Optimal repair of acute aortic dissection

Transcription

1 Optimal repair of acute aortic dissection Dept. of Vascular Surgery, The 2nd Xiang-Yale Hospital, Central-South University, China Hunan Major Vessels Diseases Clinical Center Chang Shu

2 Clinical Materials July, 2002 Feb, Patients: Male: 695, Female: 362 Age: 19-86; Mean age: 51.2 Acute phase ( less than 2 weeks): 776 cases(2 hours-2weeks) Sub-acute and chronic phase (more than 2 weeks): 281 cases ( the longest history is 16 years)

3 Complicated acute aortic dissection Involving aortic arch: 137 cases AD associated with Marfan syndrome: 34 cases Retrograde type A aortic dissection: 49 cases With severe ischemia of visceral arteries, peripheral arteries and paralysis: 117 cases AD with huge hemothorax: 53 cases

4 Clinical Results Technically success: 99.9%(775/776) 6 cases died before TEVAR Recovered uneventfully: 749(96.5%) Peri-TEVAR complications (endoleak, respiratory distress, renal insufficience, et al.): 29(3.7%) Late complications (new entry tears, endoleak, migration, et al.):35 (4.5%) Fatal cases: 9 (1.2%, including the 5 cases died before TEVAR)

5 Endovascular strategy for aortic arch diseases Debranch LSA with stent-graft and/or PDF occluder Double Chimney technique Chimney technique for LCCA/LSA Hybrid technique Fenestrated technique

6 Complication Peri-operative complication rate: 3.7% Endoleak: 17(secondary TEVAR was performed, 14 stopped, 3 continued) Subclavian steal syndrome: 2 (surgery for 1, 1recovered spontaneously) Ischemia of the SMA and renal artery: 6 (conservative therapy for 5, 1 needed a stent) Respiratory distress: 4 (conservative treatment)

7 Complication Fatal cases: 9 (5 died before TEVAR) Myocardial infarction: 2 Cerebral infarction: 1 Respiratory failure: 1

8 Follow-up The mean duration of follow-up: 31.2months (1~ 139 months), True lumen enlarged, reduced of the false lumen, thrombosis fill in it : 739/776 Late complications happened: new entry tears in distal aorta 2 stent-graft migration 6 distal false lumen dilated and formed aneurysm 3 unilateral renal atrophy 3 type A aortic dissection

9 Huge Aneurysmal Dissection Ruptured Contained Female, 74 years, Bp: 60/40, Heart rate:112/min

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11 In order to transfer the second stent-graft, we have to use the balloon to pull the first stent-graft down

12 Aneurysm combined with dissection The patient is 163 cm high, but 115 K weight, severe chest pain

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14 Marfan associated with AAD

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16 The female, 39 years old. CT angiography detected chronic type B aortic dissection. Had been given Bentall before, Her son, 18 years old, acute dissecion: the CTA of him

17 We have done TEVAR for the son, no complications happened peri-evar One year later, the patient recovered well with thrombosis in the false lumen and aortic remodeling. CTA after TEVAR

18 Bentall technique was performed for the mother 3 years ago

19 Replacement of aortic root and valves was performed 3 years ago. Abrupt severe back pain was encountered caused by TBAD.

20 The aortic dissection in the descending aorta was occluded with remodeling of related distal aorta. Two weeks after TEVAR

21 4 years after TEVAR

22 Pre-TEVAR 2 weeks after 4 years later comparison Continuous dilatation also happened in abdominal aorta and bilateral iliac arteries.

23 MFS associated with puerperal state A female,29 years old, suffered from abrupt severe back pain 1 week after caesarean section. The primary entry tear located at the orifice of the LSA

24 MFS associated with puerperal state 1 month later, the patient recovered well without any symptoms. However, CT angiography detected mild contrast in the false lumen, and the patent false lumen communicated with LSA.

25 13 months later, CTA The left carotid artery was reconstructed with the chimney stent-graft. No endoleak continued!!

26 MFS associated with dissection and pregnancy

27 A 23-year-old female, gestated for 36 months. Widen mediastinum was found by chest X-ray. And CT angiography confirmed chronic type B aortic dissection. No signs of threatened labor.

28 Caesarean section was performed followed on emergent TEVAR. The patient recovered well, and the infant was healthy. No complication happened!

29 The whole lucky family

30 Retrograde type A AD with entry tear in descending aorta

31 Retrograde type A AD

32 Retrograde type A AD

33 Retrograde type A AD on set 2 weeks later

34 Retrograde type A AD --postoperation

35 TEVAR for retrograde type A AD Emergent TEVAR also can be used Pre-TEVAR

36 Post-operation: 2 weeks later

37 Aortic arch Dissection treated by Chimney SG

38 Chimney SG Male 60 years old Hypertension for more than 20 years Abrupt chest and back pain for two days

39 LSA is involved in the aneurym. aneurym and dissection overlap. The true lumen is narrow.

40 TEVAR associated with chimney SG to reconstruct the involved left common carotid artery is the best way to treat it.

41 Bi-chimney technique used in AD

42 A 50y male, suffered from abrupt chest and back pain. The primary entry tear was unclear in CT scans. Angiography indicated a typical non- A-non-B aortic dissection involve aortic arch. The primary entry tear was between the orifices of innominate artery and LCA.

43 Bi-chimney technique was used. Two Fluency stent-grafts were used to reconstruct IA and LCCA. The LSA was covered. The patient recovered well, without any complications. Until now, several cases have received bi-chimney technique in our hospital, short-term result is acceptable, no techniquerelated complications happen, but long-term result is unclear.

44 The patient recovered well, without any serious complications

45 AAD with mal-perfusion syndrome

46 Mal-perfusion of distal aorta There is no contrast in the distal abdominal aorta

47 The true lumen is completely compressed by the false lumen. Mal-perfusion of distal aorta

48 Mal-perfusion of distal aorta

49 Post-operation Post-TEVAR, the patient recovered well.

50 TBAD with renal failure

51 TBAD with renal failure TBAR with renal failure: The reason of acute renal failure should be distinguished: ischemia of RA. others disease, such as kidney tubules impairment.

52 TBAD with renal failure A patient with abrupt renal failure caused by acute TBAD

53 The orifice of left renal artery could not be found. The renal artery was originated from true lumen, but the orifice was narrow caused by compression. TBAD with renal failure

54 4 months after operation TBAD with renal failure

55 4 months after operation. The right renal was atrophied, but the left one and renal function recovered well. TBAD with renal failure

56 AAD with Acute Paraplegia

57 AAD with Acute Paraplegia Three patients with abrupt paraplegia was caused by ischemia of arteriae lumbales and arteriae intercostales. Emergent TEVAR was performed 1-9 hours after paraplegia. Drainage of CSF Stosstherapy with adrenal cortex hormone Rise up the BP: 140/80 Anticoagulation

58 The patient had been given Emergency TEVAR

59 AAD with Acute Paraplegia Myodynamia gradually recovered 4-24 hours after operation. When discharged 4-12 weeks after operation, the patients can walk by himself. But one patient need a catheter to release dysuria untill one year later.

60 Treatment of AD involving celiac artery

61 AD involved Visceral Arteries

62 The entry tear closes to the celiac artery. Visceral arteries were involved by AD.

63 Accurately deployment of the stent-graft was key point. The bottom of the stent-graft was deployed next to SMA. A short stent-graft was appropriate to exclude the AD and prevent paraplegia simultaneously. No visceral ischemia happened!!

64 AD involved visceral arteries The patient received aortic arch replacement previously. A new AD happened, involved the visceral arteries. The celiac artery was originated form the false lumen

65 The celiac artery was originated from the false lumen, and the entry tear was next to SMA.

66 Pre- Comparison Post-

67 TEVAR+PDA occlude

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69 Familial AD + aberrant subclavian artery

70 Familial AD + aberrant subclavian A A 37-year-old female Her brother died several days before because of acute AD.

71 familial AD + aberrant subclavian artery

72 familial AD + aberrant subclavian artery

73 familial AD + aberrant subclavian artery

74 PDA occlude for type II endoleak AD related LSA Chimney tenique should be used

75 2 weeks after TEVAR, no type II endoleak lasted.

76 The apply of the distal restrictive bare stent A male, 66-year-old, encountered abrupt back pain. CT angiography indicated typical type B aortic dissection.

77 The distal restrictive bare stent With the distal restrictive bare stent technique, the distal thoracic aorta remodeling well.

78 Conclusion Most of the acute aortic dissection can be treated by TEVAR, Some Type A aortic dissection can also be treated by TEVAR; Some complicated acute TBAD can be treated endoluminally with advanced surgical skill and some assistant techniques: chimney, fenestration, branched stent-graft, hybrid-operation etc. It s conceived that Almost all aortic dissection can be treated with TEVAR in the future!

79 Thank you very much and welcome to the Second Xiang-Yale Hospital