Endovascular treatment of thrombosis (acute) of aneurysm through bifurcated endoprothesis: challenge cases

Endovascular treatment of thrombosis (acute) of aneurysm through bifurcated endoprothesis: challenge cases Fábio Luiz Costa Pereira Fabrício Machado Rossi Pablo da Silva Mendes Carlos Andre Daher Victor Sales Pereira

Disclosure Speaker name: Fábio Luiz Costa Pereira I have the following potential conflicts of interest to report: X Consulting: CMS Prod Med. Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest

AORTOILIAC OCLUSIVE DISEASE (AIOD) The endovascular techniques are applicable to treat localized or focal disease: - mainly the balloon angioplasty with or without stents Bosch JL, Hunink MG. Meta-analysis of the results of percutaneous transluminal angioplasty and stent placement for aortoiliac occlusive disease. Radiology 1997;204:87-96. Galaria II, Davies MG. Percutaneous transluminal revascularization for iliac occlusive disease: long-term outcomes in TransAtlantic Inter- Society Consensus A and B lesions. Ann Vasc Surg 2005;19:352-60. Dormandy JA, Rutherford RB. Management of peripheral arterial dis- ease (PAD). TASC Working Group. TransAtlantic Inter-Society Con- sensus (TASC). J Vasc Surg 2000;31:S1-296. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007;45:S5-67.

PATHWAYS ALTERNATIVE?... Alternative to surgical procedures : axilobifemoral bypass laparoscopic aortic surgery (robot assisted surgery) Suliman AS, Raffetto J, Seidman CS, Menzoian JO. Acute thrombosis of abdominal aortic aneurysms report of two cases and review of the literature. Vasc Endovasc Surg. 2003;37:71-5. A. Bravo Molina, S. Lozano Alonso, J.P. Linares Palomino, M. Guillén Fernández y E. Ros Díe - Thrombosed abdominal aortic aneurysms; Angiologi 2013 65 (Supl 1):22-23.

Acute Thrombosis: AAA + AIOD It s a rare, but devastating complication 0,7% to 2,8% of AAA surgically treated. Mortality rate: 49% to 56%, due a variety of other acute events Hirose H, Takagi M, Hashiyada H, Miyagawa N, Yamada T, Tada S, at al. Acute occlusion of an abdominal aortic aneurysm - case report and review of the literature. Angiology. 2000;51:515-23. Wong SS, Roche-Nagle G, Oreopoulos G. Acute thrombosis of an abdominal aortic aneurysm presenting as cauda equina syndrome. J Vasc Surg. 2013;57:218-20

Acute Thrombosis: AAA + AIOD It s a rare, but devastating complication It s 0,7% to 2,8% of AAA surgically treated. Mortality rate: 49% to 56%, due a variety of other acute events Hirose H, Takagi M, Hashiyada H, Miyagawa N, Yamada T, Tada S, at al. Acute occlusion of an abdominal aortic aneurysm - case report and review of the literature. Angiology. 2000;51:515-23. Wong SS, Roche-Nagle G, Oreopoulos G. Acute thrombosis of an abdominal aortic aneurysm presenting as cauda equina syndrome. J Vasc Surg. 2013;57:218-20

Acute Thrombosis: AAA + AIOD It s a rare, but devastating complication It s 0,7% to 2,8% of AAA surgically treated. Mortality rate: 49% to 56%, due a variety of other acute associated events Hirose H, Takagi M, Hashiyada H, Miyagawa N, Yamada T, Tada S, at al. Acute occlusion of an abdominal aortic aneurysm - case report and review of the literature. Angiology. 2000;51:515-23. Wong SS, Roche-Nagle G, Oreopoulos G. Acute thrombosis of an abdominal aortic aneurysm presenting as cauda equina syndrome. J Vasc Surg. 2013;57:218-20

Acute Thrombosis: AAA + AIOD Associated events: Postsurgical manipulation, trauma, fever, thromboembolic disease, dehydration, hypercoagulability, hypotension, atrial fibrillation, neoplasia, intraplate hemorrhage, occlusive disease of the iliac artery and rupture of AAA Small aneurysms + severe AIOD: can lead to acute thrombosis of AAA Hirose H, Takagi M, Hashiyada H, Miyagawa N, Yamada T, Tada S, at al. Acute occlusion of an abdominal aortic aneurysm - case report and review of the literature. Angiology. 2000;51:515-23. Wong SS, Roche-Nagle G, Oreopoulos G. Acute thrombosis of an abdominal aortic aneurysm presenting as cauda equina syndrome. J Vasc Surg. 2013;57:218-20

- EVAR The EVAR can reduce the high mortality rate associated with surgical treatment of this pathology in the near future. development of materials and endovascular techniques New devices: parallel stent graftt ; devices with anatomic bifurcation: Hirose H, Takagi M, Hashiyada H, Miyagawa N, Yamada T, Tada S, at al. Acute occlusion of an abdominal aortic aneurysm - case report and review of the literature. Angiology. 2000;51:515-23. Wong SS, Roche-Nagle G, Oreopoulos G. Acute thrombosis of an abdominal aortic aneurysm presenting as cauda equina syndrome. J Vasc Surg. 2013;57:218-20

- EVAR The EVAR can reduce the high mortality rate associated with surgical treatment of this pathology in the near future. development of materials and endovascular techniques New devices: parallel stent graftt; devices with anatomic bifurcation: Hirose H, Takagi M, Hashiyada H, Miyagawa N, Yamada T, Tada S, at al. Acute occlusion of an abdominal aortic aneurysm - case report and review of the literature. Angiology. 2000;51:515-23. Wong SS, Roche-Nagle G, Oreopoulos G. Acute thrombosis of an abdominal aortic aneurysm presenting as cauda equina syndrome. J Vasc Surg. 2013;57:218-20

Case 1: EVAR + AIOD MALE. 65 Y.O; OCLUSION OF THE DISTAL AORTA + SMALL SACULAR ANEURYSM 6 PREVIOUS ABDOMINAL SURGERIES, THE LAST ONE WITH USE OF A DEVICE TO TREAT A RECURRENT HERNIA THE CONVENTIONAL SURGERY WAS TECHNICALLY DANGEROUS

Case 1: EVAR + AIOD

Case 1: EVAR + AIOD THE ILIAC AND FEMORAL ARTERIES WERE OPEN, ALTHOUGH WITH IMPORTANT ATHEROSCLEROTIC DISEASE,

Case 1: EVAR + AIOD RIGHT AND LEFT FEMORAL ACCESSES UPPER ACCESS BY THE LEFT AXILAR ARTERY

Case 1: EVAR + AIOD RE-ENTRY TO THE TRUE LUMEM THROUGH THE USE OF OUTBACK DEVICE

Case 1: EVAR + AIOD KISSING-BALLON TECNIQUE

Case 1: EVAR + AIOD INPUT OF THE ENDOPROSTHESIS DELIVERY SYSTEM AFX ENDOLOGIX DEVICE

Case 1: EVAR + AIOD

Case 1: EVAR + AIOD USE OF BARE STENT IN BOTH ILIAC ARTERY.

Case 1: EVAR + AIOD 3D Angiography After 4 months

Case 2: EVAR + CRF + AIOD MALE; 62Y.O.; AAA + NON-DIALYTIC CRF (CR 4,3) + AIOD. WE USED CO 2 AS A CONTRAST MEDIA

Case 2: EVAR + CRI + AIOD 3 ACCESS WAYS; INPUT AND RELEASE OF THE AFX ENDOLOGIX DEVICE IN THE AORTIC BIFURCATION

Case 2: EVAR + CRI + AIOD FINAL ANGIOGRAPHY: TOTAL ANEURYSM EXCLUSION; ABSENCE OF STENOSIS IN AORTA OR ILIACS; WITHOUT USE OF IODATED CONTRAST

Case 3: AAA + Acute Thrombosis in Aorta M, 63Y.O; PRIMARY ANGIO-CT: A BIG AAA + THROMBOSIS OF DISTAL AORTA AND BOTH FEMORAL ARTERIES OPEN

Case 3: AAA + Acute Thrombosis in Aorta 3D RECONSTRUCTION

Case 3: AAA + Acute Thrombosis in Aorta ANGIOGRAPHY = AORTIC OCCLUSION AND VARIOUS COLLATERAL ARTERIES

Case 3: AAA + Acute Thrombosis in Aorta ANGIOGRAPHY = OPEN ILIAC ARTERIES WITHOUT DISTAL OCCLUSIVE DISEASE.

Case 3: AAA + Acute Thrombosis in Aorta

Case 3: AAA + Acute Thrombosis in Aorta ANGIOPLASTY: KISSING-BALOON TECHNIQUE IN THE AORTIC BIFURCATION

Case 3: AAA + Acute Thrombosis in Aorta PLACEMENT OF AFX ENDOLOGIX DEVICE

Case 3: AAA + Acute Thrombosis in Aorta NEW ANGIOPLASTY AFTER THE ENDOPROSTHESIS PLACEMENT

Case 3: AAA + Acute Thrombosis in Aorta FINAL IMAGE: TOTAL EXCLUSION OF THE ANEURYSM AND NORMAL INFLOW TO BOTH ILIAC ARTERY

Case 3: AAA + Acute Thrombosis in Aorta FOLLOW UP AFTER 30 DAYS.

AAA + AIOD Narrow neck in the distal aorta (<16mm) Aorta and iliacs with oclusive disease. Challenges to endovascular treatment Need specific devices to perform with safe

AAA + AIOD When using the kissing-stent technique with a stent-graft to treat AIOD... if there is another associated aortic or iliac disease, or both (as complex plaque, aneurysms with or without thrombus; little sacular aneurysms) we may lost the possibility to use another treatment in the future

CONCLUSION: The use of specific endoprosthesis to treat AAA + AIOD shows: An efficient alternative to treatment; An easy, fast and safe accomplishment; Good outcomes in acute and chronic lesions; Low cost, low morbility and low mortality rates with a favorable cost-effectiveness ratio.

Fábio Luiz Costa Pereira Instituto Capixaba de Angiologia.