Daniela Branzan MD, Department of Vascular Surgery and Department of Interventional Angiology University Hospital Leipzig
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1 Ischemic Preconditioning with Minimally Invasive Segmental Artery Coil Embolization (MISACE) prior to Endovascular TAAA Repair: Clinical Experience in 50+ Patients Daniela Branzan MD, Department of Vascular Surgery and Department of Interventional Angiology University Hospital Leipzig
2 Disclosure I do not have any potential conflict of interest.
3 Pathophysiology of SCI during TAAA Repair Reduced blood pressure Diminished arterial inflow SCI Insufficient local hemodynamics Disturbed spinal cord autoregulation Reactive, inflammatory processes 3
4 Pragmatic Approach for SCI Revascularize as many inflow arteries as possible (subclavian, hypogastric) Optimizing hemodynamic management SCI Strategies that induce development of collateral arteries = Ischemic Preconditioning of the spinal cord 4
5 Ischemic Preconditioning of the Spinal Cord Based on the Collateral Network Concept of Spinal Cord Perfusion 1 The hypothesis of a spinal blood supply depending mainly on one critical arterial input (Adamkievicz Artery) is obsolete. Paraspinal compartment Anterior radiculomedullary artery SA SA Intraspinal compartment Anterior spinal artery 1. Prof. Griepp and Mount Sinai Group, New York 5
6 Ischemic Preconditioning of the Spinal Cord Concept: occlusion of the main stem of several SAs preserving the capability of the paraspinous collateral network to build new arteries Technique: Minimal Invasive SA Staged Occlusion (MISASO) 1,2 Utility: an entirely endovascular first stage of a staged approach for TAAA repair to reduce ischemic spinal cord injury 1. Geisbüsch S et al. Thorac Cardiovasc Surg Jan;147(1): Etz CD et al. J Thorac Cardiovasc Surg Apr;149(4):
7 MISASO - Procedure local anesthesia percutaneous trans-femoral access with a 5Fr Sheath no CSF drainage clinical monitoring of the patients neurologic function for at least 48h after the procedure 7
8 MISASO - Cannulation of the SA The tower of power Guiding Catheters Diagnostic Catheters Microcatheter 8
9 MISASO Where to embolize the SA Etz et al. J Thorac Cardiovasc Surg 2015 SA should be occluded in their ostial segment 9
10 MISASO Occlusion of the Ostial Segment of SA Coils Vascular Plug No particles or fluids (CAVE: distal embolization) 10
11 Technical Aspects and Challenges Very large aneurysms sac: open the angle of a diagnostic catheter with a guiding catheter to reach the aortic wall 11
12 Technical Aspects and Challenges Very large aneurysms sac: Deflectable steerable guiding-sheath (Oscor) 12
13 Technical Aspects and Challenges Very large aneurysms sac: Deflectable steerable guiding-sheath (Oscor) 13
14 Technical Aspects and Challenges Loss of coils Removed with a snare 14
15 Problematic Patients / Exclusion Criteria - Urgent repair required - Renal insufficiency (GFR < 30 ml/min) - Severe iliac kinking / aortic elongation - Adipositas per magna 15
16 Technical Aspects and Challenges Kinked access vessels reinforced tower of power and buddy wire 12-French sheath Lunderquist Superstiff GW Tower-of-power: 6-Fr. guiding-catheter, 5-Fr. diagnostic-catheter, Microcatheter 16
17 MISASO - Leipzig Experience September 2014 December 2017 TAAA (n=57) Demographics N (%) Sex Male 43 (75) Age Mean ± SD (years) 69.6 ±7.6 Cardio-vascular Risk Factors Hypertension 57 (100) Chronic pulmonary disease 19 (33) Smoker 39 (68) Coronary artery disease 22 (38) Diabetes mellitus 21 (36) Renal Insufficiency GFR<60 ml/min/1.73m 2 20 (35) GFR Mean±SD (ml/min/1.73m 2 ) 68.9 ±19.3 Peripheral artery disease 10 (17) BMI (kg/m 2 ) Mean ± SD 27.7 ±5.1 Aneurysm Characteristics N (%) Crawford Classification Type I 5 (8.8) Type II 12 (21.1) Type III 27 (47.3) Type IV 13 (22.8) Maximal Aortic Mean ± SD 62.7 ±8.8 Diameter (mm) Previous Repair of the Aorta Thoracic aorta open repair 5 (8.7) open+ ER 2 (3.5) Abdominal aorta open repair 3 (5.2) Delta (years) 6.5 (0.5-18) Etiology atherosclerotic 54 (94.7) dissection 3 (5.3) 17
18 Patients Patent SAs at the Aortic Level Planned for Endovascular Repair Segmental Arteries SAs in the Aortic Area planned to be stented Mean ± SD Median (Range) 10 ± (2-26) 18
19 MISASO Sessions TAAA 1. MISASO (Stage 1) Optional 2. MISASO (Stage 2) Optional > 2. MISASO (Stage 3) (n=57) (n=22) 38.6% (n=24) 42.1% (n=11) 19.3% Mean interval (days) 60.5 ± 65.2 Mean interval (days) 63.2 ±
20 Patients Patients Minimally Invasive Occluded SAs Session Session Session3 Session Session Coiled Segmental Arteries Coiled Segmental Arteries Occluded SAs/Session Occluded SAs/Patient 20
21 MISASO-Results Median (Range) % occluded SAs after MISAO 77.7( ) No spinal cord ischemia! Minor complications N % Backpain Loss of Coils Unable to occlude one SA
22 TEVAR/ BEVAR/ FEVAR after MISASO No sooner that 7 days, to let the collaterals develop! 22
23 Complete Aneurysm Exclusion after MISASO TAAA (n=57) 1. MISASO (Stage 1) (n=22) Optional 2. MISASO (Stage 2) (n=24) Optional >2. MISASO (Stage 3) (n=11) Endovascular Repair of TAAA (Stage 4) (n=55)* Mean time from last MISAO to EVAR (days) 83± 62 * Two Patients died after Sessions of MISAO waiting for CMD due to global heart failure 23
24 Complete Aneurysm Exclusion after MISASO Variables No. or Mean ± SD % General Anesthesia 54 Duration of Procedure(min) 175 ± 56.7 X Ray Time (min) 60.5 ± 23.4 TEVAR FEVAR BEVAR FBEVAR CSFD Subclavian Coverage Hypogastric Patency Length of covered Aorta(mm) 270.3±
25 30 Days Results TAAA (n=57) 1. MISASO (Stage 1) (n=22) Optional 2. MISASO (Stage 2) (n=24) Optional >2. MISASO (Stage 3) (n=11) Endovas cular Repair of TAAA (Stage 4) (n=55) 30 Days Results No SCI 1 Death 25
26 Conclusion MISASO to precondition the paraspinous collateral network is clinically feasible and safe. MISASO followed by aneurysm exclusion may eliminate paraparesis and paraplegia after total endovascular repair of extensive TAAA. 26
27 Thank you! 27
28 Ischemic Preconditioning with Minimally Invasive Segmental Artery Coil Embolization (MISACE) prior to Endovascular TAAA Repair: Clinical Experience in 50+ Patients Daniela Branzan MD, Department of Vascular Surgery and Department of Interventional Angiology University Hospital Leipzig
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