Jean M Panneton, MD Professor of Surgery Program Director Vascular Surgery Chief EVMS. Arch Pathology: The Endovascular Era is here
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1 Jean M Panneton, MD Professor of Surgery Program Director Vascular Surgery Chief EVMS Arch Pathology: The Endovascular Era is here
2 Disclosures Consultant: Cook Medical, Bolton Medical, Medtronic Inc, Volcano, WL Gore Speakers Bureau: Bolton Medical, Medtronic Inc., WL Gore Scientific Advisory Board: Medtronic Inc., Mellon Medical, Volcano
3 Objectives 1. describe the technical innovations in endovascular arch repair 2. Explore the 4 methods of endovascular arch repair: 1. Hybrid procedures 2. Parallel grafts 3. In situ fenestrations 4. Branched or Fenestrated devices Endovascular arch repair with innominate back table fenestration and LSA in situ fenestration
4 Background Up to 50% of TEVAR will require deployment in Zones 0, 1 or 2 Ishimaru aortic arch zones
5 Background
6 Background
7 Case study 78 year old male patient Ruptured 8cm arch aneurysm Hypotensive, transferred to hybrid room On table CPR
8 Case study Predeployment arch study with laser in LCA and endograft in the arch Endograft deployed and retrograde angiogram of the laser fenestrated and stented LCA
9 Case study Placement of EndoAnchors at the inner curve Completion arch study with patent LCA fenestration and no endoleaks Patient discharged neurologically intact and now at 1 year follow up without reinterventions
10 Hybrid approach Arch Debranching with TEVAR LSA debranching Hemi arch debranching Total arch debranching Courtesy of Gustavo Oderich MD
11 Outcomes of open total arch vs hybrid repair 27 hybrid arch repairs vs 103 open arch repairs The early and midterm outcomes of hybrid arch TEVAR for aortic arch aneurysm were satisfactory. Hybrid arch TEVAR has the potential to be a less invasive alternative for conventional TAR J Thorac Cardiovasc Surg 2012;143:
12 The Journal of Thoracic and Cardiovascular Surgery 2013 Volume 145, Number 1 Arch repair Outcomes of open total arch vs hybrid repair Pooled analysis of operative outcomes showed that Hybrid TEVAR improves operative mortality compared to open total arch repair Surgical strategy for aortic arch aneurysm should be chosen on the basis of the patient s characteristics
13 Parallel Grafts or Chimneys TEVAR with parallel grafts technique offers a readily available off the shelf and highly customizable method of endovascular arch repair Chimneys can interfere with the sealing goal of endografts at the proximal or distal landing zones and increase the risk of type I endoleaks.
14 Parallel Grafts or Chimneys 70 years old female patient Expanding ascending aortic pseudoaneurysm s/p Ascending and aortic root replacement CAD with positive NST COPD with emphysema Referred by CTS Reversed Hemi arch debranching LSA to RCA bypass LCA transposition
15 Parallel Grafts or Chimneys Arch Study Predeployment Transient AI from delivery cone and wire in LV Patent LSA chimney and LVA
16 Parallel Grafts or Chimneys Completion angiogram after EndoAnchors : AI resolved, no endoleak, patent SATs 6 months
17 Parallel Grafts or Chimneys 101 arch branches in 94 patients Operative mortality 3.2% Stroke rate 5.3% Patency 100% J Vasc Surg 2013;58:502-11
18 In Situ Fenestration TEVAR with in situ fenestration technique offers a readily available off the shelf and highly customizable method of endovascular arch repair Quick and simple Eliminates the need for rotational alignment Less catheter manipulations Can be a bail out
19 In Situ Fenestration
20 In Situ Fenestration 22 patients with successful LSA fenestration during emergent TEVAR Operative mortality: 4.5% (1/22) No stroke Paraplegia : 4.5% ( 1/22 ) No major fenestration related complications No type I or III endoleak 100% patency of LSA stents ( 1 asymptomatic stenosis ) J Vasc Surg 2013;58:1171-7
21 Single branch device 2 current ongoing IDE trials Medtronic Valiant Mona LSA branch stent-graft Gore thoracic branch endoprosthesis
22 Single branch device Medtronic Valiant Mona LSA branch stent-graft Early Feasibility Study 11 patients 100% Technical success Phase 1 Mona LSA Trial 18 patients Stroke rate = 0%
23 Single branch device Gore thoracic branch endoprosthesis Trial Zone 2: 28 patients 100% Technical success Stroke rate: 3.6% Branch occlusion: 3.6% Zone 0-1: 8 patients 100% Technical success Stroke rate: 25%
24 Single branch device CASTOR Branched Aortic Stent-Graft System MicroPort Endovascular 11 centers in China 73 patients with aortic dissection 98.6% Technical success Unibody design Presenter with main name body and LSA branch
25 Multi branch device Chuter T et al, J Vasc Surg 2003 Chuter, Greenberg, Ivancev Abraham, Haulon Lt. Carotid access Large diameter sheath (24-26Fr) External branches Limited space for catheterization Internal branches Double reducing ties Self-oriented to outer curvature More space for catheterization
26 Multi Branch device Double inner branch Multicenter Study, patients Technical success = 32/38 Mortality = 13% Neuro events = 16% J Thorac Cardiovasc Surg 2014
27 Multi Branch device Total endovascular arch repair with dual branch device J Thorac Cardiovasc Surg 2014
28 Multi branch device Three-center experience demonstrated an improvement in patient outcome when compared with Presenter the early global name experience of the technique published in 2014
29 Multi branch device Based on the Relay Plus NBS platform Off the shelf with variable MSG diameter Large single aperture with 1 or 2 internal tunnel(s) Single: innominate Double : innominate & LCA Engaging lock mechanism for the branch stent graft
30 Multi branch device
31 Fenestrated device 383 patients in 35 centers Zone 0 in 94.7% Mean operative time = 161 min Initial success = 95.8% 30 day mortality = 1.6% Stroke rate = 1.8% J Thorac Cardiovasc Surg 2013;145:S103-9
32 The Journal of Cardiovascular surgery 2016 october;57(5): Arch repair Ancillary device Therapeutic use of EndoAnchors for proximal type I endoleak 1 yr after TEVAR & 4 vessels FEVAR for Type I TAAA
33 The Journal of Cardiovascular Surgery 2016 october;57(5): Arch repair Ancillary device Placement of Endo Anchors at inner curvature for type I endoleak Type Ia endoleak Persistent endoleak after redo TEVAR & LCA fenestration EndoAnchors deployed at inner curve Type Ia endoleak resolved
34 Summary Open arch repair is associated with significant operative morbidity and should be reserved for young and good risk patients Creative approaches for endovascular arch repair, such as parallel grafts or in situ fenestrations can be used safely with satisfactory early technical success Single or dual branch devices will offer a total endovascular solution to arch pathologies
35 Summary The endovascular era is here
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Cite this article as:
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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