tevar for ruptured aortic infections - meet congressmeetcongress.com/pdf/meet2008/sunday june...
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TEVAR for ruptured aortic infections
Department of Cardiovascular Surgery 1), Radiology 2)
Kobe University Graduate School of Medicine
Department of Radiology, Kobe Redcross Hospital 3)
A. Kitagawa 1), Y. Okita 1) , K. Okada 1), Y. Morimoto 1), M. Matsumori 1), H. Munakata 1), M. Yamaguchi 2), K. Sugimura 2) K. Sugimoto 3)
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Background
Ruptured aortic infections caused by aortoesophageal
fistula (AEF) or aortobronchial fistula (ABF) are the life-
threatening diseases.
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Objective
We analyzed our results of TEVAR (thoracic
endovascular aortic repair) for ruptured aortic
infections.
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2000.1~2008.3
Number: 6 cases (male 3, female 3) Age: 63 ±7 years old (53 - 82 )Follow-up: 1.8 ±2.0 years (7days– 3.4 years)
Etiology: AEF 4ABF 1pyothorax 1
Patients’ Profile
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TEVAR for AEF (died on 163 POD)
1) TEVAR 2) 1days after TEVAR
before after
60 year-old, male , ULP in the chronic aortic dissection, with hematemesis
Esophagectomy withcervical esophagostomy,gastrostomy & jejunostomy
3) 14days after TEVAR
sepsis
EAB with removal ofinfected aorta & stent-graft
Case 1.
Abcess formationin the
pseudolumen
MRSA graft infection
Leakage fromthe esophagealfistula
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66 year-old, male with acute spondylitis (Streptococcus)TEVAR for AEF (survived)
<endoscopy>
1) before TEVAR 2) after TEVAR 3) Staged surgery day 3: EAB + arch division
Case 2.
aorta resectionesophagectomy
No stent-graft infection
day 8:
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53 year-old, male with pyothorax(pseudomonas) broncho fistula after lung surgeryTEVAR for aortic infection (survived)Case 3.
Stent-graft infection(pseudomonas)
Bleeding fromthe distal arch
1) before TEVAR 2) after TEVAR 3) Staged surgery day 3: EAB + arch division
aorta resectionesophagectomy
day 11:
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64 year-old, female , post op of esophageal cancerTEVAR for AEF(between the reconstructed gastric roll – aorta)
1) before TEVAR 2) TEVAR
before after
(esophagectomy with cervical esophagostomy)
Case 4.
Pseudoaneurysmat the aorta suture line(repair for the fistel)
Ao
Noinfectio
n
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82 year-old, female with massive hemoptysisTEVAR for ABF (survived)
1) before TEVAR 2) after TEVAR
Case 6.
No infection
Bleeding intothe left lung
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No. age gender Etiology stent-graft prognosispathogen1 additional procedure
2. Es: esophagostomy, Gs: gastrostomy, Js: jejunostomy
Summaryop time
1 60 M AEF Z stent diedMRSAEsophagectomyEs, Gs, Js 2
120
late mortality(cancer)
4 64 F Z stent none 120
survived5 72 F Z stent drainage 90
survived2 66 M MK stent(nitinol)
staged surgery Streptocoocus160
6 82 F Z stent none 140 None survived
survived3 53 M MK stent staged surgery Pseudomonas106
AEF
pyothorax
AEF
AEF
ABF
Candida
None
(fish bone)
(spondilytis)
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Initial success of TEVAR 6 (100 %)
Mortality: 30-day 0 ( 0 %)In-hospital 1 (16.7%)late 1 (16.7%)
(cancer)
Morbidity: stent graft infection 2 (33.4%)Case 1: died (MRSA)Case 3: survived (Pseudomonas)
(day 3 EAB, day 11 removal of stent graft)
Results
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Kaplan-Meier analysis
Actuarial survival Freedom from aortic event
(year) (year)
6 5 4 2 1 6 5 4 2 1
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Discussion
EVAR for mycotic aneurysm (Kan et al, JVS 2007)EVAR is a possible alternative to treat this pathology,However, aneurysm of rupture and fever is a significant independentrisk factor for persistent infection.
vsOpen surgery TEVAR
Benefits
Drawbacks
Complete exclusion ofinfected aorta & esophagussimultaneouly
Less invasive therapy
High morbidity & mortalitydue to surgical invasiveness
Immediate hemostasis to stabilize hemodynamics
Difficulty to control severe infection
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Staged hybrid therapy for aortic infection
1st : TEVAR= bridge to stabilize hemodynamics
2nd: Open surgery(EAB followed by removal of
infected aorta and esophagectomy)
to prevent persistent infection owing to stent graft infection
1st 2nd
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1) TEVAR was an excellent modality to achieveimmediate hemostasis in the ruptured aortic infections.
2) Staged hybrid therapy might be effective forthe ruptured aortic infections.
Conclusions