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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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difference in all cause mortality or aortic‐related
mortality between the two groups, and the risk of the
combined secondary outcome of rupture and progression
of disease was the same.
Penetrating aortic ulcer (PAU) and Intramural
hemorrhage (IMH): PAU and intramural hematoma are
two entities that are separate from TBAD but may
present with similar symptoms of acute chest/back pain
associated with hypertension. Some believe that the
three entities are on the same spectrum of disease;
however, the natural progression between the three
pathologies is unknown. A PAU, as the name implies, is
an atherosclerotic ulcer on the aortic wall that erodes
into the aortic wall, whereas an intramural hematoma is
a collection of blood between the intima and the media.
The natural history of these pathologies is not as well
understood as dissection, and thus the indications for
and timing of surgical intervention are still under
investigation.
Contraindications/Caveats
In patients with ideal anatomy, TEVAR seems to be the
preferred option for most cases, with current literature
demonstrating reduced morbidity and mortality.
However, data regarding long‐term (lifelong) follow‐up
for TEVAR patients is scarce. In younger, healthier
patients with a longer life expectancy, consideration can
be made for open repair. As stated previously, the
presence of challenging anatomy, such as involvement of
major aortic branches, large diameter neck, significant
angulation, or circumferential thrombus within the seal
zones, may make endovascular repair more difficult. In
these cases, a careful risk–benefit assessment must be
made, taking into account patient comorbidities and
surgeon experience. Endovascular stent grafting for
infected TAA is not recommended, but can be considered
for patients who are poor surgical candidates.
Available Endografts
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
1. Cook Zenith Alpha (Figure 4.2):
A. Stent/graft material:
Nitinol
Tightly woven Dacron
B. Lengths (cm):
Proximal straight: 10.5–23.3
Proximal with 4 mm taper: 10.8–23.3
Distal: 14.2–21.1
Distal extension: 9.1–11.2
C. Diameter (mm):
Straight proximal: 24–46
Proximal with 4 mm taper: 30–46
Distal: 28–46
D. Delivery sheath (Inner diameter):
16, 18, 20 Fr
E. Instructions for use:
Isolated lesions of the descending thoracic
aorta having vascular anatomy suitable for
endovascular repair:
Iliac/femoral anatomy that is suitable
for access with the required
introduction systems
Nonaneurysmal aortic segments
(fixation sites) proximal and distal to
the thoracic lesion
Length of at least 20 mm
Diameter measured outer wall to outer
wall of no greater than 42 mm and no
less than 15 mm.
Figure 4.2 Cook Zenith Alpha Graft.
2. Cook TX2 Dissection Graft (Figure 4.3):
A. Stent/graft material:
Stainless steel
Standard Dacron
B. Lengths (cm):
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Straight proximal: 7.9–21.8
Proximal with 4 mm taper: 15.4–21
Proximal with 8 mm taper: 15.6–21
C. Diameter (mm):
Proximal straight: 22–42
Figure 4.3 Cook TX2 graft and dissection
stent.
Proximal with 4 mm taper: 32–42
Proximal with 8 mm taper: 32–42
D. Delivery sheath (Inner diameter*):
20–22 Fr
E. Instructions for use:
Treatment of patients with atherosclerotic
aneurysms, symptomatic acute or chronic
dissections, contained ruptures, growing
aneurysms, and/or resulting in distal
ischemia, in the descending thoracic aorta
having vascular morphology suitable for
endovascular repair:
Adequate iliac/femoral access
compatible with the required
introduction systems
Radius of curvature greater than 35 mm
along the entire length of aorta
intended to be treated
Nonaneurysmal aortic segments
(fixation sites) proximal and distal to
the aneurysm:
With a length of at least 20 mm
With a diameter measured outer
wall to outer wall of no greater than
38 mm and no less than 20 mm
With an angle less than 45°.
3. Cook TX2 Dissection Stent:
A. Stent material
Nitinol
B. Lengths (cm):
8, 12, 18, 18.5
C. Diameters (mm):
36, 46
D. Delivery sheath (Inner diameter*)
16 Fr
E. Instructions for use:
Intended to be used as a distal component
to provide support to delaminated
segments of nonaneurysmal aorta with
dissection distal to a Zenith TX2 Dissection
Endovascular Graft in the descending
thoracic aorta having vascular morphology
suitable for endovascular repair:
Aortic fixation site diameter 20–38 mm
(measured outer wall to outer wall)
Radius of curvature >35 mm along the
length of aorta that is intended to be
treated
Localized angulation <45°.
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
4. Gore cTAG with Active Control (Figure 4.4):
A. Stent/graft material:
Nitinol
ePTFE
Figure 4.4 (a) and (b) Gore cTAG
endoprosthesis.
Source: W. L. Gore & Associates, Inc.
B. Lengths (cm):
10, 15, 20
C. Diameter (mm):
Straight: 21, 26, 28, 31, 34, 37, 40, 45
Tapered: 26 × 21, 31 × 26
D. Delivery sheath (Inner diameter):
18, 20, 22, 24 Fr
E. Instructions for use:
Repair of aneurysms of the descending
thoracic aorta in patients who have
appropriate anatomy:
Adequate iliac/femoral access
Aortic inner diameter in the range of 23–
37 mm
2 cm nonaneurysmal aorta proximal and
distal to the aneurysm.
5. Terumo Aortic Relay (Figure 4.5):
A. Stent/graft material:
Nitinol
PTFE sutures, woven polyester graft
B. Lengths (cm):
Straight: 10, 15, 20, 25
4 mm Tapered: 15, 20, 25
C. Diameter (mm):
Straight: 22–46
Proximal with 4 mm taper: 28–46
D. Delivery sheath (Outer diameter):
22, 23, 24, 25, 26 Fr
E. Instructions for use:
Repair of fusiform aneurysms and saccular
aneurysms/penetrating atherosclerotic ulcers
in the descending thoracic aorta in patients
having appropriate anatomy:
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Figure 4.5 Terumo relay aortic graft.
Source: Elsevier Inc.
Iliac or femoral access vessel morphology
that is compatible with vascular access
techniques, devices, and/or accessories
Nonaneurysmal aortic neck diameter in the
range of 19–42 mm
Nonaneurysmal proximal aortic neck
length between 15 and 25 mm
Nonaneurysmal distal aortic neck length
between 25 and 30 mm.
6. Medtronic Valiant (Figure 4.6):
A. Stent/graft material:
Nitinol
Woven polyester
B. Length (cm):
Straight: 5.5, 6, 10, 17.5, 22.5
Tapered: 17.5, 18.5, 20
C. Diameter (mm):
Straight: 20, 22, 25, 28, 31, 34, 37, 40, 43,
46
Tapered: 25, 28, 31, 34, 37, 40, 43, 46
D. Delivery sheath (Outer diameter):
18, 20, 22 Fr
E. Instructions for use:
Repair of all lesions of the descending thoracic
aorta in patients having the appropriate
anatomy:
Iliac or femoral artery access vessel
morphology that is compatible with
vascular access techniques, devices, or
accessories
Figure 4.6 Medtronic valiant thoracic
endograft.
Source: Vascular News.
Nonaneurysmal aortic diameter in the
range of 18–42 mm (fusiform and saccular
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
aneurysms/penetrating ulcers), or 18–44
mm (blunt traumatic aortic injuries), or
20–44 mm (dissections)
Nonaneurysmal aorta proximal and distal
neck lengths ≥20 mm (fusiform and
saccular aneurysms/penetrating ulcers),
landing zone ≥20 mm proximal to the
primary entry tear (blunt traumatic aortic
injuries, dissections)
The proximal extent of the landing zone
must not be dissected.
Preoperative Evaluation
The evaluation of the patient with TAA should begin with
a thorough history and physical examination. In
particular, history of cardiac, pulmonary, and renal
disease should be elicited. Routine preoperative
laboratory testing, EKG, and chest radiography should
be performed.
Cardiac evaluation: Due to the advanced age of the
population and prevalence of atherosclerotic risk factors,
a significant number of patients with TAA/TAAA have
concomitant cardiac disease. Preoperative
echocardiogram can be useful for assessing myocardial
and valvular function; however, the benefit of routine
use of cardiac echo in all TEVAR patients is
controversial. Patients who have signs or symptoms of
cardiac disease should undergo further evaluation to
determine the presence and extent of coronary artery
disease. If indicated, patients should undergo coronary
revascularization prior to or during TEVAR.
Pulmonary evaluation: The presence of COPD is directly
associated with increased perioperative mortality after
TEVAR. Preoperative testing including pulmonary
function tests and arterial blood gas should be routinely
performed. Smoking cessation, if applicable, should be
encouraged. Compliance to prescribed inhalers should
be ensured as this has been directly linked to mortality in
TEVAR patients.
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