aneurysm repair where are we now? - jefferson health · 2017-04-24 · best case scenario rare !...
TRANSCRIPT
Aneurysm Repair Where are we now?
Richard Parsons M.D. FACS
Endovascular treatment of aortic disease
Anatomy
Indications for repair of AAA
• Size > than 5cm
• Expansion greater than 0.2-.4 cm/year
• Symptomatic aneurysm
• Rupture
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
Endovascular repair of Abdominal Aortic Aneurysm
Technically challenging features of endovascular aneurysm repair
Inverted funnel
Technically challenging features of endovascular repair
Thrombus
thrombus
neck Accessory rena artery
Angulated neck
Complications of repair
• Renal failure
• Colonic ischemia
• Aortic rupture
• Endoleaks
Bowel ischemia Bowel ischemia
Colon ischemia
Renal ischemia
CAUTION—Investigational device. Limited by Federal (or United States) law to investigational use.
Juxtarenal: AAA
Post treatment leaks
Endoleak classification types I-V
Type I endoleak
Type II endoleak from IMA retrograde flow
Thoracic aneurysm
Endovascular thoracic aortic aneurysm repair
Endovascular vs open Thoracic Aneurysm Repair
• Repair when 6cm or greater • Less painful • Shorter length of stay • Less morbidity and mortality
Complications of TAA repair
• Endoleak • Graft migration • Stent fracture • Delayed rupture • Infection • Paraplegia
Best case scenario rare ! • Left subclavian artery not involved • Does not extend below diaphragm • Spinal ischemia risk diminished
LSCA
Risk factors for paraplegia
• Long thoracic segment coverage
• Previous abdominal aortic repair
• Intra or postoperative hypotension
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
Thoracic dissection
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
Treatment strategies
• Open fenestration • Endovascular fenestration • Proximal endograft placement to
open the true lumen and close the false lumen
Risks of treatment
• Aortic rupture • Stroke • Spinal cord ischemia( paraplegia) • Ischemia of branch vessels( renal,
mesenteric,extremeties)
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.
Remodeling of the aorta after dissection flap is closed
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
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
Thank you!
Richard Parsons MD