22.17
Anévrisme III : Prise en charge interprofessionnelle
La prise en charge des anévrismes implique soit une thérapie médicale conservatrice, soit une intervention chirurgicale, selon la taille et les symptô…
La prise en charge des anévrismes implique un traitement conservateur pour les petits anévrismes asymptomatiques, généralement de moins de 5,5 centimètres de diamètre.
Il comprend la modification des facteurs de risque, tels que l’arrêt du tabac, la gestion de conditions telles que l’hyperlipidémie, l’hypertension et le diabète, et l’augmentation progressive de l’activité physique.
La taille de l’anévrisme est régulièrement surveillée à l’aide d’une échographie ou d’une tomodensitométrie.
Les petits anévrismes de 4,0 à 5,4 centimètres de diamètre sont surveillés tous les 6 à 12 mois, tandis que les anévrismes de l’aorte abdominale de moins de 4,0 centimètres sont surveillés tous les 2 à 3 ans.
Pour les anévrismes asymptomatiques de plus de 5,5 centimètres, une intervention chirurgicale connue sous le nom de réparation d’anévrisme ouvert est recommandée.
Il s’agit d’une incision abdominale, de l’ablation du thrombus ou de la plaque du segment aortique malade et de la suture d’un greffon synthétique aux extrémités proximale et distale de l’anévrisme.
La paroi aortique native est ensuite suturée autour du greffon.
Une autre procédure, la réparation endovasculaire d’anévrisme, consiste à placer un greffon aortique sans suture à l’intérieur de l’anévrisme de l’aorte abdominale à l’aide d’un cathéter de l’artère fémorale inséré dans l’artère fémorale.
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Q1: When is conservative treatment recommended for abdominal aortic aneurysms?
Conservative treatment is recommended for small, asymptomatic abdominal aortic aneurysms measuring less than 5.5 centimeters in diameter. This approach focuses on modifying risk factors such as tobacco cessation, managing hyperlipidemia, hypertension, and diabetes, and gradually increasing physical activity to prevent aneurysm growth and rupture.
Q2: What monitoring schedule is used for different sizes of abdominal aortic aneurysms?
Aneurysm monitoring frequency depends on size. Small aneurysms measuring 4.0 to 5.4 centimeters require ultrasound or CT scans every 6 to 12 months. Aneurysms smaller than 4.0 centimeters are monitored every 2 to 3 years. This surveillance helps detect expansion early, allowing timely intervention when necessary.
Q3: What are the key differences between open aneurysm repair and endovascular repair?
Open aneurysm repair involves a large abdominal incision where the surgeon removes thrombus or plaque and sutures a synthetic graft to the proximal and distal ends. Endovascular aneurysm repair is less invasive, placing a sutureless aortic graft inside the aneurysm via a femoral artery catheter, avoiding major abdominal surgery.
Q4: When is surgical repair recommended for asymptomatic aneurysms?
Surgical repair is advised for asymptomatic aneurysms measuring 5.5 centimeters or larger. At this size threshold, the rupture risk increases significantly, making intervention necessary. The choice between open aneurysm repair and endovascular repair depends on patient factors and anatomical considerations.
Q5: What is endoleak and why is it a concern after aneurysm repair?
Endoleak is the most common complication following abdominal aortic aneurysm repair, involving blood seeping back into the old aneurysm sac. It results from inadequate seal at graft ends, graft fabric tears, or leaks between overlapping segments. This complication can lead to continued aneurysm growth and potential rupture.
Q6: What other complications can occur after aneurysm repair besides endoleak?
Additional complications include aneurysm growth above or below the graft, aortic dissection, bleeding, aneurysm rupture, renal artery occlusion from stent migration, incisional hematoma, infection at the incision site, and graft thrombosis. Angiography is performed after repair to check for leaks and ensure graft patency.
Q7: How does surgical repair differ for iliac artery aneurysms versus saccular aneurysms?
Iliac artery aneurysm repair uses a bifurcated graft that replaces the entire affected segment. For saccular aneurysms, only the bulbous lesion is excised, and the artery is repaired using primary closure by suturing or applying an autogenous or synthetic patch graft. Both approaches aim to restore normal blood flow.