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Trattamento degli aneurismi aortici con endoprotesi e qualità della vita

Trattamento degli aneurismi aortici con endoprotesi e qualità della vita. Sergio Berti Istituto di Fisiologia Clinica del CNR Ospedale “G. Pasquinucci”, Massa. Aortic Aneurysm. The natural history of aneurysms is to enlarge and rupture.

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Trattamento degli aneurismi aortici con endoprotesi e qualità della vita

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  1. Trattamento degli aneurismi aortici con endoprotesi e qualità della vita Sergio Berti Istituto di Fisiologia Clinica del CNR Ospedale “G. Pasquinucci”, Massa

  2. Aortic Aneurysm The natural history of aneurysms is to enlarge and rupture The primary objective of aneurysm repair is to prevent rupture, while minimizing treatment related risks and preserving functional outcome

  3. TAA - AAA natural history: rupture risk

  4. TAA-AAA: indication to endovascular treatment Max diameter Fusiform TAA > 5,0 cm (≥ 5,5) Saccular Penetrating ulcer TAA < 5,0 cm TAA ≤ 5,0 cm Expansion rate > 1 cm/year

  5. New therapeutic concept

  6. EVAR vs Open surgery AAA

  7. Preoperative evaluationImaging Techniques CT MR TEE ANGIOGRAPHY

  8. Preoperative management Aneurysm morphology Endograft selection Procedure strategy

  9. Rupture of Thoracic Aneurysm • Surgical mortality 50% - 67% Johansson G. J. Thorac Card. Surg. 1995; 21:958 • EVAR mortality 3.8% - 38% Doss M. Ann. Thorac Surg 2003; 76:1465

  10. Rupture of Thoracic Aneurysm Doss. M. Ann. Thorac Surg 2003; 76:1465

  11. Penetrating ulcer 3% of acute aortic syndromes EVOLUTION % rupture 40% INTRAMURAL HEMATOMA FALSE ANEURYSM WALL RUPTURE

  12. Penetrating ulcer • Surgical mortality 16-18% • EVAR mortality 6-7% Dake MD J. Thorac Cardiovasc 1998; 116:689 Ehrlich M. Ann. Thorac Surg 1998; 66:19

  13. RM Aortic rupture

  14. Aortic rupture

  15. Aortic rupture

  16. Combined approach (Hybrid) Endovascular aortic arch Reconstruction combined with supra-aortic vessel transposition

  17. Penetrating ulcer

  18. PRE POST Talent StentGraft Penetrating Ulcer Carotid-Carotid By-Pass

  19. TAA early postoperative outcomes J Thorac Cardiovasc Surg 2007; 133:369-377

  20. Abdominal Aneurysm Endograft

  21. AAA: indication for endovascular treatment Type I Type II Type III A B C 51,7% Schumacher, J. Endovasc Surg 1997

  22. Branched Endograft

  23. Preoperative evaluation and management Aortic neck diameter Aortic neck lenth Aneurysm diameter Iliac arteries diameter Aortic neck angle

  24. <60° <90° Preoperative evaluation J. Endovasc Surg 1997; 4: 107

  25. EVAR Trial 1 : Operative mortality Intention to treat analyses using logistic regression

  26. EVAR Trial 1 : Aneurysm-related mortality

  27. Early Primary Procedure Major Morbidity RateStanford Patients Arko et al. J Endovasc Ther 2002;9:711-718

  28. Aneurysm Related DeathPrimary Treatment at Stanford 417 pts Arko et al. JVS

  29. Cumulative Hospital Utilization

  30. Early Functional OutcomePatient Questionnaire

  31. Late Functional Outcome

  32. Clinical Utility: Recovery

  33. SF-36 ™ Quality of LifeQuestionnaire

  34. MEN Choose Endograft Repair Because… • An Endograft Repair will almost always preserve “A Man’s function” Impotence 10-40% with open AAA Surgery

  35. Follow-up goals To assess: Endograft Aneurysmatic sack Anchoring zone

  36. AAA Follow up Timing Echo color Doppler 1 6 12 18 30 42 1 12 24 36 48 TC / MR scan

  37. TAA Follow up Timing 1 6 12 24 36 48 TC / MR scan

  38. Wire-less pressure sensor

  39. The CardioMEMS EndoSensor™ Implantable Sensor 14 Fr Delivery System Measurement System

  40. Post operative Follow UP“do it yourself”

  41. Conclusion Higher risk of Aneurysm related death with open surgery Significant increase in late Morbility with open surgery Early functional outcomes better with endovascular repair

  42. KEY to success: • Appropriate patient selection • Team experience • Appropriate timely follow up Conclusion • EVAR represents a viable alternative with a low risk if compared to open surgery

  43. Open questions New device technology Long term Follow up New follow up technology

  44. Trattamento degli aneurismi aortici con endoprotesi e qualità della vita Sergio Berti Istituto di Fisiologia Clinica del CNR Ospedale “G. Pasquinucci”, Massa

  45. Descending aortic rupture / perforation(69 pts) • Mortality (34 months F.U.) 12,5% • Paraplegia (34 months F.U.) 4% Stent graft emergency repair Melnitchouk S. Eur. J. Cardiothorac Surg. 2004; 25: 1032

  46. Primary Procedure MortalityStanford patients (500 pts) • Open surgery 9/24 33.7 % • Endovascular 1/17 40.6 %* *p < 0.05

  47. EVAR Trial 1 : Time to first re-intervention

  48. Survival curves for the endograft group vs the open surgical control J Thorac Cardiovasc Surg 2007; 133:369-377

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