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TRAITEMENT DES ANEVRYSMES AORTO-ILIAQUES

TRAITEMENT DES ANEVRYSMES AORTO-ILIAQUES. Service de Chirurgie Vasculaire, Hôpital Cardiologique CHRU de Lille. Supra-Aortic Trunks. Arch. Thoracic Aorta. Abdominal Aorta. Iliac. VASCULAR ANATOMY. femoral. AAA. Occlusive Disease. DISSECTIONS. Preop Imaging. DuplexScan AngioCT MRA

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TRAITEMENT DES ANEVRYSMES AORTO-ILIAQUES

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  1. TRAITEMENT DESANEVRYSMES AORTO-ILIAQUES Service de Chirurgie Vasculaire, Hôpital Cardiologique CHRU de Lille

  2. Supra-Aortic Trunks Arch Thoracic Aorta Abdominal Aorta Iliac VASCULARANATOMY femoral

  3. AAA

  4. Occlusive Disease

  5. DISSECTIONS

  6. Preop Imaging • DuplexScan • AngioCT • MRA • Angiography

  7. AAAINDICATIONS OPERATOIRES • AAA fusiformes : • diamètre ≥ 50 mm • croissance rapide > 5 mm en 6 mois • patient symptomatique • Anévrismes iliaques : diamètre ≥ 30 mm • Anévrismes sacculaires et pseudo-anévrismes

  8. Comparative studies on small AAA ADAM trial UK SAT

  9. 527 pts. under surveillance: 39 (7%) alive without surgery after 8 years Small aneurysms less than 5.5cms can be left alone, but UK SAT, N Engl J Med 2002 ...not for a long time

  10. Is surveillance a safe option ? 10 ruptures 8 deaths UK SAT, Lancet 1998 53 mm

  11. 51 55 52 ? Definition of Small AAA • US vs CT • DMin vs DMax • L-L vs A-P • 3D reconstruction

  12. CHIRURGIE CONVENTIONNELLE vs CHIRURGIE ENDOVASCULAIRE

  13. AAA endografting results Early mortality after Endografting at least one third of early mortality after Open repair of AAA: EVAR 1 trial*2.1% vs 6.2% DREAM trial° 1.2% vs 4.6% Perugia§0.9% vs 4.1% *The EVAR trial participants, Lancet 2004 ° DREAM Trial group, NEJM 2004 § Cao et al, JVS 2004

  14. AAA endografting results AAA related death advantage persists in the mid- and long-term EVAR 1 trial (4 years) * 4% vs 7% DREAM trial° (2 years)° 2.1% vs 5.7% Perugia (7 years) §2.5% vs 4.1% *The EVAR trial participants, Lancet 2005 ° DREAM Trial group, NEJM 2005 § Cao et al, JVS 2004

  15. EVAR (matched subgroup) vs UKSAT Surveillance Zarins, EJVES 2005

  16. CHIRURGIE CONVENTIONNELLE

  17. CHIRURGIE CONVENTIONNELLE

  18. CHIRURGIE CONVENTIONNELLE

  19. Voies d’abords : incision des scarpas TECHNIQUEENDOVASCULAIRE

  20. Dacron standard ( Vascutek) + stents en acier inoxydable MATERIEL : ENDOPROTHESES ZENITH ( COOK )

  21. CARACTERISTIQUES TECHNIQUES STENT SUPRA-RENAL MATERIEL

  22. INTRODUCTEUR MATERIEL

  23. TECHNIQUEENDOVASCULAIRE

  24. TECHNIQUEENDOVASCULAIRE

  25. TECHNIQUEENDOVASCULAIRE

  26. TECHNIQUEENDOVASCULAIRE

  27. TECHNIQUEENDOVASCULAIRE

  28. CRITERES ANATOMIQUES

  29. ACCES ILIAQUES ANGULATIONS

  30. CRITERES DE L’AFSSAPS (Agence Française de Sécurité Sanitaire des Produits de Santé)

  31. AVANTAGES ENDO vs CONVENTIONNELLE • Chirurgie « mini invasive » • ↘ pertes sanguines • ↘ complications de paroi • ↘ douleurs postopératoires • ↘ complications pulmonaires • pas de répercussion sur le transit intestinal • possibilité d’intervenir sous anesthésie loco-régionale ou locale • Pas de de clampage aortique • Traitement des ruptures d’anévrisme → ↘ mortalité ↘ durée hospitalisation

  32. Coût Complications « techniques » peropératoires Suivi post-opératoires risque de fuites (≠types), migration thrombose de jambage (plicature) RMN contre-indiquée INCONVENIENTS ENDO vs CONVENTIONNELLE

  33. COUT DES ENDOPROTHESES

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