Endo versus open arch repair; what is evidence, what is anecdote?
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1 Endo versus open arch repair; what is evidence, what is anecdote? Nick Cheshire NJ Cheshire MD FRCS Professor of Vascular Surgery
2 Open and Endovascular management of arch pathology Open surgery Total endovascular approach
3 Open and Endovascular management of arch pathology Open surgery Total endovascular approach Hybrid surgery
4 Therapeutic options in aortic arch disease 2017 Open Surgery Questions Hypothermic circulatory arrest Cerebral protection strategy Carrell patch v branched grafts What are appropriate measures of outcome
5 Hypothermia and cerebral protection strategies in aortic arch surgery: a comparative effectiveness analysis from the STS Adult Cardiac Surgery Database Brian R. Englum, Xia Heb, Brian C. Gulacka, Asvin M. Ganapathia, Joseph P. Mathewc, J. Matthew Brennanb, T. Brett Reeced, W. Brent Keelinge, Bradley G. Leshnowere, Edward P. Chene, Jeffrey P. Jacobsf, Vinod H. Thouranie and G. Chad Hughesa Eur J Cardio-Thoracic Surgery 52 (2017) ,521 Open Aortic Arch Replacements, Hemi or Total Arch for Aneurysm (46%) or Type A dissection(54%) Elective (36%), Urgent (16%), Emergent (46%) CompositeEndpoint : 30 day mortality, Neurological event 30 Day Stroke All patients 12% 8% Deep hypothermia No Cerebral Protection Mild hypothermia Antegrade Protection 15% 9% 7% 5%
6 Outcome of open total arch replacement in the modern era Fabrizio Settepani, MD, Antioco Cappai, MD, Alessio Basciu, MD, Alessandro Barbone, MD, and Giuseppe Tarelli, MD, J Vasc Surg 2016;63: Retrospective analysis, 21 global studies, * pts, Open Total Arch Replacement. Elective(77%) & Emergency/Urgent (23%). Aneurysmal (65%) & Dissection(35%). Mild or Mod Hypothermia: 84% Cerebral Protection: 98% (Most bilateral or triple ) n Operative Stroke All patients % 3.4% Debranch %?(1-2%) Antegrade Protection Other Techniques %?(3-5%)
7 Royal Brompton & Harefield Aorta Surgery Data 485 Aorta case in 3 yrs 3.2% Mortality v v Source and Year: NICOR Apr 2013 Mar 2016 Source and Year: HES Jan2013 Dec2016
8 Thoracic endovascular aortic repair with branched Inoue Stent Graft for arch aortic aneurysms Junichi Tazaki, MD,a Kanji Inoue, MD,b Hirooki Higami, MD,c Nobuya Higashitani, MD,c Masanao Toma, MD,d Naritatsu Saito, MD,a Masahide Kawatou, MD,e and Takeshi Kimura, MD,a Kyoto, Otsu, and Amagasaki, Japan (J Vasc Surg 2017;1-9) Multicentre, retrospective Japanese study, pts, Arch Aneurysms, Branched ISG* (Single 64; Double 18; Triple 7) Early and Long term follow up data n 30 day Peri-procedural Stroke All patients % 16%
9 n 30 day Peri-procedural Stroke/TIA All patients % 15.8%
10 n 30 day Peri-procedural Stroke/TIA All patients % 10.5%
11 J Thorac Cardiovasc Surg 2017;154:100-6 Complete Total Arch Replacement (CTAR) 337 pts Hybrid arch replacement (HAR) 58 pts Total Arch Hybrid Arch n Hospital Neurology SCI 43 14% 11.6% 4.7% Open Arch % 0% 4.7% P value ns ns
12 JTCS 2013 Mortality Stroke
13 Summary of Literature Evidence MORTALITY 5 12% 7 12% 4 13% Open Arch (n=18,286) Arch Hybrid (n=1,014) Operative Stroke Note Englum et al 12% 8% Mild HCA & ACP > DHCA & no CP Settepani e al 5.3% 3.4% Triple ACP & Spielvogel > Other Techniques Urbanski et al 8.8% 5.7%? Low Vol. Centre, Age, &redo surgery worse Konstantinos et al 9.5% 6.2% Equivalent results to Arch Hybrid Hiraoka et al 4.7% 0% Lower stroke rate with open surgery Konstantinos et al Total Endo (n=127) 11.9% 7.6% Equivalent results to Open Surgery Hiraoka et al 7% 11.6% Higher Stroke rate with Arch Hybrid Haulon et al 13.2% 15.8% Results improve with experience (7% & 10%) Tazaki et al 4% 16% Single branch > Triple Branch STROKE 0-8% 7-11% 16%
14 Case Totally endovascular? Patient 1: 42year old male Previous Bentall for bicuspid valve Previous coarctation repair Redo root 2015 ECMO 2 months Poor RV Patch blow out
15 Open surgery Summary Still gold standard What are your CP and HCA techniques? What are your outcomes? Wholly Endo Multiple branches not yet realistic for most patients Series growing; outcomes as yet unknown Chimneys/Scallops Hybrid Even lesser debranching; stoke & SCI important Embolisation protection?
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