Endovascular Management of Thoracic Aortic Pathology Stéphan Haulon, J Sobocinski, B Maurel, T Martin-Gonzalez, R Spear, A Hertault, R Azzaoui
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1 Endovascular Management of Thoracic Aortic Pathology Stéphan Haulon, J Sobocinski, B Maurel, T Martin-Gonzalez, R Spear, A Hertault, R Azzaoui Aortic Center, Lille University Hospital, France
2 Disclosures Research support, Consulting, IP Cook Medical, GE Healthcare
3 Simple Aneurysms Minimal tortuosity Short + Straight Long fixation zones Good sealing Good access
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8 Iliac Access EIA diameter >7mm Iliac tortuosity/calcification
9 Which Graft Is Better? There is no ideal graft for the thoracic aorta All grafts are acceptable for simple aneurysms of the mid-descending aorta Aneurysms Dissections Coarctation traumatic rupture There will be no comparison studies
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12 Zenith Alpha Thoracic
13 Zenith Alpha Thoracic Two-piece modular system Nitinol stents Graft diameters: mm Fr (ID) introduction system
14 Chronic Dissections Challenging Procedures Proximal and Distal Sealing Narrow true lumen Target vessels perfused by false lumen Limited experience
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17 Early Complication After TEVAR for Chronic Dissection - 70 year-old man - Acute Type B dissection February Medical treatment
18 CT Scan Follow-Up Rapid Growth
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20 LSA
21 LSA
22 Entry tear
23 TL FL
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26 Surgical approach Left Carotid-LSA bypass Thoracic endovascular aortic repair: Left subclavian artery embolisation Amplatzer Vascular Plug II 16 mm Thoracic device: ZTEG-2P PF
27 Left Carotid-LSA bypass
28 LSA Catheterization
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32 Thoracic device
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35 ICU Chest pain 24 hours after surgery CT scan Type A dissection
36 IATROGENIC TYPE A
37 Retrograde aortic dissection after thoracic endovascular aortic repair. Canaud L 1, Ozdemir BA, Patterson BO, Holt PJ, Loftus IM, Thompson MM. Ann Surg Aug;260(2): OBJECTIVE: To provide data regarding the etiology and timing of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR). METHODS: Details of patients who had RTAD after TEVAR were obtained from the MOTHER Registry supplemented by data from a systematic review of the literature. Univariate analysis and binary logistic regression analysis of patient or technical factors was performed. RESULTS: In MOTHER, RTAD developed in 16 of the 1010 patients (1.6%). Binary logistic regression demonstrated that an indication of TEVAR for aortic dissection (acute P = ; chronic P = 0.006) and device oversizing (OR 1.14 per 1% increase in oversizing above 9%, P < ) were significantly more frequent in patients with RTAD. Data from the systematic review was pooled with MOTHER data and demonstrated that RTAD occurred in 1.7% (168/9894). Most of RTAD occurred in the immediate postoperative (58%) period and was associated with a high mortality rate (33.6%). The odds ratio of RTAD for an acute aortic dissection was 10.0 (CI: ) and 3.4 (CI: ) for chronic aortic dissection. The incidence of RTAD was not significantly different for endografts with proximal bare stent (2.8%) or nonbare stent (1.9%) (P = ). CONCLUSIONS: Although RTAD after TEVAR is an uncommon complication, it has a high mortality rate. RTAD is significantly more frequent in patients treated for acute and chronic type B dissection, and when the endograft is significantly oversized. The proximal endograft configuration was not associated with any difference in the incidence of RTAD.
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40 No Compromise on Proximal Seal - Open Surgery
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42 ELEPHANT TRUNK
43 Post Type A Repair Branched Arch Endograft
44 Late Complication After TEVAR for Chronic 61-year old woman Dissection Acute type B aortic dissection (2004) Left renal stenting TEVAR+ LSA occlusion (2005) Iatrogenic type A dissection Ascending aorta + aortic valve replacement (Bentall)
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59 Checking position of wire in the true lumen
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62 Late Complication TEVAR for Chronic Dissection
63 Distal Extension August 2011 Non complicated Type B dissection BMT
64 2 nd CTA performed 5 days after admission Rapid growth of descending thoracic aorta Dynamic compression of visceral segment with Renal hypoperfusion Thoracic endograft 34x220mm distal LSA
65 Follow-up Acute Type B dissection with rapid growth: TEVAR Aneurysmal evolution of DTA: 70mm at endograft level 56mm below
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69 Narrow true lumen Perfusion of all visceral vessels by true lumen, right renal artery by both lumen Plan: Access true lumen Endograft distal extension in true lumen
70 True lumen above CT: Dead-end with no communication with the endograft
71 Fenestration with12x40mm balloon to create a re-entry tear
72 Catheterisation of the re-entry tear and the endograft lumen Exchange for a stiff wire Dilation with an 18x40mm balloon
73 Deployment of 38x202mm TX2
74 Early FU Renal failure Creatinine: 186 µmoml/l (base: 97 µmoml/l) Oliguria < 500 ml/24h BP control SBP between 150 et 210 mmhg Required 6 anti-hypertensive drugs
75 Renal artery US Symetric reduced intra-renal flow Resistance index 0.64 CTA
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77 Second procedure Stainless Steel stent Palmaz P4014 (16x40mm balloon)
78 Follow-up BP SBP between 120 and 140mmHg 3 anti-hypertensive drugs Normal renal function Creatinine 89 µmol/l Renal artery US Normal kidney perfusion Resistance index 0.5
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80 False Lumen Perfusion by Visceral Vessels
81 Fenestrated Distal Extension?
82 GE Discovery IGS 730
83 GE DISCOVERY IGS 730
84 GE DISCOVERY IGS 730
85 GE DISCOVERY IGS 730
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92 SMA Perfused by False Lumen
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94 TRUE LUMEN FALSE LUMEN
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98 Left Renal Perfused by (2) False Lumen
99 CT SMA
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107 True lumen Expansion Post TEVAR Post FEVAR
108 Expansion of true lumen
109 Expansion of true lumen Post TEVAR Post FEVAR
110 Post TEVAR Post FEVAR
111 Staged Approach 50 yo patient Step 1 (2009): Acute type A dissection with ascending aortic replacement Step 2 (2013): Redo sternotomy Tirone David + Arch repair and elephant trunk
112 Step 3 TEVAR (2013) Angiography = Confirmation True/False lumen
113 TEVAR
114 Step 3: TEVAR from Elephant Trunk and CT
115 Step 4 Aorto Bi-Iliac Open Repair Goal: Perfusion of - Both Internal Iliac - Distal lumbar arteries
116 Step 5: Fenestrated Endograft
117 Small tear in front of the right renal
118 Tear inflation
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122 3D-CT
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124 Expansion of true lumen Post TEVAR Post FEVAR
125 Post TEVAR Post FEVAR
126 Post TEVAR Post FEVAR
127 Post TEVAR Post FEVAR
128 Expansion of true lumen
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136 Post operative type 1b-2 endoleak
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155 DATA
156 Age Aneurysm Connective Previous Previous Visceral In-hospital Early major Reinterventi Technical (years) median diameter disorder aortic endovascular target mortality adverse ons(n, %) success [min-max] (mm) (n, %) repair exclusion artery (n, %) events (n, %) median (n, %) (n, %) strategy (n, %) [min-max] manage ment (n, %) Aortic arch aneurysm n=7 63[37-73] 67[64-76] 1, 14% 7, 100% 1, 14% 0 1, 14% 2, 28.5% 2, 28.5% 5, 71% TADAA n= [46-84] 61.5[55-79] 2, 8.7% 14, 87.5% 12, 75% 4, 25% 1, 6% 3, 19% 2, 12.5% 16, 100% Total n=23 64[37-84] 64[55-79] 3, 13% 21, 91% 13, 57% 4, 17% 2, 8.7% 5, 22% 4, 17% 21, 91%
157 CONCLUSIONS Simple to very complex 3D WS analysis No compromise
Objective assessment of current stent grafts: which graft for which lesion. Ludovic Canaud, MD, PhD Pierre Alric, MD, PhD Montpellier, France
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TEVAR for Chronic dissections: indications for TEVAR, long term results
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