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I. ДИАГНОСТИКА И ЛЕЧЕНИЕ
ENDOVASCULAR TREATMENT OF THE COMPLICATED AORTO-ILIAC ANEURYSM IN HIGH RISK OF COMPLICATIONS OF AN OPEN OPERATION
Ormanov B.K., Matkerimov A.Zh., Mierbekov Ye.M., Sagatov I.Ye., Sydykov Ye.T., Abilkhanov Ye.Ye.
JSC "National scientific center of surgery named after A.N. Syzganov", Almaty, Kazakhstan
Abstract
Usually an aneurysm of the abdominal aorta is located below the level of the renal arteries, but in a number of cases it can be extended to iliac arteries. We present a case of the massive aorto-iliac aneurysm with high risk of intraop-erational and postoperational complications, a performed endovascular technique (EVAR) that has been divided into 2 stages.
МРНТИ 76.29.30
ABOUT THE AUTHORS
Ormanov Baurzhan Koszhanovich -
endovascular surgeon, baurlik@mail.ru
Askar Matkerimov - Head of Angiosurgery Department, oskar@mail.ru
Mierbekov Yergali Mamatovich - Chief Researcher, MD, Professor
Sagatov Inkar Ergalievich - Head of the Department of Management of Scientific, Innovation and International Cooperation, MD, inkar_sagatov@mail.ru
Sydykov Yerlan Turzhanovich - Resident of the 3rd course of cardiac surgery, including children
Abilkhanov Yerzhan Erganatovich - Resident of the 3rd course of cardiac surgery, including children
Keywords
aneurysm, aorto-iliac aneurysm, stent-graft, endoleak.
Ашьщ отаньщ жогары Kayini бар наукаска журпзшген колка-мыкын аневризмасыньщ эндоваскулярлык eMi
Орманов Б.К., Maткeрiмов А.Ж., Миербеков Е.М., Сагатов I.E., Сыдыков Е.Т., Эбшханов Е.Е.
«А.Н. Сызганов атында™ Улттык, шлыми хирургия орталь™» АК, Алматы, Казахстан
Ацдатпа
Эдетге колка аневризмасы буйрек кан тамырларынан теменг! децгейде кездесед!, б!рак кей жагдайларда мыкын кан тамырларына да ет!п кету! ыктимал. Б!з интра-жэне отадан кей!нг! аскынулардыцжогары кауштшю бар колка-мыкын аневризмасы кез!нде наукаска керсетшген 2 этаптан т±ратын эндоваскулярлык (EVAR) ем шаралары баяндалган.
АВТОРЛАР ТУРАЛЫ
Орманов Бауыржан Косжанулы -
рентгенохирург-дэр!гер, baurlik@mail.ru Маткер!мов Аскар Жексенбиулы -
ангиохирургия бел!'мшеа'нщ мецгерушid, oskar@mail.ru
Мешрбеков Ергали Маматулы - бас
еылыми кызметкер, м.ьд., профессор Сагатов 1цнкэр Ерралиулы - птыми, инновациялык кызмет менеджментi жэне халыкаралык катынастар бел1'мшщ басшы-сы, м.ьд., inkar_sagatov@mail.ru Сыдыков Ерлан Туржанулы - Резидент 3 курса кардиохирургии, в том числе детская
Эбшханов Ержан Ерганатулы -
Резидент 3 курса кардиохирургии, в том числе детская
ТуЙ1н сездер
аневризма, аорто-подвздоч-ная аневризма, стент-графт, эндолик.
Эндоваскулярное лечение осложненной аорто-подвздошной аневризмы с высоким риском осложнений открытой операции
Орманов Б.К., Маткеримов А.Ж., Миербеков Е.М., Сагатов И.Е., Сыдыков Е.Т., Абильханов Е.Е.
АО «Национальный научный центр хирургии им. А.Н. Сызганова», Алматы, Казахстан
Аннотация
Обычно аневризма брюшной аорты находится ниже уровня почечных артерий, но в ряде случаев она может распространится на подвздошные артерии. Мы представили случай массивной аорто-подвздошной аневризмы с высоким риском возникновения интра- и послеоперационных осложнений, при которой использована эндоваску-лярная техника (EVAR), разделенная на 2 этапа.
ОБ АВТОРАХ
Орманов Бауржан Косжанович - эндо-васкулярный хирург, baurlik@mail.ru Маткеримов Аскар Жексенбиевич - Заведующий отделением ангиохирургии, oskar@mail.ru
Миербеков Ергали Маматович - Главный научный сотрудник, д.м.н., профессор Сагатов Инкар Ергалиевич -
Руководитель отдела менеджмента научной, инновационной деятельности и международного сотрудничества, д.м.н., inkar_sagatov@mail.ru Сыдыков Ерлан Туржанович -Резидент 3 курса кардиохирургии, в том числе детская
Абилханов Ержан Ерганатович -
Резидент 3 курса кардиохирургии, в том числе детская
Ключевые слова
аневризма, аорто-подвздош-ная аневризма, стент-графт, эндолик.
Fig. 2.
CT picture of an aneurysm
Introduction
Aneurysm of the abdominal aorta is a consequence of a dilation of the aorta more than 3 sm or dilation more than 50% compared with the diameter of the aorta at the level of a diaphragm. In true aneurysm the pathological process involves all three layers [3, 4]. In absence of the corresponding treatment the proceeding dilation and the thinning of a vascular wall can finally lead to the rupture of aneurysm [11]. According to diverse data in case of the rupture of aneurysm the risk of the mortality is from 80 till 90%. In case of the aneurysm of 4-4,9 sm in size the risk of aneurysm rupture during the 1 year is 11%, but in case of the size of aneurysm more than 6sm the risk increases up to 25% [2]. Open surgical operation is still a gold standard in a treatment of an aneurysm of the infrarenal part of the abdominal aorta. It is a big operation including the removal of a dilated segment and implantation of the tissue transplantant. Open surgical treatment is performed in an urgent case after the rupture of
Fig. 1.
Internal iliac arteries occlusion with Amplatzer
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an aneurysm or it can be performed by choice [6]. Despite the improvement of a technical equipment of operation theatres and systematic approach, in spread forms of an aneurysm the risk of the intra-operational and postoperational complications remains rather high. Endovascular aneurysm repair (EVAR) is a procedure of the treatment of aortic aneurysm without necessity of the performing of an open operation. Endovascular implantation of the stent-graft is the most suitable method in complicated forms of aneurysms and in the presence of concomitant diseases in patients due to safety and miniinvasive approach [9].
Case report
78-year-old non-smoking woman was hospitalized into the department of vascular surgery with arterial hypertension, maximum AP is 180/110 mm per mercury. She complained of pains in abdomen, also presence of a pulsating structure in the meso-gastric region, increased arterial pressure. The CT scanning has shown the following changes: infra-renal aortic aneurysm with bilateral big aneurysm of the iliac arteries (Fig. 2). Maximum diameter of the aorta was 58mm, and the maximum diameter of the iliac arteries was 83 mm. CT scanning detected the signs of wall thrombosis in the proximal part of abdominal aneurysm.
According to words of the patient she had an episode of a falling from height (while taking the stairs), with appearing of painful feelings around umbilicus. In 1985 the patient had an episode of the myocardial infarction, since then he was observed by an ambulatory specialist, kept a basic therapy. He has Graves's disease in anamnesis. There was no hereditary predisposition. During the long time he suffered from the arterial hypertension with a maximum increase of the arterial pressure up to 180 mm per mercury. Because of the high risk of an open operative procedure, in connection with a concomitant pathology, increased body mass (BMI higher than 40), the patient was prepared for EVAR. Endovascular occlusion of the iliac arteries was performed as a first stage as othey were involved in a structure of an aneurysm and for following prevention of the blood stroke under the stent-graft, so called endoleakes. The right and the left internal iliac arteries were occluded using periphery occluders (St. Jude, Amplatzer) (Fig. 1) that has led to complete occlusion and in 2 weeks the patient was discharged from hospital with recommendations. In 3 weeks, he was hospitalized for stent-graft implantation. There was taken a system of stent implants like Endurant of the type II (Medtronic, Minneapolis, MN). The diameter of basic bodies: the proximal one - 32 mm, the distal one - 16mm, the length - 166 mm, it was delivered and implanted into the
lumen of the aorta and the iliac arteries. The right iliac branch was dilated using a balloon under pressure 16-13 atmosphere.
Because of the massive character of the aortic aneurysm and the left iliac artery the aorta became twisted, in connection with this there were some difficulties in implantation of the left stent-graft branch. It was agreed to aspirate the left axillary artery and deliver a trap of the wire loop. The hydrophilic conductor was delivered from the left femoral artery into the descending part of the aorta; the tip of the hydrophil-ic conductor was grabbed with a trap and pulled out into a lumen of the left branch of the basic graft. The hydrophilic conductor is replaced by a catheter to a hard conductor "Amplatz". The left branch 16-13-199 mm in size was delivered using a conductor along the left iliac end of the graft, and it was moved distally for 3sm forward from the aneurysm into external iliac artery. An oblong graft was chosen to decrease the risk of stent-graft dislocation. In postoperational period there were a wound maceration and lymphar-rhea. The general condition did not suffer, there was a subfebrile temperature. During the first week the condition improved, and the patient was discharged. In 1 year after the control CT-scanning showed the complete exclusion of the aneurysm. However, there was an enlarged left common iliac artery, but it decreased up to 62 mm in size (Fig. 4).
Discussion
Implanted graft dislocation is an often expected complication in giant aneurysms. The deeper sweeping graft should be used to prevent the dislocation in such a type of case rather than offered ones in operation manuals, especially in big aneurysms of abdominal aorta [5]. Endovascular method is one of the basic methods of the surgical treatment of the aortic aneurysm. The improvement of stent-grafts, delivery devices will lead to the improvement of results and safety of the method. Meanwhile it provides us hope and ambition in the treatment of complicated cases, when the neck of an aneurysm is short, thrombosed or hard to be manipulated under angle. In this clinical case there were several complex moments: such as aortic neck angle, big cavities of an aneurysm of the left iliac artery can cause endoleak of the II type in the postoperational period, the sharp decrease of the hematocrit, and the stent-graft dislocation is not excluded too [1, 7, 8].
Fig. 3.
CT picture of in 1 year after operation
Fig. 4.
CT angiography of the left iliac artery after operation
Conclusion
We have to regard several moments in big aneurysms: the diameter of a basic body of the stent-graft must be bigger than the neck of an aneurysm not less than 15-20%, we have taken the basic body 32 mm in size, the internal diameter of the neck of an aneurysm was 25 mm, therefore the index was 28%, and also the curve and the short neck of an aneurysm could have increased the dislocation risk. Therefore it is important to choose non-multicom-ponent grafts to exclude the possible sources of the endoleak of the 2 type after stent-graft implantation.
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