An©vrysmes thoraco -abdominaux: traitement endovasculaire

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Anévrysmes thoraco -abdominaux: traitement endovasculaire. Pascal Desgranges , Hicham Kobeiter , Eric Allaire, Jean Marzelle, Nicolas louis, Fabrice Schneider, Jean-Pierre Becquemin Service de chirurgie vasculaire, d’Imagerie Hôpital Henri Mondor. I ntroduction. - PowerPoint PPT Presentation

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Anvrysmes thoraco-abdominaux: traitement endovasculairePascal Desgranges, Hicham Kobeiter, Eric Allaire, Jean Marzelle, Nicolas louis, Fabrice Schneider, Jean-Pierre BecqueminService de chirurgie vasculaire, dImagerieHpital Henri MondorIntroductionTaux de complication de la chir des ATA levAlternative: techniques hybridesEndoprothses fentres et multibranches

PrincipesPlusieurs modules

Fentre: si distance entre endoprothse / A viscrale 10 mm

MPR

CPRLimitesAccs iliofmoraux libres, non calcifis et tortueux, IE>7,5 mmAccs TSA libres, bonne morphologie de crosse (shaggy aorta) pour les branchesPas dangulation>60% de lAT basse, sus ou sous R source de rotation des modules

Composite Design6Il existe 3 types de fentre:SCALLOPSMALL FENESTRATIONLARGE FENESTRATIONTypes de Fentre

7DepthFrom 6 to 12 mmWidthAlways 10 mm

Scallop8

One low renal artery10-15 mm neckFor SMA when small fenestrations used for renal arteriesScallop9

10

DiameterFrom 8 mm to 12 mmDistance from top of graft to centre must be 10 mmLarge Fenestration11

SMA when renal arteries and SMA are close togetherAccessory renal arteriesLarge Fenestration12Height 6mmDiameterAlways 6 mmNot within 15mmof top of graft

Small FenestrationOr 8mm13Orientation Anterieure/PosterieureAnterior

Posterior

Additional Anterior check marker14

Lacets postrieurs rduisant le diamtre

15

Diameter Reducing Ties

16

Implantation proximaleReprage rnales18

Prcision

Implantation proximaleKT Renal travers FenestrationsFenestrations alignes avec vx cibles20

Proximal Graft ImplantationRenal Stenting

21

Proximal Graft ImplantationMoldelageProximal Graft implantation complete22Why use a stent?

Fenestration StentsCurrently available renal stents e.g.

Atrium Advanta V12 (Covered)EV3 (Uncovered)Genesis Palmaz (Uncovered)24

ABAngio CT 3DPositionnement du stent

26Expansion

27Flaring ou Rivetage

28Flared

29Modelage (optionnel)

30Modelage

31Endoprothses branches

Rsultats prothses fenestresHaulon S et AURC , Ann Surg, 2009N= 80 AAA juxtaR ht risque98% de succs techniqueMortalit @30j = 2,5% Fuites = 11% (3I,5II,1III)4 dcs dans le Fup=10 mois, non li lanvrysmeRsultats prothses branchesHaulon S et al , EJVES, 2009N= 33 ATA98% de succs techniqueMortalit hospitalire= 9% (3/33)Paraplgie transitoire= 11%; dfinitive= 3%2 dcs dans le Fup=11 moisFuites = 15% (4II,1III)Rsultats Branches vs. ORpour ATA +AT (n=724)R Greenberg et al, Circulation 08

J3O 5, 7% ER 8,3% OSM12 15,6% ER 15,9 % SRparaplgie

4,3 % ER7,5% OSExtension des Indications Hybrid

Chimney

Frozen trunk

Chimney

SummaryEndo tt= alternative to open surgery in the treament of TAA in high risk patientsAnatomic criteria are very importantPreop angio with multiplanar reconstruction (MPR), centerline of flow, curved planar reconstruction (CPR) must be performed on a workstation using 3D-image analysis techniques

Summary contCharacters of endoprosthesis:-modular design-Fenestrations are scallop, large and small-Branches to visceral arteries= vertical, helicoidal- Stent to connect= covered self or balloon expandableConclusionProspective registry

? Randomized study: TEVAR vs surgeryHigh-risk patients

? Medium-term outcome of TEVAR