The risk of air embolism in TEVAR and how to handle it!
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1 University Heart Center Hamburg GERMAN AORTIC CENTER No fun without bubbles? The risk of air embolism in TEVAR and how to handle it! Tilo Kölbel, Franziska Heidemann, Sebastian Debus, Nikolaos Tsilimparis German Aortic Center Dept. Of Vascular Medicine University Heart Center Hamburg
2 Disclosures Ü Research-grants, travelling, proctoring speaking-fees, IP with Cook. Ü Consultant to Philips Ü Non-approved use of coils and glue
3 Inci et al Sage Open Med 4:1-5
4 Stroke in TEVAR Ü Incidence 3-11% Ü Anterior/posterior circulation Ü Silent brain infarction up to 87% Ü Mechanism of stroke unclear Ü Mortality 20% Ullery et al. 2012; J Vasc Surg 56: Perera et al. 2015; Br J Surg 102: s2: 5 Feezor et al. 2007; J Endovasc Ther 14: Kahlert et al. 2014; Ann Thorac Surg 98:53-8 Böckler et al. 2016; Eur J Vasc Endovasc Surg: in press
5 Silent Brain Infarction in TEVAR Ü Single center, n=19 Ü Pre- and post EVAR MR Ü MRI-protocoll: DWI and FLAIR Ü No clinical apparent strokes Ü 12/19 (63%) new DWMRI-lesions Ü Most with multiple lesions (1-6) Kahlert et al. 2014; Ann Thorac Surg 98:53-8
6 Stroke Definition Kahlert et al. 2014; Ann Thorac Surg 98:53-8 Lansky et al. 2017; JACC; 69: Lansky et al. 2017; Eur Heart J; Epub
7 Mechanism of Stroke Ü Particle embolism during wire manipulation and graft release Ü Air embolisation from stent-graft Ü Hemodynamic stroke
8 Risk Factors Pathology/anatomy: Ü Landing zone Ü Arch angulation Ü Atheromatous burden Procedural: Ü Emergency Ü Cuff extension Ü LSA-coverage Ü Use of embolic protection Comorbidities: Ü History of stroke Ü Chronic renal insufficiency Feezor et al. 2007; J Endovasc Ther 14: Chung 2011; J Vasc Surg 54: Ullery et al. 2012; J Vasc Surg 56: Kotelis et al. 2012; Lang Arch Surg 397: Melissano et al. 2012; Eur j Vasc Endovasc Surg 43: Böckler et al. 2016; Eur J Vasc Endovasc Surg: in press
9 Stroke in TEVAR Associations expected if particle embolism is the dominant cause of stroke in TEVAR: Ü Plaque burden Ü Pathology: Ü More frequent in aortic aneurysm Ü Less frequent in aortic dissection Image from Melissano et al. 2012; Eur j Vasc Endovasc Surg 43:
10 Stroke in TEVAR Ü Single center Ü N=530 Ü Stroke 3.8% Ü TAA 3.4% Ü TBAD 4.9% Ullery et al. 2012; J Vasc Surg 56:1510-7
11 Stroke in TEVAR 3.9% 9.4% 5.9% Ü Single center; n=196; Age 68y Ü Stroke 4.6% Ü Pathology: No risk factor! Ü Atheroma grade: No risk factor! Proximal Extent of Repair: only risk-factor for stroke! Feezor et al. 2007; J Endovasc Ther 14:568-73
12 Use of Filter Device in TEVAR Courtesy of Dr. Janosi, Essen
13 TCD of Gas and Solid Emboli Ü Ü Ü Ü Ü Ü N=10 TEVAR Claret Filter TCD discriminating gaseous and solid emboli Pre- and post TEVAR DWMRI No clinical stroke Most HITs during Filter deployment (!) Ü >90% of HITs gaseous (!) Ü Ü 8/10 silent brain infarctions on DWMRI (!) HITs correlated with number of silent brain infarctions(!)
14 Source of Stroke in TEVAR Solid Emboli Gas Emboli
15 Carlos F Bechara FACS cfbechara@houstonmethodist.or
16 Bihemispheric TCD during Thoracic Endograft Deployment. Device Deployment Carlos F Bechara FACS cfbechara@houstonmethodist.or
17 Why would air embolism play a significant role?
18 Air in Stentgrafts Spaces in SG-assemblies are filled with air! Saline-flushing insufficiently removes air from stent-grafts.
19 Air Embolism in EVAR 5 days after Standard EVAR
20 Air-Embolism in TEVAR Standard tubular stent graft after 60ml saline flushing
21 Air-Embolism in TEVAR
22 Air-Embolism in TEVAR Courtesy of Johannes Hoffmann, Essen
23 CO 2 - Flushing Ü : n=36 Ü All complex arch and ascending TEVAR: Ü Ü Ü Branched arch Fenestrated arch Ascending TEVAR Ü All zone 0-1 Ü Stroke: 1/36 (3%) Ü minor non-disabling stroke Kölbel et al 2016; J Endovasc Surg 23: 393-5
24 Air-Embolism in TEVAR 0.79± ±0.19 Ü Bench-top model Ü N=20 tubular stentgrafts Ü Group A (10): 60ml saline Ü Group B (10):Carbondioxide +60ml saline Ü Validated volume measurement Ü 0.79ml air after standard flushing Ü 0.51ml gas after + CO 2 -flushing 60ml Saline CO ml Saline Rohlffs et al. 2016, J Endovasc Ther Epub
25 Conclusion Ü The dogma, that stroke during TEVAR is caused by particle-embolism is not proven. Ü Air-embolism may play a significant role in TEVAR-related stroke. Ü DW-MRI not yet sufficiently utilized to detect silent stroke during TEVAR. Ü Carbondioxide flushing reduces air-embolism Ü If you use CO 2 -flushing, you have to flush with saline afterwards!
26 Welcome to Hamburg October
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doi: 10.21037/acs.2018. 04.08 Cite this article as: Ferrer C, Cao P. Endovascular arch replacement with a dual branched endoprosthesis.. doi: 10.21037/acs.2018.04.08 This is a PDF file of an edited manuscript
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