoleak T- I (% - n)
Endoleak T-II (% - n)
Endoleak T- III (% - n)
Ohrlander 2008 6 0.0 0 16.7 1 16.7 1 0.0 0 0.0 0 0.0 0
Hiramoto 2009 8 0.0 0 0.0 0 12.5 1 0.0 0 0.0 0 0.0 0
Bruen 2011 21 4.8 1 28.6 6 9.5 2 4.8 1 0.0 0 0.0 0
Coscas 2011 16 12.5 2 18.8 3 0.0 0 6.3 1 0.0 0 0.0 0
Donas 2011 73 0.0 0 8.2 6 0.0 0 1.4 1 8.2 6 0.0 0
124 3 16 4 3 6 0
Overall 2.4% 12.9% 3.2% 2.4% 4.8
% 0%
Chimney EVAR series
FEVAR vs chimneys
F-EVAR Chimneys 30-d mortality: 1.5% 2.4% - Renal failure: 13.8% 12.9%
- Postoperative dialysis: 1.5% 3.5%
Endoleak type Ia: 3.2% 2.4%
ns
ns
ns
ns
P
Postoperative CT angiography
AAA shrinkage
87-year old man with symptomatic AAA
Endurant stentgraft and V12 covered stent in the „chimney technique“
Oversizing
25-30% Proximal neck Endograft
24-25mm 32mm
26-28mm 36mm
Suggested devices
Mestres G, et al. EJVES 2012
Endurant V12
Excluder Viabahn
Positioning the patient…
Long tables
7F Shuttle sheath (Cook)
Femoral access
Prostar XL (Abbott) 10 F
ACT > 250 sec
Surveillance imaging in case of renal insufficiency
CTA via transbrachial straight flush catheter (20ml contrast agent)
When they don’t work or are technically demanding/
with increased risk
Technical success n=128 (96 %) Secondary patency n=129 (98%)
Typ 1 Endoleak n=4 (3%) Typ 2 Endoleak n=24 (18 %) 30 day mortality n=1 (0.8%) Overall mortality n=5 (4%), non EVAR related
Münster Experience: 132 patients operated for aortic pathology with the
Chimney technique
Unsuitable anatomy for Chimneys: subclavian a. stenosis or type III aortic arch
Demanding anatomy for Chimneys: Tortuous descending aorta
! Pushability ! Stability
Demanding anatomy for Chimneys: Tortuousity of the pararenal aorta
Demanding anatomy for Chimneys: Aorto-iliac tortuosity
Demanding anatomy for Chimneys: Overcoming extreme tortuousity of the
aneurysm neck and iliacs
Use of flexible and low-profile abdominal endografts
Demanding anatomy for Chimneys: Renal artery stenosis?
Pre-OP Post-OP
Placement of additional bare self-expanding stents
Demanding anatomy for Chimneys: Early splitting of renal arteries
The larger the number of side branches, the greater the risk for gutters and potential persistent endoleaks.
48
Ruptured Aneurysm
49
Ruptured aneurysm treated with parallel grafts
50
CT scan after treatment of ruptured AAA with parallel grafts
12.9.2011 19.9.2011 28.11.2011
Lift technique