aaa armv lille 28092013
TRANSCRIPT
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Anévrisme de l’aorte abdominale
Prise en charge endovasculaire
Service de chirurgie vasculaireHôpital Cardiologique,
CHRU LILLE, Fr
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• Patient âgé de 80 ans hospitalisé pour la prise en charge d’un AAA rompu
• ATCD : – remplacement valvulaire aortique et mitrale en 2011– Coronaropathie : IDM en 2003 (stent IVA)– Pace maker double chambre– Insuffisance cardiaque ischémique stable (FEVG 45 %)– Fibrillation auriculaire
• FDRCV :– Tabagisme sevré il y a 10 ans (40 PA)– HTA
• TRT : cordarone 200, temerit 5, lasilix 40, previscan 20
Cas clinique
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QUE FAIRE?
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21523 patientsTaux de mortalité globale 48%
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Scoring
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First-in-manEDP AUI
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EVAR 436 patients:Eligibilité EVAR 47%
Mortalité plus faible EVAR vs OREVAR 982 patients:
Mortalité Globale 21%Morbidité Globale 41%
Nbx biais
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49 centres - 1037 patients traités (763 par chirurgie ouverte)
30d M:17% EVAR36% OR
Bénéfice évident EVAR
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Volume du centre
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AJAX•112 patients randomisés•Pas de différence pour morbi-mortalité à 30 jours
Essai(s) Randomisé(s) Publié(s)
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Absence de laparotomie
Limite les variations hémodynamiques (décompression abdominale / Anesthésie Locale)
Absence de clampage aortique
Ischémie/reperfusion et défaillance multiviscérale
Diminue les traumatismes iatrogènes
EVAR
Taux de conversion faible~ 6% [GRECO JVS 2005]
[MAYER M ANN SURG 2009]
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Absence de laparotomie
Syndrome du compartiment abdominal ~ 20%3ième secteur
AngioTDM préopératoire nécessaire
durée de prise en charge
Mais ne change pas le pronostic
EVAR
[MAYER D ANN SURG 2009]
[RESCH T J ENDOVASC THER 2003][LLOYD GM JVS 2004]
[BOYLD EJEVS 2005]
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En électif, EVAR = la panacée?
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EVAR > Chirurgie ouverte
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IFU
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EVAR ANATOMIE / ESVS Guidelines
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Advantage Windows, GE
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Aquarius Intuition, Terarecon
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OsiriX, Pixmeo
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Planification préopératoire
• Angulations / Projections
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• Longueurs / diamètres
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Endoprothèses
Talent Endurant
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Procédure teresa
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Technique endovasculaireSystème de fermeture percutanée
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Conclusions
• Traitement moins invasif• Traitement fiable• Planifications préopératoires• Sélection des anatomies
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MERCI !