Endovascular treatment of thoracic aortic diseases

Abstract

Bacground/Aim. Endovascular treatment of thoracic aortic diseases is an adequate alternative to open surgery. This method was firstly performed in Serbia in 2004, while routine usage started in 2007. Aim of this study was to analyse initial experience in endovacular treatment of thoracic aortic diseses of three main vascular hospitals in Belgrade - Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia, Clinic for Vascular Surgery of the Military Medical Academy, and Clinic for Vascular Surgery of the Institute for Cardiovascular Diseases ?Dedinje?. Methods. Between March 2004. and November 2010. 41 patients were treated in these three hospitals due to different diseases of the thoracic aorta. A total of 21 patients had degenerative atherosclerotic aneurysm, 6 patients had penetrating aortic ulcer, 6 had posttraumatic aneurysm, 4 patients had ruptured thoracic aortic aneurysm, 1 had false anastomotic aneurysm after open repair, and 3 patients had dissected thoracic aneurysm of the thoracoabdominal aorta. In 15 cases the endovascular procedure was performed as a part of the hybrid procedure, after carotidsubclavian bypass in 4 patients and subclavian artery transposition in 1 patient due to the short aneurysmatic neck; in 2 patients iliac conduit was used due to hypoplastic or stenotic iliac artery; in 5 patients previous reconstruction of abdominal aorta was performed; in 1 patient complete debranching of the aortic arch, and in 2 patients visceral abdominal debranching were performed. Results. The intrahospital mortality rate (30 days) was 7.26% (3 patients with ruptured thoracic aneurysms died). Endoleak type II in the first control exam was revealed in 3 patients (7. 26%). The patients were followed up in a period of 1-72 months, on average 29 months. The most devastating complication during a followup period was aortoesofageal fistula in 1 patient a year after the treatment of posttraumatic aneurysm. Conversion was performed with explantation of stent-graft and open aortic in situ recontruction, followed by esophagectomy and the creation of cervical and gastrical stoma. Conclusion. Having in mind initial results of the 3 main vascular clinics in Belgrade, Serbia, economical situation in our country, as well as the published international results, endovascular treatment of thoracic aortic diseases is indicated in hemodinamicaly unstable patients with acute traumatic aneurysm, or in stabile patients older than 65, as well as in case of chronic diseases of the thoracic aorta in patients with significant comorbid conditions or in patients older than 65 years. Endovascular procedures on the thoracic aorta could be performed, hower, only in high-volume centers with experience in routine open surgery of thoracic aorta.Apstrakt Uvod/Cilj. Endovaskularno lecenje oboljenja grudne aorte postaje adekvatna alternativa otvorenom hirurskom pristupu. Ova nova metoda u Srbiji je izvedena prvi put 2004. godine, a rutinski se izvodi od 2007. godine. Cilj ovog rada bio je prikaz zajednickih pocetnih iskustava u endovaskularnom lecenju oboljenja grudne aorte Klinike za vaskularnu hirurgiju Vojnomedicinske akademije, Instituta za kardiovaskualrne bolesti ?Dedinje? i Klinike za vaskularnu i endovaskularnu hirurgiju Klinickog centra Srbije. Metode. Od marta 2004. do polovine novembra 2010. godine operisan je ukupno 41 bolesnik, zbog razlicitih oboljenja grudne aorte. Dvadeset jedan bolesnik imao je degenerativnu aneurizmu grudne aorte, sest bolesnika imalo je penetrantni aortni ulkus, sest traumatsku aneurizmu istmicnog dela grudne aorte, cetiri rupturiranu aneurizmu grudne aorte, jedan anastomoticnu pseudoaneurizmu koja je nastala nakon klasicnog hirurskog lecenja aneurizme grudne aorte, a tri bolesnika disekantnu aneurizmu torakoabdominalne aorte. Kod 15 bolesnika endovaskularna procedura bila je moguca jedino u sklopu hibridne procedure ? kod pet bolesnika sa kratkim vratom ucinjena je transpozicija potkljucne arterije (cetiri bolesnika) i karotido-supklavijalni bajpas (kod jednog bolesnika); dva ilijacna konduita kod bolesnika sa neadekvatnim ilijacnim i/ili femoralnim arterijama; pet rekonstrukcija abdominalne aorte zbog udruzenog oboljenja ovog segmenta; jedan ?debrancing? aortnog luka i dva ?debrancinga? abdominalne aorte. Rezultati. U prvih 30 dana zabelezena su tri (7,26%) smrtna ishoda. U sva tri slucaja radilo se o bolesnicima koji su imali rupturu aneurizme grudne aorte. Endolik tipa II zabelezen je kod tri (7,26%) bolesnika koji su leceni konzervativno, s obzirom na to da nije bilo uvecanja aneurizmatske kese. Bolesnici su bili praceni od 1 do 72 meseca, prosecno 29 meseci. Najozbiljnija komplikacija tokom perioda pracenja bila je aortoezofagealna fistula kod jednog bolesnika. Izvrsena je konverzija tokom koje je odstranjen endovaskularni graft. U istom operativnom aktu uradjena je ezofagektomija, rekonstrukcija aorte na standardan nacin, cerviko- i gastrostoma. Zakljucak. Imajuci u vidu pocetne rezultate, ekonomske mogucnosti naseg drustva, kao i objavljene rezultate najvecih svetskih serija, endovaskularno lecenje oboljenja torakalne aorte indikovano je u slucaju akutne traumatske aneurizme hemodinamski nestabilnih bolesnika ili prisutne politraume, odnosno hemodinamski stabilnih bolesnika koji su stariji od 65 godina, kao i u slucaju hronicnih traumatskih ili degenerativnih oboljenja grudne aorte kod bolesnika sa znacajnim komorbiditetom ili kod bolesnika starijih od 65 godina. Endovaskularne procedure na grudnoj aorti, medjutim, mogu izvoditi samo ustanove koje se rutinski bave otvorenom hirurgijom grudne aorte u uslovima ekstrakorporalne cirkulacije.