Case Presentations: Advanced Thoracic Aortic Reconstructions. Eric Herget & Jehangir Appoo

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1 Case Presentations: Advanced Thoracic Aortic Reconstructions Eric Herget & Jehangir Appoo Multidisciplinary Thoracic Aortic Rounds Foothills Medical Centre November 28 th, 2014

2 Dr. Herget 2012 Th Ao Rounds: The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Hybrid Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney/Snorkel technique Sandwich technique

3 Case 1 Zone 2 Hybrid Arch

4 81 year old male with incidental finding of diffuse aortomegaly Cardiovascular Profile Mod AI Mod LV dysfunction Chronic Afib No sig CAD

5 81 year old male with incidental finding of diffuse aortomegaly Other issues Retrosternal Thyroid Goiter -compressing trachea -seen by Pulm Med & Gen Surg Temporal artery biopsy remote -?Giant Cell arteritis BPH

6 81 year old male with incidental finding of diffuse aortomegaly Social History Lives independently Skated 150 times previous season to play/referee hockey games Case presented at cath conference Opinions solicited AV may not need to be replaced Celiac origin occluded

7 Operative Plan Collar incision and sternotomy to resect thyroid Hybrid Arch: Zone 2 arch replacement with branched dacron graft TEVAR of distal arch/descending thoracic aorta

8 Intraop: Thyroid Specimen

9 Intraop

10 Exposure

11 Intraop HCA SACP XCT CPB 13mins 23mins 110mins 151mins Moderate Hypothermia 25degrees C CSF Drain

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13 Post op: Extubated night of surgery Neuro intact CSF drain removed on POD 2 Delayed CSF leak noted 1 week post removal H/A & nausea

14 Post op Imaging exclusion of aneurysm

15 VR Images

16 Take away points from Hybrid Arch Case Exposure dissect out head vessels before going on CPB if possible Creating suitable landing zones Zone 2 Antegrade vs. retrograde deployment pros and cons CSF drain management

17 Case 2 : Chimney Technique

18 56 year old male 6.5cm aortic root 4+ AI 8cm LVEDD with Severe LV Dysfunction NYHA Class IV CHF 6cm Descending Thoracic Aortic Aneurysm Dominant Left Vertebral

19 Staged Treatment Plan: Proximal reconstruction with a mechanical composite root Ascending aorta left axillary bypass Issues with carotidsubclavian at same time as proximal root operation in ill patient with 4+ aortic insufficiency TEVAR post op

20 Sept 6, 2012: 27mm CarboSeal Composite Root Ascending aortic replacement Extra-anatomic ascending aorta to left subclavian bypass Post op: Renal insufficiency resolved Tolerating ACE-I and B-Blockers

21 Sept 12, 2012 Brought to OR for TEVAR After 1 st device deployed: cardiac arrest not responsive to therapy prolonged resuscitation chest opened placed on CPB, LV vented Successfully defibrillated Woke up next day neuro intact!

22 Allowed to stabilize over the next 3 months

23 Dec 2012 (3 months post op) completion TEVAR Zone 2 LV function markedly improved low normal on good medical therapy

24 Follow-up CTA s type IA endoleak with associated progressive aneurysmal expansion of descending thoracic aorta

25 Numerous external expert opinions obtained Options considered to treat endoleak included: Additional stentgraft or Palmaz to reinforce birdbeak Aptus endovascular stapler Carotid subclavian bypass and TEVAR extension to Zone 1 Redo sternotomy and open/hybrid arch reconstruction

26 Intraop angio Hybrid Suite Left Carotid-Subclavian bypass Extended TEVAR to zone 1 access from right brachial as bailout device maldeployed salvaged with balloon assisted repositioning technique aggressive positioning in relation to inominate required to achieve seal (based on CT measurements)

27 Intraop Angios device maldeployed salvaged with balloon assisted repositioning technique brisk inflow to inominate extubated on OR table

28 Embolization left subclavian origin to eliminate outflow from aneurysm sac (thought to be contributing to endoleak persistence)

29 POD 2 asymmetric BP noted and CTA revealed thrombus at inominate origin Patient remained asympotomatic Heparin/Plavix/ASA instituted

30 POD 3 Symptomatic TIA s Risk of major stroke Neurology, Neuro-IR, Neurosurgery & ICU involved Attempted clot retrieval via right brachial access - unsuccessful

31 POD 3 Carotid- Subclavian Bypass Nitinol (bare) stent at inominate origin to trap thrombus and displace TEVAR device Improved BP in right arm now symmetric with left arm No bird beak

32 Clot resolved entirely No further neurologic events But nitinol stent crimped due to large TEVAR device BP in both arms significantly lower than legs

33 Palmaz Balloon Expanded Stent No residual pressure gradient

34 D/C home POD 12 with ASA/Plavix/Warfarin x3/12 POD 15 sudden swelling of right arm Seen at SHC ER Ultrasound shows large hematoma and 4cm pseudoaneurysm (with 3mm neck thrombin injection?) Open repair

35 Final CTA shows inominate widely patent and no further endoleak

36 Learning Points In 2014, we may be more aggressive with initial proximal operation CREATE GOOD LANDING ZONES to avoid complications Intraop fluoro has limitations need to navigate around CT imaging gold standard

37 Case 3: Snorkel and Sandwich

38 72 year old petite female 7cm ascending aortic aneurysm 5cm descending aortic aneurysm Plan: open proximal repair and observation of descending aorta OR (April 2012): replacement of ascending aorta and hemiarch

39 Ongoing enlargement of descending thoracic aorta over 2 year observation period rate of 5mm/yr now 6cm Challening anatomy due to distal landing zone Multiple options considered Isolated TEVAR to celiac Custom branched TEVAR to SMA Snorkel Hybrid laparotomy with bypass to SMA Open thoracoabdominal MARS

40 Snorkel technique Sandwich technique

41 The Evolution of Endovascular Sandwich technique

42 OR - Oct 20, 2014 snorkel/sandwich technique Extubated on OR table CSF drain removed POD 2 Discharged home POD 4 1 month clinic follow-up: Back to normal activities

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44 Post op CTA Snorkel/Sandwich