Klinik für Gefäßchirurgie Surgical treatment of thoraco ... fileSurgical treatment of...
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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
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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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
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
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und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Typ I
Typ II Typ III
Typ B Dissection an TAAA
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
Klinik für Gefäßchirurgie
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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kein 1-40 min > 40 min
NormalParapareseParaplegie
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
Klinik für Gefäßchirurgie
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
Klinik für Gefäßchirurgie
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
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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Surgical treatment of thoraco-abdominal aneurysm Indications and results
1. generation of external shunt (subclavian-iliac right side)
Klinik für Gefäßchirurgie
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
2. generation of external shunt (bi-subclavian-iliac left side)
Klinik für Gefäßchirurgie
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
1. generation of internal shunt (overpass)
Klinik für Gefäßchirurgie
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
2. generation of internal shunt (overpass)
Klinik für Gefäßchirurgie
und Nierentransplantation
Klinik für Gefäßchirurgie
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Internal shunt (Innerpass Typ A)
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Internal shunt and reno-visceral perfusion (quatropus)
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
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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Surgical treatment of thoraco-abdominal aneurysm Indications and results
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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Surgical treatment of thoraco-abdominal aneurysm Indications and results
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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%
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
und Nierentransplantation
Klinik für Gefäßchirurgie
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)
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Surgical treatment of thoraco-abdominal aneurysm Indications and results
Klinik für Gefäßchirurgie
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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 endo- vascular 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!)