Rescue procedures in acute visceral ischemia
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1 Rescue procedures in acute visceral ischemia Yvonne Bausback Dept. Interventional Angiology Division of Internal Medicine, Neurology and Dermatology University of Leipzig, Germany
2 Disclosure Speaker name: Yvonne Bausback... I have no potential conflicts of interest to report.
3 Incidence, Etiology and Mortality of Acute Mesenteric Ischemia (AMI) In 1 % causative for an acute abdomen, up to 10% in elderly Arterial emboli 50 % Arterial thrombosis 25 % Non-occlusive mesenteric ischemia (NOMI) % Mesenteric vein thrombosis 5 % Mortality acute SMA-occlusion (100) % Mansour MA. Arch Surg 1999
4 Standard therapy of an acute occlusion of the Superior mesenteric artery (SMA) Goldstandard: Laparotomy with - Exploration / resection of the bowel - Thrombectomy / patch-plasty of the SMA Revascularization for acute mesenteric ischemia (Ryer et al., J Vasc Surg Mayo Clinic Rochester) Method of revascularization Surgical 88 % Endovascular 12 %
5 Endovascular techniques for recanalization Of acute SMA-occlusions - Catheter-aspiration - 8Fr brachial access - Often multiple attempts necessary / cumbersome - Ballon-angioplasty / stent-implantation - partially ineffective, fragmentation / embolisation - Thrombolysis - Local long-term thrombolysis - Pulse-spray thrombolysis
6 Endovascular management of Acute embolic SMA occlusion: A 12 year single centre experience ( ) 37 patients: transcatheter embolus aspiration (n=37) + local thrombolysis (n=2)/ stent implantation (n=2) Primary Successfull endovascular revascularisation on demand % surgery For patients with acure SMA occlusion Without signs of sepsis or severe peritonitis Laparatomy 73 % Necrotic bowl resection 40.5 % In hospital mortality 27.0 % Raupach et al. Cardiovasc Int Radiol 2015
7 Thrombectomy-catheter for thrombotic venous / arterial occlusions AngioJet (Medrad) Rotarex (Straub Medical)
8 Single-case-report Thrombectomy-Catheter for acute SMA-Occlusions - AngioJet-thrombectomy successful in case of acute SMA-occlusion due to paradoxical embolism Sternbergh WC, et al., J Endovasc Ther 2000 Single-case-report - AngioJet-thrombectomy not sufficient - Additional ultrasound-accelerated thrombolysis Ballehaninna UK, et al., Vascular 2012
9 Rotarex for acute visceral occlusions Vascular access: - Left brachial artery - 6F/ 90 cm (Cook) wire RPM Rotarex thrombectomy 6F - Microcatheter, e.g. Quickcross (Spectranetics)
10 72 year old femal pts. LV-failure, EF 25% Intermittend Afib Acute SMA-occlusion
11 Passage with a GW and Support-catheter Slow pull-back to estimate the lenght of the occlusion
12 6F Rotarex
13
14 Rotarex For the Treatment of Acute SMA-Occlusions : - 16 patients with acute mesenteric ischemia and thrombotic proximal SMA-occlusions Etiology of SMA-occlusions: - Atrial fibrillation 9 - Acute myocardial infarction / LV-failure 5 - Multiple thrombus formations aorta 1 - Atherosklerotic occlsion 1
15 Clinical presentation - Sepsis at time of admission (2/16) 12.5 % - Mean bowl ischemia time (6 48 h) 15 h Lactate! (15/16) %" "CT: focal sign of malperfusion (9/16) % Abdominal examination ++ pain, hemorhagic diarrhea, nausea 100% Late AMI in 15/16 patients
16 Results: Rotarex -Thrombectomy of Acute SMA-Occlusions - Procedure time (17 48) mean 24 min - Technical success 100 % + Stent implantation (3/16) % + mechanical thrombectomy (7/16) % - 30 day mortality (6/16) 37.5 % - 3 deaths after within 1 year (short-bowel-syndrome, cardiac, unknown) - Ischemia-related mortality 43.5 %
17 Complications - Mayor complication 12.5 % Perforation (2/16) resolved by stentgraft implantation - Minor complication 4/16 25 % Peripheral embolisation/residual thrombus not relevant by collateral blood supply
18 Postinterventional course #CT scan (6/16) 37.5 % 50% of patients without #Laparatomy (10/16) 62.5 % bowl resection no resection (2/16) 12.5 % focal/ limited bowl resection (3/16) 18.75% extended bowl resection (2/16) 12.5 % not operable (2/16) 12.5 % 1 refused to operation
19 Summary: Clinical Pathway including Advanced Endovascular Techniques Laparoscopy AMI Endovascular revascularization CT- Scan Lactate Abdominal examination Laparotomy ICU Monitoring CT scan IMMEDIATE SUGERY: Severe Peritonis +++ SEPSIS
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