Trattamento Endovascolare degli Aneurismi dell Aorta Addominale con Colletto Prossimale Ostile: Risultati Precoci e a Medio Termine in Esperienza Monocentrica A.Lauricella - R.Silingardi Chirurgia Vascolare, Ospedali di Azienda Ospedaliero - Universitaria di Università di e Reggio Emilia
Total 52220 Pts - (25078 EVAR) US Medicare - 11 Studies - 4 RCT Johnson PG et al. J Vasc Surg 2013; 58: 582-8 Overall EVAR reintervention 40% Type I A endoleak Type I endoleak is Achille s Heel of EVAR Reintervention
Hostile Proximal neck: Identification Identifying and grading factors that modify the outcome of endovascular aortic aneurysm repair Chaikof EL et al. J Vasc Surg. 2002 May;35(5):1061-6. Aortic neck Absent Mild Moderate Severe Length (mm) > 25 25 15 15 10 < 10 Diameter (mm) < 24 24 26 26 28 > 28 Angle > 150 (<30 ) 150-135 (30-45 ) 135-120 (45-60 ) < 120 (>60 ) Calcifications / thrombus < 25% 25 50% > 50% > 50%
EVAR in Hostile Proximal Neck Prospective, mono-centre Jan 2012 Jun 2016 Elective AAA with HPN vs FPN* EVAR Treovance / Treo *HPN: Hostile Proximal Neck FPN: Favourable Proximal Neck
EVAR in Hostile Proximal Neck: Experience 2012 2016 1242 AAA treatment 1013 EVT - 229 OS ElectiveTreatment 1079 893 EVAR 186 OS Elective EVAR 893 Other treatments: Medtronic Endurant Endologix Nellix Chimney Tecnique Fenestrated Endograft 135 EVAR Hostile Proximal Neck 186 EVAR Urgent Treatment 163 120 revar 43 OS Non Hostile Proximal Neck 707 EVAR Double Proximal Fixation Bolton Treovance / Treo 51 EVAR Algoritm 153 FPN vs 51 HPN
n % Patients 204 100 Age yrs (mean, range) 76 (70-90) Male 164 80,4 HPN 51 25 FPN 153 75 ASA II 15 7.3 ASA III 183 89.7 ASA IV 6 2.9 AAA mm (mean) 57.9 (50-91) Infrarenal Neck HPN n pts (%) HPN mean (range) FPN mean (range) Length <10mm 23 (45.1) 7.3mm (3-9) 14.1mm (10-41) Angle >60 19 (37.2) 77.9 (65-95) 32.2 (5-60) Diameter >28mm 14 (27.4) 28.9mm (28-31) 23.5mm (18-28) Calcificification >50% 4 (7.8) 55% (50-100) // Thrombous >50% 18 (35.3) 68% (50-100) // Reverse Tapered 21 (41.1) 26.1mm (23-31) // Tapered 11 (21.6) 23.3mm (19-28) // 1 feature 12 (23.5) // // 2 features 21 (41.2) // // > 2 features 18 (35.3) // //
Early outcomes HPN = 51 (%) FPN = 153 (%) Adjunctive procedures 6 (11.7) 10 (6.5) Intraoperative EL IA 5 (9.8) 9 (5.9) Reinterventions within 30 days 1 (1.9) 1 (0.6) Fluoroscopy time, minutes (range) 13 30 (6-51 ) 7 45 (2-43 ) Contrast media 173cc (65-390) 95cc (30-250) Technical success 51 (100) 153 (100) Hospital stay, days (range) 4 days (2-34) 3 days (2-22) 30-day mortality 0 0 Type I endoleak within 30 days 0 0 Type B Acute Aortic Retrograde Dissection 1 (1.9%) 0
Late outcomes HPN = 51 (%) FPN =153 (%) Follow-up, months (range) 39.5 months (16-70) 44. 4 months (16-70) Type I endoleak on follow-up (%) 3 (5.9) 7 (4.6) Type II endoleak ( AAA ) on follow-up (%) 2 (3.9) 6 (3.9) Type III endoleak on follow-up (%) 0 7 (4.6) Iliach branch Thrombosis on follow-up (%) 2 (3.9%) 1 (0.6) Graft migration on follow-up (%) 0 2 (1.2) AAA Shrinkage 36 (70.6) 98 (64) AAA Stable 11 (21.6) 31 (20.3) AAA Enlargment 5 (9.8) 24 (15.7)
Late outcomes HPN = 51 (%) FPN =153 (%) Reinterventions on follow-up (%) 6 (11.7)* 25 (16.3) Conversion to open repair on follow-up (%) 1 (1.9) 1 (0.6) Aneurysm-related mortality on follow-up (%) 0 0 Overall mortality on follow-up (%) 8 (15.7) 19 (12.4) * 2 Iliac Leg Thrombosis Femoro - Femural ByPass Cross over 2 AAA Diameter for Type II EL AAA sac Embolization via Transealing 1 Type 1A Endoleak Proximal extension with cuff 1 Type 1A Endoleak Chimey Tecnique on both renal arteries
L1: 9mm L4: 120mm D3: 84mm D6: 44mm Short - Angled - Reverse Tapered P. Neck (22 31 mm) Tortuous iliac access
Final Angiography
Caso IV tipo rotto
Patients with Hostile proximal neck can be treated with EVAR Double proximal fixation, fixed connections and flexible endograft, seem to be effective for an appropriate treatment of HPN Duration of procedures, intraoperative contrast use and radiation exposure time indirectly shows an additional intraoperative difficulty. The more adverse features are present, the higher risk of early intraoperative or late type I A endoleak Midterm outcomes are similar to Favourable Proximal Neck AAA In conclusion
CHIRURGIA VASCOLARE - AZIENDA OSPEDALIERO UNIVERSITARIA DI MODENA