O R I GI N AL AR T I CLE
En d ov a scu la r t r e a t m e n t of p op lit e a l a r t e r y a n e u r y sm
Fe r n a n d o T h o m a z i n h oI; Jo se M a n o e l d a Silv a Silv e st r eI I; W a n d e r Ed u a r d o Sa r d i n h aI I; Fe r n a n d o M o t t aI I I; I g o r Sch in ca r io l P e r o z i nI V; D o m i n g o s d e M o r a i s Filh oI I
IPh y sician , Vascu lar Su r g er y Ser v ice, Hosp it al Un iv er sit ár io Reg ion al d o Nor t e d o Par an á ( HURNP) , Lon dr in a, PR, Br azil.
I IPh D. Pr of essor , Vascu lar Su r g er y , HURNP, Lon dr in a, PR, Br azil. I I IResiden t , Vascu lar Su r g er y Ser v ice, HURNP, Lon d r in a, PR, Br azil.
I VMedical st u den t , Un iv er sid ad e Est ad u al d e Lon dr in a ( UEL) , Lon d r in a, PR, Br azil.
Cor r esp on d en ce
J Vasc Br as. 2 0 0 8 ; 7 ( 1 ) : 3 8 - 4 3 .
ABST R ACT
Ba ck g r o u n d : Th e m ost com m on ly occu r r in g an eu r y sm s in t h e p er ip h er y ar e t h ose in v olv in g t h e
poplit eal ar t er y . Th ey com p r ise 7 0- 8 0 % of all su ch an eu r y sm s. Con v en t ion al an eu r y sm r epair con sist s of eit h er op en in g t h e an eu r y sm sac an d in t er posin g a b y p ass gr af t or an eu r y sm ligat ion com b in ed w it h b y p ass gr af t in g. En d ov ascu lar t r eat m en t is an alt er n at iv e t o con v en t ion al r epair .
O b j e ct iv e : To ev alu at e u se of st en t gr af t in t h e en d ov ascu lar t r eat m en t of poplit eal ar t er y an eu r y sm s. M e t h o d s: We an aly zed 1 7 m ale pat ien t s; of t h ese, 1 1 w er e t r eat ed w it h en d ov ascu lar st en t gr af t , u sin g Hem ob ah n an d Viab ah n st en t gr af t s.
Re su lt s: On e pat ien t h ad p seu d oan eu r y sm in t h e im m ed iat e post oper at iv e per iod. Am on g lat e com plicat ion s, on e pat ien t h ad dist al en d oleak af t er 7 m on t h s, an d t h er e w as st en t gr af t occlu sion in an ot h er pat ien t . Th e r em ain in g n in e pat ien t s h ad sat isf act or y Dop p ler u lt r ason og r ap h y con t r ol at 2 0 m on t h s, w h ich r esu lt ed in a p r im ar y p at en cy of 9 0 % ov er m ean f ollow- u p t im e of 2 7 m on t h s.
Co n clu sio n : En d ov ascu lar r epair of a poplit eal ar t er y an eu r y sm is f easible an d h as som e ad v an t ag es com p ar ed w it h t h e op en t r eat m en t , su ch as sh or t er h ospit al st ay an d r ecov er y .
Ke y w o r d s: Per iph er al an eu r y sm s, poplit eal ar t er y an eu r y sm , en d ov ascu lar t r eat m en t .
R ESU M O
O b j e t iv o : Av aliar o u so d e en d op r ót ese p ar a o t r at am en t o en d ov ascu lar d o an eu r ism a d e ar t ér ia poplít ea.
M e t o d o l o g i a : Nu m t ot al d e 1 7 p acien t es, t od os d o sex o m ascu lin o, 1 1 f or am t r at ados p or t écn ica en d ov ascu lar , u t ilizan do- se p r ót eses Hem ob ah n e Viab ah n .
Re su l t a d o s: Um p acien t e ap r esen t ou p seu d o- an eu r ism a n o p ós- oper at ór io im ed iat o. Den t r e as
com p licações t ar dias, u m p acien t e ap r esen t ou en d o l ea k dist al d a p r ót ese ap ós 7 m eses, e h ou v e oclu são da en d op r ót ese em ou t r o. Os n ov e p acien t es r est an t es ap r esen t ar am con t r ole d e eco- Dop p ler
sat isf at ór io aos 2 0 m eses, r esu lt an d o em u m a p er v ied ad e p r im ár ia d e 9 0 % em u m per íodo m éd io d e 2 7 m eses d e seg u im en t o.
Co n cl u sã o : O t r at am en t o en d ov ascu lar p ar a an eu r ism a d e ar t ér ia poplít ea é f act ív el e ap r esen t a alg u m as v an t ag en s em r elação ao t r at am en t o aber t o, com o m en or t em p o d e in t er n ação e d e r ecu p er ação.
P a la v r a s- ch a v e : An eu r ism a per if ér ico, an eu r ism a d a ar t ér ia poplít ea, t r at am en t o en d ov ascu lar .
I n t r od u ct ion
Poplit eal ar t er y an eu r y sm s ( PAA) ar e t h e m ost f r equ en t of all per iph er al an eu r y sm s, accou n t in g f or 7 0-8 0 % of cases. Th ey u su ally occu r in m en ov er 6 5 y ear s, an d 5 0 % of t h em ar e bilat er al. Most pat ien t s ar e sy m p t om at ic in in it ial clin ical pr esen t at ion . Con v en t ion al PAA r epair con sist s of eit h er op en in g t h e an eu r y sm sac an d in t er posin g a b y p ass gr af t or an eu r y sm ligat ion com b in ed w it h b y p ass gr af t in g.
Ov er t h e past y ear s, en d ov ascu lar su r g er y h as b ecom e an alt er n at iv e t o op en r epair , sin ce it of f er s som e ad v an t ag es w h en com p ar ed t o op en su r g er y : less b lood loss, f ast er r ecov er y an d ear ly h ospit al disch ar ge.1
Th is st u d y aim ed at assessin g u se of st en t gr af t in en d ov ascu lar t r eat m en t of PAA.
M e t h o d
Fr om Jan u ar y 2 0 0 5 t o Oct ob er 2 0 0 6 , 1 7 pat ien t s w it h PAA w er e assessed . Th ey all h ad an eu r y sm w it h d iam et er > 2 cm an d dist al p r ox im al n eck > 1 cm .
Ex clu sion cr it er ia w er e pat ien t s y ou n g er t h an 5 0 y ear s, p oor dist al ar t er ial b ed ( ab sen ce of at least on e con t in u ou s t ibial ar t er y u n t il t h e f oot ) , pat ien t s con t r ain dicat ed f or plat elet an t iaggr egat ion an d / or sy m p t om s of v en ou s an d / or n er v ou s com p r ession , an d p r esen ce of acu t e isch em ia. Elev en pat ien t s (Table 1) w er e select ed f or en d ov ascu lar t r eat m en t , an d t h r ee w er e sy m p t om at ic ( ep isod e of dist al em bolizat ion ) . All pat ien t s select ed f or en d ov ascu lar t r eat m en t h ad at least on e p at en t con t in u ou s t ibial ar t er y u n t il t h e f oot . Th e r em ain in g six pat ien t s w er e ex clu d ed d u e t o acu t e isch em ia.
All pat ien t s w er e m ale, m ean ag e 6 4 y ear s ( 5 5- 7 2 ) . An eu r y sm d iam et er an d m ean ex t en sion w er e r espect iv ely 2 5 . 8 m m ( 2 2 . 9 - 3 2 . 1 ) an d 7 2 . 7 m m ( 5 5 . 3 - 1 1 0 ) .
Of pat ien t s su b m it t ed t o t r eat m en t , t h r ee h ad bilat er al PAA, an d t w o h ad b een su b m it t ed t o op en su r g er y in t h e con t r alat er al lim b ; on e w as n ot su b m it t ed t o su r g er y b ecau se t h e an eu r y sm in t h e ot h er lim b w as sm all ( < 2 cm in d iam et er ) an d w it h ou t par iet al t h r om b i.
an eu r y sm ex t en sion an d d iam et er s. Lat er , ar t er iogr aph y w as p er f or m ed t o assess p r ox im al an d dist al ar t er ial b ed .
Mat er ials u sed w er e Hem ob ah n an d Viab ah n st en t gr af t s ( W. L. Gor e & Associat es, I n c. , Flagst af f , Ar iz) . Th ese st en t gr af t s con sist of sev er al n it in ol st en t s in t er n ally cov er ed b y a t h in PTFE lay er . Hem ob ah n w as av ailable in a d iam et er of 9- 1 3 m m an d 5 , 1 0 an d 1 5 cm in ex t en sion , u sin g a 0 . 0 2 5 ' ' g u id e w ir e an d a r elease sy st em f r om p r ox im al t o dist al. Viab ah n is av ailable in 6- 8 m m d iam et er s, 0 . 0 3 5 ' ' g u id e w ir e an d r elease sy st em f r om dist al t o p r ox im al.
Th e com m on f em or al ar t er y w as ap p r oach ed b y dissect ion u n d er local an est h esia, w it h p assag e of a 9-1 2 Fr sh eat h u sin g an t er og r ad e ap p r oach , ex cep t f or a select ed case in w h ich t h e p r oced u r e w as
p er f or m ed ex clu siv ely u sin g p er cu t an eou s t ech n iq u e, sin ce it w as a 9 Fr sh eat h . Th e pat ien t s w er e g iv en 5 , 0 0 0 I U v en ou s h ep ar in . I n ch oice of st en t gr af t , m ean ov er d im en sion in g w as ap p r ox im at ely 2 0 % . I n cases t h at r equ ir ed m or e t h an on e st en t gr af t f or r epair , ov er lap p in g b et w een gr af t s w as 2 cm . I deal n eck , b ot h p r ox im al an d dist al, w as def in ed as t h at eq u al or h igh er t h an 2 cm in ex t en sion . How ev er , if t h e st en t gr af t dist al f ix at ion ar ea coin cid ed w it h t h e ar t icu lar in t er lin e, t h er e w ou ld b e r isk of st en t f r act u r e or gr af t occlu sion , w h ich w ou ld n ot occu r if t h at ar ea w as locat ed 2- 3 cm ab ov e t h e in t er lin e. I n cases in w h ich t h e dist al f ix at ion ar ea w as locat ed at t h e in t er lin e lev el, w e ch ose t o g o 2- 3 cm b ey on d t h e ar t icu lar lin e.
Th e pat ien t s w er e g iv en plat elet an t iaggr egat ion w it h clopidogr el 7 5 m g / d ay f or 3 0 d ay s an d ASA 2 0 0 m g / d ay .
Clin ical p at en cy cr it er ia w er e palpable dist al p u lses an d / or m ain t an en ce of an k le- br ach ial in d ex ( ABI ) or ABI r ed u ct ion < 0 . 1 5 r elat iv e t o t h e p ost op er at iv e per iod. Color- f low Dop p ler f ollow - u p w as p er f or m ed 3 0 d ay s af t er t h e pr ocedu r e, an d at ev er y 3 m on t h s t h er eaf t er , or bef or e, in case pat ien t s p r esen t ed at sy m p t om .
Re su lt s
At t h e 2 0 - m on t h f ollow - u p, n in e pat ien t s h ad sat isf act or y con t r ol con f ir m ed b y color- f low Dop p ler u lt r asou n d. Th ey w er e all f ollow ed at ev er y 3 m on t h s. Th e t h r ee pat ien t s w h o h ad em b olizat ion
( occlu sion of a leg ar t er y ) w er e n ot su b m it t ed t o em b olect om y b ef or e st en t gr af t p lacem en t , sin ce t h ey h ad at least on e con t in u ou s ar t er y u n t il t h e f oot an d did n ot h av e acu t e isch em ia.
p seu d oan eu r y sm in t h e com m on f em or al ar t er y , associat ed w it h h em od y n am ic in st abilit y , w h ich
r equ ir ed su r gical in t er v en t ion . An ot h er pat ien t h ad su per f icial su r gical sit e in f ect ion , su ccessf u lly t r eat ed b y or al an t ibiot ic t h er ap y .
Am on g lat e com p licat ion s, on e pat ien t h ad dist al em b olizat ion in leg ar t er ies d u e t o an eu r y sm sac r ef illin g cau sed b y dist al en d o l ea k . Th er e w as m ig r at ion of t h e st en t gr af t dist al ex t r em it y in t o t h e an eu r y sm sac; t h is p at ien t w as t r eat ed b y t h r om b oem b olect om y associat ed w it h f em or op op lit eal gr af t . An ot h er pat ien t h ad occlu sion r epair at 9 m on t h s, w h en t h e st en t gr af t w en t b ey on d t h e ar t icu lar in t er lin e; t h is p at ien t w as t h en su b m it t ed t o f em or opoplit eal b y p ass. Th er e w er e n o d eat h s d u r in g t h e st u dy ( Tab le 2 ) .
Mean h ospit alizat ion t im e w as 2 . 6 3 d ay s. Th e on ly pat ien t w h o n eed ed t r an sf u sion h ad p seu d oan eu r y sm an d t h e lon gest h ospit alizat ion t im e.
D iscu ssion
Clin ical m an if est at ion s of PAA in clu de acu t e ar t er ial t h r om b osis, dist al em bolizat ion , v en ou s an d / or n er v ou s com p r ession an d r u p t u r e, w h ich is a r ar e com p licat ion .2 Most PAA can b e clin ically d iag n osed w h en d iam et er is lar ger t h an 3 cm .3,4 I n ou r ser ies of pat ien t s, m ost PAA w er e f u sif or m , w h ich is in ag r eem en t w it h ot h er st u dies.5
Pr esen ce of PAA can b e su sp ect ed b y ph y sical ex am in at ion w h en t h er e is in cr eased pu lsat ilit y in t h e poplit eal f ossa. Vascu lar u lt r asou n d is t h e m ost u sef u l ex am in at ion t o con f ir m diagn osis, sin ce it n ot on ly assesses am ou n t of in t r alu m in al t h r om b u s, an eu r y sm an d u n af f ect ed ar t er y d iam et er , an eu r y sm
t h r om b osis an d ad j acen t v ein com p r ession , bu t also ex clu d es en t it ies su ch as Bak er ' s cy st . An g iog r ap h ic t om og r ap h y , m ag n et ic r eson an ce an d ar t er iogr aph y can b e p er f or m ed f or su r gical p lan n in g , w it h t h e aim of assessin g p r ox im al an d dist al ar t er ies.6Som e au t h or s con sid er an g iog r ap h ic t om og r ap h y as t h e best ex am in at ion f or t h at p u r p ose.7
Tr adit ion ally , sy m p t om at ic or asy m p t om at ic PAA w it h d iam et er lar ger t h an 2 cm sh ou ld b e su r gically t r eat ed. An eu r y sm s sm aller t h an 2 cm in d iam et er an d w it h ou t par iet al t h r om b i ar e con ser v at iv ely m an ag ed an d d eser v e ser ial f ollow - u p. Elect iv e r epair h ad lim b loss r at e < 5 % in a 1 0- y ear f ollow - u p .3 Kau f f m an et al.8d em on st r at ed t h e clear dif f er en ce in t h er ap eu t ic su ccess of su r gical t r eat m en t w h en t h e pat ien t is asy m p t om at ic, com p ar ed t o t h ose w h o h ad alr ead y h av e com plicat ion s. Th e m ain an d m ost f ear ed com p licat ion is acu t e ar t er ial occlu sion d u e t o an eu r y sm t h r om b osis, w it h h ig h r isk of lim b loss ( 4 0 - 5 0 % ) ,2,9 - 11ev en u sin g p r op er t r eat m en t .
Th e t ech n iq u e f or t r eat m en t of poplit eal ar t er y an eu r y sm in v olv es an eu r y sm ligat ion t o p r ev en t
em b olizat ion associat ed w it h gr af t an d t o r est or e ar t er ial con t in u it y , u su ally p er f or m ed t h r ou g h m ed ial access, w h ich also f acilit at es r em ov al of t h e g r eat sap h en ou s v ein as ar t er ial su bst it u t e.10, 12 How ev er , f or lar g e an eu r y sm s or f or t h ose t h at cau se com p r ession of ad j acen t st r u ct u r es, post er ior access is pr ef er r ed, w it h t h e pat ien t in t h e p r on e posit ion f or d ecom p r ession , an d t h e sm all sap h en ou s v ein can b e r em ov ed an d u sed as in t er p osed gr af t .
En d ov ascu lar t r eat m en t h as r ecen t ly b een an alt er n at iv e t o op en r epair , especially f or h ig h su r gical r isk pat ien t s. Mar in et al.19w er e t h e fir st t o p er f or m en d ov ascu lar r epair of PAA. Sin ce t h en , d u e t o
ad v an ces in m at er ials, p at en cy r at es h av e sign if ican t ly in cr eased. A t h eor et ical d isad v an t ag e of t h is t ech n iq u e is t h e an at om ic r egion , w h ich is locat ed in a post er ior posit ion in r elat ion t o t h e k n ee ar t icu lat ion ; t h er ef or e, im p lan t ed gr af t is su b m it t ed t o con st an t ph y sical st r ess an d h igh er r isk of occlu sion .
Galeg o et al. ,5in t h e st u d y m en t ion ed ab ov e, t r eat ed t w o pat ien t s u sin g t h e en d ov ascu lar t ech n iq u e; in on e of t h e pat ien t s, Palm az P2 9 4® st en t w it h PTFE w as u sed ; in t h e ot h er pat ien t , Cor v it a® w as u sed . Th e f ir st case h ad occlu sion in t h e im m ed iat e p ost op er at iv e per iod, r equ ir in g su r gical r epair . Kau f f m an et al. ,8 in t w o cases t r eat ed w it h t h e en d ov ascu lar t ech n iq u e, r ep or t ed occlu sion in b ot h cases, on e at 3 an d an ot h er at 1 1 m on t h s af t er t h e t r eat m en t ; h ow ev er , b ot h of t h em h ad p r op er cir cu lat or y
com p en sat ion , w it h n o n eed of addit ion al t r eat m en t . I n Br azil, Med eir os et al.20 h av e r ecen t ly r ep or t ed en d ov ascu lar t r eat m en t u sin g Hem ob an h an d Viab an h® in t w o pat ien t s w it h bilat er al poplit eal ar t er y an eu r y sm , b ot h w it h p r esen t dist al p u lses at h ospit al disch ar ge.
How ell et al.21 r ep or t ed st en t gr af t t h r om b osis in 3 1 % at 1 2 m on t h s in a t ot al of 1 3 an eu r y sm s t r eat ed b y Wallgr af t st en t s ( Bost on Scien t if ic, Nat ick , Mass) .4Tielliu et al.22 f ou n d p r im ar y an d secon d ar y p at en cy r at es of 7 7 an d 8 7 % at 2 y ear s w h en assessin g 5 7 cases t r eat ed b y Viab an h , a sligh t ly in f er ior r esu lt com p ar ed t o op en r epair . An t on elo et al. ,1 in a com p ar at iv e st u d y w it h con v en t ion al t r eat m en t , f ou n d p r im ar y an d secon d ar y p at en cy of 8 7 an d 1 0 0 % , r espect iv ely , f or en d ov ascu lar r epair , at 2 4 m on t h s, w it h lim b salv ag e r at e of 1 0 0 % .
As t o lim b salv ag e r at es, Au liv ola et al.23 d em on st r at ed bet t er in d ex es w h en t h e PAA is t r eat ed
elect iv ely , com p ar ed t o em er g en cy t r eat m en t . Ev en if gr af t an d / or st en t gr af t p at en cy is n ot ex cellen t in t h e lon g t er m , if it is possible t o m ain t ain it p at en t f or at least 1 y ear , lim b salv ag e r at es can b e
in cr eased .14
Mor e r ecen t ly , Cu r i et al.24 r ep or t ed p r im ar y an d secon d ar y p at en cy r at es of 8 3 an d 1 0 0 % at 2 4 m on t h s, r espect iv ely , w h en assessin g 1 5 cases of PAA t r eat ed b y en d ov ascu lar t ech n iq u e.
Use of plat elet an t iag g r eg at ion an d en h an cem en t of m at er ials im p r ov e p at en cy r at es. Th e m at er ial u sed in t h e p r esen t st u d y h as t h e ad v an t ag e of b ein g f lex ible. Th is is ex t r em ely im p or t an t , b ecau se t h e poplit eal ar t er y is locat ed in an ar ea of con st an t m ov em en t , w h ich p r ed isp oses t o f r act u r e of u sed dev ices.
Con clu sion s
To dat e, st u dies com p ar in g r esu lt s of en d ov ascu lar an d con v en t ion al t r eat m en t w er e m ost ly r et r ospect iv e an d in clu d ed sm all ser ies. Th er ef or e, f u r t h er p r osp ect iv e st u dies com p ar in g op en an d en d ov ascu lar t r eat m en t ar e n eed ed .
En d ov ascu lar t r eat m en t h as b een a f easible alt er n at iv e f or pat ien t s at in cr eased su r gical r isk . We st ill h av e t o k n ow , b ased on lon ger f ollow - u p st u dies, if t h is is also t h e t r eat m en t of ch oice f or pat ien t s at low su r gical r isk , con sid er in g t h at t h is t y pe of t r eat m en t h as lit t le in t er f er en ce w it h a f u r t h er op en t r eat m en t , in case of en d ov ascu lar t r eat m en t f ailu r e.
En d ov ascu lar t r eat m en t f or PAA is f easible an d h as som e ad v an t ag es com p ar ed t o t h e op en t r eat m en t , su ch as sh or t er r ecov er y an d h ospit alizat ion t im e.
1 . An t on ello M, Fr igat t i P, Bat t occh io P, et al. Op en r epair v er su s en d ov ascu lar t r eat m en t f or asy m p t om at ic poplit eal ar t er y an eu r y sm : r esu lt s of a p r osp ect iv e r an d om ized st u d y. J Vasc Su r g . 2 0 0 5 ; 4 2 : 1 8 5 - 9 3 .
2 . Low ell RC, Glov iczk i P, Hallet t JW Jr . , et al. Poplit eal ar t er y an eu r y sm s: t h e r isk of n on op er at iv e m an ag em en t. An n Vasc Su r g . 1 9 9 4 ; 8 : 1 4 - 2 3 .
3 . Daw son I , v an Bock el JH, Br an d R, , Ter p st r a JL. Poplit eal ar t er y an eu r y sm s: lon g t er m f ollow - u p of an eu r y sm al d isease an d r esu lt s of su r gical t r eat m en t. J Vasc Su r g . 1 9 9 1 ; 1 3 : 3 9 8 - 4 0 7 .
4 . Rog g o A, Br u n n er U, Ot t in ger LW, Lar g iad er F. Th e con t in u in g ch allen g e of an eu r y sm s of t h e poplit eal ar t er y. Su r g Gy n ecol Obst et . 1 9 9 3 ; 1 7 7 : 5 6 5- 7 2 .
5 . Galeg o GN, Silv eir a PG, Baceg a NR, et al. Ap r esen t ação clín ica e t r at am en t o cir ú r gico n a d oen ça an eu r ism át ica d a ar t ér ia poplít ea. An giol Cir Vasc. 2 0 0 2 ; 1 1 : 1 1 9 - 2 5 .
6 . Mor r is- St iff G, Hay n es M, Og u n b iy i S, et al. I s assessm en t of poplit eal ar t er y d iam et er in pat ien t s u n d er g oin g scr een in g f or ab d om in al aor t ic an eu r y sm s a w or t h w h ile p r oced u r e. Eu r J Vasc En d ov asc Su r g . 2 0 0 5 ; 3 0 : 7 1 - 4 .
7 . Eb au g h JL, Mat su m u r a JS, Mor asch MD, Pear ce WH, Nem cek AA, Yao JS. Mor p h om et r ic an aly sis of t h e poplit eal ar t er y f or en d ov ascu lar t r eat m en t. Vasc En d ov ascu lar Su r g . 2 0 0 3 ; 3 7 : 2 3- 6 .
8 . Kau f f m an P, Pu ech- Leão P. Tr at am en t o cir ú r gico d o an eu r ism a d a ar t ér ia poplít ea: ex p er iên cia d e 3 2 an os. J Vasc Br as. 2 0 0 2 ; 1 : 5 - 1 4 .
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