Outcome of the target vessels in endovascular TAAA repair Case #1

Transcription

1 Outcome of the target vessels in endovascular TAAA repair Case #1 Nuno Dias Paris Endovascular Aortic Course Paris, cm Type IV TAAA T-branch 1 month Postoperative CT 2.5 months Postoperatively 1

2 2.5 months Postoperatively Pulse Spray T-lysis and Mechanical Thrombektomy Case #2 rtaaa type IV rtaaa type IV What to do? Fenestrated vs Branched? Off-the-shelf rtaaa type IV 2

3 2.5 years Postoperatively Fortune teller Issues determining patency Preoperatively Planning Intraoperative Postoperative Preoperative Planning Anatomy Target Vessel: Branch vs Fen Anatomical suitabilty of off-the-shelf 4-branched bevar Accepting 50 mm distance to TV Accepting 40 mm distance to TV in Oderich, Springer Ed % Sweet et al, JEVT 2009 Bisdas et al, JEVT

4 Renal artery anatomy in bevar Decreased patency with increased tortuosity index (> 1.1) Intraoperative determinants Sugimoto et al, EJVES 2016 Difficult catherization Experience matters? Failed catheterization 1-3 % Extreme aortic tortuosity Better planning Small aortic diameter for bevar Very severe ostial stenosis Pre-Stent Relation to target vessel suboptimal Branches more tolerant Off-the-shelf solutions Technical success 92% 98% Sveinsson et al, JVS 2015 External compression fenestrations Post operative CTA 4

5 Reintervention Cone Beam reintervention Modes of Failure for Branches Postoperative issues Endoleak Type III (Separation) Branch Occlusion (Kink) Branch Occlusion (fracture) Mastracci et al, JVS 2013 Modes of Failure Fenestrations Long-term Patency Fenestrations 93% ± 2% 90% ± 3% Kristmundsson et al, JVS

6 Complex EVAR target vessel patency Any Branch Re-intervention, Occlusion, or Branch-related Death Freedom from reinterventions Celiac Fenestration w higher instabilty Mastracci et al, JVS 2013 Mastracci et al, JVS Centre Hospitalier Regional Universitaire Lille, France 2 Vascular Center, Skåne University Hospital, Malmö 3 Guys and St. Thomas Hospital, Kings College London, UK 4 Klinikum Nurnberg, Klinikum Nuremberg, Paracelsus Medical University Nuremberg, Germany 5 Royal Free London, University College London, UK Branched Collaboration Branch Event Rates: Occlusion or Reintervention n % Celiac 7/208 3% SMA 3/ % Left Renal Artery 18/ % Right Renal Artery 17/ % Any Death, Branch occlusion or Branch Reintervention 80/235 34% Mastracci et al, EJVES 2016 Branch Collaboration Branch patency Hypothesis-generating findings Type of primary stent does not appear to be associated with occlusion or reintervention Anatomic Location of stents may be important to durability Renal stents had higher event rates regardless of the primary stent used (HR 3.51, p=0.001) Mastracci et al, EJVES 2016 Mastracci et al, EJVES

7 Renal occlusion: Branch vs Fenestration All patients Renal occlusion: Branch vs Fenestration Only type I, II and III Martin-Gonzales et al, EJVES 2016 Martin-Gonzales et al, EJVES 2016 Renal Angulation During Follow Up Renal Fenestrations: the Holy Grail in etaaa? RRA LRA Martin Gonzales et al, EJVES 2015 Renal Fenestrations: the Holy Grail in etaaa? 30-d Mortality after FEVAR Nordon et al, EJVES

8 Survival of ZFEN patients Results of EVAR of TAAA Yr Nr TAAA A = Anat C = cover Mortality Inhosp / 30-d Initial SCI Permanent Paraplegia + Paresis Assessment Rossi A - / % 5.9% Neurol Katsargyris (201 for SCI) A - / 7.8% 10.4% 4% Bisdas % / - 16% 11% Neurol Dias A - / 6.8% 39.4% 33% Neurol 23.7% 13% Neurol Repair needs only to last longer than the PATIENT and not for ever Kristmundsson et al, JVS / 11.6% 25% Neurol Maurel C - / 5.6% 2.1% Neurol Sobel C -/- 20.6% 7.7% Eagleton C 4.9% 1.4% Rossi et al, EJVES 2015; Katsargyris et al, JVS 2015; Bisdas et al, JVS 2015; Dias et al, EJVES 2015; Maurel et al, EJVES 2015; Sobel et al, JVS 2015; Eagleton et al, JVS 2013 Spinal Cord Ischemia (SCI) after TAAA repair SCI and Survival Significant incidence (0-30%) Devastating consequences Quality of life Increased mortality DeSart et al, JVS 2013 SCI onset SCI onset Immediate Early (< 72 h) > 75 % of SCI develop within 48 h Very late DeSart et al, JVS

9 SCI onset Immediate onset of SCI much less improvement (25 % vs 70 %) Poor Survival Results of EVAR of TAAA Yr Nr TAAA A = Anat C = cover Mortality Inhosp / 30-d Initial SCI Permanent Paraplegia + Paresis Assessment Rossi A - / % 5.9% Neurol Katsargyris (201 for SCI) A - / 7.8% 10.4% 4% Bisdas % / - 16% 11% Neurol Dias A - / 6.8% 39.4% 33% Neurol 23.7% 13% Neurol Maurel C - / 11.6% 25% Neurol - / 5.6% 2.1% Neurol Sobel C -/- 20.6% 7.7% DeSart et al, JVS 2013 Eagleton et al, JVS 2013 Eagleton C 4.9% 1.4% Rossi et al, EJVES 2015; Katsargyris et al, JVS 2015; Bisdas et al, JVS 2015; Dias et al, EJVES 2015; Maurel et al, EJVES 2015; Sobel et al, JVS 2015; Eagleton et al, JVS 2013 Open TAAA repair Lynn et al, J Cardiothor Vasc Anesth 2014 Summary: Survival and SCI in fevar/bevar Perioperative survival is very high The repair needs only to outlive the patient Spinal cord ischemia Still a concern But can be limited with multifactorial approach Summary: Target vessel in etaaa repair Target vessel patency is very high There are some peculiarities with different vessels and type of endograft Renal arteries seem more susceptible to adverse events, when branches are used Celiac trunk fenestrations have lower patency 9

10 Summary: Target vessel patency in fevar/bevar High patency can be achieved with: Good preoperative planning Rigorous operative technique Experience / high-volume High quality intraoperative completion imaging Standardized follow-up looking specifically into failure modes Allowing timely reinterventions Critical Issues in Aortic Endografting 2018 June 29 30, 2018 Malmö, Sweden 10