platinum coils inferior mesenteric artery inflow embolization... platinum coils inferior mesenteric artery inflow embolization... platinum coils inferior mesenteric artery inflow emboliz
Trang 1Updates on management of late complications after endovascular
aortic stent grafting
Endovascular therapy Team New Heart Watanabe Institute, Tokyo, Japan
Hiroshi Ohtake M.D ,Ph.D
Trang 2Vietnam and me
Supported by Mr Ryotaro Sugi
Special Ambassador of Vietnam and Japan
Visiting to BACH MAI Hospital, 2011
Trang 3Vietnam and me
Supported by Mr Ryotaro Sugi
Special Ambassador of Vietnam and Japan
Clinical & Research Relationship between E-hospital, 2011
Trang 4Vietnam and me
Supported by Mr Ryotaro Sugi
Special Ambassador of Vietnam and Japan
TEVAR for a young patient of aortic injury in Hanoi Medical Univ., 2013
Trang 5Introduction
• Endovascular aortic repair (EVAR) and Thoracic endovascular aortic repair (TEVAR)
changed the indication for aneurysms
Previously, only open surgery was performed elder patients,
not healthy patients, patients after thoracic or abdominal surgery were out of the indication
Trang 7Indications of TEVAR/EVAR
including various aortic pathologies
aneurysm dissection atherosclerotic ulcer traumatic injury
inflammation / infection fistula
mural thrombus / plaque tumor invasion
Trang 8However…
• EVAR and TEVAR are
– non-invasive
– without the heart-lung machine
– not clarified the management of late complications
Trang 9Late complications
• Rupture of aneurysms 1-2%
• Dissection by the edge of stentgrafts 0-2%
• Infection of the stentgrafts 0-1%
• Thrombus in the stentgrafts 0-0.5%
/ 3years
Trang 10Late complications
• Rupture of aneurysms 1-2%
• Dissection by the edge of stentgrafts 0-2%
• Infection of the stentgrafts 0-1%
• Thrombus in the stentgrafts 0-0.5%
/ 3years
Trang 11Endoleak
• The blood flow into the aneurysmal sac
through the slit between the aortic wall and device
• In some cases, the aneurysms enlarge rapidly
• If the slow enlargement, 5mm in
diameter/year should be treated
Trang 12• Blood flow from the distal side
– High risk of rupture
# Should be treated immediately
Trang 15Fatal Type 1a
Previous TEVAR
After 3 years,
Trang 16Fatal Type 1a
Coil embolization was not effective
Trang 17Fatal Type 1a
Additional TEVAR was done
Additional stentgraft
Chimney stentgraft
Trang 18Fatal Type 1a
Chimney technique
Trang 19Fatal Type 1a
• Our study
• Innovations (Phila) 2013 Jul-Aug;8(4):289-95
• Assessment of a new type I endoleak repair technique using
Trang 20Department of General and Cardiothoracic surgery - Kanazawa University
Figure 7:
An outlook image that illustrates the potential future importance of
this approach:
A Anchoring device with a longer
and thinner gutter-needle
B Camera for the precise position
of the anchoring device
C Proximal type I endoleak
Trang 21Endoleak
– Back flow from small arteries
Trang 2376M infrarenal abdominal aneurysm
2014.6.28 EVAR with Gore Excluder
2014.7.5 CT: aneurysm size = 54mm in diameter
2015.10.20 CT: aneurysm size = 60mm in diameter
persistent type II endoleak 2016.1.21 transarterial embolization for type II
endoleak
Embolization for Type 2
Trang 30middle colic artery
Trang 31middle colic artery
Trang 32middle colic artery
Trang 33middle colic artery
Trang 34middle colic artery
Trang 35middle colic artery
Trang 36middle colic artery
Trang 38marginal artery
Trang 39marginal artery
Trang 40marginal artery
Trang 41marginal artery
Trang 42marginal artery
Trang 43inferior mesenteric artery
(inflow)
Trang 44inferior mesenteric artery
(inflow)
Trang 45√inferior mesenteric artery
inferior mesenteric artery
(inflow)
Trang 46endoleak
Trang 47endoleak
Trang 48endoleak
Trang 49endoleak
Trang 50endoleak
Trang 51endoleak
Trang 52endoleak
Trang 53endoleak
Trang 54endoleak
Trang 55endoleak
Trang 56endoleak
Trang 57endoleak
Trang 58endoleak
Trang 59endoleak
Trang 60endoleak
Trang 61endoleak
Trang 62endoleak
Trang 63endoleak
Trang 64endoleak
Trang 65endoleak
Trang 66endoleak
Trang 68superior mesenteric artery
Trang 69superior mesenteric artery
Trang 70superior mesenteric artery
Trang 71superior mesenteric artery
Trang 72superior mesenteric artery
Trang 73superior mesenteric artery
Trang 74superior mesenteric artery
Trang 75superior mesenteric artery
Trang 76superior mesenteric artery
Trang 77superior mesenteric artery
Trang 78superior mesenteric artery
Trang 79superior mesenteric artery
Trang 80superior mesenteric artery
Trang 81superior mesenteric artery
Trang 82superior mesenteric artery
Trang 83superior mesenteric artery
Trang 84superior mesenteric artery
Trang 85superior mesenteric artery
Trang 86superior mesenteric artery
Trang 87superior mesenteric artery
Trang 88superior mesenteric artery
Trang 89superior mesenteric artery
Trang 90superior mesenteric artery
Trang 91superior mesenteric artery
Trang 92superior mesenteric artery
Trang 93superior mesenteric artery
Trang 94superior mesenteric artery
Trang 95superior mesenteric artery
Trang 96superior mesenteric artery
Trang 97superior mesenteric artery
Trang 98superior mesenteric artery
Trang 99superior mesenteric artery
Trang 100superior mesenteric artery
Trang 101superior mesenteric artery
Trang 102superior mesenteric artery
Trang 103superior mesenteric artery
Trang 104superior mesenteric artery
Trang 105superior mesenteric artery
Trang 106superior mesenteric artery
Trang 107superior mesenteric artery
Trang 108quadruple coaxial catheter system
Trang 1105F catheter 3F microcatheter
2F microcatheter
quadruple coaxial catheter system
7F guiding catheter
Trang 1115F catheter 3F microcatheter
2F microcatheter
quadruple coaxial catheter system
7F guiding catheter
Trang 112inferior mesenteric artery
(inflow)
Trang 113inferior mesenteric artery
(inflow)
Trang 114inferior mesenteric artery
(inflow)
Trang 115inferior mesenteric artery
(inflow)
Trang 116inferior mesenteric artery
(inflow)
Trang 154middle sacral artery
(outflow)
Trang 155middle sacral artery
(outflow)
Trang 156middle sacral artery
(outflow)
Trang 157middle sacral artery
(outflow)
Trang 158middle sacral artery
(outflow)
Trang 159middle sacral artery
(outflow)
Trang 161platinum coils
inferior mesenteric artery (inflow) embolization
Trang 162platinum coils
inferior mesenteric artery (inflow) embolization
Trang 163platinum coils
inferior mesenteric artery (inflow) embolization
Trang 164platinum coils
inferior mesenteric artery (inflow) embolization
Trang 165platinum coils
inferior mesenteric artery (inflow) embolization
Trang 166platinum coils
inferior mesenteric artery (inflow) embolization
Trang 167platinum coils
inferior mesenteric artery (inflow) embolization
Trang 168platinum coils
inferior mesenteric artery (inflow) embolization
Trang 169platinum coils
inferior mesenteric artery (inflow) embolization
Trang 170platinum coils
inferior mesenteric artery (inflow) embolization
Trang 171inferior mesenteric artery (inflow) embolization
Trang 172inferior mesenteric artery (inflow) embolization
Trang 173inferior mesenteric artery (inflow) embolization
Trang 174inferior mesenteric artery (inflow) embolization
Trang 175inferior mesenteric artery (inflow) embolization
Trang 176inferior mesenteric artery (inflow) embolization
Trang 177Endoleak
– Fracture of devices – Connection of devices
# should be treated immediately
Trang 179Endoleak
– Blood oozing through the graft
• Thin wall graft
# Observation
in many cases, disappear!
Trang 180Endoleak
– No blood oozing – Only pressure spread
• CT shows no endoleak
• However, the diameter expand
# should be treated
Trang 181Endoleak
• Type 5
– Unknown – Treatment
• Re-stentgrafting
Trang 182Late complications
• Dissection by the edge of stentgrafts 0-2%
• Infection of the stentgrafts 0-1%
• Thrombus in the stentgrafts 0-0.5%
Trang 183Late complications
• Dissection by the edge of stentgrafts 0-2%
• Infection of the stentgrafts 0-1%
• Thrombus in the stentgrafts 0-0.5%
/ 3years
Antibiotics
Open surgery
Trang 184Rare complication
6 months later
massive hemo-sputa
Trang 185Rare complication
Fistula between Aneurysmal sac and Bronchus
Trang 186Rare complication
Coil embolization
Trang 187Follow-up protocol for minor Endoleak
Over 1 year, every 1 year CT plain for NO Endoleak cases
every 6months CT plain for persistent Endoleak cases
Trang 188Conclusion
• Now, we don’t recognize all complications of EVAR/TEVAR, because many new stentgrafts are developing
• To prevent from postoperative rupture, CT scan should be performed regularly
• Catheter techniques is important to recover Endoleaks
• Endovascular team by vascular surgeons,
cardiologists, and radiologists is ideal