Kolvenbach, Ralf Robert

doi:10.1590/1677-5449.011417

Acessibilidade / Reportar erro

Brasil

Jornal Vascular Brasileiro

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

REVIEW ARTICLES • J. Vasc. Bras. 16 (4) • Oct-Dec 2017 • https://doi.org/10.1590/1677-5449.011417 copiar

Estratégias contemporâneas para reparo de aneurismas da aorta toracoabdominal: experiências reais e stents multilayer como alternativa

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

Aneurismas da aorta toracoabdominal apresentam desafios especiais no seu reparo devido à sua extensão, patologia distinta, e pelo fato de que tipicamente eles atravessam o óstio de um ou mais vasos de ramos viscerais. Historicamente, o tratamento estabelecido para aneurismas da aorta toracoabdominal foi o reparo em cirurgia aberta, com o primeiro procedimento relatado em 1955. O reparo endovascular de aneurismas da aorta toracoabdominal com endoenxertos fenestrados e/ou ramificados tem sido estudado desde o início deste século como meio de exclusão mecânica do aneurisma. Mais recentemente, stents moduladores de fluxo têm sido empregados com o objetivo de reduzir o estresse de cisalhamento na parede do aneurisma de aorta. Nesta revisão, apresentamos os principais resultados obtidos com essas técnicas, com base em revisão de literatura e experiência pessoal.

Palavras-chave:
aneurisma de aorta; cirurgia vascular; procedimentos endovasculares; stents; endoleak

Outcomes	Coselli et al. (Baylor)²⁰20 Coselli JS, LeMaire SA, Preventza O, et al. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg. 2016;151(5):1323-38. PMid:26898979. http://dx.doi.org/10.1016/j.jtcvs.2015.12.050. http://dx.doi.org/10.1016/j.jtcvs.2015.1... n = 3309	Murana et al. (St. Antonius)¹⁰10 Murana G, Castrovinci S, Kloppenburg G, et al. Open thoracoabdominal aortic aneurysm repair in the modern era: results from a 20-year single-centre experience. Eur J Cardiothorac Surg. 2016;49(5):1374-81. PMid:26612715. http://dx.doi.org/10.1093/ejcts/ezv415. http://dx.doi.org/10.1093/ejcts/ezv415... n = 542
Perioperative outcomes (≤ 30 days)
Crawford type	I, 914; II, 1066; III, 660; IV, 669	I, 128; II, 285; III, 62; IV, 48; V, 19
Operative death (≤ 30 days)	249 (7.5%)	46 (8.5%)
Spinal cord ischemia	178 (5.4%)	32 (5.9%)
Renal failure necessitating dialysis	250 (7.6%)	23 (4.2%)
Stroke	98 (3.0%)	23 (4.2%)
Respiratory failure	281 (8.5%)	42 (7.7%)
Myocardial infarction	41 (1.2%)	13 (2.4%)
Long-term outcomes
Mean follow-up		6.32 years
Freedom from repair failure	5 years: 97.9%±0.3% 10 years: 95.3%±0.6% 15 years: 94.1%±0.8%
Freedom from reintervention		1 year: 96.1%±0.1% 5 years: 86.3%±1.8% 10 years: 80.7%±2.3%
Estimated survival	1 year: 83.5%±0.7% 5 years: 63.6%±0.9% 10 years: 36.8%±1.0% 15 years: 18.3%±0.9%	1 year: 85.9%±1.5% 5 years: 74.2%±2.0% 10 years: 61.6%±2.5%

Outcomes	Verhoeven et al. (Paracelsus)²⁴24 Verhoeven EL, Katsargyris A, Bekkema F, et al. Ten-year experience with endovascular repair of thoracoabdominal aortic aneurysms: results from 166 consecutive patients. Eur J Vasc Endovasc Surg. 2015;49(5):524-31. PMid:25599593. http://dx.doi.org/10.1016/j.ejvs.2014.11.018. http://dx.doi.org/10.1016/j.ejvs.2014.11... n = 166	Eagleton et al. (Cleveland Clinic)²⁶26 Eagleton MJ, Follansbee M, Wolski K, Mastracci T, Kuramochi Y. Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysms. J Vasc Surg. 2016;63(4):930-42. PMid:26792544. http://dx.doi.org/10.1016/j.jvs.2015.10.095. http://dx.doi.org/10.1016/j.jvs.2015.10.... n = 354	Marzelle et al. (WINDOWS trial)³²32 Marzelle J, Presles E, Becquemin JP. Results and factors affecting early outcome of fenestrated and/or branched stent grafts for aortic aneurysms. Ann Surg. 2015;261(1):197-206. PMid:24670864. http://dx.doi.org/10.1097/SLA.0000000000000612. http://dx.doi.org/10.1097/SLA.0000000000... n = 268
Perioperative outcomes (≤ 30 days)
Crawford type	I, 12; II, 50; III, 53; IV, 41; V, 10	II, 128; III, 226	I, 2; II 16; III, 24; IV, 26
Target branch arteries	600	1305	1463
Technical success	157 (95%)	333 (94.1%)	230/252 (91.2%)
Operative death (≤30 days)	13 (7.8%)	17 (4.8%)	18 (6.7%)
Spinal cord ischemia	15 (9%)	31 (8.8%)	11 (4.1%)
Renal failure necessitating dialysis	9 (5.4%)	10 (2.8%)	15 (5.6%)
Stroke	2 (1.2%)	8 (2.3%)	5 (1.9%)
Respiratory failure	6 (3.6%)	32 (9.0%)	14 (5.2%)
Myocardial infarction	9 (5.4%)	10 (2.8%)	4 (1.5%)
Branch vessel occlusion	2 (1.2%)	4 (1.1%)	8/252 (3.2%)
Rupture	1 (0.6%)	1 (0.3%)	1 (0.4%)
Type I/III endoleak		10 (2.8%)	15 (5.6%)
Early reintervention	12 (7.2%)	13 (3.7%)	31 (11.6%)
Long-term outcomes
Mean follow-up	29.2±21 months	22±19 months
Estimated target branch vessel patency	1 year: 98%±0.6% 2 years: 97%±0.8% 5 years: 94.2%±1.5%	3 years: CA 96% (95%CI 0.93-0.99); SMA 98% (95%CI 0.97-1.0); RA 98% (95%CI 0.96-1.0)
Reintervention for endoleak	20 (12.0%)	67 (18.9%)
Freedom from reintervention	1 year: 88.3%±2.7% 3 years: 78.4%±4.5%	3 years: 54% (95%CI 0.47-0.61)
Estimated survival	1 year: 83%±3% 2 years: 78%±3.5% 5 years: 66.6%±6.1%	3 years: 57% (95%CI 0.50-0.63)

Outcomes	Vaislic et al. (STRATO multicenter)⁴⁰40 Vaislic CD, Fabiani JN, Chocron S, et al., and the STRATO Investigators Group. One-year outcomes following repair of thoracoabdominal aneurysms with the multilayer flow modulator: report from the STRATO trial. J Endovasc Ther. 2014;21(1):85-95. PMid:24502488. http://dx.doi.org/10.1583/13-4553R.1. http://dx.doi.org/10.1583/13-4553R.1... ^,⁴¹41 Vaislic CD, Fabiani J, Chocron S, et al., and the STRATO Investigators Group. Three-year outcomes with the Multilayer Flow Modulator for repair of thoracoabdominal aneurysms: a follow-up report from the STRATO trial. J Endovasc Ther. 2016;23(5):762-72. PMid:27280802. http://dx.doi.org/10.1177/1526602816653095. http://dx.doi.org/10.1177/15266028166530... n = 23	Benjelloun et al. (single-center Moroccan registry)⁴²42 Benjelloun A, Henry M, Taberkant M, Berrado A, Houati RE, Semlali A. Multilayer flow modulator treatment of abdominal and thoracoabdominal aortic aneurysms with side branch coverage: outcomes from a prospective single-center moroccan registry. J Endovasc Ther. 2016;23(5):773-82. PMid:27381934. http://dx.doi.org/10.1177/1526602816657087. http://dx.doi.org/10.1177/15266028166570... n = 18	Sultan et al. (initial MFM patients in 12 countries)⁴³43 Sultan S, Hynes N. One-year results of the multilayer flow modulator stent in the management of thoracoabdominal aortic aneurysms and type B dissections. J Endovasc Ther. 2013;20(3):366-77. PMid:23731310. http://dx.doi.org/10.1583/12-4077MR-R.1. http://dx.doi.org/10.1583/12-4077MR-R.1... ^,⁴⁴44 Sultan S, Sultan M, Hynes N. Early mid-term results of the first 103 cases of multilayer flow modulator stent done under indication for use in the management of thoracoabdominal aortic pathology from the independent global MFM registry. J Cardiovasc Surg. 2014;55(1):21-32. PMid:24356043. n = 103
Perioperative outcomes (≤ 30 days)
Indications	TAAA: II, 10; III, 13	TAAA: I, 4; II, 2; IV, 4; AAA: 8	TAAA: I, 11; II, 14; III, 26; IV, 24; arch aneurysms: 7; suprarenal AAA: 15; type B dissections: 6
Target branch arteries	55	61	378
Technical success	23 (100%)	18 (100%)	100 (97.1%)
Operative death (≤30 days)	0 (0%)	0 (0%)	0 (0%)
Spinal cord ischemia	0 (0%)	0 (0%)	1 (0.99%)^* * One successful deployment of a second MFM within the first 30 days, to correct for device retraction into the aneurysm sac caused by stent foreshortening; one conversion to open repair at 30 days to correct for proximal device infolding, the conversion complicated by postoperative paraplegia.
Renal failure necessitating dialysis	0 (0%)	0 (0%)	0 (0%)
Stroke	0 (0%)	0 (0%)	0 (0%)
Respiratory failure	0 (0%)	0 (0%)
Myocardial infarction	0 (0%)	0 (0%)
Branch vessel occlusion	2/55 (3.6%)	0 (0%)	0 (0%)
Rupture	0 (0%)	0 (0%)	0 (0%)
Type I/III endoleak	1 (4%)	0 (0%)
Early reintervention	1 (4%)	0 (0%)	2 (1.94%)^* * One successful deployment of a second MFM within the first 30 days, to correct for device retraction into the aneurysm sac caused by stent foreshortening; one conversion to open repair at 30 days to correct for proximal device infolding, the conversion complicated by postoperative paraplegia.
Long-term outcomes
Mean follow-up		13.4 months	11.6±3.3 months
Target branch vessel patency	1 year: 100% 2 years: 100% 3 years: 96.6% 4 years: 100%	1 year: 100%	1 year: 95.3%
Reintervention for endoleak	10 (43.5%)	1 (5.5%)
Freedom from reintervention			1 year: 89.3%
Cumulative mortality	1 year: 1 (4.3%) 2 years: 3 (13.0%) 3 years: 8 (34.8%) 4 years: 11 (47.8%)	1 year: 3 (16.7%)
Estimated survival			1 year: 86.8%

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[1] Conflicts of interest: No conflicts of interest declared concerning the publication of this article.