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W. DORIGO

W. DORIGO. Cattedra e Scuola di Specializzazione in Chirurgia Vascolare Università degli Studi di Firenze www.chirvasc-unifi.it. LINEE GUIDA SICVE. Walter Dorigo. SICVE. ( 2003 ). LINEE GUIDA SICVE Rev. 2013. Patologia ostruttiva aorto-iliaca e delle arterie degli arti inferiori.

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W. DORIGO

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  1. W. DORIGO

  2. Cattedra e Scuola di Specializzazione in Chirurgia Vascolare Università degli Studi di Firenze www.chirvasc-unifi.it LINEE GUIDA SICVE Walter Dorigo

  3. SICVE (2003)

  4. LINEE GUIDA SICVERev. 2013 Patologia ostruttiva aorto-iliaca e delle arterie degli arti inferiori Coordinatore: Dr. F. Peinetti Collaboratori SICVE: Dr. G. Bellandi, Dr. A. Cappelli, Dr. W. Dorigo, Dr. M. Gargiulo, Dr. A. Sarcina Collaboratori “esterni”: referente GISE, referente SIRM

  5. METODOLOGIA The Scottish Intercollegiate Guidelines Network (SIGN) develops evidence based clinical practice guidelines for the National Health Service (NHS) in Scotland http://www.sign.ac.uk

  6. FORZA DELLE RACCOMANDAZIONI www.clinicalevidence.com/ceweb/about/guide.jsp

  7. DEFINIRE GLI ENDPOINTS (J Vasc Surg, 2009)

  8. Trattamento delle lesioni aterosclerotiche estese (TASC-II C e D) Fonti • Linee guida di altri paesi o società scientifiche • Revisioni Cochrane (21 nel biennio 2012-13) • Letteratura Indicizzata • Dati di ricerche in corso • Opinioni documentate

  9. Trattamento delle lesioni aterosclerotiche estese (TASC-II C e D) (J Vasc Surg, 2007)

  10. Distretto aorto-iliaco (Leville et al., J Vasc Surg 2006)

  11. Distretto femoro-popliteo (Conrad et al., J Vasc Surg 2006)

  12. LINEE GUIDA POST TASC-II (JACC, 2011-2013)

  13. (JACC, 2013)

  14. LINEE GUIDA POST TASC-II (Eur Heart J, 2011)

  15. (Eur Heart J, 2011)

  16. WHEN? (Eur Heart J, 2011)

  17. LINEE GUIDA POST TASC-II (EJVES 2011)

  18. (EJVES 2011)

  19. (EJVES 2011)

  20. Open vs. endo nelle lesioni TASC-II C e D FONTI • Linee guida di altri paesi o società scientifiche • Revisioni Cochrane (21 nel biennio 2012-13) • Letteratura Indicizzata • Dati di ricerche in corso • Opinioni documentate

  21. REVISIONI COCHRANE POST TASC-II (2008) There is limited evidence for the effectiveness of bypass surgery compared with other treatments; no studies compared bypass to no treatment. Further large trials are required. (2009) There is limited benefit to stenting lesions of the superficial femoral artery in addition to angioplasty, however this cannot be recommended routinely based on the results of this analysis.

  22. REVISIONI COCHRANE POST TASC-II (2010) There was a clear primary patency benefit for autologous vein when compared to synthetic materials for above knee bypasses. In the long term (five years) Dacron confers a small primary patency benefit over PTFE for above knee bypass. PTFE with a vein cuff improved primary patency when compared to PTFE alone for below knee bypasses. Further randomised data is needed to ascertain whether this information translates into improvement in limb survival.

  23. REVISIONI COCHRANE POST TASC-II (2013) There is some evidence that a vein cuff at the distal anastomosis site improves primary graft patency rates for below knee PTFE graft, but this does not reduce the risk of limb loss. Evidence for this beneficial effect of vein cuffed PTFE grafts is weak and based on an underpowered trial. Pre-cuffed PTFE grafts have comparable patency and limb salvage rates to vein cuff PTFE grafts. The use of spliced veins improved secondary patency but this did not translate into improved limb salvage. The use of an AVF alone showed no added benefits. A large study with a specific focus on below knee vein cuff prosthetic grafts, including PTFE, is required

  24. Open vs. endo nelle lesioni TASC-II C e D FONTI • Linee guida di altri paesi o società scientifiche • Revisioni Cochrane (21 nel biennio 2012-13) • Letteratura Indicizzata • Dati di ricerche in corso • Opinioni documentate

  25. Overall, there was no significant difference in AFS or OS between the two strategies. However, for those patients who survived for at least 2 years after randomization, a BSX-first revascularization strategy was associated with a significant increase in subsequent OS and a trend towards improved AFS. (J Vasc Surg 2010)

  26. Open vs. endo (J Vasc Surg 2012)

  27. The Hb-PTFE graft significantly reduced the overall risk of primary graft failure by 37%. Risk reduction was 50% in femoro-popliteal bypass cases and in cases with critical ischaemia. (Eur J Vasc Endovasc Surg 2011)

  28. (Eur J Vasc Endovasc Surg 2011)

  29. Stent medicato vs. PTA (infrapop.) (JACC 2012)

  30. Stent medicato vs. BM stent (infrapop.) (JACC 2012)

  31. Cosa si fa oggi in una struttura di chirurgia vascolare ad alto volume chirurgico? Distretto aorto-iliaco • BMT (linee guida CHEST 2012) • Lesioni TASC-II a, b, c: • Endovascolare (eventualmente ibrido) • Lesioni TASC-II d con buona L.E.: • Chirurgia • Lesioni TASC-II d con scarsa L.E.: • Endovascolare (eventualmente ibrido)

  32. Cosa si fa oggi in una struttura di chirurgia vascolare ad alto volume chirurgico? Distretto femoro-popliteo • BMT (linee guida CHEST 2012) • Lesioni TASC-II a, b, c: • Endovascolare (eventualmente ibrido) • Lesioni TASC-II d con buona L.E.: • Chirurgia* • Lesioni TASC-II d con scarsa L.E. e CLI: • Endovascolare (eventualmente ibrido) *con vena o bonded graft

  33. Cosa si fa oggi in una struttura di chirurgia vascolare ad alto volume chirurgico? Distretto femoro-popliteo • Endo: PTA e/o stent in base alla lunghezza ed alla morfologia della lesione nell’AFS; PTA nel distretto infrapopliteo. Ruolo dei DES e dei DEB da definire • Chirurgia: vena autologa se disponibile. In alternativa protesi con cuffia distale. Ruolo delle protesi biochimicamente modificate

  34. Cosa si fa oggi in una struttura di chirurgia vascolare ad alto volume chirurgico? Fallimento endo • Asintomatico o claudicatio IIa: BMT • Claudicatio IIb o CLI (recenti): trombolisi • Claudicatio IIb non recente: tentativo di endo rescue • CLI non recente: conversione open (o tentativo endo in paz. ad alto rischio)

  35. REVISIONE SICVE 2013 Non è una mission impossible

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