Thoraco-Abdominal AneurysmsEndovascular Approach

Chirurgie Vasculaire - Hôpital CardiologiqueCHRU de Lille - France

HYBRID PROCEDURES

CONCEPT

• Endovascular repair of complex aortic aneurysms involving :

– Visceral vessels (juxtarenal, pararenal, TAAA)

– Both common iliac arteries

CONCEPT

• Sealing zones determined on pre operative CT = length of aorta to be covered

• Endograft designed with fenestrations and / or branches to perfuse vessels covered by fabric

Endovascular Options to Perfuse Target Vessels

– REINFORCED FENESTRATIONS

BRANCHES

PRELOADED CATHETER

Bridging Stentgraft

SIZING: 3D-Volume Rendering

Bone Removal

CPR

LEFT RENAL

at 2.45

Short neck AAA,Juxta and Pararenal Aneurysms

PROCEDURE

POST-OPERATIVE CT

Type IV TAAA

ANGULATION OF AORTIC BRANCHES

Contemporary Retrospective Comparative Analysis

• Consecutive elective TAAA repair over 5 years

• Retrospective review

• All films pre and post procedure evaluated– All patients classified using identical criteria

• Outcomes evaluated– 30 day mortality

– 12 month survival

– Paraplegia

• Timing

• SeverityGreenberg R, Lu Q, et al, Circ In Press 2008

Comparison of Patients (N=734)

Age (mean ±SD) 62.7±13 71.3±12 P<0.001Smoking (%) 54 62 P=0.03Diabetes (%) 5 11 P=0.003Cardiac History of CAD (%) 33 50 P<0.001 EF<30 (%)* 3 6 P=0.03Pulmonary FEV1* 2.2±0.8 1.7±0.8 P<0.001 <1 liter (%)* 3 20 P<0.001 FEF 25-75%* 1.7±0.9 0.9±0.7 P<0.001

History of cancer (%)9 13 P=0.09

Renal <40 (%) 9 17 P=0.001 <60 (%) 28 40 P=0.001

Aortic diameter (cm, mean ±SD) 6.2±1.3 6.3±1.3 P=0.9

SR (n=372) ER (n=352)

Repair n

Mortality at 30 days

Mortality at 1 year SCI

n %* Rate** n %* Rate** n %

0 ERSR

163136

88

54

0.620.73

2015

1211

0.140.13

11

11

I ERSR

8251

61

72

0.940.24

15 2

19¶

40.250.04

87

1014

II ERSR

1659

110

617

0.802.36

513

3622

0.450.30

313

1922

III ERSR

2262

28

912

1.161.68

713

3421

0.520.27

16

510

IV ERSR

6964

34

46

0.550.80

816

1222

0.180.30

21

32

All ERSR

352372

2031

67

0.721.07

5559

1615

0.210.19

1528

48

Paraplegia

ORN=372

ERN=352

n % n %

Immediate SCI 8 29 2 13

Delayed SCI 20 71 13 87

Total 28 15

Greenberg R, Lu Q, et al, Circ In Press 2008

LIMITS

• PRICE

• EMERGENCIES

• TRAINING

CONCLUSIONS

• Endoprothèses multibranches = alternative à la chirurgie conventionnelle

• LIMITES– Patients à haut risque chirurgical– Résultats à moyen et long terme ?