Vaskulárna medicína 2-3/2018

Percutaneous endovascular aortic therapy – from and where we go?

Objective: Aim of our study was to compare selected parameters of the percutaneous endovascular aortic therapy (PEVAR) in patients of Cinre Hospital, in the period from 10 months (from 1.1. to 1.11.2018). We compared selected parameters of similar technically difficult PEVAR procedures, in order to identify and quantify the potential gain of 3D navigation PEVAR (nPEVAR) in comparison to the current 2D PEVAR navigation. Material and methods: During the reported period, we gradually analyzed the various data (duration of PEVAR, dose of ionizing radiation on the patient/doctor, contrast burden for patient, occurrence and analysis of early/late complications, periprocedural blood loss and the differences in accuracy to the optimal interventional simulation) related to the nPEVAR and compared them in an environment of indirect PEVAR, without radiation/spinal protection staff. For the representation of a variety of technically difficult and challenging PEVAR reconstructions, we tracked and compared the whole spectrum of nPEVAR procedures in 37 selected patients: thus the simple PEVAR aneurysms of the thoracic or abdominal aorta, aortic dissections, complex thoracoabdominal PEVAR procedures, adverse anatomy of the aortic landing zones, flowmodulator implantation, as well as aortic stenotic lesions. Monitored and analyzed were also data from the PEVAR procedure in different clinical stages of the aortic dissease, including acute aortic syndromes and ruptures of the aorta. Results: Ongoing part of the study is the extensive analysis of data in progress. On the basis of preliminary collected data in Cinre, the nPEVAR with the use of FO in comparison with PEVAR without, or with indirect visual navigation, as well as the use of the Zero gravity radiation protection and spinal protection led to substantial percentage reduction and the difference between the two procedures. In the parameter of the length and duration the nPEVAR was associated with a 30-40% reduction of the overall duration of the procedure and 40-60% reduction of fluoroscopy times in comparison with the PEVAR in 2D navigation. In doses of ionising radiation for the patient, there was a reduction in the range of 40-60% in favour for nPEVAR, reduction of radiation on the operator reached 30-40%. The absolute major differences were in the reduction of radiation dose to the operating staff in the case of nPEVAR combined with the use of Zero gravity radiation protection. In this case was the radiation dose compared with a simple PEVAR for staff reduced by 90 %! In the next reported parameter of contrast burdens for the patient, the reduction of the admitted contrast volume ranged from 50 to 90%, according to the complexity of anatomy and always in favor of nPEVAR. Even in appropriate anatomical conditions, it is possible to navigate and perform nPEVAR with zero contrast, followed by early native dynaCT and ultrasound control. Periprocedurál blood losses were in the case of nPEVAR reduced in the range of 20-25%. Conclusion: Until now was EVAR and PEVAR performed under the control of the 2D image fluoroscopy, however the latest technological possibilities can open to EVAR and PEVAR the new third dimension - 3D navigated PEVAR (nPEVAR) using FO linked the 3D dimension of the MDCT/CBCT image with fluoroscopy. This enabled us to achieve 100% technical success rate even in complex procedures. With nPEVAR navigation is the incidence of complications of this 3D navigated miniinvasive treatment of aortic diseases closer to zero. PEVAR in the new conditions, with the use of nPEVAR and FO, significantly increases the accuracy, safety and effectiveness of previous treatment possibilites, reducing early and late complication rates, and shifts the future of EVAR/PEVAR to the next new dimension.

Keywords: percutaneous endovascular aortic therapy, center of interventional neuroradiology and endovascular therapy, navigation, image fusion, zero gravity