Cập nhật về xử trí bệnh lý động mạch chủ do nhiễm trùng

Updates on management of Infective Aortopathy Boonprasit Kritpracha, MD Prince of Songkla University Hat Yai, Thailand Prince of Songkla University Hat Yai, Thailand Infected Aneurysms Classification Mycotic aneurysms (from septic emboli) Microbial arteritis with aneurysm Infected prexisting aneurysms Post-traumatic infected false aneurysms Reddy DJ, Weaver MR “Infected Aneurysms” in Rutherford’s textbook of vascular surgery 2005, p 1581-96 Prince of Songkla University Hat Yai, Thailand Infected Aortic Aneurysms Diagnosis Fever Abdominal/back or chest pain A phase V phase Leukocytosis Characteristics in imaging studies Saccular aneurysm in normal-appearing vessel Inflammatory tissue around aorta Leakage Erosion of vertebral body Prince of Songkla University Hat Yai, Thailand Infected Aortic Aneurysms We are dealing with problems 1) Aortic infection 2) Weakened aortic wall that leads to rupture Antibiotics alone??? Prince of Songkla University Hat Yai, Thailand Infected Aortic Aneurysms Medical treatment is almost always failed 32 patients1: Medical treatment alone, mortality, 57% Operated-on, mortality, 28% Hsu RB et al J Vasc Surg 2008; 47:270-6 Prince of Songkla University Hat Yai, Thailand Retrospective study, 11 years (Jan 2000 – Dec 2010) 16 no aortic resection patients - medical treatment alone Hospital mortality 78% (7/9) deaths – ruptured aortic aneurysms sepsis stroke patients – EVAR + medical treatment Hospital mortality 0% Yu SY, et al; J Vasc Surg 2012;56:943-50 Prince of Songkla University Hat Yai, Thailand Infected Aortic Aneurysms Aug 28, 2008 5.3 cm 19 days Sep 16, 2008 8.5 cm Prince of Songkla University Hat Yai, Thailand Infected Aortic Aneurysms Dec 23, 2010 62x67 mm days Dec 26, 2010 68x76 mm Prince of Songkla University Hat Yai, Thailand Infected Aortic Aneurysms We are dealing with problems 1) Aortic infection 2) Weakened aortic wall that leads to rupture I Antibiotics alone does not work > 50% chance of MR Any other choices? Prince of Songkla University Hat Yai, Thailand Infected Aortic Aneurysms I Medical treatment alone - >50% MR II Surgical treatment – 30+% MR III Endovascular therapy - 50%1 II Endovascular therapy is the best choice Hsu RB et al J Vasc Surg 2008; 47:270-6 Prince of Songkla University Hat Yai, Thailand 83 yo female Massive upper GI bleeding, 7-cm arch aneurysm พริม่ 948765 Prince of Songkla University Hat Yai, Thailand 83 yo female Massive upper GI bleeding, 7-cm arch aneurysm Expired TEVAR + Carotid-carotid bypass + Carotid-L subclavian bypass + Innominate artery chimney พริม่ 948765 Prince of Songkla University Hat Yai, Thailand 50 y-o male Esophageal perforation from FB False aortic arch aneurysm สุวฒ ั น์ 1944757 Prince of Songkla University Hat Yai, Thailand 50 y-o male Esophageal perforation from FB False aortic arch aneurysm สุวฒ ั น์ 1944757 50 y-o male Esophageal perforation from FB False aortic arch aneurysm TEVAR + Carotid-L subclavian bypass + parenteral ATB + lifelong oral ATB 6-month PO สุวฒ ั น์ 1944757 Prince of Songkla University Hat Yai, Thailand ... Endovascular therapy of infected aortic aneurysms 90 cases: 72 males, 18 females Thoracic aorta 16 Thoracoabdominal average age 64 years (39-88) Excluded previous aortic surgery Thoracic & Abdominal... problems 1) Aortic infection 2) Weakened aortic wall that leads to rupture I Antibiotics alone does not work > 50% chance of MR Any other choices? Prince of Songkla University Hat Yai, Thailand... Infected Aortic Aneurysms I Medical treatment alone: >50% MR II Surgical treatment alone: >30% MR Endovascular therapy? Prince of Songkla University Hat Yai, Thailand Roles of EVAR in Infected Aneurysms