Il trattamento endovascolare dell aorta sottorenale (EVAR) mediante anidride carbonica (AI-CO 2 )
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1 Il trattamento endovascolare dell aorta sottorenale (EVAR) mediante anidride carbonica (AI-CO 2 ) V. Vento S Ancetti, G Indelicato, C Mascoli, R Pini, G Faggioli, M Gargiulo, A Stella. Vascular Surgery - Alma Mater Studiorum University of Bologna, Italy
2 Introduzione: Current Trend in AAA Treatment 5.2% 74% OR EVAR EVAR OR Dua A et al, J Vasc Surgery 2014
3 Introduzione: Causes of death in EVAR patients Rajesh et al, The Lancet 2016
4 Introduzione:
5 Introduzione: Renal impairment is an independent predictor of mortality after OR and EVAR Sailer A et al. Eur Radiol Patient with pre-existing CRF are more likely to have a progressive renal dysfunction following EVAR Greenberg RK et al. J Vasc Surg 2004 Contrast induced nephropathy (CIN) in EVAR ranged between 2%-16% Zarkowsky et al, J Vasc Surgery 2016 Chao A et al. J Vasc Surg 2007
6 Introduzione: N Author Year Journal Title 1 Chao A et al 2007 J Vasc Surg 2 Criado E et al 2008 J Vasc Surg 3 Criado E et al 2012 J Vasc Surg 4 Huang SG et al 2013 Ann Vasc Surg 5 Sueyoshi E et al Manual injection Not optimal control of the gas output De Almeida Mendes C et al 7 De Angelis C et al 2017 J Vasc Surg 2017 Ann Vasc Surg Int J Cardiovasc Imaging. Carbon dioxide digital subtraction angiography-assisted endovascular aortic aneurysm repair in the azotemic patient. Catheter-less angiography for endovascular aortic aneurysm repair: a new application of carbon dioxide as a contrast agent. Endovascular aortic aneurysm repair with carbon dioxide-guided angiography in patients with renal insufficiency. A prospective study of carbon dioxide digital subtraction versus standard contrast arteriography in the detection of endoleaks in endovascular abdominal aortic aneurysm repairs. The use of CO 2 in EVAR procedure has not been standardised yet IMG. Indian J of Radiology and Imaging 2009 Carbon dioxide digital subtraction angiography as an option for detection of endoleaks in endovascular abdominal aortic aneurysm repair procedure. Carbon Dioxide as Contrast Medium to Guide Endovascular Aortic Aneurysm Repair. Carbon dioxide (CO2) angiography as an option for endovascular abdominal aortic aneurysm repair (EVAR) in patients with chronic kidney disease (CKD). Dua A et al, J Vasc Surgery 2014
7 Scopo dello studio è di indagare l'efficacia di un nuovo metodo standardizzato d iniezione di CO 2 nelle procedure EVAR.
8 Materiali e Metodi: A consecutive series of 20 patients undergoing EVAR for AAA, underwent both ICA and CO 2 A. The contrast media was delivered in the suprarenal aorta by pigtail using automatic injector The CO 2 was delivered through a brand new automatic injector by a 10F 11cm long sheet in the external iliac artery.
9 Materiali e Metodi: CO 2 Diagnostic Angiography proximal and distal landing zone CO 2 Completion Angiography patency of the renal artery and of the hypogastric artery AAA sac exclusion
10 Risultati:
11 Risultati: CO 2 Diagnostic Angiography * * : Detected : Undetected Detected vessels with CO 2 Diagnostic Angiography N % Patient 20 Lowest renal artery (RA) visualization Lowest RA not visualised 9 45 Hypogastric artery visualization 19 95
12 Risultati: Bi/Tri-Dimensional morphological pre-operative characteristics AAA diameter (mm) AAA Total Volume (mm 3 ) AAA Lumen Volume (mm 3 ) Distance RA - Aortic bifurcation (mm) Distance RA Hypogastric Artery (mm) Distance RA apex of 10F sheet (mm)
13 Risultati: Bi/Tri-Dimensional morphological pre-operative characteristics RA mean No RA mean P * (T-student) AAA diameter (mm) 56,11 (8,7) 56,06 (8,3) 0,989 AAA Total Volume (mm 3 ) 150,45 (65,9) 158,19 (93,4) 0,831 AAA Lumen Volume (mm 3 ) 74,97 (17,6) 69,12 (30) 0,059 Neck diameter (mm) 111,17 (11,4) 105,93 (16,5) 0,414 Distance RA- Aortic Biforcation (mm) 23,36 (2,5) 23,22 (3,8) 0,923 Distance RA - Right Hypogastric artery (mm) 176,53 (13,8) 174,53 (26,8) 0,873 Distance LRA - Left Hypogastric artery (mm) 176,35 (14,5) 178,39 (31,4) 0,849 Distance LRA - 10F sheet apex (mm) 190,13 (15,7) 190,98 (25,8) 0,929
14 Risultati: CO 2 Completion Angiography CO 2 completion angiography N % Patient 20 Lowest renal artery (RA) visualization Hypogastric artery visualization Endoleak I/III 0 - Endoleak II 6 33,3 : Detected : Undetected CO2 DSA detected 6 EL II VS 0 ICA-DSA
15 Risultati: *
16 Ann Vasc Surg J Vasc Surg. 2015
17 Conclusioni: Le procedure EVAR, nella maggior parte dei casi, possono essere efficacemente eseguite con la sola AI-CO 2. l AI-CO 2 permette anche una migliore identificazione degli endoleak. Potrebbe costituire una valida alternativa all ICM nei pazienti nefropatici. Necessita ulteriore affinamento nella visualizzazione delle aa renali negli aneurismi di grandi dimensioni
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