Teresa Martín González, MD; Blandine Maurel, MD, PhD; Adrien Hertault, MD; Jonathan Sobocinski, MD, PhD; Rafaëlle Spear, MD, PhD; Richard Azzaoui,

Transcription

1 Teresa Martín González, MD; Blandine Maurel, MD, PhD; Adrien Hertault, MD; Jonathan Sobocinski, MD, PhD; Rafaëlle Spear, MD, PhD; Richard Azzaoui, MD; Tara M Mastracci, MD; Stéphan Haulon, MD, PhD Aortic Centre, Hôpital Cardiologique CHRU Lille, France

2 Introduction Postoperative renal impairment +++ complication Several definitions renal impairment Katsargyris A, Oikonomou K, Klonaris C, Töpel I, Verhoeven ELG. Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift? J Endovasc Ther Off J Int Soc Endovasc Spec 2013;20(2): Kristmundsson T, Sonesson B, Dias N, Törnqvist P, Malina M, Resch T. Outcomes of fenestrated endovascular repair of juxtarenal aortic aneurysm. J Vasc Surg 2014;59(1): Poorly description mid and long-term

3 Renal outcomes Renal function Renal composite outcome

4 Postoperative Acute Renal Failure 9.8% - 35 % Katsargyris A et al J Endovasc Ther Off J Int Soc Endovasc Spec 2013 Kristmundsson T et al,j Vasc Surg 2014 Marzelle et al. Ann Surg Lille study RIFLE criteria 29% o mortality before 6 moths o 40.7% returns to baseline level at 1 year

5 Postoperative Acute Renal Failure Athero-embolii Technical failure Contrast induced nephropathy

6 Athero-embolii

7 Failed catheterisation

8 Failed catheterisation

9 Failed catheterisation

10

11 Risk factors: CKD (egfr <60ml/min) Diabetic nephropathy Cardiac insufficiency Quantity contrast product Hyperosmolar contrast Athero-embolii Multiple myeloma Contrast induced nephropathy

12 Postoperative Acute Renal Failure Contrast induced nephropathy

13 Postoperative Acute Renal Failure Contrast induced nephropathy - products egfr <60 ml/min iodinaxol > iohexol (Reed; JACC Cardiovasc Interv 2009) Low-osmolar / iso-osmolar > hyper-osmolar (ACC/AHA; KDIGO)

14 Postoperative Acute Renal Failure Contrast induced nephropathy - hydration Isotonique saline > Isotonique 0.5% (Weisbord, Clin J Am Soc Nephrol 2008) Sodium bicarbonate Isotonique saline (Merten, JAMA 2004 /Brar, JAMA 2008 /Jang JS, CJ 2012 )

15 Postoperative Acute Renal Failure Contrast induced nephropathy acetylcisteine High risk patients (Kelly, Ann Intern Med 2008/2012 KDIGO)

16 Postoperative Acute Renal Failure Contrast induced nephropathy Lille protocol Isotonic saline: o 1mL/kg /h (12h before) (12h after) Acetilcysteine: o 1200 mg/12h (2 days)

17 Renal outcomes Renal function Renal composite outcome

18 Renal composite outcomes (occlusion, dissection, fracture, kinking, stenosis, endoleak) Mechanical factors Insufficient planning Device failure

19 Renal composite outcomes Procedural complications: Failed catheterisation Perforation-haematoma Dissection Kinking Thrombosis Rupture Endoleak Incorrect endograft deployment

20 Rupture

21 Dissection

22 Kinking

23 70cc 200 spin 5 sec 150 images

24 Incomplete fleuring

25 25

26 26

27 Incomplete fleuring

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33 Renal composite outcomes Mid-term and late complications: Fracture Thrombosis Kinking Stenosis Endoleak

34 Stent stenosis

35 Stent fracture

36 Stent fracture

37 Stent thrombosis RRA

38 Endoleak type III LRA

39 Endoleak type III LRA

40 Endoleak type III RRA

41 Renal composite outcomes Lille Data : 316 cases FEVAR & BEVAR 2004 Oct 2012 (FU>12-month Oct 2013): 225 patients = 433 target renal vessels 374 fenestrations (FEVAR) + 53 branchs (BEVAR) Mean follow-up: 2.4 years

42 Renal composite outcomes Lille Data Technical success Periprocedural events from initiation of the procedure to first 24h postoperative (Chaikof 2002) 96.4% technical success 4/433 failed target vessels catherization (1%) 4 deaths (including on table rupture)

43 Renal composite outcomes Lille Data Postoperative >25% decrease in egfr RIFLE classification 29% of patients: 27.2% (50 patients) FEVAR 38.9% (14 patients) BEVAR (p=ns)

44 Renal composite outcomes Lille Data All FU renal events 8.7% postoperative event: -7.2% (13 target vessels) FEVAR -16.2% (6 target vessels) BEVAR (p=ns)

45 Renal composite outcomes Lille Data Freedom for renal composite outcome 30-day: 98.6% [95.8; 99.6] 5-year: 84.5 [76.5; 89.9] CI 95%

46 Renal composite outcomes Lille Data Freedom for renal occlusion 30-day: 99.5% [96.7; 99.9] Accesory renal artery fenestration: HR=7.960 [1.643; ], p= year: 94.4% [89.3; 97.1] CI 95%

47 Renal composite outcomes Lille Data Freedom for secondary intervention 30-day: 98.6 [95.7; 99.5] 5-year: 91.2 [84.2; 95.2] CI 95%

48 CONCLUSIONS Learning curve o High volume centers o Planning o Technical success Hybrid OR with advanced imaging applications Rigorous FU CT scan + doppler US

49 Thank you for your attention