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Juxtarenales Aortenaneurysma
5-10mm Halslänge
EVAR und sonst nichts ?!
A. Hyhlik-Dürr
Klinik für Gefäßchirurgie und endovaskuläre Chirurgie
Klinikum Augsburg
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Suprarenal 5 %
Juxtarenal 15 %
Infrarenal 70%
Aorto-iliakal 25 %
Isoliert iliakal < 2%
Lokalisation abdomineller Aneurysmem
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Therapieziel EVAR
Ausschaltung des Aneurysmas
Verhinderung der Ruptur
Verhinderung eines Aneurysmaassoziierten Todes
Reduktion der Reinterventionen
3
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Was ist ein kurzer Hals?
Aussehen
Form
Beschaffenheit
Berechnung 4
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< 10 mm outside IFU
5 Hyhlik-Dürr A, Böckler D et al, EVC 2012 Chapter, & JCVS 2012, 53:111-8
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Was können wir tun um den kurzen Hals zu kaschieren?
14.07.2017 6
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7
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14.07.2017 8
Modernisieren?
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9
Ergebnisse
Technischer Erfolg 99,1%vs. 97,1% n.s.
Mortalität 30 Tage 1,3% vs. 2,9% n.s.
Konversionen 0 vs. 2
Typ I EL 0,8% vs. 7,4%
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Eigene Daten
14.07.2017 10
A
Number or median
(% or range)
B
Number or median
(% or range)
Primary technical success 46 (92%) 39 (97.5%)
30-day mortality 1 (2%) 0
Graft limb occlusion 2 (4%) 0
Primary endoleak
Type I
Type II
6a (8%)
3a (6%)
3a (6%)
13 (32.5%)
1 (2.5%)
12 (30%)
Cardiac complications 1 (2%) 0
Respiratory complications 0 0
Renal failure (≥1.2 mg/dL) 2 (4%) 2 (5%)
Stroke 1 (2%) 0
Intraoperative blood
transfusion
3 (6%) 0
Conversion 0 0
ICU stay (days) 0 (0-28) 0
Hospital stay (days) 5 (3-28) 6 (4-49)
Reinterventions 5b (8%) 3 (7.5%)
Anatomical parameter Median or number (range or %)
Aortic neck angulation by MPR
(degrees)
19.9 (1-73.1)
Aortic neck angulation ≥ 60 ° 10.0 (20)
Diameter at the level of the lowest
renal artery (mm)
22.3 (16.9-30.7)
Diameter 10 mm distal to the lowest
renal artery (mm)
22.5 (13-51.7)
Diameter of the aneurysm (mm) 56.6 (48-82.3)
Diameter of aortic bifurcation (mm) 26.5 (12.9-82)
Diameter of the common iliac artery
(mm)
Right
Left
10.1 (4.5-17.5)
9.4 (5-24.3)
Diameter of the external iliac artery
(mm)
Right
Left
7.5 (3.3-13.3)
7.3 (4.1- 13.9)
Length of the proximal aortic neck
(mm)
12.0 (5.0-48)
Aortic neck ≤10mm 19.0 (38)
Iliac tortuosity index
Right
Left
1.3 (1-2)
1.3 (1.1-2)
Indications a
Short proximal aortic neck length
(≤15 mm)
Severe iliac tortuosity (ITI ≥1.4)
Narrowed access vessels
31 (62%), median 10 mm (5.0-14)
16 (32%)
27 (54%), median 5.8 mm (3.3-7.0)
Chalenging Anatomy
50 40
ENGAGE
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Suprarenale Fixierung ein muss?
14.07.2017 11
EVAR
Halslänge<
10mm
n=60
ASA 3(85);4(15)%
FU 51 Monate
Überleben 5J 70%
EL I 5% 2 Tod;1RI
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14.07.2017 12
Fixieren
EL Ia 2/9 = 22%
mit Anchor = 0%
Chimney 5/9 = 55%
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14.07.2017 13
Neue Technologie einsetzten
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14.07.2017 15
Da setzen wir noch eins drauf
July 2013 – September 2016:
200 pts. mit Nellix
13 pts. NINA 6,5%
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14.07.2017 16
Neue Technologie einsetzten
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5-10mm Halslänge
EVAR und sonst nichts ?! Zusammenfassung
14.07.2017 18
EVAR bei kurzem Hals kann funktionieren
Bei Komplikationen Outcome schlechter
Technik wird anspruchsvoller bei Erweiterung des endovaskulären Repertoirs
Wir haben ja noch die Hosenträger
Outside IFU Ranomisierte
Studien
Mortalität 3-8J FU 21.5-40% 13,7-47%
Aneurysma related
Mortality
0-11% 1,2 -7%
Typ I EL 3,8-15% 6,6-6,9%