THERE IS NO ONE-SIZE-FITS-ALL: THE CHOICE OF A TAILORED TREATMENT · THE CHOICE OF A TAILORED...

THERE IS NO ONE-SIZE-FITS-ALL: THE CHOICE OF A TAILORED

TREATMENT

Domenico Palombo Vascular and Endovascular Surgery Unit

IRCCS San Martino IST University of Genova

Roma CAPUT MUNDI

26-27 MAY 2015

INTRODUCTION

r-TAAA: TREATMENT

r-TAAA

OPEN REPAIR

HYBRID REPAIR

ENDOVASCULAR REPAIR

PERISCOPE & CHIMNEY

HOME MADE FENESTRATED STENT GRAFT

T-BRANCHED STENT GRAFT

Vascular and Endovascular Unit - IRCCS San Martino IST – University of Genoa

r-TAAA OPEN REPAIR


r-TAAA OPEN REPAIR

Thoracotomy and laparotomy

Proximal aortic clamping

Visceral, renal and spinal cord

ischemia

Left heart bypass or CEC and

retrograde perfusion for TAAA type II

and III


r-TAAA OPEN REPAIR

30-day Mortality 60% 1983-1996

23 patients

St. Mary’s Hospital UK

30-day Mortality: 46.5% 40 patients

Contemporary results of open repair of ruptured descending thoracic and thoracoabdominal aortic aneurysms

Joel E. Barbato, MD, Jang Yong Kim, MD, Mazen Zenati, MD, PhD, Ghassan Abu-Hamad, MD, Robert Y. Rhee, MD, Michel S. Makaroun, MD, and Jae-Sung Cho, MD, Vasc Surg 2007;45:667-76

Repair of Ruptured Thoracoabdominal Aortic Aneurysm is Worthwhile in Selected Cases. A. W. Bradbury, N. W. Bulstrode, G. Gilling-Smith, G.Stansby, A. O. Mansfield and J. H. N. Wolfe. Eur J Vasc Endovasc Surg 17, 160–165 (1999)

30-day Mortality: 15% 1996

21 patients

Clinic for Cardiovascular Surgery ,Lausanne, Switzerland

Surgery for ruptured thoracic and thoraco-abdominal aortic aneurysms. L. K. Von Segesser, M. Genoni, A. Kiinzli, M. Lachat, U. Niederh~iuser, P. Vogt, M. SchSnbeck, M. Turina. Eur J Cardio-thorac Surg (1996) 10: 996-1002

30-day Mortality in the last 30 years


r-TAAA OPEN REPAIR patients Risk Factors

Ruptured thoracoabdominal aortic aneurysm treatment in the United States: 1988 to 1998 John A. Cowan, Jr, MD, Justin B. Dimick, MD, Reid M.

Wainess, BS, Peter K. Henke, MD, James C. Stanley, MD, and Gilbert R. Upchurch, Jr, MD. (J Vasc Surg 2003;38:319-22.)

Contemporary results of open repair of ruptured descending thoracic and thoracoabdominal aortic aneurysms Joel E. Barbato, MD, Jang Yong Kim, MD, Mazen Zenati, MD, PhD, Ghassan Abu-Hamad, MD, Robert Y. Rhee, MD, Michel S. Makaroun, MD, and Jae-Sung Cho, MD, Vasc Surg 2007;45:667-76

1988-1998 1996-2006

Total patients 321 40

Mean age 71,5 75,5

Men 63% 61%

Women 37% 39%

COPD 16,1% 45%

Diabetes Mellitus 4,4% 2,5%

Previous myocardial infarction 3,7% 67,5%

Renal disease 0,9% /

30-day MORTALITY 53,8% 46,5%

Increased

patients

comorbidity

stable mortality

rate


r-TAAA OPEN REPAIR: patients Risk Factors

Advanced Age

= Higher mortality

Outcomes in open repair of the thoracic and thoracoabdominal aorta. Charles Acher, MD,a and

Martha Wynn, MD,b Madison, Wisc JOURNAL OF VASCULAR SURGERY 4S October Supplement 2010

Age by decade Mortality %

< 60 1.56

60-70 14.67

70-80 24.27

> 80 41.94


r-TAAA HYBRID REPAIR



NO Thoracotomy

NO Proximal aortic clamping

Limited and selective Visceral, renal

and spinal cord ischemia

No Left heart bypass or CEC and


and III



Review An Emergency Visceral Hybrid Procedure for Ruptured Thoraco-Abdominal Aortic Aneurysms E.M.

von Meyenfeldt a, J.M. Schnater a, J.A. Reekers b, R. Balm a,*Eur J Vasc Endovasc Surg (2009) 38, 162e168

• 32 PATIENTS

• SYMPTOMATIC OR RUPTURED

• 30-day mortality 0%-71%

• Included pararenal aneurysms


Literature data


Hybrid Approach to Emergent and Urgent Treatment of Complex Thoracoabdominal Aortic Pathology Gkremoutis a, T. Schmandra a, M. Meyn, T. Schmitz-Rixen, M. Keese Eur J Vasc Endovasc Surg (2014) 48, 407e413

30 PATIENTS

Single center experience

SYMPTOMATIC OR RUPTURED

30-days mortality 26,7%

36,8 % in emergency cases

9,1% in urgent cases

Included only TAAA

HIGH RISK PATIENTS


Literature data

r-TAAA ENDOVASCULAR REPAIR



NO Thoracotomy and laparotomy

NO aortic clamping

NO Visceral, renal and spinal cord

ischemia

NO Left heart bypass or CEC and


and III


ENDOVASCULAR TREATMENT OPTIONS FOR r-TAAA

r-TAAA ENDOVASCULAR

REPAIR

PERISCOPE & CHIMNEY


T-BRANCHED STENT GRAFT



Accurate preoperative endovascular planning is mandatory

ENDOVASCULAR TREATMENT OPTIONS FOR r-TAAA


PERISCOPE & CHIMNEY

9 patients

6 TAAA

30-days mortality 11%

(including also PRAA+AAA)


Multiple Periscope and Chimney Grafts to Treat Ruptured Thoracoabdominal and Pararenal Aortic Aneurysms. Felice Pecoraro, MD1,2; Thomas Pfammatter, MD3; Dieter Mayer, MD1; Thomas Frauenfelder, MD4; Dimitri Papadimitriou, MD5; Lukas Hechelhammer, MD3; Frank J. Veith, MD1,6; Mario Lachat, MD1; and Zoran Rancic, MD, PhD1. J Endovasc

Ther. 2011 18:642–649


PERISCOPE & CHIMNEY

5 patients all TAAA

30-days mortality 0%

HIGH RISK PATIENTS

Urgent Endovascular Treatment of Thoraco-abdominal Aneurysms Using a Sandwich Technique and Chimney Grafts e A Technical Description. R.R. Kolvenbach a,*, R. Yoshida b, L.

Pinter a, Y. Zhuc, F. Lind. Eur J Vasc Endovasc Surg (2011) 41, 54e60



PERISCOPE & CHIMNEY

Authors age sex COPD DM CD CRF HP

Bisdas T. & al. 2013

68 F X X X

Marino M. & al. 2014

76 F X X

Constantinou J. 2013

64 M X X X

Paludetto G. & al. 2014

80 ? X X X

Francisca H. & al. 2006

79 F X X X X

Richardson S. & al. 2011

65 F X X X

Felix J.V. & al. 2011

79 F X X

Median Age 73 years

30 –day Mortality 0%

Characteristics of the reviewed case reports concerning patients with rupture of

TAAA treated by endovascular repair



PERISCOPE & CHIMNEY

Limitations:

Access through the subclavian

artery and the aortic arch

(High Risk of stroke)

Access through the iliac arteries

Target vessels length and diameter

High risk of treatment failure (M. Lachat)




12 high risk patients (8 TAAA)

Urgent or emergence

In hospital survival 92%

No reinterventions during follow-up

Modified Fenestrated Stent Grafts: Device Design, Modifications, Implantation, and Current Applications. Gustavo S. Oderich and Joseph J. Ricotta. Perspectives in Vascular Surgery and Endovascular Therapy 21(3) 157–167 The Author(s) 2009

HIGH VOLUME VASCULAR CENTERS

with specific skills





T-BRANCHED Stent graft

Zenith® t-Branch™

Only CE-marked off-the-shelf solution for the endovascular management of patients with thoraco-abdominal aortic aneurysms

Saving time when treating critical patients





ACCURATE PREOPERATIVE ENDOVASCULAR PLANNING



Off the shelf multibranched stent graft is

applicable to 88% of TAAA

How many vascular centers could do it ?

A Standardized Multi-Branched Thoracoabdominal Stent-Graft for Endovascular Aneurysm Repair. Matthew P. Sweet, MD, MS1; Jade S. Hiramoto, MD1; Ki-Hyuk Park, MD, PhD2; Linda M. Reilly, MD1; and Timothy A.M. Chuter, DM1. J Endovasc Ther. 2009;16:359–364


CONCLUSION

r-TAAA OPEN REPAIR

• YOUNG PATIENTS

• LOW RISK


?

CONCLUSION


• HIGH RISK PATIENTS

• OLDER PATIENTS

• FAVOURABLE ANATOMY


CONCLUSION


• ANATOMICALLY FEASIBLE

• HIGH RISK PATIENTS FOR NOW, IN THE FUTURE MIGHT BE FOR ALL

• PERISCOPE-CHIMNEY MIGHT BE A BRIDGE SOLUTION FOR NOW

Waiting for new off-the-shelf devices


CONCLUSION

• OPEN, HYBRID AND ENDOVASCULAR TREATMENT OF r-TAAA SHOULD BE DONE:

• IN HIGH VOLUME CENTRES

• WITH A MULTIDISCIPLINARY TEAM

• IN A HYBRID AND DEDICATED O.R.

With all facilities and skills


THERE IS NO ONE-SIZE-FITS-ALL: THE CHOICE OF A TAILORED

TREATMENT

Domenico Palombo Vascular and Endovascular Surgery Unit

IRCCS San Martino IST University of Genova

Roma CAPUT MUNDI

26-27 MAY 2015

Date post:	18-Sep-2018
Category:	Documents
Upload:	buitu
View:	217 times
Download:	0 times

THERE IS NO ONE-SIZE-FITS-ALL: THE CHOICE OF A TAILORED TREATMENT · THE CHOICE OF A TAILORED...

Documents