traitement des anevrysmes aorto-iliaques
DESCRIPTION
TRAITEMENT DES ANEVRYSMES AORTO-ILIAQUES. Service de Chirurgie Vasculaire, Hôpital Cardiologique CHRU de Lille. Supra-Aortic Trunks. Arch. Thoracic Aorta. Abdominal Aorta. Iliac. VASCULAR ANATOMY. femoral. AAA. Occlusive Disease. DISSECTIONS. Preop Imaging. DuplexScan AngioCT MRA - PowerPoint PPT PresentationTRANSCRIPT
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TRAITEMENT DESANEVRYSMES AORTO-ILIAQUES
Service de Chirurgie Vasculaire,
Hôpital Cardiologique
CHRU de Lille
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VASCULARANATOMY
Supra-Aortic Trunks
Arch
Thoracic Aorta
Abdominal Aorta
Iliac
femoral
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AAA
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Occlusive Disease
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DISSECTIONS
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Preop Imaging
• DuplexScan
• AngioCT
• MRA
• Angiography
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AAAINDICATIONS OPERATOIRES
• AAA fusiformes :– diamètre ≥ 50 mm– croissance rapide > 5 mm en 6 mois– patient symptomatique
• Anévrismes iliaques : diamètre ≥ 30 mm
• Anévrismes sacculaires et pseudo-anévrismes
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ADAM trial UK SAT
Comparative studies on small Comparative studies on small AAAAAA
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Small aneurysms less than
5.5cms can be left
alone, but
...not for a long time
527 pts. under
surveillance:
39 (7%)
alive without surgery after
8 yearsUK SAT, N Engl J Med 2002
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UK SAT, Lancet 1998
10 ruptures
8 deaths
Is surveillance a safe option ?Is surveillance a safe option ?
53 53 mmmm
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Definition of Definition of SmallSmall AAA AAA
• US vs CT
• DMin vs DMax
• L-L vs A-P
• 3D reconstruction5155
52
??
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CHIRURGIE CONVENTIONNELLE vs CHIRURGIE
ENDOVASCULAIRE
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Early mortality after Endografting Early mortality after Endografting
at least one third of early mortalityat least one third of early mortality
after Open repair of AAA:after Open repair of AAA:
EVAR 1 trial*EVAR 1 trial* 2.1% vs 6.2%2.1% vs 6.2%
DREAM trial°DREAM trial° 1.2% vs 4.6%1.2% vs 4.6%
PerugiaPerugia§§ 0.9% vs 4.1%0.9% vs 4.1%
AAA endografting resultsAAA endografting results
*The EVAR trial participants, Lancet 2004° DREAM Trial group, NEJM 2004§ Cao et al, JVS 2004
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AAA related death advantage AAA related death advantage persists in the mid- and long-termpersists in the mid- and long-term
EVAR 1 trial (4 years) * EVAR 1 trial (4 years) * 4% vs 4% vs 7%7%
DREAM trial° (2 years)°DREAM trial° (2 years)° 2.1% vs 2.1% vs 5.7% 5.7%
Perugia (7 years) Perugia (7 years) §§ 2.5% vs 2.5% vs 4.1%4.1%
AAA endografting resultsAAA endografting results
*The EVAR trial participants, Lancet 2005° DREAM Trial group, NEJM 2005§ Cao et al, JVS 2004
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EVAR n=312
UKSAT
n=527
p
Op mortality 1.9 % 5.9 % 0.001
AAA death 0.8%/y 1.6%/y 0.03
Total mortality 6.4%/y 8.3%/y 0.02
Zarins, EJVES Zarins, EJVES 20052005
EVAR (matched subgroup) vs UKSAT Surveillance
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CHIRURGIE CONVENTIONNELLE
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CHIRURGIE CONVENTIONNELLE
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CHIRURGIE CONVENTIONNELLE
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TECHNIQUE ENDOVASCULAIRE
Voies d’abords : incision des scarpas
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MATERIEL : ENDOPROTHESES ZENITH ( COOK )
Dacron standard ( Vascutek) + stents en acier inoxydable
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MATERIEL• CARACTERISTIQUES TECHNIQUES
– STENT SUPRA-RENAL
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MATERIEL– INTRODUCTEUR
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TECHNIQUE ENDOVASCULAIRE
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TECHNIQUE ENDOVASCULAIRE
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TECHNIQUE ENDOVASCULAIRE
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TECHNIQUE ENDOVASCULAIRE
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TECHNIQUE ENDOVASCULAIRE
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CRITERES ANATOMIQUES
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– ACCES ILIAQUES
– ANGULATIONS
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• CRITERES DE L’AFSSAPS (Agence Française de Sécurité Sanitaire des Produits de Santé)
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AVANTAGES ENDO vs CONVENTIONNELLE
• Chirurgie « mini invasive »
– ↘ pertes sanguines– ↘ complications de paroi– ↘ douleurs postopératoires– ↘ complications pulmonaires– pas de répercussion sur le transit intestinal– possibilité d’intervenir sous anesthésie loco-régionale ou locale
• Pas de de clampage aortique
• Traitement des ruptures d’anévrisme
→ ↘ mortalité
↘ durée hospitalisation
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INCONVENIENTS ENDO vs CONVENTIONNELLE
• Coût• Complications « techniques » peropératoires• Suivi post-opératoires
– risque de fuites (≠types), migration– thrombose de jambage (plicature)
• RMN contre-indiquée
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COUT DES ENDOPROTHESES