The innovative technology is intended to improve graft anchoring while minimising the potential for endoleaks and migration that can result from the endovascular treatment of complex Abdominal Aortic Aneurysms AAA. Starnes commented: "Although several endografts are being studied under our protocol, the TREO abdominal aortic endograft has become our platform of choice because of its deliverability, conformability and graft design conducive to creating fenestrations. TREO is most likely to allow strut-free fenestrations in our series. The balloon expandable device has been designed to enable reliable engagement into the main body graft while improving conformability to the native artery. Furthermore, we are convinced that the system helps us contribute to personalised therapy. Terumo will advance the development of the Aortica's products, and then launch them in the U.
|Published (Last):||3 June 2013|
|PDF File Size:||11.71 Mb|
|ePub File Size:||6.58 Mb|
|Price:||Free* [*Free Regsitration Required]|
Thoracic endovascular repair TEVAR has emerged as a valid alternative for thoracic aortic aneurysm repair as it is less invasive. Recent systematic review and meta-analysis of comparative studies found that TEVAR, compared to open surgery, may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay. This review will address some of the reported complications after this procedure.
These include: mortality, stroke, spinal cord ischemia, retrograde dissection, device malfunction, access complications, endoleak, and migration.. Aortic aneurysms are the 13 th leading cause of death in the United States.
The prevalence of aortic aneurysms appears to be increasing secondary to heightened awareness, improvements in imaging, and an aging population 1. The incidence of thoracic aortic aneurysms TAA is 5. The mean age at diagnosis ranges between years, with a male-to-female ratio of 3.
Patients with thoracic aneurysms often have significant comorbidities including hypertension, coronary artery disease, chronic obstructive pulmonary disease, and congestive heart failure 3. Descending thoracic aortic aneurysms are classified into three types Fig.
Classification of descending thoracic aortic aneurysms. Open surgery involves thoracotomy, aortic cross-clamping, and major blood loss with potentially significant impacts on the heart, lung, kidneys, brain and the spinal cord.
As a result, this approach is associated with significant morbidity and mortality with variable results in different centers 5—8. Two additional devices were later approved 11 , In all three pivotal trials, endovascular repair compared favorably to the traditional open repair for management of degenerative aneurysms.
More complex aneurysms extending to the aortic arch vessels are now commonly treated with endovascular repair Fig. A recent systematic review and meta-analysis of comparative studies found that TEVAR, compared to open surgery, may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay The aim of this review is to address some of the reported complications after this procedure.
These include: mortality, stroke, spinal cord ischemia, retrograde dissection, device malfunction, access complications, endoleak, and migration. Zone 0: repair involving the innominate artery. Zone 1: involving the left carotid artery. Zone 2: involving the left subclavian artery. Zone 3: involving the proximal third of the descending thoracic aorta. Zone 4: involving the distal two thirds of the descending thoraci aorta. B and C: placement of a device in zone 3 or 4 without any revascularization.
D: coverage of the left subclavian artery with a left carotid subclavian bypass. E: coverage of the left carotid and subclavian arteries with a carotid-carotid and carotid subclavian bypass. F: complete arch coverage with ascending aorta to innominate and left carotid bypass as well as a left carotid subclavian bypass. According to a systematic review and meta-analysis which included 42 non-randomized studies 38 comparative, 4 registries involving 5, patients, the cumulative day risk of mortality was 5.
The cumulative all-cause mortality at 1, 2, and 3 years did not differ significantly between the two groups. Although TEVAR patients were significantly older, other baseline characteristics including coronary artery disease, diabetes, chronic obstructive pulmonary disease, hypertension and renal insufficiency were not significantly different between the two groups.
Although TEVAR has a pattern of complications that are unique to endovascular procedures, perioperative stroke has a similar rate in both open and endovascular interventions 6. Stroke is among the most feared and devastating complications of endovascular and open repairs of the thoracic aorta. Perioperative stroke after TEVAR may be related to systemic factors hypotension, hypertension, anticoagulation , intracranial causes hemorrhage, edema, CSF drainage or emboli air, atheroma, thrombus Embolization may be related to the use and advancement of wires, catheters, and devices into a diseased atheromatous aortic arch, with dislodgement of atherosclerotic plaque to the brain.
As a result, patients with a significant atherosclerotic burden and those with aneurysms close to the aortic arch are inherently at higher risk. This is likely related to lengthy manipulation of catheter, wires and devices within the aortic arch. Figure 3 demonstrates a completion angiogram from a patient on our service with an extent C aneurysm.
A total of 5 devices were placed through an extremely tortuous anatomy. The patient suffered a perioperative left hemispheric stroke. A completion angiogram from a patient with an extent C aneurysm who suffered a perioperative left hemispheric stroke. In a review of patients, Khoynezhad, et al. Feezor, et al. Five out of these nine patients Six patients Those patients with a dominant left vertebral artery or incomplete circle of Willis underwent a prophylactic carotid-subclavian bypass.
They recommended the elective revascularization of the LSA carotid-subclavian bypass in the setting of a dominant left vertebral artery or an incomplete circle of Willis. The incidence of permanent paraplegia is also significantly different between the two modalities 1.
Spinal cord ischemia has been related to several risk factors, including aortic aneurysmal disease, extent of aortic repair or coverage 19 , previous abdominal aortic aneurysm repair 20 , compromised hypogastric artery inflow 17 , and left subclavian artery coverage Several diagnostic and therapeutic adjunctive methods have been used, including cerebrospinal fluid CSF drainage, to reduce the arterial-CSF gradient Due to our large thoracoabdominal experience, we have been able to carry out this protocol with a low 1.
The catheter is clamped and removed on postoperative day one if the patient remains neurologically intact. The use of 3 or more stent grafts correlating with the length of coverage was significant in patients experiencing SCI paraplegia-paraparesis with 53 vs. Coverage and occlusion of the T10 level intercostal arteries was also more frequent in patients with SCI than in those without neurological symptoms 40 vs. LSA coverage was also found to be an important risk factor for neurological complications.
LSA was covered in patients, of whom 40 had a revascularization procedure transposition or bypass. The rate of combined neurologic complications paraplegia or stroke was 8. The authors recommended routine, prophylactic revascularization of the LSA in patients who required coverage of this vessel by the endograft at the proximal landing zone.
The most significant risk factors in this study for developing SCI were: aortic aneurysm, the need for an iliac conduit, and an occluded or excluded hypogastric artery Preemptive revascularization offers no protection against CVA, perhaps indicating a heterogeneous etiology.
Revascularization may reduce the risk of SCI, although limited data temper this conclusion. Based on all available evidence, the current recommendations from the Society for Vascular Surgery Practice Guideline are as follows 14 : — Recommendation 1: in patients who need elective TEVAR where achievement of a proximal seal necessitates coverage of the left subclavian artery, we suggest routine preoperative revascularization, despite the very low-quality evidence grade 2, level C.
Recommendation 2: in selected patients who have an anatomy that compromises perfusion to critical organs, routine preoperative LSA revascularization is strongly recommended, despite the very low-quality evidence grade 1, level C. Recommendation 3: in patients who need urgent TEVAR for life-threatening acute aortic syndromes where achievement of a proximal seal necessitates coverage of the left subclavian artery, we suggest that revascularization should be individualized and addressed expectantly on the basis of anatomy, urgency, and availability of surgical expertise grade 2, level C.
It is defined as an intimal tear distal to the transverse arch with retrograde extension into the ascending aorta Fig. Retrograde dissection is defined as an intimal tear distal to the transverse arch with retrograde extension into the ascending aorta. Eggebrecht, et al. The majority of the RAAD cases were reportedly associated with the use of proximal bare spring stent grafts, with direct evidence of device-related injury at surgery or autopsy in half of the patients.
Dong, et al. The stent grafts were landed in zones 2 2 patients and 3 9 patients. RAAD developed intraoperatively in 2 patients and postoperatively in the rest 2 h to 36 months.
Clinical manifestations included syncope, hypotension, dyspnea, hypoxemia, chest pain and sudden death. Three patients had Marfan syndrome. The site of new entry was identified at the tip of the proximal bare spring in 9 patients Three patients died perioperatively Authors concluded that RAAD is not a rare complication after endovascular repair of type B aortic dissection.
Predisposing factors may include aortic wall fragility, disease progression, and stent graft-related causes. In relation to the abdominal aorta, the complexity of device delivery and deployment in the thoracic aorta is related to several factors including larger hemodynamic forces, more tortuous anatomy, and larger devices delivered over a relatively longer distance.
In a comprehensive summary of failure modes of aortic endografts, Lee discusses their prevention and management Intraoperative factors include inability to advance the delivery system, unintended device movement and maldeployment This has been reported in the literature and can usually be salvaged with endovascular techniques.
Additional endografts and bare stents can be placed to increase the radial force 31 , Finally, all endografts are subject to material failure.
These include metal fractures and fabric tears. This further highlights the need for long-term surveillance imaging of all endovascular aortic repairs. Attention to proper surgical and endovascular techniques is paramount. Liberal use of iliac conduits in patients with borderline anatomy cannot be overemphasized. This further underlines the necessity of performing these procedures in an operating room by a team that is well versed in open and endovascular bail-out techniques to address these complications.
Endoleak remains one of the principal reasons for endovascular repair failure. It is defined as persistent blood flow outside the endograft and within the aneurysm sac, and it is classified in four types 33 : I a inadequate seal at proximal end of endograft, and b inadequate seal at distal end of endograft. There is paucity of information on the true incidence of endoleaks outside of the few clinical trials.
The overall incidence of endoleaks from a meta-analysis of reported studies is This, however, may be an overestimate, as many studies do not report endoleaks. The results of the three published US trials are summarized below: — Makaroun, et al. Endoleak occurred in Most endoleaks were thought to be type I. Three patients required five endovascular reinterventions for endoleaks. These additional procedures took place from , days after the original repairs.
Fairman, et al.
Abdominal Stent Grafts
WO2014064311A1 - Endoprotesis aórtica para tratamiento de aneurisma - Google Patents
You will be leaving the Cook Medical website that you were viewing and going to a Cook Medical website for another region or country. Not all products are approved in all regulatory jurisdictions. The product information on these websites is intended only for licensed physicians and healthcare professionals. Cook offers disease-specific treatment options that are designed to help you provide a durable repair in the thoracic aorta. Maximize your seal in the abdominal aorta with a variety of disease-specific Zenith endovascular grafts. Cook offers a portfolio of procedure-specific accessories to support your endovascular procedures. Discover a variety of regional training opportunities.