Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3742_Библиотеки_им_академика_М_И_Перельмана
.pdf
170 Section 8: Aortoiliac Disease
95. RATIONALE
Diagnostic angiography for intermittent claudication demonstrating left common iliac artery (CIA) occlusion ex tending
into the left ex ternal iliac artery (EIA) with distal reconstitution.
Left external iliac artery (EIA) stenosis 9 months after initial intervention (a) and status post-endovascular intervention
with angioplasty and self-expanding stent (b).
Section 8: Aortoiliac Disease 171
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Computed tomography urogram demonstrating left hydroureteronephrosis from persistent fibrosis approximately
2 years after initial stenting of left common iliac artery (CIA) and subsequent stenting of left external iliac artery (EIA).
Arrow indicates transition point of ureter at level of persistent fibrosis.
It is extremely uncommon to develop left lower quadrant flank pain years after left iliac stenting unless there is concern for aneurysmal disease. Ureteral complications after open aortoiliac
reconstruction have been well documented in the literature, but ureteral complications following iliac stenting are uncommon. Those were first described in 2014 with the development of
left hydronephrosis 2 months following iliac artery stenting in the Japanese literature. In this
patient moderate left ureteral hydronephrosis developed in close proximity to the left common iliac stent without any abnormalities in the right kidney and right ureter. The patient was
treated by robotic-assisted ureterolysis and omental wrap. There was a dense scar tissue forming an inflammatory rind adherent to the left common iliac artery. In open aortoiliac reconstruction during tunneling of the graft, which is tunneled posterior to the ureter, it can result
in scar tissue with involvement of the ureter resulting in hydronephrosis. This type of hydronephrosis rarely requires intervention and really does not progress. In this patient, because
of significant pain in the left flank and extensive scar tissue formation, ureterolysis became
necessary.
Correct Answer D Computed tomography urogram
Reference
Hans, S. S., Lee, M. M., & Jain, N. (2020). Ureteral stenosis following iliac artery stenting. J Vasc Surg
Cases Innov Tech, 6(3), 469–472. PMID: 32923750
172 Section 8: Aortoiliac Disease
96. RATIONALE
Aortogram v ia left femoral artery access showing right common iliac a rtery occlusion.
Guide wire crossing the right external iliac artery post-stent angioplasty of the right common iliac stent extending into
the distal aorta and kissing balloon in the left common iliac stent.
Section 8: Aortoiliac Disease 173
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Abdominal and pelvic aortogram showing successful aortoiliac stenting.
Percutaneous revascularization (stenting) for TASC D lesions can be technically challenging, more so in patients who have flush occlusion of the common iliac artery. The presence of
concomitant aortic or common femoral artery disease determines the approach to be used for
access. The ipsilateral retrograde femoral approach is generally preferred but may not always be
successful. The contralateral femoral approach is usually not successful because of lack of support, and in this patient because of the cephalad extension of the common iliac stent, it would
have been almost impossible to pass the catheter/sheath up and over from the contralateral
approach. In this situation, left brachial access is a suitable option with or without contralateral
balloon occlusion of the patent common iliac artery. In some centers, a 6 Fr sheath or larger
in the brachial artery necessitates a brachial artery cutdown to prevent brachial artery access
complications.
Correct Answer D Placement of a kissing stent in the right common iliac artery and stenting
of the right external iliac artery with left brachial access
Reference
Bechara, C. F., Barshes, N. R., Lin, P. H., & Kougias, P. (2012). Recanalization of flush iliac occlusions
with the assistance of a contralateral iliac occlusive balloon. J Vasc Surg, 55(3), 872–874. PMID:
22169670
97. RATIONALE
Sachwani et al. reported results of iliac stenting in 103 limbs (100 patients) and compared
those with the results of aortofemoral grafting in 101 patients with iliac artery occlusions.
Iliac stenting had lower morbidity, shorter hospital length of stay, and equivalent secondary
174 Section 8: Aortoiliac Disease
patency as compared to aortofemoral graft reconstruction. However, primary patency was
inferior in the iliac stenting group as compared to aortofemoral grafting. At 72 months, the primary patency for aortofemoral bypass was 91% as compared to 73% for iliac stenting (P = 0.10).
Secondary patency was equivalent with 98% in aortobifemoral group and 85% in the iliac stenting group. The average hospital length of stay was 7 ± 2 days in the aortobifemoral group and
1 ± 0.2 days in the iliac stenting group (P = 0.001). There were no periprocedure deaths in the
iliac stenting group, and there were four deaths in aortobifemoral group (P = 0.58). In patients
with iliac artery occlusions with severe calcification, the use of bare-metal stents may result
in iliac artery perforation, particularly in patients in whom oversized iliac stents are deployed.
Results of PTFE-covered self-expanding stents versus bare-metal stents for chronic iliac artery
occlusions revealed a higher midterm patency for covered self-expanding stents.
Correct Answer D Inferior primary patency but equivalent secondary patency
Reference
Sachwa ni, G. R., Hans, S. S., Khoury, M. D., et al. (2013). Results of i liac stenting and aortofemoral graft-
ing for iliac artery occlusions. J Vasc Surg, 57(4), 1030–1037. PMID: 23177535
98. RATIONALE
There is a reported higher risk of vessel rupture during angioplasty in patients with eccentric
severely calcified stenoses/occlusions in the iliac segment. In order to prevent rupture, the use
of covered stents in severely calcified iliac arteries with significant stenosis or occlusions has
been advocated by some investigators. Long-term follow-up of the randomized Covered versus
Balloon Expandable Stent Trial (COBEST), demonstrated significantly higher patency of covered
stents versus bare-metal stents at 5 years. Covered stents may also decrease the risk of distal
embolization in calcified complex lesions. During deployment of covered stents, meticulous
calculation of the stent length should be taken into consideration to avoid inadvertent coverage
of the origin of the hypogastric artery. Intravascular shock wave lithotripsy should be considered in severly calcific lesions prior to angioplasty/stent deployment.
Correct Answer C Patients with eccentric plaque with severe calcification involving 75% of
the circumference of the artery
Reference
Mwipatayi, B. P., Sharma, S., Daneshmand, A., et al. (2016). Durability of the balloon-expand-
able covered versus bare-metal stents in the Covered versus Balloon Expandable Stent Trial
(COBEST) for the treatment of aortoiliac occlusive disease. J Vasc Surg, 64(1), 83–94.e81.
PMID: 27131926
99. RATIONALE
Following balloon angioplasty and stenting, an inflammatory response occurs in the host artery
with myointimal proliferation and tissue ingrowth. Symptomatic iliac artery in-stent restenosis occurs with a frequency of 10% at 1 year and is probably more common at longer follow-up.
In-stent restenosis may be more common in patients with more complex lesions. The treatment
options include standard balloon angioplasty, cutting balloon angioplasty, and consideration
for placement of a covered stent. Thrombosis may form in a segment of severe in-stent restenosis and will require thrombolysis with use of catheters (McNamara, Angio-Jet) and pharmacomechanical thrombectomy along with tissue plasminogen activator (tPA) administration. Such
Section 8: Aortoiliac Disease 175
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
patients need to be monitored in the critical care unit. Failure to treat thrombus and perform
angioplasty for in-stent restenosis may result in distal embolization.
Correct Answer B 10%
Reference
Kudo, T., Chandra, F. A., & Ahn, S. S. (2005). Long-term outcomes and predictors of iliac angioplasty
with selective stenting. J Vasc Surg, 42(3), 466–475. PMID: 16171589
100. RATIONALE
176 Section 8: Aortoiliac Disease
(a) Occlusion of left common and iliac artery TASC-D lesion. (b) Contrast extravasation due to left iliac artery rupture
during intervention.
Iliac artery rupture during angioplasty/stenting and during passage of the stent graft during EVAR is an underreported complication. An incidence of 0.8%–0.9% of iliac rupture
during iliac artery angioplasty and stenting has been reported. Iliac rupture during stenting presents as back pain, left lower quadrant pain or flank pain, nausea, and a decrease
in blood pressure. In the case of small perforations, classic signs may not be present. The
major predictors of iliac artery rupture are severe eccentric calcification in the plaque
and oversizing of the postangioplasty balloon catheter. Fluid resuscitation and contrast
injection to confirm contrast extravasation should be performed immediately along with
balloon tamponade and placement of a covered stent at the site of the perforation. If the
sheaths are pulled in the recovery room and hypotension occurs, a prompt return to the
intervention suite or hybrid OR should be done to evaluate the site of the bleeding with
deployment of a covered stent at the site of the perforation. After deployment of a covered
stent, a contrast study should be performed to confirm hemostasis. Repairs of perforation
closer to the common femoral artery are associated with high procedure success and low
morbidity and mortality, whereas perforations closer to the aorta are more treacherous
with inferior outcomes.
Correct Answer C Contrast angiography
Reference
Allaire, E., Melliere, D., Poussier, B., et al. (2003). Iliac artery rupture during balloon dilatation: what
treatment? Ann Vasc Surg, 17(3), 306–314. PMID: 12712371
101. RATIONALE
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Left rectus sheath hematoma.
Section 8: Aortoiliac Disease 177
Rectus sheath hematoma due to inadvertent perforation of the deep/inferior epigastric
artery during arteriography/intervention may occur. Rectus sheath hematoma may also
occur following application of the closure device. Predisposing factors include large access
sheath size, repeat or multiple punctures of the artery, concomitant use of anticoagulants,
advanced age, female gender, and history of hypertension. A non-contrast CT scan is diagnostic unless the hematoma is large and painful. Conservative treatment is usually successful in small- to moderate-sized hematomas. However, in large hematomas with significant
pain and discomfort, coil embolization of the deep epigastric artery or operative ligation
may be necessary.
Correct Answer B Rectus sheath hematoma
Reference
Osinbowale, O., & Bartholomew, J. R. (2008). Rectus sheath hematoma. Vasc Med, 13(4), 275–279.
PMID: 18940904
102. RATIONALE
Distal embolization has been reported with a frequency of 8.8%–24% and is more common following interventions for iliac artery occlusions as compared to those with iliac
artery stenoses. In patients with suspected thrombosis within a segment of iliac artery
stenosis, consideration should be given to pretreatment with thrombolytic agents or use of
a mechanical thrombectomy device. Balloon angioplasty as the primary therapy in such
cases is associated with a higher risk of embolization. A variety of stent misadventures
such as acute stent thrombosis (stent deployed subintimally), balloon rupture during
partial stent deployment, stent migration, stent crush, and compression of the contralateral iliac artery may occur. Acute stent thrombosis should be an extremely rare event, and
178 Section 8: Aortoiliac Disease
when it occurs it is usually related to an unrecognized dissection distal to the stent. A rare
but dreaded complication of stent implantation is stent infection with septic endarteritis
and development of a mycotic pseudoaneurysm.
Correct Answer B Distal embolization
Reference
Timaran, C. H., Stevens, S. L., Freeman, M. B., & Goldman, M. H. (2002). Predictors for adverse out-
come after iliac angioplasty and stenting for limb-threatening ischemia. J Vasc Surg, 36(3),
507–513. PMID: 12218974
103. RATIONALE
(a) Near-focal occlusion of the infrarenal aorta.
A focal stenosis approaching near occlusion is relatively uncommon and is more prevalent
in young women with a history of severe nicotine abuse, hyperlipidemia, and premature
ovarian failure. Traditionally, aortic endartectomy and/or aortic bypass grafting have
been the standard treatment option for these symptomatic patients. However, open aortic
reconstruction has significant morbidity and even mortality. In men, open aortic reconstruction may result in erectile dysfunction and retrograde ejaculation. During the last
two to three decades endovascular options have largely supplanted open aortic reconstructions. A technical success of 82% has been reported with deployment of a covered
stent. Technical success is defined as residual stenosis of less than 15% or a trans-stenotic
systolic pressure gradient of less than 10%. More contemporary series have reported
Section 8: Aortoiliac Disease 179
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
technical success of 91.7%.1 Use of a covered stent near the origin of the inferior mesenteric
artery may result in its occlusion; therefore, the evaluation of the mesenteric circulation
by preoperative imaging studies is absolutely necessary to prevent bowel infarction. Since
the availability of balloon-expandable covered stents requiring lower-profile sheaths for
their deployment, the procedure has become much more simplified. Preangioplasty of the
lesion should be avoided in patients suspected of overlying thrombus in order to decrease
the likelihood of distal embolization. Spinal cord ischemia has been reported with covered
stenting for aortic occlusion.
2
Correct Answer C Covered stent
References
1. Grimme, F. A., Reijnen, M. M., Pfister, K., et al. (2014). Poly tetrafluoroethylene covered stent plac ement for focal occlusive disease of the infrarenal aorta. Eur J Vasc Endovasc Surg, 48(5), 545–550.
PMID: 25218651
2. Hans, S. S., Ngo, W., & McAllister, M. (2014). Paraplegia after aortic and superior mesenteric arter y
stenting for occlusive disease. Ann Vasc Surg, 28(2), 492.e417–499. PMID: 24295883
104. RATIONALE
Соседние файлы в папке Библиотека им академика М.И. Перельмана