Klinik für Gefäßchirurgie Surgical treatment of thoraco ...chuliege-imaa.be/archives_2010/liege-backup2010/... · Paraparese Paraplegie. Surgical treatment of thoraco-abdominal

Surgical treatment of thoraco-abdominal aneurysm Indications and results

W. Sandmann 1,3, K. Grabitz1 , A. Sagban1 , B. Weis-Müller1, D. Grotemeyer1, G. Fürst2

Heinrich-Heine Universität Düsseldorf

¹Klinik für Gefäßchirurgie und Nieren TX ²Institut für Radiologie ³Klinik für Gefäßchirurgie, St. Bernhard Hospital, Kamp-Lintfort

Klinik für Gefäßchirurgie

und Nierentransplantation


1





2

0

10

20

30

40

50

60

70

80

90

1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Mai 09

TAA

TAA

Incl. TAAA V (Safi et al) 1032 cases





3





4





5





6





7





8

Typ I

Typ II Typ III

Typ B Dissection an TAAA





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10





11





12





13





14





15





16

214

2 1

145

12 725

926

0

50

100

150

200

250

kein 1-40 min > 40 min

NormalParapareseParaplegie





17





18





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Consequences of the „clamp and repair“ principle • Significant increase of arterial blood pressure proximal to clamp • Critical cardiac afterload – myocardial dilatation/failure • Ischemia distal to clamping

spinal, visceral, renal pelvis and legs peripheral nerv ischemia




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1. generation of external shunt (subclavian-iliac right side)




21


2. generation of external shunt (bi-subclavian-iliac left side)




22


1. generation of internal shunt (overpass)




23


2. generation of internal shunt (overpass)




24


Internal shunt (Innerpass Typ A)




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Internal shunt and reno-visceral perfusion (quatropus)




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Disadvantages of shunt – compared to pump techniques depending on cardiac function additional oxygenation not possible cooling and rewarming only possible indirectly operation time probably longer




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Advantages of shunt compared to pump techniques Reduced costs (personnel, material) less or no heparine reduced hemolysis applicable in all descending thoracic aorta aneurysms




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Recent continous series of 50 patients undergoing open repair for TAAA with internal (n=10) or external (n=40) shunt at Heinrich-Heine-University Düsseldorf Type of TAAA I (n=5), II (n= 15), III (n= 23), IV (n= 1), V (n= 6) Type of procedure elective Pathology aneurysm intakt, no dissection, no rupture Mean TAAA diameter 7.5 cm Operative and 60 days mortality none Permanent spinal deficit paraplegia (n=2%), paraparesis (n=4%) Stroke none On dialysis at discharge n=4%





median follow up 4,3 y, max. 11,3 y 125 patients > 70 y (min. 70, max. 91 y) 17 patients > 79 y);

30 d mortality 16,8 %

paraplegia 4,8 %

dialysis 15,2 %

TAAA n

I 24

II 32

III 48

IV 18

V 3

30 sarnival timo (month)





31 Evoked potential recording





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Expert Consensus Document on the Treatment of Descending

Thoracic Aortic Disease Using Endovascular Stent-Grafts Editors: L.G. Svensson, N.T. Kouchoukos, D.C. Miller Report from the Society of Thoracic Surgeons Endovascular Surgery Task Force Ann. Thorac Surg 2008; 85: S1-41





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Contemporary Results of Open Surgical Graft Replacement of the Thoracic Aorta N.T. Kouchoukos, B.W. Lytle, L.G. Svensson, H.J. Safi, J.S.Coselli Because there are no prospective, randomized studies comparing outcomes Of patients treated with open versus endovascular procedures, results of open operations based on reports from single centers and nonrandomized comparisons from Investigational Device Exemption (IDE) studies of open versus endovascular stent-graft procedures proveide the only useful information (this is discussed in more detail in text that follows. Unfortunately, the endovascular literature is replete with examples of comparisons of endovascular procedures with either remote older open surgical procedures or open procedures with considerably greater extents of repair (eg. thoracoabdominal aneurysm or aortic arch repairs) Ann. Thorac Surg 2008; 85: S1-41





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Conclusions • Open surgery for management of TAAA has a clinical history of 50 years. It is the standard.

• Whether open surgery, which uses a lot of adjuncts and supportive measures remains the gold standard depends on the progress both open and endovascular techniques can achieve regarding patient survival and major morbidity (stroke, paraplegia, renal failure, intestinal ischemic complications etc.) and on the durability of the procedure.

• The aims of both methods are prevention from rupture and maintenance of unrestricted permeability of adjacent arteries.





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• All publications from 2008 and recent years show, that endovascular stent grafting compared to open repair has only limited applicability. TEVAR focus in cases for which the technique seems appropriate and due to the selection process results sometimes seem equal or even better than open surgery.

• There is nothing wrong with TEVAR provided the necessary expertise is present to compare with the possibilities of open repair.

• For now, open repair remains the gold standard for treatment of TAAA and TEVAR should be limited to those institutions only, where surgery not only masters any type of TAAA but also can deal successfully with all the early and the late pitfalls of TEVAR (and there will be more than you would expect!)

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Klinik für Gefäßchirurgie Surgical treatment of thoraco ...chuliege-imaa.be/archives_2010/liege-backup2010/... · Paraparese Paraplegie. Surgical treatment of thoraco-abdominal