What is the best treatment for False Lumen growth after type B Dissection
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1 What is the best treatment for False Lumen growth after type B Dissection Nikolaos Tsilimparis, Fiona Rohlffs, Yuk Law, Sebastian Debus, Tilo Kölbel N. Tsilimparis, MD, PhD, FEBVS Deputy Head of German Aortic Center Dept. Of Vascular Medicine University Heart Center Hamburg
2 Disclosures Travelling, proctoring speaking-fees, PI with Cook Medical.
3 FL-Aneurysm in Chronic AD 70% N=100: 51 post TAAD; 49 TBAD FU: 53±26 months: FL-Aneurysm Aortic arch 3% Upper desc. aorta 14% Mid desc. aorta 8% Lower desc. aorta 4% Abdominal aorta 3% ⅓ Song et al. 2007; JACC 50:
4 Expert Consensus on CTBAD Fattori et al. 2013, JACC 61:
5 Open Surgery for CTBAD 19 studies, n=970, 58y mean age 30d mortality: 11% Stroke: 6%, SCI: 5%, CNI: 8% 3/10y survival: 74/50% Conclusion: poorer compared to TEVAR Tian et al. 2014; Ann Cardiothorac Surg 3:340-50
6 Failure to Remodel in Chronic Dissection Perfusion and pressure unchanged in false lumen Presence of Intercostals originating from false lumen False lumen back flow to Intercostals FL-TAA in 1/3 of TEVAR-patients!
7 Direct False Lumen Occlusion TEVAR-extension to CA Embolisation by Plugs, coils, glue Candy-plug Knickerbocker-technique Does not restrict further distal techniques like fenestrated EVAR
8 Coils, Plugs, Glue Preop. CT Intervention Postop. CT
9 Iliac Occluder Idrees et al. 2014; J Vasc Surg 60:
10 Knickerbocker-Technique Kölbel et al. 2014; J Endovasc Ther 21:
11 Candy-Plug 50mm 22mm Amplatzer plug II 22mm ZIP iliac-occluder Kölbel et al. 2013; J Endovasc Ther 20: 484-9
12 Candy-Plug October 2013 January 2014 January 2016
13 Candy-Plug February 2016 July 2016
14 FL-Aneurysm in Chronic AD N=100: 51 post TAAD; 49 TBAD 20% FU: 53±26 months: FL-Aneurysm Aortic arch 3% Upper desc. aorta 14% Mid desc. aorta 8% Lower desc. aorta 4% Abdominal aorta 3% Song et al. 2007; JACC 50:
15 fevar in Chronic Type A/B N=31, 17 months FU 6 Type II EL; 6 type 1b EL 30d-mortality: 9.6% Technical success: 93.5% FL-thrombosis: 88% Oikonomou et al. 2014; Eur J Vasc Endovasc Surg 48: 641-8
16 Challenges in fbevar for TBAD Narrow True-Lumen Stiff dissection membrane Origin of the renovisceral vessels from different Lumina Triple-Barrel complex Dissections Dissected distal landing zones Target vessels (SMA/celiac/renals) Iliac vessels distance from main graft to target vessels
17 Case 1 56-year-old female Type B Aortic dissection 3 years ago Thoracic Aortic FL-Aneurysm of 7cm Entry 3cm behind LSA No Abdominal FL-Aneurysm Ascending aorta 4.6cm
18 Options Frozen Elephant Trunk? Open thoracic or thoracooabdominal repair? False Lumen Occlusion? Fenestrated branched endograft?
19 Planning of a Candy-Plug
20 False lumen access
21 TEVAR
22 TEVAR extension to the celiac
23 Access in FL at the visceral level
24 Candy Plug
25 Final Result
26 Next generation Candy Plug II Shorter (70mm vs. 110) No central occluder or Plug needed Over the wire dilatator retrieval But Attention required while retrieving dilatator
27 Candy Plug II implantation False lumen access CP II deployment Final angigram
28 Case 2 67year old patient
29 Options Frozen Elephant Trunk? Open thoracic or thoracooabdominal repair? False Lumen Occlusion? Fenestrated branched endograft?
30 Staged approach FET, TEVAR+Candyplug + Fenestration
31 Preconditioning of the aorta
32 Procedural steps
33 Procedural steps
34 Secondary F/B EVAR F/B EVAR
35 Secondary F/B EVAR FET, TEVAR+Candyplug + Fenestration F/B EVAR
36 Case 3 30-year old female patient Marfan Stentgraft in the thoracic with good seal No ascending pathology
37 Options? Frozen Elephant Trunk? Open thoracic or thoracooabdominal repair? False Lumen Occlusion? Fenestrated branched endograft?
38 Reversed Elephant Trunk
39
40 Treatment of DeBakey I Dissections
41 Endovascular approach for post open repair residual dissection aneurysms Sobocinski et al. Ann Thorac Surg 2016;102:
42 Branched Endografts for Arch Post- Dissection Aneurysms => 48 patients with Arch branched endografts 20 patients with Arch dissections post open ascending repair Indications: chronic false lumen aneurysms n=19 persistent malperfusion syndrome post open repair n=1 Mean diameter of the post-dissection aneurysms: 63±12mm Tsilimparis et al. Eur J Cardiothorac Surg Mar 28
43 Adjunctive measures for FL Occlusion Candy Plug n= 7 Knickerbocker n= 3
44 Chronic Dissection Strategy FL-Aneurysm in CAD
45 Chronic Dissection Strategy FL-Aneurysm in CAD TEVAR to the Celiac
46 Chronic Dissection Strategy FL-Aneurysm in CAD TEVAR to the Celiac + FL-Occlusion
47 Chronic Dissection Strategy FL-Aneurysm in CAD TEVAR to the Celiac + FL-Occlusion
48 Chronic Dissection Strategy FL-Aneurysm in CAD TEVAR to the Celiac + FL-Occlusion Fen/Branch EVAR
49 Chronic Dissection Strategy FL-Aneurysm in CAD TEVAR to the Celiac + FL-Occlusion Fen/Branch EVAR
50 Chronic Dissection Strategy FL-Aneurysm in CAD TEVAR to the Celiac + FL-Occlusion Fen/Branch EVAR + FL-Occlusion
51 Hamburg Algorithmus in Chronic dissections 61 false lumen aneurysms in chronic aortic dissection treated by endovascular means 3 Previous open repair 10 TEVAR alone 33 TEVAR and Candy Plug 4 TEVAR and Spotstenting 11 Knickerboc ker Secondary FB-EVAR 3 Primary FB-EVAR
52 Conclusion Tubular stent-graft sufficient in majority cases of TBAD. False lumen backflow limiting treatment success in chronic TBAD. Techniques for false-lumen embolisation: Plugs, coils, glue Candy-plug Knickerbocker-technique Experience promising, but future role to be defined. F/B stentgrafts reserved for abdominal FL-aneurysm.
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