Jean M. Panneton, MD, FRCSC, FACS. Professor of Surgery, Chief & Program Director Division of Vascular Surgery. Norfolk, VA
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1 Jean M. Panneton, MD, FRCSC, FACS Professor of Surgery, Chief & Program Director Division of Vascular Surgery Eastern Virginia Medical School Norfolk, VA The Houston Aortic Symposium Houston TX, February th 2017
2 Disclosures Consultant: Cook Medical, Bolton Medical, Medtronic Inc, Volcano, WL Gore Speakers Bureau: Bolton Medical, Medtronic Inc., WL Gore Advisory Board: Medtronic Inc., Mellon Medical, Volcano Eastern Virginia Medical Center
3 Indications: For prophylaxis or therapy Migration/ Type 1 Leak Severe Angulation Prophylaxis Difficult landing Therapy Birdbeaking Component separation revision 3
4 Can we predict TEVAR failures? ANATOMIC SEVERITY GRADING SCORE ASG score= 24 Anatomic criteria assessed for 4 distinct segments of DTA Each characteristic graded from 0-3 All categories added to obtain a composite ASG score ( range 2 to 57 ) ASG score= 43 J Vasc Surg 2016;64:
5 Can we predict TEVAR failures? Freedom from postoperative endoleak requiring reintervention at 2 years * * 100% 69% *P=0.002 Sensitivity=92% Specificity=50% *For an ASG *For an score ASG 24 score 24 This novel anatomic severity grading system can successfully identify patients at increased risk for postoperative endoleak formation and endoleak requiring reintervention following TEVAR for primary DTA
6 Prophylactic indication: challenging anatomy Pre TEVAR hemiarch debranching
7 Prophylactic indication: challenging anatomy Placement of EndoAnchors at the inner curvature Completion Aortogram after prophylactic EndoAnchors No endoleak after 23 3 years follow up no migration no endoleaks
8 Prophylactic indication: preventing upward migration Distal TEVAR with celiac catheterization Circumferential placement of EndoAnchors at distal end Completion Aortogram after prophylactic 2 yrs follow up No migration No endoleaks
9 Therapeutic indication: revision Type Ia endoleak 2 years after 4 vessels FEVAR with PMEG treated with proximal EndoAnchors and Onyx CTA 3 years after EndoAnchor rescue with no endoleak
10 Therapeutic indication: revision Treating failed EVAR (migration & type I endoleak) with 3 vessels FEVAR w/ ZFEN & AUI conversion & EndoAnchors
11 Therapeutic indication Proximal type I endoleak 1 yr after TEVAR & 4 vessels FEVAR for Type I TAAA Redo TEVAR with Left CCA Laser Fenestration with residual type I endoleak
12 Therapeutic indication Placement of EndoAnchors at the inner curvature Completion Aortogram after EndoAnchors rescue CTA at 12 months: no endoleaks
13 Procedural Technique: Guide selection & deployment Recommended Heli-FX Guide Selection Aortic Inner Diameter mm mm mm Guide Tip Reach 22 mm 32 mm 42 mm Controlled, Tactile, Intuitive, Safe 2 steps process: Recapture & Release 18Fr OD, 90cm working length 22 mm 32 mm 42 mm
14 Procedural Technique: advanced deployment Ascending aorta deployment in RAO view Side arch deployment in barrel view
15 Procedural Technique: outer arch deployment Undersize the guide for the outer curvature Easy Zone 1 Tricky Zone 1
16 Procedural Technique: antegrade deployment Arch aneurysm requiring sternotomy and total arch debranching with antegrade TEVAR
17 Procedural Technique: antegrade deployment Antegrade deployment of posterior EndoAnchors zone 0 3D 6 months
18 Indications Experience in TEVAR & CEVAR N = 101 procedures TEVAR, FEVAR, ChEVAR N =54 =54 TEVAR N = 47 FEVAR or ChEVAR Study Population Mean age = 73 years Male gender = 72 ( 71.3% ) Dec June 2016 Mean Follow up = 14.3 months Range = 1 to 42 months Treated for: Arch / DTA 22 TAAA 35 Pararenal AAA 22 Juxtarenal + failed EVAR 22
19 Procedural Indications N = 101 procedures TEVAR, FEVAR, ChEVAR N = 45 Index procedure N = 39 Prophylactic N=6 Therapeutic N = 56 Redo procedure N = 36 Therapeutic N = 20 Prophylactic
20 Procedural Success Total of 930 Endo Anchors were deployed ( 9.8 / pt ) Technical success rate = 99.6% Aortic Deployment Zones Zone of No. of EndoAnchor EndoAnchors Zone 0 12 Zone 1 75 Zone 2 61 Zone 3 39 Zone 4 8 Zone Zone 6 86 Zone 7 84 Zone Zone 9 98 Endoanchors retrieval 0.39% ( N=3 ) 2 by snare technique 1 retrieval with Aptus system
21 Procedural challenges Proximal Landing Zones Index Operations N=27 Redo Operations N=27 Total Zone Zone Zone Zone Zone Zone N=54 56 % landed in the arch & 41 % Zones 0-1
22 Procedural Outcome N = 54 TEVAR N = 37 Prophylactic N = 17 Therapeutic NO 5.9% Endoanchor related reinterventions Endoanchor related reintervention No type I or III endoleak No migration 1 type Ia / Ib endoleaks No migration
23 & CEVAR Procedural Outcome Freedom from Type I endoleak by Anatomy by Indication & 2 yrs & 2 yrs 94 1 & 2 yrs & 2 yrs 94 1 & 2 yrs
24 Summary EndoAnchors can be used prophylactically during TEVAR for complex aneurysms and appear to prevent migration and late endoleak formation, however longer follow up is needed EndoAnchors can be used therapeutically for type I & III endoleaks in index or redo TEVAR and can effectively eliminate endoleaks and reduce recurrences Type I endoleak after total arch debranching and redo TEVAR Type I endoleak after total arch debranching and redo TEVAR resolved after zone 0 EndoAnchors
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