vascular and endovascular surgery division university of florence ateromasia emboligena dellaorta...
TRANSCRIPT
Vascular and Endovascular Surgery DivisionUniversity of Florence www.chirvasc-unifi.it
Ateromasia emboligena Ateromasia emboligena dell’aorta toracicadell’aorta toracica
R. PULLI
Ateromasia emboligena dell’aorta toracicaAteromasia emboligena dell’aorta toracica
Patologia spontanea
In corso di procedure invasive
•Trattamento endovascolare
•Tronchi epiaortici•Aorta toracica
Ateromasia emboligena dell’aorta toracicaAteromasia emboligena dell’aorta toracica
Patologia spontanea– Stroke– Embolia periferica– Embolia viscerale
In corso di procedure invasive– Stroke– Paraplegia
Embolia periferica o viscerale…Embolia periferica o viscerale…
…is a rare clinical syndrome requiring a high index of suspicion.
Ateromasia emboligena dell’aorta toracicaAteromasia emboligena dell’aorta toracica
IMPORTANZA DELLO STUDIO CON TEE
Trattamento endovascolareTronchi epiaortici
Trattamento endovascolareTronchi epiaortici
Volume 331:1729-1734 December 29, 1994 Number 26
Transluminal Placement of Endovascular Stent-Grafts for the Treatment of Descending
Thoracic Aortic Aneurysms
Michael D. Dake, D. Craig Miller, Charles P. Semba, R. Scott Mitchell, Philip J. Walker, and Robert P. Liddell
Trattamento degli aneurismi toracici ESPERIENZA EUROPEA
Registro Italiano di Chirurgia VascolareSICVEREG
Aneurismi toraciciDissecazioni di tipo B (acute e croniche)Rotture traumatiche dell’aortaPseudoaneurismiUlcere penetrantiFistole (aorto-bronchiali, aorto-esofagee)
Trattamento endovascolare:spettro di applicabilità
Permette una rapida diagnosi differenziale Permette una rapida diagnosi differenziale con l’IMA, il tamponamento cardiaco e con l’IMA, il tamponamento cardiaco e l’embolia polmonarel’embolia polmonare
Può essere eseguito al letto del paziente e Può essere eseguito al letto del paziente e non richiede più di 15 minutinon richiede più di 15 minuti
Operatore dipendente; lunga learning curveOperatore dipendente; lunga learning curve
Specificità elevata; sensibilità minoreSpecificità elevata; sensibilità minore
Erbel L et al., Lancet 1989
“ “TEE is the study of choice in non trauma patients TEE is the study of choice in non trauma patients with possible aortic abnormalities”with possible aortic abnormalities”
Ecocardiografia transesofagea
Department of Vascular SurgeryDepartment of Vascular Surgery University of FlorenceUniversity of Florence
ENDOVASCULAR TREATMENT OF THORACIC ENDOVASCULAR TREATMENT OF THORACIC AORTAAORTA
(2000 – 2007)(2000 – 2007)
100 cases100 cases100 cases100 casesAtherosclerotic Atherosclerotic aneurysmaneurysm
57 57 (56,6%)(56,6%)
Type B chronic Type B chronic dissectiondissection
21 21 (21,3%)(21,3%)
Type B acute dissectionType B acute dissection 3 (3%)3 (3%)Traumatic aortic ruptureTraumatic aortic rupture 14 14
(14,1%)(14,1%)Penetrating aortic ulcerPenetrating aortic ulcer 3 (3%)3 (3%)Intramural haematomaIntramural haematoma 2 (2%)2 (2%)
36 cases36 cases36 cases36 cases
Aortic arch pathologiesAortic arch pathologies 1313
Thoracoabdominal aortic Thoracoabdominal aortic aneurysmaneurysm
1010
Multilevel aortic diseaseMultilevel aortic disease 1313
36 males; mean age 73 years 36 males; mean age 73 years (range 65-81)(range 65-81)
Department of Vascular SurgeryDepartment of Vascular Surgery University of University of FlorenceFlorence
COMPLEX LESIONSCOMPLEX LESIONS(2000 – 2008)(2000 – 2008)
5 cases5 casesCarotid to subclavian Carotid to subclavian
artery bypassartery bypass
1 case1 caseSubclavian artery Subclavian artery
transpositiontransposition
Zone 23 case3 case
Ascending aorta to Ascending aorta to innominate and left innominate and left
common carotid artery common carotid artery bypass + carotid to bypass + carotid to
subclavian artery bypasssubclavian artery bypass
Zone 0
Zone 1
1 case1 case Ascending aorta to left common carotid Ascending aorta to left common carotid andand
subclavian artery bypasssubclavian artery bypass1 case1 case Subclavian to subclavian artery bypassSubclavian to subclavian artery bypass
with carotid transpositionwith carotid transposition2 case2 case Carotid to carotid to subclavian artery Carotid to carotid to subclavian artery bypassesbypasses
HYBRID TREATMENT OFHYBRID TREATMENT OFAORTIC ARCHAORTIC ARCH
Ishimaru S, 2002
HYBRID TREATMENTHYBRID TREATMENTOF AORTIC ARCHOF AORTIC ARCH
HYBRID TREATMENTHYBRID TREATMENTOF AORTIC ARCHOF AORTIC ARCH
HYBRID TREATMENT OFHYBRID TREATMENT OFAORTIC ARCH: RESULTS AORTIC ARCH: RESULTS
(N=13)(N=13)
Mortality: 1 (7.5%)Stroke: -Complications:
- frenic nerve paralisis 1 (7.5%)Endoleak:
- type II 1 (7.5%)Secondary procedures: -
Follow-up [mean (range)]: 12 months (1-24)
HYBRID PROCEDURESHYBRID PROCEDURESFOR AORTIC ARCHFOR AORTIC ARCH
Author NComplete
debranching
Earlystroke/death
Earlyneuroeven
ts
Survival(%)
Kieffer, 200516
8 31% 25% 56 at 2y
Schumacher, 2006
25
9 20% 4% 76 at 2y
Zhou, 200616
13 6% - 92 at 1.3y
Bergeron, 200625
15 12% -92 at 1.2y
Inglese, 200615
15 - -93 at 1.5y
Melissano, 200737
14 16% 11%89 at 1.5y
Spinal cord angiogram
HYBRID TREATMENT OF HYBRID TREATMENT OF THORACOABDOMINAL AORTA:THORACOABDOMINAL AORTA:
Spinal angio-MRI evaluationSpinal angio-MRI evaluation
HYBRID TREATMENT OFHYBRID TREATMENT OFTHORACOABDOMINAL AORTATHORACOABDOMINAL AORTA
HYBRID TREATMENT OFHYBRID TREATMENT OFTHORACOABDOMINAL AORTATHORACOABDOMINAL AORTA
HYBRID TREATMENT OFHYBRID TREATMENT OFTHORACOABDOMINAL AORTATHORACOABDOMINAL AORTA
HYBRID TREATMENT OFHYBRID TREATMENT OFTHORACOABDOMINAL AORTA: RESULTS (N=10)THORACOABDOMINAL AORTA: RESULTS (N=10)
Mortality:Mortality:- perioperative (MOF, 2 bleeding)- perioperative (MOF, 2 bleeding) 3 (30%)3 (30%)
- follow-up (MI)- follow-up (MI) 11
Endoleak:Endoleak:- type II- type II 11
Secondary procedures:Secondary procedures: -- Paraplegia:Paraplegia: -- Renal insufficiency:Renal insufficiency: -- Bypass graft patency:Bypass graft patency: 96%96%
Follow-up [mean (range)]: 9 months (1-21)
HYBRID PROCEDURESHYBRID PROCEDURESFOR THORACOABDOMINAL FOR THORACOABDOMINAL
AORTAAORTA
Author N Completedebranchi
ng
Early mortali
ty
Paraplegia
Endoleak
Bypass
patency
Fulton, 2005 2 1 - - - 100%
Resch, 200613
4 23% 30% 23%
Black, 200626
21 23% - 23% 98%
Zhou, 200615
10 7% - - 95%
Gawenda, 2007
6 2 - - - 100%
Conclusioni
L’ateromasia emboligena dell’aorta toracica è una evenienza non frequente, ma con conseguenze spesso disastroseLa diagnostica deve far uso di metodiche ultrasonografiche (TEE) in associazione ad angio-TC o angio-RMIl trattamento è controverso, comprendendo l’anticoagulazione, la terapia trombolitica o trattamenti più invasivi, chirurgico od endovascolare
Conclusioni
L’impiego sempre più diffuso di metodiche endovascolari ha contribuito all’aumento di incidenza di complicanze emboliche in presenza di aorta toracica ateromasicaIn questo caso il riconoscimento di tale complicanza è più difficile ed il trattamento più complessoLa prevenzione rimane il punto cruciale da sviluppare ulteriormente