ANEURISMA POPLITEO

TRATAMIENTO ENDOVACULAR DE ANEURISMAS
POPLITEOS
(PEAR)
LUIS R. SANCHEZ ESCALANTE
ANGIOLOGO Y CIRUJANO VASCULAR
MONTERREY, NL, MEXICO
DISCLOSURE
MEDTRONIC-COVIDIEN CONSULTING
BOSTON-SCIENTIFIC CONSULTING
EPIDEMIOLOGIA
70-80 % PAA
MORBILIDAD ELEVADA
RIESGO DE ISQUEMIA
EMBOLIZACION
RUPTURA BAJA
H 20:1 M
J Vasc Surg 2012;55:1647-53.
PRIMER CASO REPORTADO
CASE REPORT
1994
Transfemoral endoluminal stented graft repair
of a popliteal artery aneurysm
Michael L. Marin, MD, Frank J. Veith, MD, Thomas F. Panetta, MD,
Jacob Cynamon, MD, Curtis W. Bakal, MD, William D. Suggs, MD,
Kurt R. Wengerter, MD, Hector D. Barone, MD, Claudio Schonholz, MD, and
Juan C. Parodi, MD, New York) N.Y.) and Buenos Aires) At;gentina
This report describes the use of an endoluminally placed stented graft to repair a large (2.6
by 2.6 by 15 cm) popliteal aneurysm in a 63-year-old man with advanced heart disease.
Two balloon-expandable stents were attached to a 6 mm polytetrafluoroethylene graft,
which was inserted with the patient receiving local anesthetic through a proximal
superficial femoral artery arteriotomy. Repeat arteriography and duplex ultrasonography
performed up to 3 months after the procedure documented graft and distal artery patency
and complete aneurysmal exclusion without distal emboli. This experience demonstrates
technical feasibility and early graft patency. However, additional experience and follow-up
will be needed to assess the value of this minimally invasive procedure in the management
of popliteal aneurysmal disease. (J VAse SURG 1994;19:754-7.)
Aneurysms of the popliteal artery are the most
frequently encountered peripheral artery aneurysms.
The true incidence of these aneurysms is unknown;
preferably with autologous saphenous vein, and
ligation of the popliteal artery proximal and distal to
the aneurysm or partial or complete excision with
gradual mass effect with subsequent compression of the vein, bypass, and/or nerve. Rupture of an excluded PAA has also been reported secondary to
[32]
retrograde collateral flow (analogous to a type II endoleak after endovascular abdominal aortic aneurysm repair).
Thus, PAA treatment should also
[33]
include aneurysm sac decompression and ligation of geniculate vessels whenever possible.
The management of a PAA in the elective setting has historically been considered crucial because of the risk of aneurysm thrombosis, leading to acute
ischemia and limb loss. Yet the more recent literature places less emphasis on the timing of the operation. Aulivola and colleagues analyzed the
outcomes of elective versus emergent operative repair of PAAs and found no differences in the 5-year survival rate for elective versus for emergent cases
[21]
(84.3% vs 82.5%; p > .26) in relation to the urgency of PAA repair or the presence of symptoms ( ).
The outcome after PAA repair is more affected by
the presence or absence of acute ischemia. Outcomes following repair of PAAs in the face of acute ischemia are often poor, even if urgent
[3,5]
revascularization is undertaken. About one-third of patients with acute preoperative ischemia will require amputation,
and operative mortality rates
[5]
range from 5 to 11%. In contrast, elective repair in the absence of acute ischemia may be carried out with significantly diminished rates of limb loss and
[34]
[3]
perioperative mortality.
Furthermore, long-term graft patency rates are improved in limbs undergoing repair prior to the onset of symptoms.
OPEN vs ENDO
Table 1. Summary of Individual Series Reviewing Popliteal Aneurysms With Outcomes
Series
[28]
Antonello et al (2005)
[22]
Aulivola et al (2004)
[34]
Martelli et al (2004)
[37]
Harder et al (2003)
[24]
Dijkstra et al (1998)
Patients
(n)
26
39
36
24
17
Aneurysms
30
51
42
36
23
Variables
Autogenous Endovascular Autogenous Prosthetic Autogenous Prosthetic Autogenous Prosthetic Autogenous Prosthetic
Primary
patency*
(%)
Secondary
patency,*
% (n)
Late
patency,*
% (n)
Limb
salvage, %
(n)
15
20
49
100
93
96
90 (36)
100 (36)
95 (42)
3
19
23
100
100
80 (24 )
78 (36)
85 (60)
17
6
100
100
100 (39)
91
96
66 (48)
96 (15)
07/04/15 18:28
100
100
98
96 (120)
100
www.medscape.com
Update
on
the
Diagnosis
and
Management
of
Popliteal
Aneurysm
and
Literature
http://www.medscape.com/viewarticle/543361_print
Página 2 de 6
Review
Albeir Y. Mousa, MD, Robert B. Beauford, MD, Peter Henderson, BA, Prem Patel, MD, Peter L. Faries, MD, Lucio Flores, MD, Richard Fogler, MD
Vascular. 2006;14(2):103-108.
VIAHBAN ENDOPROSTHESIS
PATENCY
2-6 a
PERMEABILIDAD
SALVAMENTO
INVESTIGADOR EXTREMIDADES
PERMEABILIDAD
PRIMARIA 1 A
DE ESTREMIDAD
PRIMARIA
Antonello
21
81%
71% (6 años)
100%
Tielliu
73
84%
70% (5 años)
100%
Thomazinho
11
90%
—
100%
Curi / Jung
15
100%
83 (2 años)
100%
Midy
42
90%
86 (4 años)
96%
Ascher
15
82%
—
100%
ANGIO CT
TRANS PROCEDIMIENTO
LANDING ZONE >2cm
PAA TROMBOSADO
PAA TROMBOSADO
OVERLAP ZONE
CONCLUSIONES
PAER es seguro disminuye riesgos quirurgicos
Permeabilidad primaria comparable al tratamiento Qx
Una buena selección de pacientes disminuye
complicaciones y fracasos de la terapia
Es de suma importancia un seguimiento estrecho a los
pacientes