Η παρουσίαση φορτώνεται. Παρακαλείστε να περιμένετε

Η παρουσίαση φορτώνεται. Παρακαλείστε να περιμένετε

Κωνσταντίνος Γ. Μουλακάκης Επιμελητής Β Αγγειοχειρουργός, Αγγειοχειρουργική Κλινική, “ Aττικόν” Νοσοκομείο Κωνσταντίνος Γ. Μουλακάκης Επιμελητής Β Αγγειοχειρουργός,

Παρόμοιες παρουσιάσεις


Παρουσίαση με θέμα: "Κωνσταντίνος Γ. Μουλακάκης Επιμελητής Β Αγγειοχειρουργός, Αγγειοχειρουργική Κλινική, “ Aττικόν” Νοσοκομείο Κωνσταντίνος Γ. Μουλακάκης Επιμελητής Β Αγγειοχειρουργός,"— Μεταγράφημα παρουσίασης:

1 Κωνσταντίνος Γ. Μουλακάκης Επιμελητής Β Αγγειοχειρουργός, Αγγειοχειρουργική Κλινική, “ Aττικόν” Νοσοκομείο Κωνσταντίνος Γ. Μουλακάκης Επιμελητής Β Αγγειοχειρουργός, Αγγειοχειρουργική Κλινική, “ Aττικόν” Νοσοκομείο Μυκωτικά Ανευρύσματα – Μόλυνση Ενδοπρόθεσης 2014

2 "infected aneurysm" has gradually replaced the original designation "mycotic aneurysm“

3 Μυκωτικά Ανευρύσματα – Αιτιολογία και Παρ άγοντες Κινδύνου 1.Βακτηριακή Ενδοκαρδίτιδα (σηπτικά έμβολα) 2.Αρτηριακό Τραύμα, ή τραύμα του ενδοθηλίου (Τοξικομανείς, Στεφανιογραφίες, ΧΝΑ) 3.Φλεγμονή, Μικροβιαιμία (Ουρολοίμωξη, Πνευμονία, Εκκολπωματίτιδα) 4.Διασπορά από Φλεγμονή περιξ της αορτής (σπονδυλίτιδα, γαστρεντεριτιδα με προσβολή παραορτικών λεμφαδένων) 5.Διαταραχές ανοσοποιητικού συστήματος (70%) 6.Αθηροσκλήρωση (αποικισμός πλακών από μικρόβια)

4

5 Ο ρόλος της ενδαγγειακής αποκατάστασης στη θεραπεία των Μυκωτικών ανευρυσμάτων

6

7 21 patients, 17 abdominal and four thoracic infected aortic aneurysms were treated with an endovascular stent graft. Five patients presented with fistula complications, 1 aortoesophageal, 1 aortobronchial, 1 aortocaval, and 2 aortoenteric fistulas. J Vasc Surg 2011

8 The overall in-hospital mortality was 19% (4/21): 60% (3/5) in the fistula group and only 6% (1/16) in the nonfistula group. During the follow-up period, one of the two survivors in the fistula group died at 18 months from unrelated causes. there were no deaths in the 15 patients of the nonfistula group with an average patient follow-up of 22 months (range, 1-54

9  11 patients – endovascular repair of 13 MAAs  Aortic arch (n=1), descending TAA (n=4), suprarenal AAA (n=3), infrarenal AAA (n=5)  Mean follow-up 27 months Sorelius JVS 2009

10

11

12 Clough EJVES 2009 Retrospective case series 673 AAA – 19 (2.8%) infected 16 TAAs, 7 AAAs 6 RAA (32%) 15 (79%) positive blood cultures Staphylococcus aureus (+)

13 Clough EJVES 2009

14 Stroke (n=1), CSF drainage/ paraplegia (n=1) 30-day mortality = 11% Survival 20 months = 73% All 8 deaths aneurysm related! Overall Mortality in follow-up 42%

15 Patel JVS 2010 Retrospective case series 27 patients – TEVAR for infected aneurysm 26 high-risk for surgery

16 Patel JVS year survival 58.4% 27 patients

17 Endograft infection Graft infection after endovascular aneurysm repair (EVAR or TEVAR) is an underrecognized and underreported event. The incidence of aorto-iliac stent-graft infection ranges from 0.4% to 0.7% (1). Although rare, it may have devastating consequences. Mortality rates range from 25% to 100% 1.Setacci C. et al. Management of abdominal endograft infection. J Cardiovasc Surg T.W. Swain, et al. Management of infected aortic prosthetic grafts. Vasc Endovascular Surg S. O’Connor, et al. A systematic review and meta-analysis of treatments for aortic graft infection. JVS.2006 (0.6% to 3% for open aortic graft infection 2,3 )

18 Pathogenesis Bacterial inoculation during endovascular procedure Pre-existing -mycotic aneurysm or inflammatory aneurysm-, could result in intestinal necrosis and fistula formation Remote source of sepsis (eg, endocarditis, pneumonia, urinary tract infection) Cancer or immunodeficiency Repeated secondary procedures Stent migration Erosion of the aorta and the duodenum by embolization coils Fabric rupture ?? Erosion of the aorta by the hooks and barbs Endoleak and endotension may lead to aorto-enteric fistula formation ?? Stent Graft Related Setacci C. et al. Management of abdominal endograft infection. J Cardiovasc Surg. 2010

19 Clinical Presentation Low grade infection Systemic Sepsis Aortoenteric Fistula (41%) Abdominal or back Pain Abscess (psoas) Pseudonaurysm Urinary tract infection Low grade infection Systemic Sepsis Fistula (aortoesophageal or broncial) (38%) Chest Pain Abscess (periaortic) Pseudonaurysm Pneumonia, mediastinitis Aortic Endograft InfectionThoracic Endograft Infection 52% % 50% % Numan F. et al. Management of endograft infections. J Cardiovasc Surg. 2011

20 Εμπλεκόμενοι Μικροοργανισμοί St.Aureus 22% Streptococcus sp. 11% Multiple pathogens 21% Candida Ablicans, Mycetes 6% E.Coli Enterococci Pseudomonas, Serratia, Klebsiella, Ent.Cloacae 20-83% αναγνωρίζεται και ταυτοποιείται ο υπεύθυνος μικροβιακός παράγοντας Numan F. et al. Management of endograft infections. J Cardiovasc Surg Setacci C. et al. Management of abdominal endograft infection. J Cardiovasc Surg ↑f

21 Διάγνωση μολυσμένου Μοσχεύματος βαθμός υποψίας Καλλιέργειες Ενδοσκοπικός Ελεγχος (AEF) CT / MR PET CT Πυρηνικός Ελεγχος,Σπινθηρογράγημα

22 Απεικονιστική διάγνωση της λοίμωξης της ενδοπρόθεσης 18 FDG PET/CT

23 Management of Infected Endograft Depends on : 1.Patient’s clinical status 2.Co-morbidities 3.Presence of preoperative sepsis 4.Microorganisms involved

24 1. ΑΝΟΙΚΤΗ ΧΕΙΡΟΥΡΓΙΚΗ ΑΝΤΙΜΕΤΩΠΙΣΗ

25 Management of Infected Endograft Graft Excision & Extra-anatomic bypass Neo-aortoiliac System Procedure In Situ Aortic Graft Replacement (Homograft, Silver Graft) Graft Excision is the GOLD STANDARD Fiorani P, et al. Endovascular graft infection: preliminary results of an international enquiry. JEVT 2003 High mortality and morbidity rates, especially when undertaken in unstable, septic patients with severe comorbidities Variable results on patency and reinfection rates

26

27

28

29

30

31

32 Factors that may influence the feasibility of aortic stent-graft explantation The fixation system (hooks or barbs) the associated periaortic inflammatory reaction and endograft incorporation the presence of any additional grafts, cuffs, or coils placed as secondary interventions Technique of Aortic stent-graft explantation JEVT 2010

33 2. ΠΑΡΟΧΕΤΕΥΣΗ, ΧΕΙΡΟΥΡΓΙΚΟΣ ΚΑΘΑΡΙΣΜΟΣ, ΔΙΑΤΗΡΗΣΗ ΤΟΥ ΜΟΣΧΕΥΜΑΤΟΣ

34 Pryluck DS et al. Percutaneous drainage of aortic aneurysm sac abscesses following endovascular aneurysm repair.Vasc Endovascular Surg.2010 Deshmukh H. et al. Percutaneous management of complications (aortoenteric fistula and sac abscess) following bypass surgery for abdominal aortic aneurysm.Cardiovasc Intervent Radiol S.J. Hulin* and G.E. Morris.Eur J Vasc Endovasc Surg.2007 Management of Infected Endograft in High Risk patients for open repair Surgical or CT-guided percutaneous placement of drains into the aneurismal sac abscess contiguous to the graft, in conjunction with irrigation of the perigraft area followed by appropriate antibiotic therapy Promising results in patients without signs of severe sepsis

35 CT-guided percutaneous drainage followed by appropriate antibiotic therapy Pryluck DS et al. Percutaneous drainage of aortic aneurysm sac abscesses following endovascular aneurysm repair.Vasc Endovascular Surg.2010 Deshmukh H. et al. Percutaneous management of complications (aortoenteric fistula and sac abscess) following bypass surgery for abdominal aortic aneurysm.Cardiovasc Intervent Radiol Management of Infected Endograft in High Risk patients for open repair S.J. Hulin* and G.E. Morris.Eur J Vasc Endovasc Surg.2007

36 A 63-year old man, smoker Hostile abdomen Previous MI AF under oral anticoagulants COPD Severe obesity (BMI: 36.6) Symptomatic 8.1 cm pararenal abdominal aortic aneurysm multiple coils were deployed followed by biological glue infusion resulting in successful type Ia endoleak treatment….BUT EVAR 1 month CT type-Ia endoleak CASE 1

37 Endograft Infection Fever up to 39,4 C Lower back Pain Leucocytosis Increased CRP CTA Presence of air in the aneurysm sac cavity Blood Cultures: E.Coli and Ent. Faecalis Eight months later….

38 Percutaneous continuous drainage of aortic aneurysm sac abscess for 15 days CT- guided percutaneous continuous drainage followed by Vancomycin intrasac administration for 15 days Oral administration of moxifloxacin ( 400 mg daily dose x 30d) Mini-Laparotomy : Sigmoid detached from the inflammatory mass, omentoplasty.

39 CTA : No presence of air in the sac cavity Decrease of aneurysm sac diameter Patient remains asymptomatic, afebrile. WBC : 5.300, CRP:9 Follow-up at 18 months

40 Excision of the eroded part of the duodenum or the bowel and interposition of the omentum, without further aortic reconstruction, followed by antibiotic therapy. Management of Infected Endograft in High Risk patients for open repair 63-year old man Infection 3 years after EVAR. Patient presented unstable, with sepsis and massive bleeding due to AEF CASE 2

41 interposition of the omentum, without further aortic reconstruction Patient died on 3 rd postoperative day due to MOF

42 Πρόγνωση Θνητότητας λόγω Μόλυνσης του Ενδομοσχεύματος Fungal or gram negative species Presentation with severe sepsis AEF Bleeding requiring massive transfusion Advanced ASA physical status Age > 65 Renal insufficiency Stableford J. Endograft Infection after EVAR. October 2009

43 Ανασκόπηση της Βιβλιογραφίας 129 reported cases (36 post TEVAR, 93 post EVAR) Range of endograft infection 0.2-3% Mean Time to presentation 15.4 m (1-96 m) 33% Early 4 months Numan F. et al. Management of endograft infections. J Cardiovasc Surg Setacci C. et al. Management of abdominal endograft infection. J Cardiovasc Surg Cernohorsky P.,JVS 2011

44 AuthorPtsType of EndograftProcedure Schlensak C., JVS 20015Stentor 2, Vanguard 3EVAR Eggebrecht H., JEVT 20043N.D.TEVAR Sharif MA, JVS 20076Zenith 4, Talent 2EVAR Brown KE.,JVS 20086TAG 5, Cuff 1EVAR Girdauskas E,J.Thor.Card.Surg N.D.TEVAR Sarantzis N., JEVT 20085Ebdofit 3, Anaconda 1, Powerlink 1EVAR Heyer KS, JVIR TAG 4, Excluder 3, Zenith 2, Ancure 1 5 EVAR 5 TEVAR Kelso RL, JVS 20094Excluder 2, AneuRx 1, Ancure 1EVAR Chiesa R.,J.Card.Surg.20107Zenith 3, Endofit 1, TAG 1, Relay 1, N.D. 1 TEVAR Cernohorsky P.,JVS Zenith 3, Talent 92 TEVAR/ 10 EVAR Ανασκόπηση της Βιβλιογραφίας (Σειρές ≥ 3pts)

45 AuthorPtsManagementMortality Schlensak C.5 Stent Removal and Extra-an. BP (5)Not Described Eggebrecht H.3 Conservative (3)100% Sharif MA 6 Stent Removal and Extra-an. BP (3) Conservative (2) None (Early Death) (1) 50% Brown KE. 6 Stent Removal and Extra-an. BP (1) Conservative (1) Unknown (4) 66.6% Girdauskas E4 Stent Removal and reconstruction (4)25% Sarantzis N. 5 Stent Removal and Extra-an. BP (3) None (Early Death) (2) 60% Heyer KS 10 Stent Removal and Extra-an. BP (3) Conservative (4) Stent Removal and reconstruction (3) 30% 3/4 pts treated conservatively Kelso RL 4 Stent Removal and Extra-an. BP (2) Stent Removal and aortobifemoral (1) Inraoperative Death (1) 1 Death 3 Lost in FU Chiesa R. 7 Stent Removal and Extra-an. BP (1) Stent Removal and reconstruction (2) Conservative (1) None (periop. Death) (3) 71% Cernohorsky P.12 Surgical Repair (6) Conservative (6) 25%

46 Review of the literature Clinical Outcomes in 102 pts Overall Mortality 40.1% TEVAR 64.7%, EVAR 30.1% TEVAREVAR Surgical Treat.ConservativeSurgical Treat.Conservative Mortality(8/17) 47.1%(7/10) 70%17/ %(4/6) 66.6% Numan F. et al. Management of endograft infections. J Cardiovasc Surg. 2011

47 Review of the literature Clinical Outcomes in 102 pts EVAR- Surgical Repair Overall Mortality (17/60) 28.3% aorta ligation and extra anatomic BP (42) - Mortality (13/42) : 30.9% In situ reconstruction (18) - Mortality ( 4 /18) : 22.2% TEVAR - Surgical Repair Thor. aorta ligation and extra-anatom. BP (5) In situ reconstruction (9) Esophageal or bronchial repair (3) Overall Mortality (8/17) 47.1%

48

49

50

51

52 Μόλυνση Ενδομοσχεύματπος μετά από EVAR

53 AuthorStudy designType of procedure N of patients treated with endograft preservation Moulakakis et al, case series2EVAR, 1ch-EVAR3 Lyons et al, case seriesEVAR3 Faccenna et al, case reportAUI + fem-fem1 Lowe et al, case reportEVAR1 Solomon et al, case reportEVAR1 Kloppenburg et al, case reportEVAR1 Cernohorsky et al, Retr. cohort studyEVAR6 Gavens et al, case reportEVAR/TEVAR1 Morgan-Rowe et al, case reportFEVAR1 Van den Eynde et al, case reportEVAR1 Watkins et al, case reportEVAR1 Pryluck et al, case seriesEVAR2 Blanch et al, Retr. cohort studyEVAR1 Saleem et al, case reportEVAR1 Hulin et al, case reportEVAR1 Sharif et al, Retr. cohort studyEVAR3 Ghosh et al, case reportEVAR1 Ohki et al, Retr. cohort studyEVAR1 Total 30

54 Number of patients30 Gender (%male)94 Age (years, mean ± SE)72.8 ±8.4 Setting of the EVAR procedure ● Elective (%) ● Emergent (%) Reintervention (%)13 Time to infection (mean, days)360±81 Μόλυνση Ενδομοσχεύματπος μετά από EVAR

55

56

57

58 Infected Endograft as “bridging “ procedure after Aortoenteric Fistula

59

60 AuthorStudy designType of procedureN of patients Lyons et al, Retr. cohort studyTEVAR9 Muradi et al, case reportTEVAR1 Akkoyunlu et al, case reportTEVAR1 Cernohorsky et al, Retr. cohort studyTEVAR2 Motloch et al, case reportelephant trunk1 Numan et al, case reportTEVAR1 Ishikawa et al, case reportTEVAR1 Gavens et al, case reportTEVAR1 Chiesa et al, Retr. cohort studyTEVAR16 d'Ettorre et al, case reportTEVAR1 Eggebrecht et al, Retr. cohort studyTEVAR5 Isasti et al, case reportTEVAR1 Heyer et al, Retr. cohort studyTEVAR4 Martens et al, case reportTEVAR1 Bockler et al, Retr. cohort studyTEVAR1 Czerny et al, case reportTEVAR1 Total 47 Μόλυνση Ενδομοσχεύματπος μετά από TEVAR

61 Preservation of Endograft Number of patients 47 Gender (%male)75 Age (mean, years) 69.3 (95% CI 66.5 to 72.1) Setting of the procedure  Elective (%)  Emergent (%) Indication for TEVAR  Atherosclerotic aneurysm55.3%  Aortic dissection17.0%  Pseudoaneurysm following open aortic repair 14.9%  Mycotic aneurysm6.4%  Secondary AEF following open repair4.2%  Cutaneous left subclavian aneurysm fistula following radiotherapy 2.1% Time to infection (mean, days)292.5 (95%CI to 406.2)

62 Endograft preservation seems not a durable option. It can be offered to patients who refuse surgery or as a palliative option or bridging procedure for severely ill patients. The in-hospital mortality rate in group A was 42% and reached 81.8% in a mean follow-up period of 8.6 months. The in-hospital mortality rate in group B was 36.6%. Four (9.7%) further deaths due to reinfection or fistula recurrence were recorded in a mean follow-up period of 15.3 months, leading to an overall mortality of 46.3%.

63 Μόλυνση Ενδομοσχεύματος - Συμπεράσματα 1.Η ανοικτή αποκατάσταση αποτελεί gold standard σε ασθενείς με προσδόκιμο επιβίωσης, που συνοδεύεται με υψηλή θνητότητα 15-40%. (Υπάρχει πάντα κίνδυνος για υποτροπή της σήψης) 1.Η συντηρητική αντιμετώπιση με παροχέτευση και διατήρηση του μοσχεύματος θα πρέπει να γίνεται σε υψηλού χειρουργικού κινδύνου ασθενείς που δεν μπορούν να υποβληθούν σε ανοικτή επέμβαση 2.Η παροχέτευση και ο συνοδός χειρουργικός καθαρισμός έχουν καλύτερα αποτελέσματα σε σχέση με την αντιβιωτική αγωγή από μόνη της. 3.Η παρουσία επικοινωνίας, εκτεταμένης φλεγμονής-σήψης, είναι αρνητικός προγνωστικός παράγοντας για συντηρητική αντιμετώπιση με διατήρηση του μοχεύματος. 4.Σε συντηρητική αντιμετώπιση συνιστάται αντιβιωτική αγωγή εφ’ όρου ζωής

64 5. Στην μόλυνση μετα από TEVAR, η διατήρηση του μοσχεύματος έχει εξαιρετικά απογοητευτικά αποτελέσματα 6. Όταν συνυπάρχει επικοινωνία η ενδαγγειακή αποκατάσταση συνίσταται για τον έλεγχο της αομορραγίας, την βελτίωση της γενικής κατάστασης του ασθενή και σαν γέφυρα για μελλοντική εξαίρεση του μοσχεύματος. Μόλυνση Ενδομοσχεύματος - Συμπεράσματα


Κατέβασμα ppt "Κωνσταντίνος Γ. Μουλακάκης Επιμελητής Β Αγγειοχειρουργός, Αγγειοχειρουργική Κλινική, “ Aττικόν” Νοσοκομείο Κωνσταντίνος Γ. Μουλακάκης Επιμελητής Β Αγγειοχειρουργός,"

Παρόμοιες παρουσιάσεις


Διαφημίσεις Google