Endovasküler Aort Anevrizma Tamiri: Erken Ve Geç Dönem Vasküler Komplikasyonları

Amaç: İnfrarenal abdominal aort anevrizmasının (AAA) 5,5 cm çapın üzerine çıktığı olgularda rüptürün önlenmesi amacı ile bir girişim yapılması önerilmektedir. Yirmi yıldan uzun süredir uygulanan endovasküler stent ile aort anevrizması tamiri, daha kısa yoğun bakımda kalış süresi, daha az kanama ve daha kısa ameliyat ve hastanede yatış süresi gibi avantajlarla ön plana çıkmaktadır. Ancak bu metotda da erken ve geç dönem komplikasyonlar gelişmektedir. Bunlar arasında da vasküler komplikasyonlar morbiditeyi ve mortaliteyi arttırtan bir tabloyu oluşturmaktadır. Bu çalışmada Endovasküler Aort Anevrizma Tamiri (EVAR) uygulanan olguların erken ve geç dönem vasküler komplikasyonları değerlendirilecektir. Gereç ve Yöntem: Bu çalışmaya Haziran 2000-Ocak 2010 tarihleri arasında infrarenal AAA nedeni ile endovasküler aort onarımı uygulanan ardışık 79 olgu dahil edildi. Olguların arşivden dosyaları çıkartıldı ve poliklinik takipleri retrospektif olarak incelendi. Demografik veriler ve anevrizmanın özellikleri erken dönem ve geç mortalite ve morbidite ve vasküler komplikasyonlar oranları incelendi. Bulgular: Olguların ortalama yaşı 67,4±2,49 (33-86) idi. Olguların büyük bölümü erkekti (%85). Perioperatif mortalite %1,2 olarak saptandı. Rüptür bir olguda görüldü (%1,2). Tip I, tip II ve tip V endoleakler sırasıyla %5, %7,2 ve %3,7 olarak saptandı. Anevrizma çapı %8,8 olguda artış gösterdi, %65 olguda küçüldü ve %27 olguda stabil kaldı. Dokuz olguda (%11) greft bacak trombozu, 3 (%3,6) olguda migrasyon ve 1 (%1,2) olguda yalancı anevrizma gelişti. Tip Ia endokaçağı olan bir hastaya cerrahi konversiyon uygulandı. Ortalama takip süresi 26,7 ay (6 ay-10 yıl) olarak saptandı. On ikinci ay, 24. ay ve 48. aylarda genel sağkalım beklentisi sırasıyla %91,2, %82,1 ve %70,7 olarak tespit edildi. Sonuç: AAA’nın endovasküler stent greft ile onarımı sonrası perioperatif mortalite ve morbidite düşüktür fakat uzun dönem takiplerde ek girişim gerektirecek komplikasyonların çıkabileceği akıldan çıkarılmamalı ve hastalar aynı titizlikle ömür boyu takip edilmelidir. Komplikasyon oranları yüksek olmasına rağmen her komplikasyona girişim yapılmasına gerek yoktur ve komplikasyonlar endovasküler yolla çözülebileceği için mortalite ve morbiditesi de düşüktür.

Anahtar Kelimeler:

Endovasküler aort anevrizma tamiri, abdominal aort anevrizması, vasküler komplikasyon

Vascular Complications of Endovascular Aortic Aneurism Repair: Short and Long Term Follow-Up

Objective: An intervention is recommended in patients, who present with an infrarenal abdominal aortic aneurysm (AAA) of more than 5.5 cm in diameter. Endovascular repair, which has been carried out more than 20 years provides reduced perioperative mortality rates and shorter intensive care and hospital stay, and less bleeding. However, it is not without complications in the short and long term. Vascular complications constitute a major part of them and may contribute to the mortality and mobidity rates. This study aims to evaluate the incidence of vascular complications of Endovascular Aortic Aneurysm Repair (EVAR) in short and long term.Materials and Methods: This study included 79 consecutive patients, who have undergone endovascular repair for an infrarenal abdominal aortic aneurysm, between June 2000- Jan 2010. The archive files and follow-up data of the patients were analyzed. Demography of patients, aneurysm spesifications, mortality and morbidity rate in short and long term and vascular complications were analyzed.Results: The mean age of the patients were 67.4±2.49 (33-86). The majority of the patients was male (85%). Perioperative mortality was 1.2%. Rupture occurred in a patient (1.2%) during the follow-up. Type I, type II and type V endoleak were present in 5%, 7.2% and 3.7%, respectively. Sac enlargement occured in 8.8% of the patients, whilst 65% of the aneurysm shrinked and 27% stayed stable in diameter. Limb thrombosis occured in 9 (11%) patients, migration in 3 (3.6%) patients and pseudoaneurysm in 1 (1.2%) patient. A conversion to open surgery was carried out for a Type Ia endoleak. The mean follow-up was 26.7 mo (6 mo-10 years). The probability of survival was 91.2%, 82.1% and 70.7% at 1st, 2nd and 4th years respectively. Conclusion: Perioperative mortality and morbidity rates are low following endovascular repair for an AAA. However, it should be noted that follow-up can be troublesome anytime with vascular complications, which may necessitate an interventiom. Therefore, a life-long meticulous follow-up is essential. Although the incidence of vascular complications may be high, not every vascular complication needs to be repaired. Furthermore, many of the complications can be managed by endovascular means with lower rates of mortality and morbidity.

Keywords:

Endovascular aortic aneurism repair, abdominal aortic aneurysm, vascular complication,

PDF

___

1. United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010; 362: 1863-71.
2. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee WA, Mansour MA, Mastracci TM, Mell M, Murad MH, Nguyen LL, Oderich GS, Patel MS, Schermerhorn ML, Starnes BW. J Vasc Surg. 2018 Jan;67(1):2-77.e2.
3. Cochennec F, Becquemin JP, Desgranges P, Allaire E, Kobeiter H, Roudot-Thoraval F. Limb graft occlusion following EVAR: clinical pattern, outcomes and predictive factors of occurrence. Eur J Vasc Endovasc Surg. 2007 Jul;34(1):59-65
4. Maldonado T.S., Rockman C.B., Riles E., Douglas D., Adelman M.A. and Jacobowitz G.R. et al., Ischemic complications after endovascular abdominal aortic aneurysm repair, J Vasc Surg 40 (4) (2004 Oct), pp. 703–9.
5. Erzurum V.Z., Sampram E.S., Sarac T.P., Lyden S.P., Clair D.G. and Greenberg R.K. et al., Initial management and outcome of aortic endograft limb occlusion, J Vasc Surg 40 (3) (2004 Sep), pp. 419–23.
6. Ng R.L., Gillies T.E., Davies A.H., Baird R.N. and Horrocks M., Iliofemoral versus femorofemoral bypass: a 6-year audit, Br J Surg 79 (10) (1992 Oct), pp. 1011–1013.
7. Lipsitz E.C., Ohki, T. Veith, F.J. Rhee S.J., Gargiulo N.J. 3rd and Suggs W.D. et al., Patency rates of femorofemoral bypasses associated with endovascular aneurysm repair surpass those performed for occlusive disease, J Endovasc Ther 10 (6) (2003 Dec), pp. 1061–1065.
8. Perler B.A. and Williams G.M., Does donor iliac artery percutaneous transluminal angioplasty or stent placement influence the results of femorofemoral bypass? Analysis of 70 consecutive cases with long-term follow-up, J Vasc Surg 24 (3) (1996 Sep), pp. 363–369.
9. Rayt HS, Sandford RM, Salem M, Bown MJ, London NJ, Sayers RD. Conservative management of type 2 endoleaks is not associated with increased risk of aneurysm rupture. Eur J Vasc Endovasc Surg. 2007 Jul;34(1):59-65
10. Timaran CH, Ohki T, Rhee SJ, Veith FJ, Gargiulo NJ, Toriumi H et al. Predicting aneurysm enlargement in patients with persistent Type 2 endoleaks, J Vasc Surg 2004; 39: 1157–1162.
11. Lipsitz EC, Ohki T, Veith FJ, et al: Delayed open conversion following endovascular aortoiliac aneurysm repair: Partial (or complete) endograft preservation as a useful adjunct. J Vasc Surg 38(6):1191-1198, 2003.
12. Fransen GA, Vallabhaneni SR Sr, van Marrewijk CJ, et al: Rupture of infra-renal aortic aneurysm after endovascular repair: A series from EUROSTAR registry. Eur J Vasc Endovasc Surg 26(5):487-493, 2003.
13. Van Marrewijk C.J., Fransen G., Laheij R.J., Harris P.L., Buth J. and Eurostar Collaborators, Is a Type 2 endoleak after EVAR a harbinger of risk? Causes and outcome of open conversion and aneurysm rupture during follow-up, Eur J Vasc Endovasc Surg 27 (2) (2004), pp. 128–137.
14. Hinchliffe R.J., Singh-Ranger R., Davidson I.R. and Hopkinson B.R., Rupture of an abdominal aortic aneurysm secondary to Type 2 Endoleak, Eur J Vasc Endovasc Surg 22 (2001), pp. 563–565
15. Politz J.K., Newman V.S.and Stewart M.T., Late abdominal aortic rupture after AneuRx repair: a report of three cases, J Vasc Surg 31 (2000), pp. 599–606.
16. Jones J.E., Atkins M.D., Brewster D.C., Chung T.K., Kwolek C.J. and LaMuraglia G.M. et al., Persistent Type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes, J Vasc Surg 46 (2007), pp. 1–8.
17. Van Marrewijk C., Buth J., Harris P.L., Norgren L., Nevelsteen A. and Wyatt M.G., Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: the EUROSTAR experience, J Vasc Surg 35 (3) (2002), pp. 461–473.
18. Abraham C.Z., Chuter T.A.M., Reilly L.M., Okuhn S.P., Pethan L.K. and Kerlan R.B. et al., Abdominal aortic aneurysm repair with the Zenith stent graft: short to midterm results, J Vasc Surg 36 (2002), pp. 217–225
19. Lee J.T., Aziz I.N., Lee, Haukoos J.S., Donayre C.E. and Walot I. et al., Volume regression of abdominal aortic J.T. aneurysms and its relation to successful endoluminal exclusion, J Vasc Surg 38 (2003), pp. 1254–1263
20. Malina M, Länne T, Ivancev K, Lindblad B, Brunkwall J. Reduced pulsatile wall motion of abdominal aortic aneurysms after endovascular repair.Malina et al. J Vasc Surg 1998; 27: 624-31
21. Steinmetz E, Rubin BG, Sanchez LA, Choi ET, Geraghty PJ, Baty J et al. Type 2 endoleak after endovascular abdominal aortic aneurysm repair: a conservative approach with selective intervention is safe and cost-effective, J Vasc Surg 2004; 39: 306–313.
22. Baum R.A., Carpenter J.P., Golden M.A., Velazquez O.C., Clark T.W. and Stavropoulos S.W. et al., Treatment of Type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques, J Vasc Surg 35 (1) (Jan 2002), pp. 23–29
23. Ferrari M., Sardella S.G., Berchiolli R., Adami D., Vignali C.and Napoli V. et al., Surgical treatment of persistent Type 2 endoleaks, with increase of the aneurysm sac: indications and technical notes, Eur J Vasc Endovasc Surg 29 (1) (Jan 2005), pp. 43–46
24. Richardson W.S., Sternbergh 3rd W.C. and Money S.R., Laparoscopic inferior mesenteric artery ligation: an alternative for the treatment of Type 2 endoleaks, J Laparoendosc Adv Surg Tech A 13 (6) (Dec 2003), pp. 355–358
25. Helmy A, Shaida N. Treatment of Type II Endoleaks with a Novel Agent: Precipitating Hydrophobic Injectable Liquid (PHIL). , Cardiovasc Intervent Radiol. 2017 Jul;40(7):1094-1098. doi: 10.1007/s00270-017-1603-7. Epub 2017 Feb 13.
26. Namazi MH, Khaheshi I, Serati AR, Movahed MR. The Safety of Using Large Amount (30 cc) of Onyx (Ethylene-vinyl Alcohol Copolymer) for the Treatment of Large Type II Endoleak after Endovascular Repair of Abdominal Aortic Aneurysm. Int J Angiol. 2016 Dec;25(5):e169-e172. doi: 10.1055/s-0036-1593826. Epub 2016 Dec 15.
27. Chaikof EL, Blankensteijn JD, Harris PL, White GH, Zarins CK, Bernhard VM, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg 2002;35(5):1048–60
28. Parodi JC, Palmaz JC, Barone HD: Transfemoral intraluminal graft implantation for abdominal aortic aneurysm. Ann Vasc Surg 5:491-499,1991
29. Chuter TA, Risberg B, Hopkinson BR, Wendt G, Scott RA, Walker PJ, Viscomi S, White G. Clinical experience with a bifurcated endovascular graft for abdominal aortic aneurysm repair. J Vasc Surg. 1996 Oct;24(4):655-66.
30. Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, Muhs BE.Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur J Vasc Endovasc Surg. 2009 Jan;37(1):15-22. Epub 2008 Nov 12. Review.
31. Veith FJ, Baum RA, Ohki T, Amor M, Adiseshiah M, Blankensteijn JD, Buth J, Chuter TA, Fairman RM, Gilling-Smith G, Harris PL, Hodgson KJ, Hopkinson BR, Ivancev K, Katzen BT, Lawrence-Brown M, Meier GH, Malina M, Makaroun MS, Parodi JC, Richter GM, Rubin GD, Stelter WJ, White GH, White RA, Wisselink W, Zarins CK. Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference J Vasc Surg. 2002 May;35(5):1029-35. Review.
32. Tonnessen H., Sternbergh III W.C. and Money S.R., Mid- and long-term device migration after endovascular abdominal aortic aneurysm repair: a comparison of AneuRx and Zenith endografts 5, J Vasc Surg 42 (3) (2005), pp. 392–400.
33. Zarins C.K., Bloch D.A., Crabtree T., Matsumoto A.H.,. White R.A and Fogarty T.J., Stent graft migration after endovascular aneurysm repair: importance of proximal fixation 11, J Vasc Surg 38 (6) (2003), pp. 1264–1272.
34. van Herwaarden J.A., van de Pavoordt E.D., Waasdorp E.J., Albert V.J., Overtoom T.T. and Kelder J.C. et al., Long-term single-center results with AneuRx endografts for endovascular abdominal aortic aneurysm repair 1, J Endovasc Ther 14 (3) (2007), pp. 307–317.
35. Sternbergh III W.C., Money S.R., Greenberg R.K. and Chuter T.A., Influence of endograft oversizing on device migration, endoleak, aneurysm shrinkage, and aortic neck dilation: results from the Zenith Multicenter Trial 11, J Vasc Surg 39 (1) (2004), pp. 20–26.
36. Waasdorp E.J., de Vries J.P., Hobo R., Leurs L.J.,. Buth J and Moll F.L., Aneurysm diameter and proximal aortic neck diameter influence clinical outcome of endovascular abdominal aortic repair: a 4-year EUROSTAR experience, Ann Vasc Surg 19 (6) (2005), pp. 755–761.
37. Mohan I.V., Harris P.L., van Marrewijk C.J., Laheij R.J. and T.V. How, Factors and forces influencing stent-graft migration after endovascular aortic aneurysm repair 8, J Endovasc Ther 9 (6) (2002), pp. 748–755.
38. Patel SR, Allen C, Grima MJ, Brownrigg JRW, Patterson BO, Holt PJE, Thompson MM, Karthikesalingam A. A Systematic Review of Predictors of Reintervention After EVAR: Guidance for Risk-Stratified Surveillance. Vasc Endovascular Surg. 2017 Aug;51(6):417-428. doi: 10.1177/1538574417712648. Epub 2017 Jun 28.