Aortic Arch pathology options: Open,Hybrid, fenestration, Chimney or branched stent-graft?
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1 Aortic Arch pathology options: Open,Hybrid, fenestration, Chimney or branched stent-graft? Chang Shu, M.D., Ph.D Vascular Surgery Center National Center for Cardiovascular Diseases. Fuwai Hospital, CAMS & PUMC Beijing, China
2 Disclosure of Conflicts None.
3 Total Volume of Aortic Surgery in Fuwai Hospital( ) 1143 cases 1143 aortic operations in 2016: 1.9% of mortality. 573 open repair, 93 hybrid procedure, 477 endo-repair
4 Current Approaches for Arch Open Repair Total arch replacement Hybrid Techniques Hybrid arch replacement Debranching + TEVAR Extra-anatomic bypass + TEVAR Total Endo Techniques Fenestrated stent-graft Branched stent-graft Chimney technique
5 OPEN REPAIR: Total arch replacement Suitable for arch anatomy, with or without elephant trunk implantation and ascending replacement. Standard approach with credible long-term durability.
6 OPEN REPAIR: Total arch replacement Standard option(2014 ESC, 2010 ACC/AHA/ACCF) Circulatory arrest is mandatory Peri-operative complications(cerebral, renal, spinal) Risk arises in aged patient and co-morbidities IRAD:Mortality 24.7%( Circulation 2004) IRAD:Mortality 17%-26% (2016)
7 Age Distribution in Treated Patients in Fuwai Hospital Percentage of aged patients increased every year, age is the first risk factor of mortality and it limits open repair utilization.
8 Categories of Hybrid Procedure De-branching: Arch branch transposition Hybrid arch replacement RSA LCCA RCCA LCCA LSA RSA LSA Extra-anatomic bypass + TEVAR
9 Debranching Procedure Ascending - Supra Aortic Branches transposition Aortic arch pseudoaneurysm Hybrid technique was adopted. Ascending aorta innominate artery left carotid artery LSA bypass was achieved first. Then TEVAR was used. The patient recovered unevertfully.
10 Hybrid Arch Replacement Avoided DHCA, regular CPB Extended landing zone in prosthetic graft, reduce retrograde TAAD Antegrade and retrograde delivery could be selected Reduced complication compare with total arch replacement
11 Hybrid procedure Mata Analysis Results(2010) Overall 30-day mortality:8.3% EL:9.2% stroke:4.4% paraplegia:3.9% No affect between On or off-pump.
12 Hybrid procedure Elephant Trunk Arch Debranching: 30-day Mortality: 9.5% 11.9% Cerebrovascular events 7.6% 3.6% Spinal cord Injury 6.2% 5.0%
13 For aortic arch pathology, minimal invasive option is preferred in decision-making. Massive Invasive Open repair: Better exposure Less Invasive Hybrid: Interim Minimal Invasive Total-Endo Noninvasiv e Adopted from Ivan Casserly MB
14 Endovascular aortic repair in Fuwai Hospital 101 of 477 patients received total endovascular arch branch revascularization plus TEVAR/EVAR in 2016
15 Endovascular aortic repair in Fuwai Hospital & Second Xiangya Hospital(Nov2015-Nov2017) Total TEVAR 1593 Arch branch revascularization Single Chimney 168 Double Chimney 16 Triple Chimney 2 Fenestration Fenestration Single Chimney 168 Double Fenestration 8 Triple Fenestration 6 Snorkel Single Chimney Double Chimney Triple Chimney Fenestration Double Fenestration Triple Fenestration Snorkel
16 Total Endovascular Repair of Supra-arch Branch Fenestrated Technique Chimney Technique Branched Stent-graft Double Chimney Technique
17 Chimney Stent-graft (CSG) Nov, 2007 The 1 st case of CSG 2008 CSG + PDA occluder 2009 Double CSG 2016 Triple CSG
18 Double Chimney Technique During 1.5 years follow up, no complication happened. As a result, double chimney technique can be used for retrograde type A aortic dissection with caution.
19 Double Chimney Technique The patient, 84 years old, male, received TEVAR for aortic aneurysm in 2005, and suffered from chest pain for 1 month. With the development of popularization of endovascular technique and increasing of average life span, more and more post-tevar complications will happen and need secondary intervention in the future. Double chimney technique is a efficient and safe technique to extend the proximal landing zone of aortic arch, especially for aged patient.
20 Triple Chimney Technique 3 months after TEVAR plus triple chimney procedure Double chimney with LSA snorkel stent
21 Institutional outcomes in Fuwai Team Chimney Cohort 122 cases report from our center Overall results: Technical Success Rate:98.6% 84.2% free from any EL 80.6% free from any adverse events
22 Institutional outcomes in Fuwai Team Report of our center shows well results using double chimney. 87.0% free from any Endoleaks 73.8% free from any adverse evenets
23 Chimney Stent-graft (CSG) 2017 Meta-analysis report 373 patients and 387 CGs Overall technical success :91.3% Pooled 30-day mortality:7.9% Overall early type Ia EL:9.4% Early patency,:97.9% Late patency:92.9% Retrograde type A dissection:1.8% Stroke, 2.6%
24 Fenestration Technique Fenestration In Vitro Fenestration In Situ Fenestration Off-the-shelf Fenestration Physician-modified Fenestration In Situ Needle Fenestration In Situ Laser Fenestration
25 In Vitro Fenestration: Physician-modified fenestration
26 Antegrade fashion: Via femoral access Retrograde fashion: Via branchial access Fenestration: Branch stent insertion Pre-dilation and modelling of fenestration
27 On-the-table manner of In vitro fenestration plus LSA branch stenting
28 Double Fenestration plus chimney LCCA + LSA: in vitro fenestration with Viabahn insertion Inominate artery: Chimney with Fluency insertion
29 Fenestrated Graft: In situs fenestration Ballooned fenestration needle in facilitating in situs Fenestration
30 In situ fenestration
31 In situ fenestration
32 In situs fenestration: from single to multiple branch Total 3-Arch Repair Using In Situ Fenestration for Arch Aneurysm, reported by Katada in 2016 Success rate: 6/ Ann Thorac Surg 2016 Ann Thorac Surg 2016
33 Physician-modified vs Off-the-shelf Fenestration Overall clinical treatment success : Physician-modified fenestration 91.4% Off-the-shelf fenestration 95.0%
34 Branched stent-graft Branched stent-graft
35 Branched Stent-graft under Trials Adapted from Endovascular Today Cook arch-branch Available in the EU, Canada, and South America Over 100 patients have been treated with this system Ascending aortic diameters must be 38 mm to ensure good proximal fixation and seal Relay NBS Plus 47 patients have been treated with these custom devices in Europe Gore TAG thoracic branch endoprosthesis Currently being studied in the United States for a zone 0 2 deployment The Valiant Mona LSA stent -graft system Volcano type cuff Allowing for 20 to 30 of mal-alignment between the cuff and the SCA Castor Micro-port First single-arm branched stent-graft available in China
36 Conclusion and Prospective Open portion procedure remains standard approach for aortic arch pathology with long-term durability yet higher mortalities. Hybrid and total endovascular procedure may substitute open repair for patients with significant comorbidities. Endo-techniques and devices, including fenestrated stent-graft/ branched stent-graft/ chimney technique are expected and should be done individually according to the aortic arch pathology. For total endo-technique(fenestration and chimney approach, etc.), long-term durability, efficacy and safety remains to be investigated in larger patient cohorts before being widely adopted.
37 2018 China Vascular Congress (CVC) & Annual Meeting of National Society of Vascular Surgery, Thank China (NSVS) You! Welcome You! August 2018, Beijing, China
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