Chirurgia endovasculara

Principii, indicatiiChirurgia endovascularaChirurgia endovascularaRadiologia Interventionala (RI) este o subspecialitate de radiologie-imagistica medicala ce reuneste totalitatea metodelor si tehnicilor instrumentale de abord percutan ghidat radio-imagistic, practicate in scop diagnostic sau/si terapeutic.1953-SELDINGER-comunica prima data tehnica de cateterism percutan arterial ce foloseste un fir ghid introdus pe acul de punctie arteriala,urmat de introducerea coaxiala a unui cateter de calibru mai mare dect acul;metoda sta la baza TUTUROR METODELOR DE ABORD INTERVENTIONAL PERCUTAN,ATIT VASCULAR CIT SI NON-VASCULARChirurgia endovasculara1964-DOTTER,JUDKINS (Oregon-USA) executa prima Angioplastie Percutana Transluminala (APT) dilatarea unei stenoze femurale,folosind tehnica 11211g622l Seldinger si un sistem de catetere coaxiale cu calibru crescator1975-GIANTURCO-creeaza si aplica spiralele metalice ca agent emboligen in EAT (embolizre arteriala terapeutica) 1976-GRUNTZIG (Elvetia),inventeaza si aplica pe animal si la om cateterul cu dublu lumen si balon gonflabil,ce a permis aplicarea APT in toate teritoriile vasculare

Chirurgia endovasculara1983-FOTIADE (spit.Fundeni,Bucuresti)- efectuiaza primele angioplastii periferice in Romania,aplicate in acelasi an si la cl.rad.Iasi1983-DANIIL,G.Ionescu (Cl.Radiol-Iasi)-realizeaza primele embolizari arteriale splenice1985-PALMAZ(SUA)-inventeaza si aplica prima endoproteza arteriala expandabila (a.iliaca)In decursul ultimilor 25 ani ,o multitudine de inventii si noi tehnologii aplicate au accelerat si perfectat progresiv metodele si tehnicile de radiologie interventionala; perfectionarea unor instrumente interventionale si de abord-ace catetere, fire ghid,proteze,agenti emboligeni ,etc.

MATERIALE SI INSTRUMENTE

Trusa Seldinger standard-cuprinde :-ac-trocar de punctie vasculara compus din canula si mandrin bizotat;-fir ghid cu partea distala flexibila,adaptat in diametru acului si cateterului de introdus;-catetere de dimensiuni si curburi distale diferite,adecvate la tipul de vas ce trebuie cateterizatAccesorii la trusa Seldinger:-teci dilatatoare din teflon;-teci arteriale cu brat lateral si ventil,pentru schimbarea cu usurinta a cateterelor in timpul aceleiasi proceduri; conexiuni si robinete cu 1-2 si 3 cai pentru etansarea externa a cateterelor Cateterele pot avea un singur orificiu distal sau orificii multiple laterale si calibre diferite:cele pentru diagnostic vascular sunt in general cu calibru mic (3-6 Fr.)iar cele terapeutice-pentru drenaje percutane au calibre mai mari (8-14 Fr)(1Fr(French) =0,33mm)

SALA DE RADIOLOGIE INTERVENTIONALA

Sala trebuie sa indeplineasca criterii de asepsie si posibilitati de dezinfectie ca si o sala de operatii chirurgicale dotata cu aparat de fluoroscopie cu circuit TV si posibilitati de angiografie digitala (achizitie rapida de serii de imagini-cu 1-7 imag/sec); C- arm;Aparatul de radiologie trebuie sa aiba 2 ecrane unul pentru preluarea imaginii arteriografice ( care este inghetata), altul pentru preluarea imaginii in timp real ( toate manevrele endovasculare se executa sub control radiologic)Medicul si asistentii care efectueaza manevrele endovasculare poarta sorturi de protectieMetode interventionale vasculare

Angioplastia percutana transluminala (APT)Endoprotezarea vasculara percutanaEmbolizarea arteriala terapeuticaShunt transjugular intrahepatic porto-sistemic (TIPSS)Montajul unui filtru in vena vava inferioaraANGIOPLASTA PERCUTANA TRANSLUMINALADefinitie:Remodelarea /recalibrarea lumenului vascular stenozat/trombozat prin tehnici de dilatare a stenozelor si recanalizare a trombozelorIndicatii:-patologie arteriala ateromatoasa,displazica , generatoare de stenoze si tromboze;unele obstructii venoase Teritorii vasculare -artere: coronare, carotide,tr.brahiocefalic,renale, aorta, iliace,femurale,poplitee; -vene:-vena cava superioara,tr.brahiocefalic,vena cava inferioara,shuntul a-v pentru dializa;procedura de APT venoasa este frecvent urmata de endoprotezarea venei

ANGIOPLASTA PERCUTANA TRANSLUMINALAPRINCIPIUL METODEI APT de dilatare a stenozelor:cateterismul Seldinger al vasului-tinta-trecerea unui fir ghid trans-stenotic -pozitionarea cateterului de APT cu balonul degonflat in leziunea stenotica -gonflarea balonului cu substanta de contrast sub presiune controlata manometric-degonflarea balonului si retragerea cateterului-angiografie de control al remodelarii arterei

ANGIOPLASTA PERCUTANA TRANSLUMINALAPRINCIPIUL METODEI APT de recanalizare a trombozelor:cateterismul Seldinger al vasului-tinta forajul trans-tromb cu fir ghid,instrumente speciale mecanice,laser,etc ; pozitionarea unui cateter fin in tromb infuzie controlata de agent fibrinolitic control angiografic/aprecierea recanalizariiprocedura de angioplastie a stenozei restante cu balon endoprotezare percutana(optional)

ANGIOPLASTA PERCUTANA TRANSLUMINALA

ANGIOPLASTA PERCUTANA TRANSLUMINALA

ENDOPROTEZAREA VASCULARAEndoprotezarea este indicata : Dupa APT:daca stenoza restanta este > de 30% daca exista decolare intimala importantadupa recanalizarea trombozelor in re-stenozarea tardiva dupa APT Endoprotezarea per primam:in stenoze excentrice cu calcificari intinselocalizari particulare (a.renala,carotida,etc)anevrisme de aorta abdominala sau toracicain traumatisme de arc aortic, aorta aorta toracica

PRINCIPIU de TEHNICA a ENDOPROTEZARII VASCULARE

Dupa APT:-se pastreaza firul ghid in lumenul stenozat:-se introduce proteza colabata,montata pe cateter-balon (proteza Palmaz expandabila cu balon) sau montata in cateter-tutore(proteza auto-expandabila tip Wallstent)-se pozitioneaza proteza in lumenul stenotic-se gonfleaza balonul cu contrast si se expandeaza proteza-se degonfleaza balonul si se retrage cateterul din proteza fixata la perete-se executa angiografie de control

EndoprotezareStent:balon expandabil auto-expandabil- pe vasele tortuoaseEndoproteza ( covered stent) : cu invelis de PTFE sau Dacron- pe vase anevrismale, perforatii iatrogene/rupturi ale fistulelor a-v ( restenoza intrastent redusa, dar induc neoplazie intimala)articulata fenestrataStenturi

Stenturi

Stenturi

Stenturi

Stenturi

Stenturi

Stenturi

Stenturi

Endoproteze

Chirurgia endovascularaThe conditions most often treated by endovascular stent surgery are: coronary artery disease narrowing (stenosis) of the carotid artery in the neck, a risk factor for stroke and aortic aneurysmarteriovenous fistula

Chirurgia endovascularaDiagnostic inaintea procedurii-arteriografie, angio-CT ( anevrisme) sau angio- RMN ( carotide)Cu 12 ore inainte de implantarea unui stent, pacientul trebuie sa evite consumul de alimente sau lichide.Se monteaza o linie IV pt administrarea de anticoagulante si substanta de contrastSe dezinfecteaza zona de punctie si se radeCu o ora inaintea procedurii se administreaza un sedativ

Chirurgia endovascularaAfter stent surgery, the patient will spend several hours in the recovery room to be monitored for vital signs (temperature, heart rate, and breathing) and heart sounds. Pressure will be applied to the catheter insertion site in the groin to prevent bleeding; a weight may be applied to the leg to restrict movement. For the first 24 hours, the patient will have to lie flat and limit activities. Drinking fluids will be especially important to help flush out the dye that was used for x rays during the procedure. Stent recipients are usually placed on aspirin therapy or anti-clotting (anticoagulant) medication immediately after surgery. They will remain on it indefinitely to prevent clots from occurring in the stent. There are no other postoperative precautions, although dietary and lifestyle changes may be recommended to reduce such risk factors as high cholesterol and smoking that could lead to new blockages from ongoing buildup of plaque in the body's blood vessels. Patients are advised not to have magnetic resonance imaging (MRI) procedures after the surgery because of the effect of magnetism on the metal stents. Stents are not affected by metal detectors.

Chirurgia endovascularaRisks The greatest risk with stent implantation is the formation of clots within the stent. Aspirin and oral anti-clotting medications are usually given after stent placement to minimize this risk, which has been reported to occur in about 11.5% of patients undergoing endovascular stent surgeries. There has been no evidence of long-term complications from stent implantation, according to the American Heart Association. A variety of complications can occur with stent grafting for emergency aneurysm repair. Movement of the stent ( endoleak) within the vessel can occur in up to 10% of cases, requiring repeat surgery. Clots can occur in the vessel and migrate to other areas of the body, causing heart attack or stroke. About 2% of patients will require an additional open surgical procedure to correct the aneurysm or complications that occur after emergency endovascular repair.

Chirurgie endovascularaMorbidity and mortality rates Deaths have not been reported either during or immediately following endovascular stent surgeries that are linked to the surgical procedure. Stent procedures have been shown to increase survival (by reducing restenosis) among people with coronary artery disease. The mortality rate for surgically treated abdominal aortic aneurysm is about 5% and increases to 50% for aneurysms that rupture. Thoracic aneurysms also have a mortality rate of about 5%, rising to 67% if ruptured. Stent grafting has been shown overall to have lower rates of morbidity and mortality than conventional open procedures.

Chirurgia endovascularaAnticoagulation/Antiaggregant TherapyThe majority of operators give 5000 IU of heparin intraarterially at the time of the procedure. Full heparinization (5001000 IU/h) can be continued for 12 to 24 h, particularly in difficult casesto increase the activated partial thromboplastin time to two or three times normal; alternatively, low-dose, low molecular weight heparin therapy is administered until hospital discharge All patients should receive antiaggregant therapy, usually aspirin (100325 mg/day), on a lifetime basis, alone or in combination with clopidogrel ,although there is no evidenceof improved outcome with the addition of clopidogrel to this regime.

Tratamentul restenozelor The currently accepted method for treating iliac in-stent restenosis, due to either intimal hyperplasia or disease progression following PTA/stenting, is repeated balloon dilation and/ or implantation of a second stent Repeat stent placement (resulting in a stent sandwich) may show excellent short-term technical success,however, it bears the disadvantage of consequent arterial wall overexpansion, with the potential of the induction of further neointimal response There is no proof at present that stent placement in a restenosed vessel is beneficial to prevent future stenosis Directional atherectomy appears to be a useful method by debulking the stent of its neointimal tissue prior to the upcoming balloon dilation or further stent placement Atheroablation techniques in general have not been widely acceptedon the grounds of additional cost and skill demand Cutting balloon angioplasty offers an attractive therapeutic alternative for the treatment of iliac in-stent restenosis, however, adequate scientific evidence is still lacking.

Complicatiile chirurgiei endovasculareObezitatea si comorbiditatile cardiace si renale cresc rata complicatiilor majoreCea mai frecventa complicatie este hemoragia la locul punctiei ( 2,9%)- hematom, hemoragie intra-, pro-, sau retroperitonealaPseudoanevrismEmbolizare distalaInfarct miocardicNecroza tubulara renala- IRAAVCdecesRezultatePatency following percutaneous transluminal angioplasty (PTA) is highest for lesions in the common iliac artery and progressively decreases for lesions in more distal vessels. Anatomic factors that affect the patency include severity ofdisease in run off arteries, length of the stenosis/occlusion and the number of lesions treated.Clinical variables impacting the outcome also include diabetes,renal failure, smoking and the severity of ischemia.Clasificarea TASV

TASCThe Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC) was published in January 2000 as a resultof cooperation between fourteen medical and surgical vascular, cardiovascular,vascular radiology and cardiology societies in Europe and North America. In subsequent years, the field has progressed with the publication ofthe CoCaLis document and the American College of Cardiology/American Heart Association Guidelines for the Management of Peripheral Arterial Disease Aiming to continue to reach a readership of vascular specialists, but alsophysicians in primary health care who see patients with peripheral arterial disease (PAD), another consensus process was initiated during 2004 (TASC II)This new consensus document has been developed with a broader international representation, including Europe, North America, Asia, Africa and Australia, and with a much larger distribution and dissemination of the information.Clasificarea TASCWhile the specific lesions stratified in the following TASC classification schemes have been modified from the original TASC guidelines to reflect inevitable technological advances, the principles behind the classification remain unchanged.A lesions represent those which yield excellent results from, and should betreated by, endovascular means; B lesions offer sufficiently good results with endovascular methods that this approach is still preferred first, unless an open revascularization is required for other associated lesions in the same anatomic area; C lesions produce superior enough long-term results with open revascularization that endovascular methods should be used only in patients at high risk for open repair; D lesions do not yield good enough results with endovascular methods to justify them as primary treatment. Finally it must be understood that most PAD requiring intervention is characterized by more than one lesion, at more than one level, so these schemes are limited by the necessity to focus on individual lesions. TASC classification of aorto-iliac lesions

TASC classification of aorto-iliac lesions

TASC classification of aorto-iliac lesions

TASC classification of aorto-iliac lesions

Recommendation : Treatment of aortoiliac lesions

TASC A and D lesions: Endovascular therapy is the treatment of choice for type A lesions and surgery is the treatment of choice for type D lesions TASC B and C lesions: Endovascular treatment is the preferred treatment for type B lesions and surgery is the preferred treatment for good-risk patients with type C lesions. The patients co-morbidities, fully informed patient preference and the local operators long-term success rates must be considered when making treatment recommendations for type B and type C lesions .TASC classification of femoral popliteal lesions

TASC classification of femoral popliteal lesions

TASC classification of femoral popliteal lesions

TASC classification of femoral popliteal lesions

CFA common femoral artery; SFA superficial femoralarteryTreatment of femoral popliteal lesions

TASC A and D lesions: Endovascular therapy is the treatment of choice for type A lesions and surgery is the treatment of choice for type D lesions TASC B and C lesions: Endovascular treatment is the preferred treatment for type B lesions and surgery is the preferred treatment for good-risk patients with type C lesions. The patients co-morbidities, fully informed patient preference and the local operators long-term success rates must be considered when making treatment recommendations for type B and type C lesions .Estimated success rate of iliac artery angioplasty from weighted averages (range) from reports of 2222 limbs

Claudication ( %) 76% ( 81-94)Technical success - 96% (9099)Primary patency :1 yr - 86% (8194) 3 yr- 82% (7290) 5 yr- 71% (6475)Pooled results of femoral popliteal dilatationsPTA: stenosis :1 yr patency 77 % (7880);3 yr patency 61% (5568); 5 yr patency 55% (5262)PTA: occlusion: 1 yr patency 65% (5571); 3 yr patency 48%(4055); 5 yr patency 42 %(3351)PTA+stent: stenosis : 1 yr patency 75% (7379); 3 yr patency 66 %(6470)PTA+stent: occlusion : 1 yr patency 73% (6975); 3 yr patency 64% (5967)

PTA Percutaneous Transluminal AngioplastyRecurenta Risk factors for recurrence were analyzed by multivariate stepwise backward regression analyses in various studies. Clinical stage of disease (intermittent claudication versus critical limb ischemia), length of lesion and outflow disease were most commonly found as independent risk factors for restenoses.Endovascular treatment of infrapopliteal occlusive disease

Endovascular procedures below the popliteal artery are usually indicated for limb salvage and there are no data comparing endovascular procedures to bypass surgery for intermittent claudication in this region.Angioplasty of a short anterior or posterior tibial artery stenosis may be performed in conjunction with popliteal or femoral angioplasty. Use of this technique is usuallynot indicated in patients with intermittent claudication.