aneurisma cronico dell’aorta toracicafisiokinesiterapia-news.it/download/aneurismaoto.pdf ·...
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ANEURISMA CRONICO ANEURISMA CRONICO DELLDELL’’AORTA AORTA
TORACICATORACICA
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Blood Vessel Layers• Tunica intima
– Lines lumen– Endothelial cell layer– And subendothelial cell layer of loose
connective tissue• Tunica media
– Circular layers of smooth muscle cells – Thick in arteries– Also lots of elastic fibers
•Tunica Adventitia
–Loose connective tissue
•Contains Fibroblasts and collagen fibers
–Vaso vasorum
•Blood supply to the blood supply
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Aneurisma-Definizione
• ANEURISMA=dilatazione patologica localizzata di un segmento arterioso
• VERO ANEURISMA=dilatazione di un tratto di arteria che supera di oltre il 50% il calibro originale della stessa e la cui parete è formata da tutte le tre tuniche del vaso
• FALSO ANEURISMA=ematoma organizzato
False aneurysm (aneurysm spurium)
Dissecting aneurysm
Arteriovenous aneurysm
Cirsoid aneurysm
Saccularaneurysm
Fusiform(Spindle) aneurysm
Medial necrosis
Arteriosclerosis
Erosion in TB or
ulceration
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AneurismaAneurisma delldell’’AortaAorta ToracicaToracicaAorta Aorta AscendenteAscendenteArco Arco AorticoAorticoAorta Aorta DiscendenteDiscendenteAorta Aorta ToracoaddominaleToracoaddominaleType I:Type I: Proximal descending to proximal Proximal descending to proximal abdominalabdominalType II:Type II: Proximal descending to Proximal descending to
infrarenalinfrarenalType IIIType III: : Distal descending with Distal descending with
abdominalabdominalType IVType IV: : Primarily abdominalPrimarily abdominal
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EZIOLOGIAEZIOLOGIAAterosclerosiAterosclerosiDisordini del Disordini del tess.connettivotess.connettivo o necrosi cistica o necrosi cistica della media della media (S. di (S. di MarfanMarfan,S. di ,S. di EhlersEhlers--DanlosDanlos))Malattie infiammatorie Malattie infiammatorie (granulomatosi,arterite a cellule (granulomatosi,arterite a cellule giganti,arterite di giganti,arterite di TakayasuTakayasu))SifilideSifilideDissezione aorticaDissezione aorticaTrauma aorticoTrauma aorticoInfezioniInfezioniGravidanzaGravidanza
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SINTOMISINTOMI40% 40% ASINTOMATICIASINTOMATICISINTOMISINTOMI pipiùùcomuni:comuni:--dolore dolore toracico/dorsaletoracico/dorsale--disfoniadisfonia--disfagiadisfagia--tosse,dispneatosse,dispnea--anginaangina--pletora e edemapletora e edema--ictus,ischemie ictus,ischemie delle delle estremitestremitàà,infarti ,infarti renali, ischemia renali, ischemia mesentericamesenterica
Aneurysm with ascending aorta location. This diagram clearly shows how an aneurysm here would cause a hoarse voice as it stretches the recurrent laryngeal nerve.
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SEGNISEGNI
Soffio da rigurgito Soffio da rigurgito aorticoaortico con o con o senza senza manifestazioni manifestazioni perifericheperifericheAmpia pressione Ampia pressione differenzialedifferenzialeDeviazione Deviazione trachealetrachealeSoffio Soffio paravertebrale paravertebrale
Aorta with aortic dilatation limited to the ascending aorta. The damage to the vessel wall often extends to the aortic valve ring, causing severe aortic valve insufficiency
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DIAGNOSTICA PER IMMAGINIDIAGNOSTICA PER IMMAGINI
RX ToraceRX ToraceTomografia computerizzataTomografia computerizzataAortografiaAortografiaAngioAngio--RisonanzaRisonanza MagneticaMagneticaEcocardiografia Ecocardiografia transtoracicatranstoracicaEcocardiografia Ecocardiografia transesofageatransesofagea
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RX TORACERX TORACE
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TOMOGRAFIA TOMOGRAFIA COMPUTERIZZATACOMPUTERIZZATA
Aortic aneurysm
Descending thoracic aortic aneurysmwith mural thrombus at the level of the left atrium, showed on CT scan with contrast
mural thrombus
aortic aneurysm
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ECOCARDIOGRAFIA ECOCARDIOGRAFIA TRANSTORACICATRANSTORACICA
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Ecocardiografia Ecocardiografia TransesofageaTransesofagea
There is gross dilatation of the ascendingaorta, with loss of the sinotubular junction(note the 1 cm markers on the left side of the sector).
Marked dilatation of the ascending aorta has resulted in functional aortic regurgitation. There is limited opening and closing of the AV because the leaflets are suspended from the markedly dilated sino-tubular junction. A large diastolic coaptation defect of the AV is apparent. Colour flow Doppler imagingconfirms the presence of severe aortic regurgitation (jet width > 40% of outflow tract width).
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AortografiaAortografia
•Sensitive and specific
•Invasive
•Can be done Time consuming
•intraoperatively if needed
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Storia Naturale•L’evoluzione naturale
degli aneurismi vascolari èla progressiva dilatazione sino alla rottura del vaso.
•Secondo la legge di Laplace, al progressivo aumento del diametro
corrisponde un incremento della tensione di parete con conseguente tendenza alla
fissurazione
•The only independent predictor of rapid expansion (>0.5cm/yr) is an initial aortic diameterlarger than 5cm
•Aneurysms that are 5cm or smaller show mean growth rates of 0.17cm/yr
•Aneurysms larger than 5cm grow by 0.79cm/yr
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EpidemiologiaEpidemiologia degli degli ANEURISMIANEURISMI((-- -- --) e degli ) e degli ANEURISMI ROTTIANEURISMI ROTTI((——))
Incidenza:Incidenza:400/100000 400/100000 ((>65anni)>65anni)670/100000 (>80 670/100000 (>80 anni)anni)
Incidenza rottura:Incidenza rottura:20/100000(20/100000(>65 >65 anni)anni)100/100000(>80 100/100000(>80 anni)anni)
STORIA NATURALE
0
20
40
60
80
100
120
0 2 4 6 8 10 12
years
surv
ival TAA
T-AAAAAA
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ROTTURA:Esami radiologiciROTTURA:Esami radiologici
irregularity continuity of the aortic outline
increased attenuation of the mediastinum which is consistent with mediastinal hematoma
widening of the mediastinal contourand deformity and blurred margins of the superior mediastinum
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TRATTAMENTOTRATTAMENTOFARMACOLOGICOFARMACOLOGICO
BETABETA--BLOCCANTIBLOCCANTI
CHIRURGICOCHIRURGICO
sostituzione con sostituzione con PROTESI SINTETICHEPROTESI SINTETICHE
Uso di Uso di ENDOPROTESI ENDOPROTESI
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Indication for operation– Symptoms– 5.0-6.0 cm size in Ascending Aorta– 5.5-6.0 size cm in Aortic Arch– 5.0-6.0 cm size in Descending Aorta– Marfans >5.0-5.5cm– Growth > 1 cm per year
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INCISIONE INCISIONE TORACICA TORACICA POSTERIORE POSTERIORE SINISTRA SINISTRA INCISIONE INCISIONE TORACOLAPAROFRENITORACOLAPAROFRENICACA
Terapia ChirurgicaTerapia Chirurgica-- VIE DVIE D’’ACCESSOACCESSO
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• Sostituzione Ao Ascendente• Sostituzione Ao Ascendente + sostituzione valvolare
TRATTAMENTO CHIRURGICO TRATTAMENTO CHIRURGICO
•
L’aorta ascendente e la valvola aortica
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CHIRURGIA DELLCHIRURGIA DELL’’AORTA ASCENDENTE AORTA ASCENDENTE E DELLE DELL’’ARCO AORTICOARCO AORTICO
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SOSTITUZIONE DELLSOSTITUZIONE DELL’’AORTA AORTA ASCENDENTEASCENDENTE
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REIMPIANTO DEI TRONCHI REIMPIANTO DEI TRONCHI EPIAORTICIEPIAORTICI
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COMPLICANZECOMPLICANZE
Danno cerebraleDanno cerebraleParesi e ParaplegiaParesi e ParaplegiaDisfunzione e Insufficienza renaleDisfunzione e Insufficienza renaleDisfunzione polmonareDisfunzione polmonareReinterventoReintervento
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PROTEZIONE CEREBRALE DURANTE CHIRURGIA DELL’AORTA E
DELL’ARCO• IPOTERMIA PROFONDA CON
ARRESTO DI CIRCOLO (DHCA)
• PERFUSIONE CEREBRALE RETROGRADA (CRP)
• PERFUSIONE CEREBRALE SELETTIVA(SCP)ANTEROGRADA SECONDO KAZUI
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MONITORAGGIO DELLA MONITORAGGIO DELLA TEMPERATURATEMPERATURA
IN CASO DI IPOTERMIA PROFONDA ED IN CASO DI IPOTERMIA PROFONDA ED EVENTUALE ARRESTO DI CIRCOLO, IL EVENTUALE ARRESTO DI CIRCOLO, IL
RAFFREDDAMENTO DELLE RADICI RAFFREDDAMENTO DELLE RADICI DEGLI ARTI O DELLA TESTA CON DEGLI ARTI O DELLA TESTA CON
BORSE DI GHIACCIO RIMANE BORSE DI GHIACCIO RIMANE TUTTORA UNO DEI PRESIDI PIUTUTTORA UNO DEI PRESIDI PIU’’
VALIDIVALIDI
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1) IPOTERMIA PROFONDA E ARRESTO DI CIRCOLO
(DHCA)
• TECNICA SEMPLICE• CAMPO ESANGUE E LIBERO DA CANNULE• FACILE ISPEZIONE DELL’ANEURISMA• OPEN AORTIC ANASTOMOSIS
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Protective mechanism of brain during HCA• Exact mechanism
– unknown– Major effect
• hypothermic metabolic suppression
Safe Duration of HCA•Temp Cerebral Metabolic Rate Safe Duration of HCA• (°C) (% of baseline) (min)
•37 100 5•30 56 (52-60) 9 (8-10)•25 37 (33-42) 14 (12-15)•20 24 (21-29) 21 (17-24)•15 16 (13-20) 31 (25-38)•10 11 (8-14) 45 (36-62)
•Q10 : 2.3 (to 15 °C; 2.05, 15-11.4 °C; 3.5)
(Ann Thorac Surg 1999;67:1895-9)
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•⇓ in O2 demand, ⇑ in ischemic tolerance
•Degree of protection is not proportional to metabolic rate reduction
•inhibition of biosynthesis, release, and uptake of these excitatory neurotransmitters
•Glutamate remained depressed even after rewarmingto normothermia
Hypothermic protection
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Cerebral Vascular Resistance and Flow During Hypothermic CPB
(Ann Thorac Surg 1999;68:867)
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DHCA
TEMPO LIMITE DI SICUREZZA (TEORICO)
MC CULLOUGH: Annals Thoracic Surgery 1999; 54:609-16
30 MINUTI A 1530 MINUTI A 15°°CC
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2) PERFUSIONE CEREBRALE RETROGRADA
• WASH OUT EMBOLICO
• SUPPORTO NUTRITIVO
UEDA Y. (Osaka Prefectural General Hospital-JAPAN) Journal Cardiovascular Surgery 1990; 31: 553-8
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CASISTICA
COSELLI J. (590 Pazienti di cui 290 con DHCA E CRP)
MORTALITAMORTALITA’’3.4 %3.4 %
DHCA + CRPDHCA + CRP DHCADHCA
MORTALITAMORTALITA’’14.8 %14.8 %
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3) PERFUSIONE CEREBRALE 3) PERFUSIONE CEREBRALE SELETTIVA SECONDO KAZUISELETTIVA SECONDO KAZUI
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TECNICA DI CANNULAZIONE SELETTIVA
• TRONCO ANONIMO
• ARTERIA CAROTIDE COMUNE SINISTRA
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VANTAGGI
ALLO STATO ATTUALE DELLE CONOSCENZE NON E’ POSSIBILE INDICARE UNA METODICA DI PROTEZIONE CEREBRALE VALIDA IN ASSOLUTO PER LA CHIRURGIA DELL’AORTA, TUTTAVIA SULLA BASE DELLA LETTERATURA E DELL’AMPIA CASISTICA RIPORTATA, SI PUÒ RITENERE LA SCP COME LA MIGLIORE TECNICA DI PROTEZIONE CEREBRALE PER:
• SICUREZZA DEI TEMPI DI ARRESTO CIRCOLATORIO
• RIDUZIONE DELLE COMPLICANZE COAGULATIVE, POLMONARI E MICROEMBOLICHE LEGATE ALL’IPOTERMIA PROFONDA
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MONITORAGGIO NEUROLOGICO MONITORAGGIO NEUROLOGICO INTRAOPERATORIOINTRAOPERATORIO
DOPPLER TRANSCRANICODOPPLER TRANSCRANICO
ELETTROENCEFALOGRAMMAELETTROENCEFALOGRAMMA
PESsPESs
NIRSNIRS
SbjVOSbjVO22
CMROCMRO2(TEORICO)2(TEORICO)
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MONITORAGGIO NEUROLOGICOMONITORAGGIO NEUROLOGICO
DOPPLER TRANSCRANICODOPPLER TRANSCRANICOVALUTAZIONE DEL FLUSSO EMATICO CEREBRALEVALUTAZIONE DEL FLUSSO EMATICO CEREBRALE
EEG, PESEEG, PESSSVALUTAZIONEVALUTAZIONE DEL DANNO NEURONALEDEL DANNO NEURONALE
SbjVOSbjVO22,NIRS, CMRO,NIRS, CMRO22VALUTAZIONE DELLO STATO METABOLICO E DELLA VALUTAZIONE DELLO STATO METABOLICO E DELLA OSSIGENAZIONE DEL CERVELLOOSSIGENAZIONE DEL CERVELLO
LL’’AUMENTO DEL CONSUMO DI OSSIGENO AUMENTO DEL CONSUMO DI OSSIGENO EE’’ INDICE DI SOFFERENZA CEREBRALEINDICE DI SOFFERENZA CEREBRALE
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TCDTCD
DOPPLER TRANSCRANICODOPPLER TRANSCRANICO
ELETTROENCEFALOGRAFIAELETTROENCEFALOGRAFIA
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NEAR INFRARED SPECTROSCOPYNEAR INFRARED SPECTROSCOPY
NIRSNIRS
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JUGULAR VENOUS OXIMETRYJUGULAR VENOUS OXIMETRY
SSBJBJVOVO22
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CMROCMRO22
CMROCMRO2 2 == (CONSUMO CEREBRALE DI O(CONSUMO CEREBRALE DI O22))
CBF CBF X X aa--vjDOvjDO22
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TRATTAMENTO POSTOPERATORIO
• RISCALDAMENTO ATTIVO PER OTTENERE LA STABILIZZAZIONE TERMICA
• EVITARE E/O CONTROLLARE L’IPERGLICEMIA
• INSTAURARE TRATTAMENTO PRECOCE IRA CON CRRT
• SEDAZIONE CON PROPOFOL 1-2 mg/Kg/h
• SOGLIA LIMITE DI RISVEGLIO: IIa GIORNATA (VALUTAZIONE EEG E/O TAC CEREBRALE)
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Blood supply of spinal cord
• 75% : ASA
• 25% : PSA from PICA
• ASA from :– Radicular a from intercostal– and lumbar aa.– Basilar, vertebral, cervical– Iliac a.
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Radicular arteries
• 6 ∼ 10 ant radicular a• T3 ∼ T7
– usually one radicular a
– poor afferent supply
– may be discontinuous
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Artery of Adamkiewicz
Major ant. Major ant. radicularradicular
arteryarteryFrom TFrom T77 ∼∼ LL11
Larger than the otherLarger than the other
Hairpin bendHairpin bend
PerfusesPerfuses the spinal cord the spinal cord
distal to junction with ASAdistal to junction with ASA
ASA above ARM is smaller ASA above ARM is smaller
in diameter than below the in diameter than below the
ARMARM
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Sites of Arteria Radicularis Magna
• Based on this finding, recommend, whenever possible, all intercostal and lumbar arteries from T6 down to and including L1 should be reattached
(Lars G. Svensson, 1998)
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(Safi, et al.)
A) During ACC, distal A) During ACC, distal AoAo. Pr. decreases markedly, causing a reduction in . Pr. decreases markedly, causing a reduction in spinal a. perfusion Pr. and a subsequent increase in CSspinal a. perfusion Pr. and a subsequent increase in CSF Pr. B) LA to F Pr. B) LA to LtFALtFA bypass, or distal aortic perfusion, increases distal bypass, or distal aortic perfusion, increases distal AoAo. Pr. leading to . Pr. leading to an increase in the spinal a. perfusion Pr., thus increaan increase in the spinal a. perfusion Pr., thus increasing blood flow to sing blood flow to the spinal cord. the spinal cord. The addition of CSFD further decreases CSF Pr. and The addition of CSFD further decreases CSF Pr. and augments the perfusion of the spinal cord. Moderate hypoaugments the perfusion of the spinal cord. Moderate hypothermia (32thermia (32°°C) C) p r o v i d e s a d d i t i o n a l s p i n a l c o r d p r o t e c t i o n .p r o v i d e s a d d i t i o n a l s p i n a l c o r d p r o t e c t i o n .
CSF drainage
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Gott shunt
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• Kouchoukos et al : 9.8% early mortality, 6.5% cord injury• Crawford et al : paraplegia in 2/25 due to unable to anastomose critical intercostal aa• Distal perfusion pr > 60 mmHg
CPB (with hypothermic TCA)
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An approach to spinal cord protection during descending or thoracoabdominal aortic repairs
Lars G Svensson (ATS 1999;67:1935-6)
• LA fem bypass • systemic hypothermia
(29 - 30 º C)• CSF drainage• IT papaverine• Various topical and local
cooling techniques• Reattachment of
intercostals btw T6 - L2
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Unfortunately, there are no prospective
randomized studies showing that any one
method is significantly effective, but it is likely
that a combination of various techniques and
agents reduces the risk of this dreaded
complication
By Lars G. Svensson
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Mortalità PostOperatoria MORTALITA' %
20
15
109
65
3
A.Ascendente Arco Aortico A.Discendente A.Toracoaddominale
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Prognosi
0
20
40
60
80
100
120
0 2 4 6 8 10 12
Years after surgery
Surv
ival
(%)
• ____ A.toracoaddominale ____Arco Aortico• ____ A. Discendente ____ A.Ascendente
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CAUSE DI MORTECAUSE DI MORTE
PRECOCIPRECOCI--Infarto miocardicoInfarto miocardico--Scompenso Scompenso cardiacocardiaco--EmorragiaEmorragia--Disfunzione Disfunzione neurologicaneurologica
TARDIVETARDIVE--Scompenso Scompenso cardiacocardiaco--Rottura di un Rottura di un nuovo aneurismanuovo aneurisma--Insufficienza Insufficienza renalerenale--insufficienza insufficienza respiratoriarespiratoria
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ENDOPROTESIENDOPROTESI