Thoracic Endovascular Aortic Repair (TEVAR) Indications and Basic Procedure
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1 Thoracic Endovascular Aortic Repair (TEVAR) Indications and Basic Procedure Tilo Kölbel, MD, PhD University Heart Center Hamburg University Hospital Eppendorf
2 Disclosure Speaker name: Tilo Kölbel, MD I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company X Other: Proctoring, travel, research-grants, patents with Cook Medical I do not have any potential conflict of interest
3 History Michael Dake, Radiologist, Stanford, USA First clinical report on TEVAR 1994: Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysm Dake et al. 1994; N Engl J Med 331:
4 Descending Aorta: Open Repair vs. TEVAR Metaanalysis of comparative studies TAA and dissection (n = 5888) TEVAR better: 30d mortality Paraplegia Transfusion Cardiac and resp. compl. Kidney function Reintervention Hospital and ICU stay Cheng at al. 2010; JACC 55:
5 Disease Specific Indication Aneurysm Dissection Transsection Coarctation
6 Thoracic Aortic Aneurysm Operative treatment (TEVAR) if: Diameter > 5.5-6cm Diameter growth >0.5-1cm/year Symptoms: Pain Local compression Rupture Aneurysm
7 Type B Aortic Dissection Operative treatment (TEVAR) if: Acute: Malperfusion: visceral, renal, peripheral Rupture and hemorrhage Early dilatation, other prognostic factors Chronic: False-lumen aneurysm > 5.5-6cm False-lumen aneurysm growth > 0.5-1cm/year Claudication, rupture and hemorrhage
8 Type B Aortic Dissection
9 Traumatic Aortic Rupture Operative treatment (TEVAR) if: Grade 2-lesion (intramural hematoma) Grade 3-lesion (pseudoaneurysm) Grade 4-lesion (hemorrhage)
10 Coarctation Operative treatment (TEVAR) if: Symptoms: Claudication Headache peak-to-peak gradient of >20 mm Hg at rest or >30 mmhg after exercise. Left Ventricular dysfunction and hypertrophy Refractory hypertension
11 Standard Procedure Efficacy Costs Time Mistakes
12 Planning Most technical Errors follow insufficient planning!
13 Workstation
14 Access Mikropunktionsset: 27 G Nadel Draht 2 Hülsen
15 Access
16 Access 6F-sheath for access-side Heparine 100IU/kg, ACT Stiff double-curved wire into ascending aorta Angio catheter into arch from contralateral femoral artery or brachial artery Serial Dilators
17 Iliac Conduit
18 Paving and Cracking
19 Through&Through-Wire Stiff Guidewire Soft transbrachial Throughwire
20 Graft Preparation Remove peel-away, mandrin, etc. Fasten screws, stop-cocks. Flush central lumen and graft. Follow graft-specific instructions.
21 Arch-angiography
22 Arch-angiography
23 Proximal Deployment
24 Component Overlap Overlap 5cm in TAA 2cm in dissection
25 Distal Deployment
26 Dilatation Compliant Balloon
27 Final Angiography Reposition pigtail Overview Apnea Late images
28 Access Closure Percutaneous Open surgical Fascial Closure Technique
29 Summary Rapid development of devices, techniques, and operator skills. TEVAR is the standard of care for lesions in the descending thoracic aorta. Preoperative planning, device-selection and sizing of TEVAR is mandatory. Endovascular treatment will continue to challenge open surgery also for lesions of the aortic arch and the ascending aorta.
30 Thoracic Endovascular Aortic Repair (TEVAR) Indications and Basic Procedure Tilo Kölbel, MD, PhD University Heart Center Hamburg University Hospital Eppendorf
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