The hypogastric issue: how important is the hypogastric patency? Why not a sandwich technique? Nilo J Mosquera, MD.

Transcription

1 + 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

2 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

3 SITE LONDON CARDIOVASCULAR May. Barcelona. Spain. SYMPOSIUM; 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): Mehta M, Veith FJ (J Vasc Surg 2001) 2. Razavi MK, DeGroot M (J Vasc Interv Radiol 2000) 3. Karch LA, Hodgson K (J Vasc Surg 2000) 4. Yano OJ, Morrissey N, (J Vasc Surg 2001) 5. Semmens JB, (J Endo- vasc Ther 2006) n Complication Conclusion Unilateral internal ilac occlusion - buttock claudication -impotence -colonic ischemia -spinal ischemia all symptoms/complications 12 to 37% Hypogastric preservation seems reasonable 1. Arko FR, Lee WA (J Vasc Surg ) 2. Dix FP, Titi M (Eur J Vasc Endovasc Surg 2005) 3. Dorigo W, Pulli R (Eur J Vasc. Endovascular Surg 2007) Bilateral occlusion Significative Increase in mortality and morbidity -colonic ischemia -spinal ischemia Hypogastric preservation is mandatory Colon and spinal ischemia is directly related to hypogastric patency.

4 SITE LONDON CARDIOVASCULAR May. Barcelona. Spain. SYMPOSIUM; October 2011 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 Initial Experience Malina M, Dirven M (J Endovasc Ther. 2006) Serracino-Inglot F, Bray AE (J Vasc Surg, 2007) 10 10%/90%/90% 1-32 months 8 0%/100%/100% 1-14 months Current experience Haulon S, Greenberg RK (Eur J Vasc Endovasc Surg, 2007) Donas KP, Torsello G (J Vasc Surg. 2011) 53 6%/94%/89% 14.2 months (mean FU) %/98.4%/98.4% 60 months Good results mid-term FU

5 iliac branched endografts ARE a demonstrated powerful approach to many cases.

6 SITE May. Barcelona. Spain. LONDON CARDIOVASCULAR SYMPOSIUM; October 2011 But with clear limitations related to anatomy.

7 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

8 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.

9 At the literature: two different technical approaches for the same concept. Double barrell sandwich approach. Initially described by Armando Lobato in , published at Journal Endovascular Therapy February 2011

10 Sandwich-graft technique (double barrell): the schematics Proximal graft: sealing zone (d) (b) (a) (c) Sandwich segment: 60 mm minimum (d) Area calculation: (Πr 2) Π1/2a 2 = Π1/2b 2 + Π1/2c 2 Free segment: conecting to internal iliac Distal graft: connect to external iliac

11 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

12 Modified Sandwich-graft technique : the schematics Proximal graft: acting aortic neck Chimney segment providing inflow Sandwich segment: overlapped between grafts Distal graft: providing sealing Free segment: conecting to internal iliac

13 Flexible and conformable grafts. permit to apply sandwich techniques in patients with unsuitable anatomy for iliac branched devices.

14 Initial and mid-term FU reported.

15 Sandwich technique with Aorfix TM endograft: global experience* Groups/Technique n Technical success Freedom for MAE Patency Endoleak/AAA related complications FU Double barrell Hussain T. North West London Hospitals. NHS trust. London. UK *Results presented at: 3 100% 100% 100% None/None 6 weeks Garcia I. Valdecilla Hospital. Santander. Spain 1 100% 100% 100% None/None 2 months De Blas M. Donosti Hospital. S Sebastian Spain Ciostek Brodnowski Hosp Warsaw. Poland 1 100% 100% 100% None/None 12 months 1 100% 100% 100% None/None 20 months Szopinsky P. Inst of Haematology, Warsaw. Poland % 93% 93% None/None 3 years Modified Sandwich gra: technique Mosquera NJ et al CHUO Hospital Ourense. Spain *Results presented at: % 91% 91% None/none 6-32 months Good inmediate and mid-term FU results 31 procedures 6 centers 3 countries

16 Sandwich technique endograft: published experience Author Reference Pub type N T Success Patency Mosquera N Técnicas Endovasculares, Technical report/case report 1 100% 100% Lobato A J Endovasc Ther Technical report Mosquera N J Cardiovasc Surg (Torino) Tecnical report/clinical series 4 100% 100% Friedman SG J Vasc Surg Technical report/case report 1 100% 100% Yoshida R Ann Vasc Surg Case report 1 100% 100% Ricci C Cardiovasc Intervent Radiol Clinical series 7 100% 100% 2012 Hennedige T Ann Vasc Surg Technical report/case report 2 100% 100% Lobato A J Vasc Surg Clinical series % 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

17 Modified Sandwich-graft technique: case #1. CASE 1: APRIL years old male >90 mm AAA and iliac aneurysm Extremely complex iliac anatomy and tortuous access vessel (Not a chance for Z-BIS )

18 SITE May. Barcelona. Spain. Modified Sandwich-graft technique: case #1. Aorfix bifurcated endograft + Viabahn (WL Gore): 8 mm diameter, mm length (120 mm effective length) 1 month FU 24 month FU

19 Modified Sandwich-graft technique: extreme iliac angulation Preoperative 18 month FU

20 Modified Sandwich-graft technique: bilateral sandwich-graft 6 month FU 1 month FU

21 Double barrell Sandwich-graft technique Images courtesy of Dr Tahir Hussain North West London Hospitals. NHS trust. London. UK. Intraoperative 1 month FU

22 Summary: (a) (d) Sandwich technique is a feasible and (b) (c) safe alternative to iliac branched devices. flexible and conformable endografts had demonstrated good performance in sandwich technique with both double barrell and modified technique.

23 Conclusions: (a) sandwich technique results had been confirmed (c) 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.

24 + 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