poplitealarterienaneurysma: endovaskuläre therapie · thromboembolie & ruptur verhindern 2....

Poplitealarterienaneurysma: Endovaskuläre

Therapie

Reza Ghotbi

Helios Klinikum München-West/Dachau

Gefäßchirurgische Klinik

Lehrkrankenhaus der LMU

1. Thromboembolie & Ruptur verhindern

2. Extrmitäterhalt

1. Sichere Aneurysmaausschaltung

2. Reduktion der Reinterventionen,

Morbidität.

Therpieziele

Contemporary Treatment of Popliteal Artery Aneurysm in Eight

Countries: A Report from the Vascunet Collaboration of Registries European Journal of Vascular and Endovascular Surgery Volume

47 Issue 2 p. 164e171 February/2014


Countries: A Report from the Vascunet Collaboration of Registries

Australia has a median age of 74 years, Sweden the median is only 69 years,

the average of 70 years.

the overall proportion of endovascular repairs in the studied countries (22.2%)

was quite similar to that reported from the USA in 2007 (23.6%).


Countries: A Report from the Vascunet Collaboration of Registries European Journal of Vascular and Endovascular Surgery Volume

47 Issue 2 p. 164e171 February/2014

Objective:

The aim of this review was to evaluate the safety and efficienc after EVR and OSR:

Results:

RCT and four retrospective cohort studies with 652 cases (236 EVR, 416 OSR)

Median follow up of 33 months

EVR & OSR showed equal primary patency rates

Lengths of operation and hospitalization significantly shorter following EVR

30 day graft thrombosis and 30 day re-intervention were significant higher for EVR.

No effect on mortality or limb loss.

Conclusion:

EVR for popliteal artery aneurysm showed mid-term results comparable to

Open surgery and appears to be a safe alternative to OSR.

M. von Stumm a,*, H. Teufelsbauer b, H. Reichenspurner a, E.S. Debus c

Eur J Vasc Endovasc Surg (2015) 50, 351e359

Two Decades of Endovascular Repair of Popliteal

Artery Aneurysm; Metaanalysis

Endoleak 9% (0-38%) 7% (0-20%)

Aneurysm growth 7% (0-36%) 3% (0-17%)

Mortality 3y 12% 4%

Prim. Ass. Patency

1y-3y

87%-86% 74%-87%

Sec. Patency 1y-3y 90%-81% 87%-85%

Sec. Patency 1y 90% 87%

Amputation 1y 7% 2%

Amputation 3y 4% 3%

n= 4247 OR Endovasc

Tsilimparis N,et al, Ann Vascular Surg: Tabular Review of the Literature, Apr2012

Metaanalyse: Endograft vs offene Verfahren

Planungsfehler:

Anatomie,

Endograft

Was muss man vermeiden?!

Zu Lange Rekonstruktionen:


European Journal of Vascular and Endovascular Surgery Volume

48 Issue 2 p. 161e168 August/2014

Long-term Outcomes and Sac Volume Shrinkage after Endovascular Popliteal

Artery Aneurysm Repair

27 Patienten,

mittlere Nachbeobachtungszeit 72 Monate Ergebnisse:

Revisionsfreie Offenheitsrate : 70,4 %

Assistierte Offenheitsrate : 92,6 %

Reinterventionsrate : 29,6 %

(1/3 Halsdegeneration!)

VascularDiseaseManagement, Volume 4-July 2007:123-127


Zu kurze Rekonstruktionen:

Notfallindikationen: Run Off ?

Endovascular treatment popliteal artery aneurysms and follow-up Annals of Vascular Surgery Volume 41, May 2017


Notfallindikationen: Bypass

Surgical management of popliteal artery

aneurysms: Which factors affect outcomes? JOURNAL OF VASCULAR SURGERY March 2006

Inclusion criteria

1. All PAA with a diameter >2 cm

2. at least one patent native tibial vessel

3. a proximal and distal landing zone with

a length of >1 cm;

4. both elective and urgent EVPAR were

included as well as urgent cases

previously treated with thrombolysis.

Exclusion criteria

1. age <50 years old;

2. a history of thrombophilia;

3. contraindication to antiplatelet therapy

4. superficial femoral artery aneurysm

Long-term Outcomes and Sac Volume Shrinkage after Endovascular Popliteal

Artery Aneurysm Repair European Journal of Vascular and Endovascular Surgery Volume

48 Issue 2 p. 161e168 August/2014

2005-2010: EVPAR mittlere Nachbeobachtungszeit 24 Monate

54 Patienten, 61 Poplitealarterienaneurysmen

Follow up: 40 Pat /43 PAA, 24 Monate Amputationsrate 0%

Frühverschlussrate 6,9%

Reinterventionsrate 18,6%

Revisionsfreie Offenheitsrate: 81,4 %

Assistierte Offenheitsrate: 95,3 % Chirurg 2013 Mar;84(3):243-54

Eigene Daten

2005-2010: EVPAR mittlere Nachbeobachtungszeit 24 Monate

Follow Up: 40 Pat /43 PAA, 24 Monate

proximale Halsdegeneration n=1

Stentdiskonnektion – Stentokklusion n=2

Stentfraktur n=1

Edgestenose – Restenose – Stentverschluss n=3

Frühverschluss n=1 (HIT)

Revisionen=8

Bypassanlage n=2

endovaskuläre Revision n=6

Eigene Daten

Methods: Seventy-five PAAs repaired in 66 patients (64 male and 2 female) over the past 13 years.

Fifty-two aneurysms (69%) were treated with open surgical exclusion and/or bypass using

autologous vein (69%) or polytetrafluorethylene (31%) conduit.

Since 2001, ER was considered in patients with high medical risk, in 23 limbs (31%) were

pre scribed clopidogrel and/or aspirin.

Results: Patients treated endovascularly were older (82 vs. 70 years old, P 1⁄4 0.01), lower

complication rates (8% vs. 17%, P 1⁄4 0.02). Mean surveillance interval was 39 months

with similar 4-year survival (67.9% open and 73.7% endovascular). Primary and secondary

patencies were 67.2%, 67.2% after ER and 65.5%, 78.4% for open at 4 years,

Secondary interventions were required after 48.1% of endovascular and 54.1% of ORs.

Three limbs were lost in the series (2 open and 1 ER)

Conclusions:

Similar outcomes can be expected after endovascular and open PAA repair with

adherence to specific anatomic and technical selection requisites .

Wooster et al.Ann Vasc Surg 2016; 30: 253–257

Late Longitudinal Comparison of Endovascular and Open Popliteal Aneurysm Repairs

Journal of Vascular Surgery Leake et al, Volume 65, Number 1

January 2017

Meta-analysis of open and endovascular repair of popliteal

artery aneurysms (14/1979 Studies)


January 2017


artery aneurysms


January 2017


artery aneurysms

CONCLUSIONS

Endovascular repair for PAA has a lower wound complication rate and shorter length of

hospital stay compared with open repair. This comes at the cost of an inferior primary patency

but not secondary patency out to 3 years.

PAA 2011-2017 n=53

•EVPAR elektiv 36% n=19

•Akuter Verschluß/Ruptur 19% n=10 (EVPAR

n=2, Prothese 3, Vene 5, Amputation 2)

•Elektiver Venenbypass 45% n= 24

Eigene Daten

• Endovaskuläre Therapie der PAA ist technisch gut machbar und

sicher.

• Perioperative Mortalität und Morbidität ist minimal.

• Mid-term patency und Beinerhaltsrate für limitierte Läsionen bei

suffizientem „run-off“ vergleichbar mit Bypasschirurgie.

• Lokale (Stent induzierte?) Progression ist relativ häufig daher

Covering sollte über die eigentliche Läsion hinaus erfolgen.

• Dauermedikation mit Clopidogrel sinnvoll.

• Konkurrierende Verfahren?

Konklusion: Endografts gehören zum Therapiestandard bei Poplitealarterienaneurysma

poplitealarterienaneurysma: endovaskuläre therapie · thromboembolie & ruptur verhindern 2....

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