TEVAR for Chronic dissections: indications for TEVAR, long term results
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1 TEVAR for Chronic dissections: indications for TEVAR, long term results J Sobocinski, R Azzaoui, B Maurel, R Spear, T Martin-Gonzalez, A Hertault, S Haulon Centre de l Aorte, Chirurgie vasculaire, Hôpital Cardiologique, CHRU Lille, Fr
2 Chronic dissections Common problem? up to 49% during FU after open surgery for type A AD up to 73% at 5 years after type B dissections Tsai TT Circulation 2006;114:I350-6 Zierer A. Ann Thorac Surg 2007;84: Fattori R. JACC Cardiovasc Interv 2013;6: Jonker FH. Ann Thorac Surg 2012;94:
3 Chronic dissections - Predictors Morphological factors depicted at the onset Aortic diameters, Entry tears, Hemodynamical factors depicted at any time during FU False lumen patency other factors Demographics, medical therapy,
4 Chronic dissections - Screening CTA MRA PET/CT
5 Chronic dissections - Screening CTA MRA PET/CT Clough,R.EJEVS2012
6 Chronic dissections - Screening CTA MRA PET/CT Kato K, J Nucl Med2010
7 Indications for TEVAR in chronic dissection Max Diameter >5.5-6cm [Elefteriades. ATS 2002] Unfit for open surgery? Life expectancy >2y Not recommended with elastopathy [Mormmetz 2009]
8 Indications for TEVAR in chronic dissection Challenging anatomy Proximal and Distal Sealing Narrow true lumen Target vessels perfused by false lumen Limited experience
9 Indications for TEVAR in chronic dissection No compromise on the proximal sealing zone >2cm long Non dissected segment
10 Indications for TEVAR in chronic dissection Hybrid with SAT Debranching: acceptable strategy to promote safer sealing zone
11 Indications for TEVAR in chronic dissection BUT better to propose open arch repair if patient fit
12 Indications for TEVAR in chronic dissection BUT better to propose open arch repair if patient fit
13 Indications for TEVAR in chronic dissection If not, Assessment for an arch branched device feasibility
14 Management of the distal sealing zone Not possible to achieve a satisfactory classical distal sealing zone 1 st stage of a more extensive repair (F-EVAR) Warning: Deployment of the device within the false lumen
15 Complications/risks after TEVAR Early Similar to TAA repair with SCI Death
16 Complications/risks after TEVAR Early Similar to TAA repair with SCI Death Pseudocoarctation
17 Complications/risks after TEVAR Early Similar to TAA repair with SCI Death Pseudocoarctation Iatrogenic Type A
18 Complications/risks after TEVAR Late Persistant back-flow in the false lumen and continuation of aortic expansion
19 Complications/risks after TEVAR Late Persistant back-flow in the false lumen and continuation of aortic expansion
20 Complications/risks after TEVAR Late Persistant back-flow in the false lumen and continuation of aortic expansion
21 Complications/risks after TEVAR Late Persistant back-flow in the false lumen and continuation of aortic expansion Intimal Flap tear by the device Aorto-esophagal Fistulae
22 Clinical trial INSTEAD (Nienaber C et al.) Mixed of SUB-ACUTE & CHRONIC type B AD Uncomplicated, From 2-52 weeks RCT: BMT vs EDP+BMT Multicentric (7), 140 patients Excluded patients with thrombosed False lumen
23 Circ Cardiovasc Inter2013
24 Registry Virtue (Thompson M et al.) Prospective, non-randomised, European multicentric registry Acute, Sub-acute & chronic type B AD Chronic >92 days: complicated/symptomatic diameter > 5.5 cm or expanding >0.5 cm/y N=26, associated with abdominal aneurysm in 27% 30d 3y All-cause mortality 0 26% SCI 4% Dissection-related mortality 9% Rupture 4% Reintervention 39%
25 Registry MOTHER (Patterson BO et al.)
26 TEVAR retrospective data Hughes GC 2014 Scali ST 2013 Parsa 2011 Kang, WC Song SW 2014 Leshnower 2013 n interval onset 32 mo 16 mo 46 mo 25 mo 18 mo max preop diameter abdominal extension 100% 63% 100% 100% 61% 30d death 0 2.5% 0 5% d SCI 0 17% d stroke % 0 0 FU 54 mo 26 mo 27 mo 34 mo 10 mo Aortic-related death 0 All-cause Survival 70% at 5y 78% at 5y 80% at 3y F-F-reintervention 70% at 3y 77% at 5y 73% at 3y 90% at 1y No clear message Very heterogeneous results++ Probably safe procedure but what are we expecting?
27 TEVAR failed to improve overall survival BMT= β-blockers N=303; Baseline diam 41mm 4Y survival= 83% (TEVAR) vs 69% (BMT) (P NS) BMT vs BMT+TEVAR
28 N=104 30d death= 10% SCI= 5% Survival= 68% at 5y BUT 20% CAD 29% visceral reimplantation OPEN REPAIR
29 JTCS 2012 N=169 with 81 limited to the DA 30d death= 8% SCI= 2.5% Survival= 54/55% at 5y Reintervention= 14% BUT 22% CAD 46% PAD OPEN REPAIR
30 Aortic remodeling TEVAR positively alters Aortic remodeling: False lumen thrombosis True lumen expansion But Usually limited to the descending thoracic aorta and mainly along the stent graft++
31 Aortic remodeling Factors of prognosis Initial Extension of the AD Visceral vessels arising from the FL Number of re-entry tears Patency of the FL Length of the aortic coverage
32 PETTICOAT in chronic dissection Promote better remodeling? Small cohort (11), FU 12mo No comparative data vs Stentgraft alone
33 Tips & tricks but not validated in large cohorts
34 Tips & tricks but not validated in large cohorts Spot stenting of any large re-entry along the intimal flap AVS 2013
35 Conclusion Chronic Dissection = known predictors of late expansion in the acute phase Adequate surveillance Extensive disease Scarce and heterogenous literature on TEVAR Positive remodeling effect limited to the stented segment
36 Conclusion
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