Αγγειακές Επιπλοκές στη Διαµηριαία και Διαορτική Αντικατάσταση της Αορτικής Βαλβίδας Σ. Δάρδας 1,2, Δ. Τσικαδέρης 1, Ε. Θεοφιλογιαννάκος 1, Τ. Κέλπης 1, Α. Πίτσης 1, Ν. Μεζίλης 1, Β. Νινιός 1, Π. Δάρδας 1 Κλινική Άγιος Λουκάς, Θεσσαλονίκη και Kettering General Hospital, Kettering Leicestershire, UK
Σκοπός Η διακαθετηριακή αντικατάσταση της αορτικής βαλβίδας αποτελεί πλέον µια καταξιωµένη µέθοδο για την αντιµετώπιση ασθενών υψηλού χειρουργικού κινδύνου µε σοβαρού βαθµού στένωση της αορτικής βαλβίδας. Σκοπός αυτής της εργασίας είναι να αναλυθούν οι αγγειακές επιπλοκές της µεθόδου στη δική µας σειρά ασθενών δεδοµένου ότι η επιπλοκή αυτή έχει συσχετισθεί µε παράταση της νοσηλείας, αύξηση του κόστους και της θνητότητας των ασθενών.
From: Management of Vascular Access in Transcatheter Aortic Valve Replacement: Part 2: Vascular Complications J Am Coll Cardiol Intv. 2013;6(8):767-776. doi:10.1016/j.jcin.2013.05.004 FREQUENCY 1.9-17.3% Table Title: Vascular Access and Complication Rate in Larger Series ( 100 Patients) of Predominantly Transfemoral Transcatheter Aortic Valve Implantation Date of download: 4/6/2016 Copyright The American College of Cardiology. All rights reserved.
Vascular Complications of the Iliofemoral Arteries Major predictors of iliofemoral vascular complications small vessel dimensions (sheath-to-femoral artery ratio >1.05) moderate or severe iliofemoral calcification center experience
From: Vascular Complications After Transcatheter Aortic Valve Replacement: Insights From the PARTNER (Placement of AoRTic TraNscathetER Valve) Trial J Am Coll Cardiol. 2012;60(12):1043-1052. doi:10.1016/j.jacc.2012.07.003 Figure Legend: Distribution of Type of Major Vascular Complications After Transcatheter Aortic Valve Replacement Vascular dissection, vessel perforation, and access site hematoma were the most frequent causes of major vascular complications. Date of download: 10/15/2014 Copyright The American College of Cardiology. All rights reserved.
64 Ασθενείς Μέθοδος Μέση ηλικία 82±5 έτη 64 Ασθενείς 60 ΔΙΑΜΗΡΙΑΙΑ 4 ΔΙΑΟΡΤΙΚΗ 30 ΑΝΤΡΕΣ 34 ΓΥΝΑΙΚΕΣ Σοβαρού βαθµού στένωση της αορτικής βαλβίδας Εκφύλιση βιοπροσθετικής βαλβίδας Συσκευή σύγκλεισης της µηριαίας αρτηρίας: 10 (15,66%) Prostar 54 (84,33%) Proglide
Αποτελέσµατα Κανένας ασθενής της δια-αορτικής προσπέλασης δεν εµφάνισε κάποια αγγειακή επιπλοκή. ΔΙΑΜΗΡΙΑΙΑ ΠΡΟΣΠΕΛΑΣΗ: 9 (15%) εµφάνισαν αγγειακές επιπλοκές (οµάδα Α) 51 (85%) δεν εµφάνισαν αγγειακές επιπλοκές (οµάδα Β) Έγινε στατιστική ανάλυση µε χ2 Συσχέτιση P value Φύλο 0.17 Στεφανιαία Νόσος 0.94 Είδος συσκευής σύγκλεισης 0.35 STS Score 0.65 Διάµετρος Μηριαίας Αρτηρίας 0.37 Θνητότητα 0% Ανάγκη Χειρουργείου 0% Τύπος Αγγειακής Επιπλοκής: 1 Ασθενής: ρήξη ρίζας Αορτής 1 Ασθενής: θρόµβωση µηριαίας 1 Ασθενής: διαχωρισµός µηριαίας 1 Ασθενής: ψευδοανεύρυσµα 5 Ασθενείς: ρήξη µηριαίας Η µέση νοσηλεία των ασθενών µε αγγειακή επιπλοκή ήταν 7,5±2,27 µέρες,ενώ η µέση νοσηλεία των υπολοίπων ήταν 7,19±2,71 µέρες.
Iliofemoral dissection prolonged inflation of a balloon with appropriate diameter results in successful apposition of the intima and underlying media more extensive dissection may warrant selfexpanding or balloon-expandable stent deployment or a surgical graft mortality of iliofemoral dissection is low
DISSECTION
BALLOON POST BALLOON
Vascular Perforation Aorta Iliac vessels Contributing Factors - Sheath to vessel diameter - Female gender - Tortuosity - Calcification - Location of Calcification
Bailouts Rupture Endovascular Repair Open Repair (Endovascular rescue)
RUPTURE RUPTURE BALLOON
POST BALLOON COVERED STENT
FINAL
Complications Associated With Femoral Access Acute Vessel Closure DO NOT hold fully occlusive pressure on a severely diseased artery for more than 10 minutes Do not deploy closure devices in a significantly diseased femoral artery Assess distal pulses before and immediately after hemostasis is complete to assure no new compromise has occurred If patient complains of foot/leg pain or numbness consider acute vascular compromise! this is an EMERGENCY SCRIPPS CLINIC
THROMBOSIS PRE THROMBOSIS
BALLOON POST BALLOON
FINAL after prolonged balloon inflation
Aortic rupture Acute or delayed aortic annular rupture is a rare (0-2%) but serious complication with a very poor prognosis, even if emergent surgery is performed Annular rupture may occur after balloon valvuloplasty after valve implantation (more frequently with balloon-expandable valves)
Predictors Post dilation Oversizing 20% Calcifications (LVOT-Sub annular) Annulus Eccentricity? Prevention: Sizing/Slow inflation/self Expandable if adverse features present
History 88 female Hypertensive - hyperlipidemic History of LOC syncope Echo: severe AS AV gradient 90 mmhg Good LV LVH 2D echo before TAVI LHC: Normal cors
EUROSCORE 31.3% Iliacs 8mm Femorals 7mm Annulus : 2.4 x 1.9 mm Mean annular diameter: 2.32 mm Transfemoral TAVI - EVOLUT R 26 mm
Immediately post deployment: incomplete apposition and moderate AR
Post dilation semi-compliant balloon 22mm
Immediately post dilatation patient became hypotensive; A large pericardial effusion with tamonade was noted; Aortogram showed intraannular rupture with minimal residual AR Tamponade Intraannular rupture
Patient was treated conservatively with pericardial drainage, heparin reversal, interruption of all antithrombotics- antiplatelets and immobilization. In consultation with cardiac surgeons and getting advice from TAVI forum, we did not start any antithrombotics-antiplatelets for 6 days Pericardial effusion disappeared and drain removed day number 5 Day number 6, patient developed TIA with dysphasia, CT was normal; started on Aspirin and TIA resolved completely. She started mobilization. Day number 12, patient developed signs of pulmonary embolism. CT showed left lower lobe thrombi. CT aortogram did not show paraaortic false aneurysm. She was started on heparin and clinical picture improved
Patient discharged day number 14 on aspirin and subcutaneous heparin 2 months later remains fully asymptomatic Echo shows no pericardial fluid and minimal AR Subcutaneous heparin is stopped; patient remains on long term aspirin 2D echo 2 months later no pericardial fluid Colour echo 2 months later minimal paravalvular AR
Vascular Complications: What can we do to prevent them? Appropriate screening Angio CT scan/ivus Respecting iliac and femoral diameter Calcium Tortuosity Adjunctive techniques US guided puncture Cross-over balloon occlusive technique (CBOT)
Συµπέρασµα Οι αγγειακές επιπλοκές κατά τη διαδερµική αντικατάσταση της αορτικής βαλβίδας είναι σχετικά συχνές. Αφορούν κυρίως τη µηριαία αρτηρία και η αντιµετώπισή τους είναι άριστη µε διαδερµική µέθοδο και χωρίς ανάγκη χειρουργικής αντιµετώπισης.