Why not a sandwich technique?

Transcription

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The hypogastric
issue: how important
is the hypogastric
patency?
Why not a sandwich
technique?
Nilo J
Mosquera,
MD.
Endovascular Therapy
Area.
Angiology and
Vascular Surgery
Department.
Complexo Hospitalario
Universitario de
Ourense. CHUO.
Spain
SITE 2013. 8-11 May. Barcelona. Spain.
Disclosure
Speaker name:
Nilo J Mosquera, MD.
x
I have the following potential conflicts of interest to report:
x
Consulting: Lombard Medical, Cook Medical, WL Gore, Medtronic,
Endologix.
Employment in industry
Shareholder in a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest
SITE
2013. 8-11
May. Barcelona. Spain.
LONDON
CARDIOVASCULAR
SYMPOSIUM; 28-29 October 2011
EVAR : concerns about pelvic circulation
Up to 40% AAA have common iliac disease*.
*Ghosh J, Murray D, Paravastu S, et al. Contemporary management of aorto-iliac aneurysms in the
endovascular era. Eur J Vasc Endovasc Surg. 2009;37(2):182-188.
n
1. Mehta M, Veith FJ
(J Vasc Surg 2001)
2. Razavi MK, DeGroot M
(J Vasc Interv Radiol 2000)
Unilateral
internal ilac
occlusion
3. Karch LA, Hodgson K
(J Vasc Surg 2000)
Complication
-‐buttock claudication
-impotence
-colonic ischemia
-spinal ischemia
Conclusion
Hypogastric preservation
seems reasonable
all symptoms/complications
12 to 37%
4. Yano OJ, Morrissey N,
(J Vasc Surg 2001)
5. Semmens JB,
(J Endo- vasc Ther 2006)
1. Arko FR, Lee WA
(J Vasc Surg. 2004 )
2. Dix FP, Titi M
Bilateral
occlusion
Significative Increase in
mortality and morbidity
Hypogastric preservation
is mandatory
(Eur J Vasc Endovasc Surg 2005)
3. Dorigo W, Pulli R
(Eur J Vasc. Endovascular Surg
2007)
-colonic ischemia
-spinal ischemia
Colon and spinal ischemia is directly related to hypogastric patency.
SITE
2013. 8-11
LONDON
CARDIOVASCULAR
…EVAR for aorto-iliac aneurysm: Iliac
branch devices
Now a days this is a regular therapy with great clinical success
and mid-term results
Authors
n
Complication/technical success/
Patency
FU
10
10%/90%/90%
1-32 months
8
0%/100%/100%
1-14 months
53
6%/94%/89%
14.2 months (mean FU)
64
5.9%/98.4%/98.4%
60 months
Initial Experience
Malina M, Dirven M
(J Endovasc Ther. 2006)
Serracino-Inglot F, Bray AE
(J Vasc Surg, 2007)
Current experience Haulon S, Greenberg RK
(Eur J Vasc Endovasc Surg, 2007)
Donas KP, Torsello G
(J Vasc Surg. 2011)
Good results mid-term FU
…iliac branched endografts ARE a demonstrated
powerful approach to many cases.
SITE
2013. 8-11
LONDON
CARDIOVASCULAR
But with clear limitations
related to anatomy.
…summarizing: we should preserve
the hypogastric but there are
LIMITATIONS (IFU) to implant iliac
branch devices:
Complex and tortuous anatomies are real
contraindications.
Most of the patients with indication for iliac branch
technique, specially those with big common iliac
aneurysm have tortuous anatomy
These are somehow complex procedures:
advance skills in endovascular therapy are
required
Sandwich graft technique: an
alternative to iliac branch.
As proposed initially by Armando Lobato: can be
easily applied to iliac branch technique
This technique can be performed with standard
and more conformable EVAR devices.
Less but also complex
procedures: mid-experienced
groups
Less expensive technology.
At the literature: two different technical
approaches for the same concept.
…Double barrell sandwich approach. Initially described by Armando
Lobato in 2008-2010, published at Journal Endovascular Therapy
February 2011
Sandwich-graft technique (double
barrell): the schematics
(a) Proximal graft:
sealing zone
(d) Area calculation: (Πr2)
Π1/2a2 = Π1/2b2 + Π1/2c2
Distal graft: connect
to external iliac
(b) (c) Sandwich
segment: 60 mm
minimum (d)
Free segment:
conecting to
internal iliac
At the literature: two different technical
approaches for the same concept.
…Modified sandwich approach.
Described by our group, published at
Tecnicas Endovasculares, November
2010
…priority: external iliac patency.
…TAAA technique applied to
hypogastric preservation
Modified Sandwich-graft
technique : the schematics
Proximal graft:
acting aortic neck
Chimney
segment
providing inflow
Sandwich segment:
overlapped between grafts
Free segment: conecting to
internal iliac
Distal graft:
providing sealing
Flexible and conformable grafts.
…permit to apply sandwich techniques in
patients with unsuitable anatomy for iliac
branched devices.
Initial and mid-term FU reported.
Sandwich technique with AorfixTM
endograft: global experience*
Groups/Technique
n
Technical
success
Freedom for MAE Double barrell
Hussain T.
North West London Hospitals.
NHS trust. London. UK
Garcia I.
Valdecilla Hospital. Santander. Spain
De Blas M.
Donosti Hospital. S Sebastian Spain
Ciostek
Brodnowski Hosp Warsaw. Poland
Szopinsky P.
Inst of Haematology, Warsaw. Poland
Patency
Endoleak/AAA related
complications
FU
*Results presented at:
3
100%
100%
100%
None/None
1
100%
100%
100%
1
100%
100%
100%
None/None
12 months
1
100%
100%
100%
None/None
20 months
13
100%
93%
93%
None/None
3 years
None/None
6 weeks
2 months
Modiﬁed Sandwich gra: technique *Results presented at:
Mosquera NJ et al
CHUO Hospital Ourense. Spain
11
100%
91%
Good inmediate and mid-term FU results
31 procedures 6 centers 3 countries
91%
None/none
6-32 months
Sandwich technique
endograft:: published experience
endograft
Author
Reference
Pub type
Mosquera N
Técnicas Endovasculares, 2010.
Technical report/Case report
Lobato A
J Endovasc Ther. 2011
Technical report
Mosquera N
N
T Success
Patency
1
100%
100%
J Cardiovasc Surg (Torino). 2011 Tecnical report/clinical series
4
100%
100%
Friedman SG
J Vasc Surg. 2011
1
100%
100%
Yoshida R
Ann Vasc Surg. 2012
Case report
1
100%
100%
Ricci C
Clinical series
7
100%
100%
Hennedige T
Cardiovasc Intervent Radiol
2012
Ann Vasc Surg. 2012
2
100%
100%
Lobato A
J Vasc Surg. 2013
Clinical series
40
100%
93.8%
De Rubertis B
J Vasc Surg 2012
Clinical series
22
88%
91%
Good inmediate and mid-term FU results
78 procedures 7 centers 6 countries.
Different grafts: Lombard Medical Aorfix. WL Gore Excluder.
Endologix AFX…
Modified Sandwich-graft
technique: case #1.
CASE 1: APRIL 2010
82 years old male
>90 mm AAA and iliac aneurysm
Extremely complex iliac anatomy and tortuous
access vessel
(Not a chance for Z-BIS®)
Modified Sandwich-graft technique: case #1.
Aorfix® bifurcated endograft + Viabahn® (WL Gore): 8 mm
diameter, 100+50mm length (120 mm effective length)
1 month FU
24 month FU
Modified Sandwich-graft technique:
extreme iliac angulation
Preoperative
18 month FU
Modified Sandwich-graft technique:
bilateral sandwich-graft
6 month FU
1 month FU
Double barrell Sandwich-graft technique
Images courtesy of Dr Tahir Hussain North West London Hospitals.
NHS trust. London. UK.
Intraoperative
1 month FU
Summary:
(a) …Sandwich
technique is a feasible and
(c) (b) (d) safe alternative to iliac branched devices.
…flexible and conformable
endografts had demonstrated
good performance in sandwich
technique with both double
barrell and modified technique.
Conclusions:
(a) …sandwich technique results had been
(c) confirmed
for different grafts by different
(b) (d) groups in different countries.
…these are initial results, they are quite
promising but long term FU is needed.
+
The hypogastric
issue: how important
is the hypogastric
patency?
Why not a sandwich
technique?
Nilo J
Mosquera,
MD.
Endovascular Therapy
Area.
Angiology and
Vascular Surgery
Department.
Complexo Hospitalario
Universitario de
Ourense. CHUO.
Spain

Why not a sandwich technique?

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