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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3823_Библиотеки_им_академика_М_И_Перельмана
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Figure 3.8 Stent position confirmation during
deployment.
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Figure 3.9 Final result.
Table 3.1 Major adverse events associated with
vertebral angioplasty.
Source: Data from Eberhardt et al. (2006); Jenkins et al. (2010).
Event Frequency (%)
TIA 1–2%
Major stroke 1–2%
MI 0%
Death <1%
Importantly, extend the stent into the subclavian artery
by 1–2 mm if stenting the proximal vertebral artery to
assure complete coverage of the ostium. Ensure with
fluoroscopy that the stent is well seated prior to
deployment. The guidewire should always be kept within
view during the procedure to prevent perforation and
causing fatal intracranial hemorrhage. Care should be
exercised when using a hydrophilic guidewire. Multiple
catheters, guidewires, balloons, and stents can be used in
vertebral interventions not limited to those described in
this guide (Table 3.1).
Management of Potential
Complications
A team approach including a neurologist,
neurointerventional radiologist, and a cardiologist is
recommended to assist the interventionalist in dealing
with any complications that may arise. Periprocedural
complications of vertebral artery stenting include both
adverse events associated with vertebral angioplasty as
well as all other complications that accompany
percutaneous procedures. Management of these
complications requires repeat imaging to treat
mechanical complications of the angioplasty procedure
or catheter‐directed thrombolysis for thromboembolic
events. The frequencies of these major adverse events are
quite low (Table 3.2) [5, 8].
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Table 3.2 Interventional tools.
Source: Jenkins Vertebral artery interventions, Adapted from Schillinger
and Minar (2010) [6].
Size Device
Guide catheter 6‐Fr Envoy
Judkins right
Internal mammary
Multipurpose
Guidewires 0.014
in.
Balance middle weight
(Abbott)
Wisper (Abbott)
Choice PT (Cordis)
Embolic protection 4–6
mm
Filterwire (BSC)
Stents balloon
expandable
3–6
mm
Vision (Abbott)
RX Herculink Elite (Abbott)
Express renal/biliary SD
(BSC)
Multi‐link ultra coronary
stent (Cordis)
Stents self‐
expanding
4–7
mm
Xpert pro peripheral stent
(Abbott)
Postprocedural Care
1. Plavix (75 mg daily) should be continued for one
month after the procedure if bare‐metal stents are
used with aspirin (81 mg daily) to be continued
indefinitely. If drug‐eluting stents are used, dual
antiplatelet therapy should be continued six months
to one year.
2. Dual antiplatelet therapy is frequently continued
indefinitely with the use of drug‐eluting stents to
prevent the occurrence of late stent thrombosis.
3. Duplex ultrasound should be performed at 3, 6, and
12 months and yearly thereafter, if VBI symptoms
resolve. Patients with recurrent symptoms should
undergo repeat angiography to identify restenosis or
progression of atherosclerotic disease.
References
1 Markus, H.S., Larsson, S.C., Kuker, S.C. et al. (2018).
Stenting for symptomatic vertebral artery stenosis:
the vertebral artery ischaemia stenting trial. J. Vasc.
Surg. 67 (3): 986.
2 Markus, H.S., Larsson, S.C., Kuker, W. et al. (2017 Sep
19). Stenting for symptomatic vertebral artery
stenosis. Neurology 89 (12): 1229.
3 (2001). Endovascular versus surgical treatment in
patients with carotid stenosis in the carotid and
vertebral artery transluminal angioplasty study
(CAVATAS): a randomised trial. The Lancet 357
(9270): 1729–1737.
4 Jenkins, J.S. (2014). Percutaneous treatment of
vertebral artery stenosis. Interv. Cardiol. Clin. 3 (1):
115–122.
5 Jenkins, J.S., Patel, S.N., White, C.J. et al. (2010).
Endovascular stenting for vertebral artery stenosis. J.
Am. Coll. Cardiol. 55 (6): 538–542.
6 Schillinger, M. and Minar, E. (2010). Complex Cases in
Peripheral Vascular Interventions, 308. CRC Press.
7 Garry, B.P. and Bivens, H.E. (1988). The Seldinger
technique. J. Cardiothorac. Anesth. 2 (3): 403.
8 Eberhardt, O., Naegele, T., Raygrotzki, S. et al. (2006).
Stenting of vertebrobasilar arteries in symptomatic
atherosclerotic disease and acute occlusion: case
series and review of the literature. J. Vasc. Surg. 43
(6): 1145–1154.
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4
Endovascular Repair of Thoracic
Aortic Aneurysms: Catheter‐Based
Therapy
John Denesopolis, Patricia Yau, and Aksim G.
Rivera
Department of Surgery (Vascular Surgery), Albert
Einstein College of Medicine-Jacobi Medical Center,
Bronx, NY, USA
Introduction
Thoracic aortic pathology has increasingly become a
major cause of mortality in the United States, accounting
for at least 13 000 deaths annually, with incidence 5.6–
10.4 cases per 100 000 people. Thoracic aortic aneurysm
(TAA) is predominantly a disease of the older people,
with risk factors similar to that of patients with
abdominal aortic aneurysm (AAA), i.e. smoking,
hypertension, and atherosclerotic disease. The majority
are degenerative in etiology, though approximately 20%
are sequelae of chronic aortic dissection. Most diagnosed
thoracic aortic and thoracoabdominal aortic aneurysms
(TAAA) are not symptomatic, and are incidentally noted
on imaging obtained for unrelated reasons [1].
The use of endovascular stent grafting, first popularized
for AAAs, has now become a mainstay of treatment for
TAA. Thoracic endovascular aortic repair (TEVAR) has
been shown to have clear benefit in morbidity and
mortality to open repair in more recent literature. In
patients with less‐than‐ideal anatomy, e.g. involvement
of major aortic branches, tortuous anatomy, large
diameter neck, etc., the advantage of endovascular repair
over open repair becomes less pronounced. However,
with more sophisticated technology, as well as the advent
of fenestrated, branching, and hybrid techniques, the use
of TEVAR in patients with complex aortic pathology has
proven to be safe, effective, and durable. Additionally,
the indications for use of TEVAR have expanded to
include blunt traumatic aortic injury, aortic dissection,
and acute aortic syndromes.
Relevant Anatomy
Aortic Anatomy
The thoracic aorta consists of four main parts: the aortic
root, the ascending thoracic aorta, the aortic arch, and
the descending thoracic aorta. The aorta normally
enlarges as it progresses distally, and moves
posterolaterally in the proximal portion, and
anteromedially closer to the diaphragm. Aneurysmal
dilatation is defined as 1.5 × normal diameter; normal
diameter for the descending aorta is 2.0–2.3 cm.
Aneurysm morphology is characterized as fusiform or
saccular, with saccular aneurysms having a higher risk of
rupture.
Crawford Classification for TAA/TAAA
Type I: arises from above 6th intercostal space,
extends to above the renal arteries
Type II: arises above 6th intercostal space, extends
distal to the renal arteries
Type III: arises in the distal half of the descending
thoracic aorta (below the 6th intercostal space),
extends into the abdominal aorta
Type IV: limited to abdominal aorta (diaphragm to
aortic bifurcation)
Type V: distal half of descending thoracic aorta to
visceral abdominal aorta
Landing Zones (Figure 4.1)
Zone 0: proximal to innominate artery
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Zone 1: proximal to CCA
Zone 2: proximal to origin of left SCA
Zone 3: proximal descending aorta (<2 cm from left
SCA)
Zone 4: 2 cm distal to SCA, to proximal half of
descending thoracic aorta (T6)
Zone 5: distal half descending thoracic aorta to
celiac artery
Zone 6: celiac to SMA
Zone 7: SMA to suprarenal aorta
Zone 8: perirenal aorta
Zone 9: infrarenal aorta
Zone 10: common iliac arteries
Zone 11: external iliac arteries
Figure 4.1 Aortic landing ones.
Preoperative planning for TEVAR requires consideration
of proximal and distal landing zones and the potential
for coverage of major aortic branches. At least 20 mm of
proximal and distal landing zone is recommended to
allow adequate seal. If there is significant tortuosity, a
longer sealing zone may be desired.
Consideration of aortoiliac anatomy is important for
determining arterial access and potential need for iliac
conduit for graft delivery. The right iliac artery is the
preferred route of graft delivery. The access vessel should
be at least 7 mm in diameter. If there is not an
adequately sized vessel, or if there is significant
atherosclerotic disease, an iliac conduit may be required
for device delivery. In rare cases where the entire iliac
system is diseased, direct aortic access or an iliac
endoconduit may be used (described below).
Implication of Aortic Anatomy on Spinal Perfusion
Spinal cord ischemia is a particularly devastating
complication that may occur in 3–7% of patients
following TEVAR. Rates of spinal cord ischemia have
remained the same despite increasing use of
endovascular repair. The blood supply to the spinal cord
consists of the posterior spinal arteries (arising from the
vertebral or posterior inferior cerebellar arteries),
anterior spinal artery (originates from the vertebral
arteries), and supported by the artery of Adamkiewicz
(usually takes off between T8 and L2). This network is
reinforced by collaterals from the radicular arteries,
which are supplied by inflow vessels:
subclavian/vertebrals, thyrocervical and costocervical
trunks, intercostals, lumbar arteries, and branches of
hypogastric. Thus, the risk of spinal cord ischemia is
increased with coverage of the left SCA and coverage of
the hypogastric. Increased length of aortic coverage,
renal insufficiency, prior abdominal aortic repair, and
intraoperative hypotension are other risk factors for
spinal cord ischemia. Coverage of the left SCA also
significantly increases the risk of stroke, particularly in
60% of patients with a dominant left vertebral artery.
Revascularization of the left SCA, usually by carotid to
subclavian bypass, is mandatory in these patients if the
left SCA is covered. If surgical reconstruction is
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contraindicated and left SCA coverage is anticipated,
preoperative evaluation should include imaging to assess
patency of the right vertebral artery and continuity of the
circle of Willis.
Indications/Contraindications to
Procedure
Indications
Asymptomatic TAA/TAAA
The goal of surgical intervention for asymptomatic
TAA/TAAA is the prevention of rupture. The most
important risk factors for rupture for TAAs are size, rate
of expansion, and saccular morphology. Current criteria
for elective repair of asymptomatic TAA are maximum
diameter >5.5 or growth >5 mm over six months [2].
Blunt Aortic Injury (BAI)
TEVAR has largely replaced open repair as first‐line
surgical management for BAI. Traditionally, the goal has
been for definitive surgical repair as early as possible;
however, recent data has shown decreased risk of
mortality in delayed (>24 hours) repair.
Acute Aortic Syndromes
Type B aortic dissection (TBAD): First‐line treatment for
uncomplicated TBAD continues to be medical
management with tight blood pressure control. However,
TBAD with malperfusion may be treated with TEVAR
with the goal of sealing the proximal tear and allowing
reexpansion of the true lumen [3, 4]. Between 40 and
60% of TBAD which are treated with medical
management undergo aneurysmal degeneration of the
false lumen, requiring surgical intervention. There may
be a role for elective TEVAR in the subacute period. The
INSTEAD trial investigated treatment of subacute TBAD,
comparing those treated with endograft and medical
management. The data revealed that there was no
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