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AM Settembrini, D Mazzaccaro, M Carmo, G Pozzetti, T De Rosa, R Dallatana, L Freni

VALUTAZIONE DEI FATTORI DI RISCHIO PER MORTALITA’, ENDOLEAK E REINTERVENTO DOPO EVAR. AM Settembrini, D Mazzaccaro, M Carmo, G Pozzetti, T De Rosa, R Dallatana, L Freni PG Settembrini Cattedra e Scuola di Specializzazione in Chirurgia Vascolare Università degli Studi di Milano

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AM Settembrini, D Mazzaccaro, M Carmo, G Pozzetti, T De Rosa, R Dallatana, L Freni

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  1. VALUTAZIONE DEI FATTORI DI RISCHIO PER MORTALITA’, ENDOLEAK E REINTERVENTO DOPO EVAR AM Settembrini, D Mazzaccaro, M Carmo, G Pozzetti, T De Rosa, R Dallatana, L Freni PG Settembrini Cattedra e Scuola di Specializzazione in Chirurgia Vascolare Università degli Studi di Milano Divisione di Chirurgia Vascolare, Ospedale San Carlo Borromeo, MIlano

  2. CLINICAL EVALUATION High operative risk Low operative risk Favorable anatomical features Unfavorable anatomical features Open surgery No surgical therapy EVG EVAR: indicazioni

  3. Caratteristiche anatomiche

  4. Complicanze • endoleaks • renali • cardiologiche • trombosi di graft • rottura aortica • morte • conversione chirurgica • …

  5. Stato dell’arte Becquemin JP, Pillet JC, Lescalie F, Sapoval M, Goueffic Y, Lermusiaux P, Steinmetz E, Marzelle J, for the ACE trialists. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg 2011;53:1167-73. Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT, Matsumura JS, Kohler TR, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009;302:1535-42. EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005;365:2179-86. The United Kingdom EVAR Trial Investigators. Endovascular versus Open Repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-71. Blankensteijn JD, de Jong SE, Prinssen M, van der Ham AC, Buth J, van Sterkenburg SMM, et al. Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 2005;352:2398-405. De Bruin JL, Baas AF, Buth J, Prinssen M, Verhoeven EL, Cuypers PW, van Sambeek MR, Balm R, Grobbe DE, Blankensteijn JD; DREAM Study Group. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010 May 20;362(20):1881-9. Leurs LJ, Buth J, Laheiji RJ, for the EUROSTAR Collaborators: Longterm results of endovascular abdominal aortic aneurysm treatment with the first generation of commercially available stent grafts. Arch Surg 142:33-41, 2007.

  6. Stato dell’arte: mortalità e reintervento A significant interaction was observed between age and type of treatment (P=0.006); survival was increased among patients under 70 years of age in the endovascular-repair group but tended to be better among those 70 years of age or older in the open-repair group N Engl J Med 2012

  7. Malas MB and Freischlag JA. Interpretation of the Results of OVER in the Context of EVAR Trial, DREAM, and the EUROSTAR Registry. Semin Vasc Surg 2010,23:165-169.

  8. EVAR vs Open • ACE: • - No difference between cumulative survival free of death and major adverse events during hospitalization and at 3 years. • - EVAR was associated with higher reintervention rates (16%) and higher aneurysm-related mortality rates (4%) • OVER: • - Lower postoperative death after EVAR and no difference at 2 years. • DREAM: • - Lower postoperative death after EVAR and similar survival rates at long-term, but more reintervention in EVAR group at 6 years. • EVAR-1: • - Lower postoperative death after EVAR but more aneurysm-related deaths and reinterventions in EVAR group at long-term. Il reintervento rimane il tallone di Achille dell’EVAR…

  9. Studio retrospettivo su 10228 pazienti trattati con EVAR tra 01/01/1999 e 31/12/2008 Basso numero di complicanze con adesione alle linee guida per EVAR!!! • Endoleak • Età > 80 anni • Ø Colletto aortico > 28 mm • Angolo colletto > 60° • Ø A.Iliaca comune > 20 mm Schanzer A, Greenberg RK, Hevelone N, Robinson WP, Eslami MH, Goldberg RJ, Messina L. Predictors of Abdominal Aortic Aneurysm Sac Enlargement After Endovascular Repair. Circulation. 2011;123..

  10. Nostra Esperienza Gennaio 2003-Maggio 2012

  11. Comorbidità

  12. Caratteristiche anatomiche

  13. Dati tecnici Endograft aorto bisiliaco (124, 77.6%) Chimney technique in 2 casi Mezzo di contrasto iodato: 186 cc (IQR 124.5-250 cc) Durata della procedura: 190 minuti (IQR 155-210 min) Degenza: 5 giorni (IQR 4-9 days)

  14. Risultati perioperatori

  15. Risultati a lungo termine Su 146 pz (91.2%) con follow-up mediano di 16.4 mesi (IQR 6.2-37.6 mesi)

  16. Libertà da endoleaks

  17. Risultati a lungo termine: endoleaks e reinterventi

  18. FR per mortalità

  19. FR per endoleak

  20. FR per reintervento

  21. Conclusioni • La sopravvivenza dopo EVAR è significativamente correlata all’età, rottura preoperatoria e presenza di sintomi. • Nessun fattore analizzato si è dimostrato predittivo per lo sviluppo di EL o complicanze che richiedessro un reintervento. • Il campione analizzato necessita sicuramente di un aumento e di una sua nuova analisi • Questi risultati dimostrano la necessità di follow-up a lungo termine dopo EVAR

  22. www.chirurgiavascolaremilano.it

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