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_3820_Библиотеки_им_академика_М_И_Перельмана
.pdf
CHAPTER 4 Thoracic endografting for thoracic aneurysm using the Gore TAG device 31
https://t.me/med1917
(a)
Fig. 4.7 (a) IVUS catheter advanced into the proximal thoracic aorta to determine the proximal and distal landing zone
diameters, and diameter and length of the aneurysm. (b) IVUS image of a thoracic aneurysm.
(b)
Fig. 4.8 Device sheath for an endograft advanced into the
thoracic aorta.
Fig. 4.9 Advancement of an endoluminal graft and its
positioning for the exclusion of a thoracic aneurysm.
32 PAR T I Aorta
https://t.me/med1917
(a)
(b)
(a) (b)
Fig. 4.10 (a) Deployment of an
endoluminal graft to exclude a thoracic
aneurysm. (b) Balloon angioplasty of the
proximal end for adequate xation to the
aortic wall to prevent a type1 endoleak.
Fig. 4.11 (a) Completion
angiogram and (b) illustration
demonstrating an adequate
position of an endograft with
exclusion of an aneurysm.
CHAPTER 4 Thoracic endografting for thoracic aneurysm using the Gore TAG device 33
https://t.me/med1917
Fig. 4.12 Repair of a femoral arteriotomy used for device sheath introduction.
Fig. 4.13 Angioseal vascular devices used to achieve hemostasis of a percutaneous retrograde puncture.
34 PAR T I Aorta
https://t.me/med1917
Fig. 4.14 Reconstructed 3D CT scan demonstrating the
satisfactory exclusion of a thoracic aortic aneurysm
withno endoleak.
performed prior to discharge to confirm exclusion
of the thoracic aortic aneurysm and to identify
any endoleaks that may have been missed on
operative angiograms.
Appendix: preference card
EQUIPMENT:
– 18 GAUGE ACESS NEEDLE
– INDEFLATOR FOR THERAPEUTIC BALLO-
ONING OF ILIAC ARTERIES
– 60CC SYRINGE FOR PROFILE BALL O-
ONING OF AORTA AND GRAFT
JUNC TIONS
– GUIDEWIRE .035 180CM ANGLED
GLIDEWIRE / 260CM ANGLED FOR
(THORACIC)
– GUIDEWIRE .035 260CM COOK LUNDER-
QUIST ({x2} ABDOMINAL) / LUNDERQUIST(LES3) FOR (THORACIC {x1})
– SHEATH 5FR, 6FR OR 9FR 11CM COR DIS
BRITE-TIP FOR PERCUTANEOUS CONTRA
– SHEATH 12FR OR 14FR FOR POST
ENDOLUMINAL GRAFT BALLOONING
– FLUSH CATHETER 5FR OR 6FR 100CM TR
FLUSH / PIGTAIL / OR MARKER PIGTAIL
– BALLOON CORDIS OPTA-PRO 80CM OR
ABBOTT FOX PTA 75CM (FOR LESIONSOF
THE ILIAC VESSELS / TO ALLOW
DELIVERY OF THE ELG)(SIZE TO BE
DETERMINED BY PHYSICIAN)
– BALLOON CORDIS MAXI-LD 14,15,16,18,
20,22,25X4CM FOR GRAFT JUNCTION
(SIZE TO BE DETERMINED BY PHYSICIAN)
– BALLOON COOK CODA 32MM OR
40MM (SIZE TO BE DETERMINED BY
PHYSICIAN)
– ENDOLUMINAL GRAFT (SIZE TO BE
DETERMINED BY PHYSICIAN)
PROCEDURE PEARLS:
– PATIENT PLACED SUPINE
– EKG LEADS AND EKG WIRES ARE
POSITIONED SO THEY DO NOT
APPEARON THE FLOUROSCOPIC
IMAGES
– POSSIBLY PREP THE PATIENT ARM OUT
FOR BRACHIAL FEMORAL WIRE
(USEDFOR DIFFICULT ACCESS
ANATOMY SUCH AS EXTREMELY
TORTUOUS ILIACS)
1 OBLIQUE INCISION TO EXPOSE CFA
(THORACIC / ENDOLOGIX {x1 SIDE CUT
DOWN}) (ANEURX / EXCLUDER / ZENITH
{x2SIDE CUT DOWN})
2 PUNCTURE BOTH CFA WITH 18 GA.
NEEDLE
3 PLACE .035 ANGLED GLIDEWIRE
THROUGH NEEDLE LUMEN; UNDER
FLOURO- SCOPIC GUIDANCE ADVANCE INTO
DISTAL AORTA; (PERCUTANEOUS) MAKE
ASMALL INCISION AT THE PUNCTURE SITE
WITH A SCALPEL; LEAVE GUIDEWIRE IN
PLACE AND REMOVE THE NEEDLE; WHILE
LEAVING THE GUIDEWIRE IN PLACE; DILATE
THE TRACT WITH A MOSQUITO HEMOSTAT
4 PLACE THE 5FR, 6FR OR 9FR(IVUS) 11CM
BRITE-TIP SHEATH OVER THE GUIDEWIRE
AND ADVANCE WELL INTO THE VESSEL;
REMOVE THE OBTURATOR OF THE SHEATH
LEAVING THE SHEATH AND GUIDEWIRE
IN PLACE; FLUSH SHEATH WITH HEPARANIZED SALINE; HAVE ANESTHIOLOGIST /
CRNA ADMINISTER 3000–5000 UNITS OF
HEPARIN I.V.
CHAPTER 4 Thoracic endografting for thoracic aneurysm using the Gore TAG device 35
https://t.me/med1917
– IF SHEATH IS NOT ABLE TO BE ADVANCED;
PLACE A CORDIS 4FR DILATOR OVER THE
WIRE AND EXCHANGE THE WIRE FOR
A STIFFER .035 GUIDEWIRE (E.G..035
75CM AMPLATZ); REMOVE THE DILATOR
KEEPING THE WIRE IN PLACE; THEN
PLACE SHEATH OVER THE STIFF
GUIDEWIRE AND ADVANCE WELL INTO
THE VESSEL; REPLACE THE STIFF
GUIDEWIRE WITH THE ORIGINAL
GLIDEWIRE
5 UNDER FLOUROSCOPIC GUIDANCE
ADVANCE THE GLIDEWIRE INTO THORACIC
AORTA
6 PLACE 5FR OR 6FR FLUSH CATHETER
OVER THE GUIDEWIRE AND ADVANCE
INTO THE PROXIMAL ABDOMINAL AORTA
AT THE LEVEL OF (L1-L2 VERTEBRAL SPACE
FOR RENAL ARTERY VISUALIZATION (ABD):
ADVANCE INTO ASCENDING THORACIC
AORTA TO VISUALIZE THE GREAT VESSELS
(THORACIC))
7 POSITION IMAGE INTENSIFIER FOR
IMAGING (ABD) AP WITH A 10–15 DEGREE
CRANIAL ANGULATION (THORACIC) 40–60
DEGREE LAO ANGUULATION
8 SHOOT AN AORTAGRAM TO DETERMINE
IF YOU HAVE ADEQUATE LENGTH LANDING ZONE (ROADMAP FOR IVUS
MEASUREMENTS)
9 PLACE THE LUNDERQUIST GUIDEWIRE
INTO FLUSH CATHETER AND REMOVE
FLUSH CATHETER LEAVING THE
LUNDERQUIST IN PLACE
10 PLACE 8.2FR PV IVUS PROBE OVER THE
WIRE AND PERFORM IVUS EXAMINATION
(TAKE DIAMETER MEASUREMENTS /
EVALUATE PLAQUE AND THROMBUS
BURDENS / PERFORM LONGITUDINAL PULL
THROUGH / TAKE LENGTH MEASUREMENT)
11 REMOVE IVUS PROBE LEAVING THE
LUNDERQUIST WIRE IN PLACE
12 SHOOT A RETROGRADE ANGIOGRAM
THROUGH THE SHEATH TO EVALUATE
THEACCESS VESSELS (IF NEEDED PERFORM
ANGIOPLASTY)
13 THROUGH CONTRALATERAL SHEATH
PLACE FLUSH CATHETER IN POSITION TO
PERFORM AORTAGRAM PRIOR TO ELG
DEPLOYMENT
14 CHOOSE THE APPROPRIATE SIZED ELG
15 INTRODUCE ELG DELIVERY SHEATH
OR ELG DELIVERY DEVICE INTO THE CFA
OVER THE LUNDERQUIST WIRE (FOLLOW
THE SHEATH/DELIVERY SYSTEM AS IT
PASSES THROUGH THE AORTA AND ILIAC
VESSELS
16 ROTATE THE C-ARM TO APPROPRIATE
ANGLE FOR AORTAGRAM (SEE #7)
17 SHOOT AORTAGRAM (ROADMAP) TO
DEPLOY THE ELG
18 PLACE A NEEDLE AT THE PROXIMAL
LANDING ZONE
19 DEPLOY THE ELG (SMALL PUFFS OF
CONTRAST THROUGH THE FLUSH
CATHETER AID IN ACCURATE
DEPLOYMENT)
20 FOLLOW THE IFU FOR EACH SPECIFIC
DEVICE DEPLOYMENT STEPS
21 AFTER ELG IS DEPLOYED REMOVED
THE FLUSH CATHETER FROM BEHIND THE
ELG BY PLACING THE ANGLED GLIDEWIRE
THROUGH THE CATHETER
22 IF THE ELG IS A BIFURCATED ABDOMINAL
ELG; CANNULATE THE CONTRA-LATERAL
GATE; SELECT THE APPROPRIATE LIMB
ANDDEPLOY ACCORDING TO THE DEVICE
SPECIFIC IFU
23 PROFILE BALLOON THE LANDING ZONES
AND OVERLAPPING AREAS WITH MAXI-LD
BALLOON(S) OR CODA BALLOON
24 REINTRODUCE THE FLUSH CATHETER
AND CHECK FOR ENDOLEAKS
25 PERFORM RETROGRADE ANGIOGRAM
THROUGH THE SHEATHS TO CHECK FOR
DISTAL SEAL OF THE ELG
26 DEPLOYMENT OF CLOSURE DEVICE IN
ACESS VESSELS WITH SHEATHS LESS THAN
12FR. REPAIR OF ACCESS VESSELS WITH
SHEATH SIZE LARGER THAN 12 FR
Reference
1 Diethrich EB, Ramaiah VG, Kpodonu J, et al. Endovascular
and Hybrid Management of the Thoracic Aorta. A casebased approach, 1st edn. Oxford: Wiley-Blackwell. 2008.
5
https://t.me/med1917
CHAPTER 5
Axillary/subclavian access
forendovascular management
ofascending and descending
aortic pathologies
Eduardo Keller Saadi
Federal University of Rio Grande do Sul, Hospital de Clinicas de Porto Alegre; Center for Aortic Diseases,
Hospital Mae de Deus, Porto Alegre, Brazil
Introduction
Endovascular approaches are being increasingly
utilized to treat a variety of thoracic aortic diseases
(TADs), including aneurysms, pseudoaneurysms,
dissections, penetrating aortic ulcers, traumatic
aortic rupture, and coarctation. The treatment of
descending aorta pathologies is well established
but it is also possible to treat the arch and, more
recently, the ascending aorta as the last frontier.
Adequate vascular access is crucial to obtain good
results. Thoracic endovascular aortic repair
(TEVAR) is usually done through the femoral
arteries. Transfemoral access can be achieved by
direct surgical cut-down and surgical suture closure of the artery, percutaneous puncture with
surgical suture closure, or percutaneous puncture
with percutaneous closure of the femoral artery.
Although there has been a dramatic improvement
in device profiles and navigability with external
hydrophilic coating in commercially available
devices, the diameter of devices remains sizeable.
Sometimes access is impossible or not recommended because of the small size of the vessels,
obstruction, calcification, dissection, or extreme
tortuosity. Vascular access complications such as
dissection, iliac rupture, and thrombosis are stillfrequent. Achieving safe and successful endovascular
access for introduction and deployment of the stentgraft device is an important and often challenging
step during TEVAR. Currently available thoracic
endografts still have a large profile. In 10–30% of the
patients suitable for TEVAR, inadequate femoral
artery access anatomy will be found. Alternative
access sites are important. The axillary/subclavian
artery approach is a viable alternative in cases where
the femoral arteries are not appropriate.
Vascular access evaluation
Complete anatomic evaluation of the thoracic
aortic pathology and the access vessels are key
to success. Preoperative meticulous planning is
fundamental. Physical examination with pulse
palpation and echo Doppler can be used as an initial
screening. Currently, helical computed tomographic angiography (CTA) is the most useful
imaging modality for detailed assessment of access
arterial anatomy, overtaking axial computed tomography (CT) and digital subtraction angiography
Endovascular and Hybrid Therapies for Structural Heart and Aortic Disease, First Edition.
Edited by Jacques Kpodonu and Raoul Bonan.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
36
CHAPTER 5 Axillary/subclavian access forascending and descending aortic pathologies 37
https://t.me/med1917
(DSA) (Fig.5.1). CTA demonstrates with sharp precision the course and appearance of all vessels of
interest and provides the necessary tools for sizing
Fig. 5.1 CT with 3D reconstruction of the abdominal aorta
and iliac and femoral arteries to evaluate groin access.
Note the calcication in the distal aorta and left iliac
artery but without obstruction, stenosis, or extreme
tortuosity, with good size vessels (>8 mm).
and measurements of the devices and helps to
determine the most appropriate access site (Fig.5.2).
Technique
Under general or local anesthesia the axillary artery
is exposed through an incision in the delto-pectoral groove. The pectoralis major muscle is divided
in the direction of its fibers and the insertion of
thepectoralis minor divided. The axillary artery is
easily seen superior to the axillary vein and dissected. The arterial wall is thin and usually free
from atherosclerosis (Fig. 5.3). Care should be
taken to avoid any injury to the brachial plexus.
Following the administration of heparin (1 mg/kg)
a side biting clamp is applied and an anastomosis
constructed with an 8 or 10 mm Dacron tube with
a running suture of 6-0 prolene (Fig.5.4). The tube
is brought from the same incision or, in cases when
the artery is too deep, through a new small stab
incision and left long and parallel to the artery
(Fig.5.5). The tube is left at least 25 cm long, away
from the artery. A 7 Fr sheath is snared to the
extremity of the Dacron tube to avoid bleeding and
facilitate the manipulation of wires and catheters,
and the insertion of the device (Fig.5.6; Video5.1).
Fig. 5.2 CT with 3D reconstruction of the aortic arch
showing a type B dissection involving the left subclavian
artery and a bovine arch with a good angulation to access
the descending aorta. In this patient the right axillary
artery would be the preferred access.
38 PAR T I Aorta
https://t.me/med1917
Fig. 5.3 Right axillary artery exposed and repaired with
tapes.
Fig. 5.5 Alternatively, a stab incision in the skin is used to
exteriorize the Dacron tube parallel to the axillary artery.
Fig. 5.4 An 8 mm Dacron tube anastomosed to the right
axillary artery with 6-0 prolene.
The endoprosthesis is introduced by the distal
end with or without the sheath, depending on the
device selected, through the Dacron graft and on
an extra stiff Landerquist 260 cm long guide wire
(Cook Medical, Bloomington, IN) (Fig. 5.7;
Video 5.2). If there is not another access the
Dacron tube can be punctured more proximally
and another 5 or 6 Fr sheath inserted (Figs5.8 and
5.9). Catheters and the rigid guide wire, as well as
the endoprosthesis, can be inserted after enlarging
the hole with an 11 blade, while keeping the distal
end of the graft for angiographic control (Fig.5.10).
An aortography is done with a pigtail introduced
from the same graft, the contralateral arm, or from
the groin for diagnostic landmarks and before
opening the device (Video5.3). The endoprosthesis is then deployed (Video 5.4). Balloon
accommodation is performed in the usual fashion
through the axillary access (Video5.5). Final aortography is performed to check there are no
endoleaks. The wires are removed and the Dacron
tube ligated with two large clips 1 cm away from
the axillary artery and reinforced with a running
suture of 5-0 prolene. The incision is closed in
layers and no drains left. At least one CT scan is
done in the early postoperative period to confirm
the correct position of the endograft and the
absence of endoleaks (Fig. 5.11). Follow-up is
maintained for the patient’s lifetime.
Discussion
The feasibility of endovascular surgery depends on
many anatomic factors, including the diameter and
the disease state of the access vessels [1–4]. Stenosis,
calcifications, tortuosity, small sizes, or dissection of
both femoral and iliac arteries can make the introduction of a large sheath hazardous or impossible.
Aorto-iliac artery stenosis and obstruction is not
uncommon in elderly patients. Women and small
patients often have femoral arteries that are not
Fig. 5.6 Introducer snared to the distal end of the tube to avoid bleeding and allow manipulation of wires and catheters.
https://t.me/med1917
Fig. 5.7 Introducing the endoprosthesis through the distal end of the tube without the sheath.
Fig. 5.8 Puncture in the Dacron graft in cases where there is no other access vessel.
40 PAR T I Aorta
https://t.me/med1917
compatible in size with large diameter sheaths and
introducers needed to deploy thoracic endoprosthesis. A conduit anastomosed to the iliac artery is an
option when the femoral arteries are not adequate
[5]. Direct extraperitoneal access to the abdominal
aorta with or without a conduit is also possible but is
a big operation. An alternative to groin access is the
axillary artery. The exposure of the axillary artery
through a small infraclavicular incision is familiar
to cardiovascular surgeons as arterial return in
cardiopulmonary bypass in aortic arch surgery [6].
They are often good-sized vessels and usually free
from atherosclerosis, even in patients with extensive
aorto-iliac occlusive disease.
Both axillary arteries can be used. The decision
of the side to use is made based on anatomic details
and its angle detected in the preoperative multislice
CT scan with 3D reconstruction. If both arteries
are of good size and the angle in relation to the
aortic arch is favorable, preference is given for the
left subclavian artery. We believe there is less
chance of debris embolization to the carotid artery
when we avoid the brachiocephalic trunk. If the
left subclavian artery is involved by dissection or
a neurysm we use the right. Careful evaluation
should be taken in patients with prior myocardial
revascularization with the left internal mammary
artery (LIMA), where the risk of left subclavian
artery dissection or temporary occlusion of LIMA
Fig. 5.9 Another introducer in place proximally in the tube
while maintaining the distal end for angiographic control.
Fig. 5.10 Endoprosthesis introduced directly through the Dacron tube after enlarging the hole with an 11 blade and
keeping the distal end to control deployment.
Fig. 5.11 Postoperative CT showing two grafts implanted
in the descending aorta through the left axillary artery.
Соседние файлы в папке Библиотека им академика М.И. Перельмана