Vural ÖZCAN, Sabit SARIKAYA, Fürüzan NUMAN, Cengiz KÖKSAL, Burhan MEYDAN, Mustafa ZENGİN

Endovasküler anevrizma tamirinde ek vasküler cerrahi girişimler

Amaç: Abdominal ve torasik aort anevrizması tanısı olan hastalarda sıklıkla eşlik eden farklı yerleşimli aterosklerotik tutulumlar vardır ve mevcut arteriyel darlık veya tıkanıklıklar endovasküler işlemi zorlaştırabilir veya mümkün kılmaz. Çalışmamızda, endovasküler stent greft tedavisi (EVSG) uygulanan hastalarımızda karşılaştığımız cerrahi revaskülarizasyon gerektiren arteriyel yaralanmaları ve endovasküler tedaviye hastayı hazırlamak için ve/veya tedavinin bir parçası olarak yapılan vasküler girişimleri irdelemeyi amaçladık. Materyal ve Metod: 2002 - 2003 yılları arasındaki 16 aylık dönemde, 13 yüksek riskli ve seçilmiş hastaya abdominal aort anevrizması (AAA) ve/veya torasik aort anevrizması (TAA) tanısıyla endovasküler stent greft tedavisi uygulandı. Bu hastaların yedisinde tanı TAA, dördünde AAA, ikisinde hem TAA, hem de AAA idi. Oniki hastamızda giriş yeri olarak femoral arter, bir hastamızda da iliyak arter kullanıldı. Abdominal aort anevrizması tanısıyla tedavi edilen dört hastamızda aorto-iliyak stent greft, iki hastamızda aorto-biiliyak stent greft kullanıldı. Bulgular: Dört hastamızda EVSG sırasında femoral arter yaralanması tespit edildi. Bu hastalardan ikisinde femoral arter yaralanması safen ven greft interpozisyonu, iki hastada yama konarak tamir edildi. Aorto-iliyak stent greft ile tedavi edilen dört AAA hastamıza işlem sonrası femoro-femoral bypass uygulandı. Distal arkus aort ve inen aort anevrizması tanısıyla takip ettiğimiz bir hastamıza endovasküler tedavi öncesi sağ subklavyan - sol karotiko-subklavyan bypass işlemi, olası endoleak önlenmesi için yapıldı. Sonuç: Günümüzde aort anevrizmalarının endovasküler tedavisi seçilmiş ve yüksek riskli hastalarda yaygın olarak kullanılan bir tedavidir. Endovasküler tedavi aşamasında ek vasküler cerrahi girişimler sıklıkla, arteriyel yaralanmaları tedavi etmek veya EVSG uygulanmasını mümkün kılmak için gerekmektedir.

Supplemental vascular procedures for endovascular aneurysm repair

Background: Patients with abdominal or thoracic aortic aneurysms which have the concomitant arterial diseases that may complicate or even exclude them from necessary endovascular stent graft repair (EVAR). In the current study, we aimed to describe arterial injuries encountered during EVAR and supplementary vascular surgical procedures to enable EVAR. Methods: Between 2002 - 2003, 13 selected high-risk patients treated for thoracic aortic aneurysm (TAA) and/or abdominal aortic aneurysm (AAA) with endovascular devices were reviewed. Seven patients were treated for TAA, four patients for AAA, and two patients for both AAA and TAA. Femoral artery was the access site for 12 patients and common iliac artery for one patient. Aortoiliac stent graft was used in four patients treated due to AAA and aorto-biiliac stent graft in two patients. Results: In four cases, femoral artery injury was encountered during EVAR. In two cases saphenous vein graft interposition and patch plasty was performed for revascularization. Femoro-femoral bypass was performed in four patients who were treated with aorto-iliac stent grafts, after EVAR. The right subclavian to left carotico-subclavian bypass was performed in one patient with TAA, in order to enable endovascular stent deployment. Conclusions: Endovascular stent graft treatment is widely used for the treatment of aortic aneurysms in selected and high-risk patients. However, vascular surgical interventions are always the part of the treatment, used either to repair access site injury or as supplementary to enable stent graft deployment.

PDF

___

1) Hinchliffe RJ, Hopkinson BR. Current concepts and contraversies in endovascular repair of abdominal aortic aneutysms. J Cardiovasc Surg 2003;44:481-503.
2) Arbatlı H, Yagan N, Demirsoy E, ve ark. Abdominal aort anevrizmalarının endovasküler tedavisi. Anadolu Kardiyol Derg 2003;3:115-21.
3) Teufelsbauer H, Prusa AM, Wolff K, et al. Endovascular stent grafting versus open surgical operation in patients with infrarenal aortic aneurysms: A prospective score adjusted analysis. Circulation 2002;106:782-7.
4) Lamme B, de Jange I, Reekers JA, et al. Endovascular treatment of thoracic aortic pathology: Feasibility and mid term results. Eur J Vasc Endovasc Surg 2003;25:532-9.
5) Wolf YG, Fogarty TJ, Olcatt CIV, et al. Endovascular repair of abdominal aortic aneurysms: Eligibility rate and impact on the rate of open repair. J Vasc Surg 2000;32:519-23.
6) Woodburn KR, Chant H, Davies JN, et al. Suitability for endovascular aneurysm repair in an unselected population. Br J Surg 2001;88:77-81.
7) Ahn SS, Rutherford RB, Johnston KW, et al. Reporting standarts for infrarenal endovascular abdominal aortic aneurysm repair. J Vasc Surg 1997;25:405-10.
8) Geraghty PJ, Sicoral GA. Abdominal aortic aneurysm repair in high-risk and elderly patients. J Cardiovasc Surg 2003;44:543-7.
9) Taylor RM, Gaines PA, McGuinnes CL, et al. Thoracic aortic stent grafts; early experience from two centers using commercially available devices. Eur J Vasc Endovasc Surg 2001;22:70-6.
10) Carpenter JP, Baum RA, Baker CF, et al. Durability of benefits of endovascular versus conventional abdominal aortic aneurysm repair. J Vasc Surg 2002;35:222-8.
11) Tanquilit EM, Ouriel K. Current outcomes in endovascular repair of abdominal aortic aneurysms. J Cardiovasc Surg 2003;44:503-9.
12) Yano OJ, Faries PL, Morrinsoy N, et al. Ancillary techniques to facilitate endovascular repair of aortic aneurysms. J Vasc Surg 2001;34:69-75.
13) Hernetta JP, Korch LA, Hodgson KJ, et al. Special iliac artery considerations during aneurysm endografting. Am J Surg 1999;178:212-8.
14) Blum U, Vashage G, Lammer J, et al. Endoluminal stent grafts for infrarenal abdominal aortic aneurysms. N Eng J Med 1997;336:13-20.
15) May J, White GH, Yu W, et al. Current comparison of endoluminal versus open repair in the treatment of abdominal aortic aneurysms: Analysis of 303 patients by life table method. J Vasc Surg 1998;27:213-20.
16) Lee WA, Berceli SA, Huber TS, et al. Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair. J Vasc Surg 2003;38:459-63.
17) Arman MP, Yusuf SW, Latief K, et al. Anatomical suitability of abdominal aortic aneurysms for endovascular repair. Br J Surg 1997;84:178-80.
18) Chiter TA, Faruqi RM, Reilly LM, et al. Aortomonoiliac endovascular grafting combined with femorofemoral bypass: An acceptable compromise or a preferred solution? Semin Vasc Surg 1999;12:176-81.
19) Hinchliffe RJ, Alric P, Wenham PW, Hopkinson BR. Durability of femorofemoral bypass grafting after aortouniiliac endovascular aneurysm repair. J Vasc Surg 2003;38:498-503.
20) Grabenwoger M, Hutschala D, Ehrlich M, et al. Thoracic aortic aneurysms: Treatment with endovascular slef expandable stent graft. Ann Thorac Surg 2000;69:441-5.