Spontaneous rupture of abdominal aortic aneurysm after successful

ROTTURA “TAMPONATA”
DI AAA DOPO EVAR
Dott.A.Sanna
U.O Chirurgia Generale
Ulss 17
Dir. Prof.M.Frego
Anamnesi
• Uomo, 59 anni
• Ex fumatore, iperlipemia mista
• Iperteso, importante cardiopatico
1987 IMA con residua acinesia ant. ventricolo sin
1990 Triplice bypass aorto-coronarico, aneurismectomia
ventricolo sin, Coumadin, Lanoxin, Adalat
1995 Colecistectomia laparotomica
Febbraio 2000 diagnosi di AAA Ø 6 cm,
trattam. endovascolare
in altra sede: “Vanguard” retta
ictus minor p.o.
endoleak tipo I all’ angiotac p.o.
Agosto 2000 re-trattamento endovascolare con
protesi “Excluder” biforcata
Febbraio 2001 controllo angiotac: regolare esclusione
aneurismatica
3 luglio 2001ore 18.40’ RICOVERO D’URGENZA IN ALTRA
SEDE PER “ADDOME ACUTO”
forti algie addominali da 3 ore, vomito
ADDOME: disteso ma trattabile, diffusamente dolente,
ernia inguino-scrotale destra incarcerata
Rx diretta :
discreta distensione di anse del tenue, colon
trasverso meteorico, non falci d’aria ...
endoprotesi aortica tortuosa
ECOGRAFIA e Rx TORACE: negativi…
LABORATORIO: WBC:17.610; RBC: 4.530.000;
HB: 14,4 g; HCT: 43,1%;PLT: 186.000
PT 40%
ore 19.50’ (t=70’)
DIAGNOSI: occlusione intestinale da ernia inguinoscrotale strozzata
RIDOTTA MANUALMENTE CON DIFFICOLTA’
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LAPAROTOMIA ESPLORATIVA
emoperitoneo 300 cc
ematoma retroperitoneale !!!!
DIAGNOSI: rottura di AAA
emodinamica stabile
TRASFERIMENTO URGENTE IN
1a CLINICA CHIRURGICA, PADOVA
REINTERVENTO CHIRURGICO
4 luglio 2001 ore 01:05 (t=525)
CLAMPAGGIO SOPRARENALE
25’
ROTTURA ANT. TAMPONATA DALL’ENDOPROTESI
NON SANGUINANTE !
ESTRAZIONE ENDOPROTESI
ROTTURA STENT
PROSSIMALE !
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emodinamica sempre stabile
rottura anteriore AAA tamponata dall’endoprotesi !
rimozione endoprotesi e innesto aortico retto Ø 18
ernioplastica inguinale dx intraperitoneale
emorecupero 600 cc
TEMPO TOTALE DALLA ROTTURA
9 ORE CIRCA !
INCIDENCE AND RISK FACTORS OF LATE RUPTURE ,
CONVERSION AND DEATH AFTER ENDOVASCULAR
REPAIR OF AAA : THE EUROSTAR EXPERIENCE
Harris PL, J Vasc. Surg, Oct 2000
• 2.464 pts , mean follow up 12,19 months
• Cumulative risk of rupture 1% per year
• Significant risk factors for rupture: proximal type
I and III leaks, graft migration and kinking
• Cumulative risk of late conversion 2,1% per year
• Global risk of failure 3% per year
RUPTURED ABDOMINAL AORTIC ANEURYSM
AFTER ENDOVASCULAR REPAIR
Bernhard VM, J Vasc. Surg, Juin 2002
• 5/686 EVT first generation, mean follow-up 42 mths
• 2/3260 EVT market approved, specifically in the
subgroup of 166 tube grafts (37,5 months)
• overall mortality 4/7 (57%) and surgical
mortality 3/6 (50%)
• LITERATURE SEARCH : 40 additional ruptures of
other devices, mainly due to type I and III leak, with
an overal mortality 50% and operative mortality 41%
• CONCLUSION: outcome of postendograft rupture is
similar to rupture without prior endograft therapy
Complications in endovascular repair of abdominal aortic
aneurysms: treatment and prevention.
2011
re-intervention rate 10.4% (29/279)
overall complication rate 12.9% (36/279)
including endoleak 5.7% (16/279)
stent-graft migration 1.1% (3/279)
aneurysm expansion or rupture 5.4% (15/279)
limb occlusion 2.5% (7/279)
stent-graft infection 1.4% (4/279)
Chronic contained abdominal aortic aneurysm
rupture after suprarenal fixation fatigue fracture
• 20 days before his admission to our hospital, he had undergone a
secondary iliac limb extension for treatment of post-EVAR rupture.
• On admission, abdominal plain radiography identified suprarenal
fixation fracture as a possible reason for CCR, but computed
tomographic angiography failed to confirm any endoleak or "active"
bleeding and rupture.
• The patient received medication treatment for possible diverticulitis
and was kept under close monitoring for suspected failure of recently
performed secondary endovascular procedure and CCR
.
Ptoulias GA et al. Ann Vasc Surg. 26(7) 2012 oct
Chronic contained abdominal aortic aneurysm
rupture after suprarenal fixation fatigue fracture
A day later, the abdominal pain symptoms
worsened, and a new computed
tomographic angiography confirmed the
suspected CCR. The patient was treated
successfully by "open" repair using a Y
prosthesis
Ptoulias GA et al. Ann Vasc Surg. 26(7) 2012 oct
Chronic contained abdominal aortic aneurysm
rupture after suprarenal fixation fatigue fracture
Lifelong post-EVAR follow-up with high
level of both clinical and imaging
diagnostic accuracy is essential for the early
recognition and proper treatment of EVAR
pitfalls.
Ptoulias GA et al. Ann Vasc Surg. 26(7) 2012 oct
Conclusione
Possibile effetto tamponamento parziale
dell’endoprotesi
Conclusione
Presentazione clinica anomala!!!