Toward Total Endovascular Therapy of the Aorta. Adam W. Beck, MD. Associate Professor of Surgery Division of Vascular Surgery and Endovascular Therapy

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1 Toward Total Endovascular Therapy of the Aorta Adam W. Beck, MD Associate Professor of Surgery Division of Vascular Surgery and Endovascular Therapy University of Alabama at Birmingham

2 Disclosures Grant Support: Cook Medical, Medtronic Inc, W.L. Gore & Associates, Consultant Cook Medical, Medtronic, Inc, Physician Education Cook Medical, Terumo All proceeds to UAB **Off label use of devices will be discussed

3 Historical Perspective There is no disease more conducive to clinical humility than aneurysm of the aorta. -Sir William Osler

4 Aortic Aneurysm

5 Endovascular Revolution

6 Juan Parodi (1991) Endovascular Revolution

7 Endovascular Revolution TEVAR: 1994: First successful TEVAR 2005: Gore TAG approved for use in the U.S.

8 How Does A Stent Graft Work? Synergy of Form and Function Form Function Stent Graft Seal Fixation

9 Infrarenal Aortic Devices (2000)

10 Devices (2017) 6 Commercially available devices ~70% of AAAs amenable to repair (within IFU)

11 Anatomic Challenges to EVAR Neck Iliac Anatomy Access

12 Juxtarenal Fenestrated EVAR FDA approved 2013

13 Anatomic Challenges to EVAR

14 Open Repair of TAA and TAAA Mortality 10-25% Morbidity Pulmonary: 30-50% Cardiac: 10-25% Renal: 10-20% Paralysis/Paraplegia: 5-40% Stroke: 5-10%

15 Open Repair of TAA and TAAA Current Adjuncts CSF Drainage Distal Aortic Perfusion Intercostal Reimplantation Expeditious Surgery Hypothermia Spinal Cooling Neuroprotective drugs SCI: 5-20%

16 Pioneers and Investigational Device Exemptions Roy Greenberg Tim Chuter

17 Thoracoabdominal Aneurysm Repair Open Repair Hybrid Debranching Repair Endovascular Repair Parallel ( Chimney ) stents Fenestrated/Branched Endografts Physician-modified Custom devices - requires Investigational Device Exemption

18 Alternatives? Hybrid TAAA Repair

19 Second stage (TEVAR) sometimes not completed Physiologic impact similar to open TAAA Largely Abandoned

20 Alternatives? Parallel stents: Chimneys

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24 406 TAAA Patients!

25 ACTIVE SPONSOR-INVESTIGATOR F/BEVAR IDE STUDIES Matt Sweet and Ben Starnes University of Washington Tim Chuter UC-San Francisco San Francisco, CA David Kuwayama U. Of Colorado Denver, CO Gustavo Oderich Mayo Clinic Rochester, MN Matt Eagleton Cleveland Clinic Cleveland, OH Adam Beck, MD UABMC Birmingham, AL Darren Schneider Cornell University New York, NY Mark Farber UNC-Chapel Hill Chapel Hill, NC Andy Schanzer U. Massachusetts Worcester, MA Carlos Timaran UT-Southwestern Dallas, TX Anthony Lee Lynn Heart and Vascular Institute Boca Raton, FL

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31 Challenge: Spinal Cord Ischemia Achilles Heel?

32 Endovascular Repair: Acute Spinal Cord Ischemia Aortic coverage/intercostal Thrombosis Hemodynamics (Hypotension) Intercostal, Subclavian, Hypogastric, Lumbar Arterial coverage/ligation

33 SCI: Spinal Cord Perfusion Artery of Adamkiewicz T9 - T12/L1

34

35 UF Branched/Fenestrated Spinal Cord Ischemia No SCI Any SCI N= % 31.7% In-house mortality: N=10 (4.1%) % % 8 Juxtarenal Suprarenal IV III II I *Unpublished Data

36 UF Branched/Fenestrated Spinal Cord Ischemia Temporary vs. Permanent Recovered Function Permanent SCI % 10.71% % % 0 Juxtarenal Suprarenal IV III II I

37 Spinal Cord Ischemia

38 Spinal Cord Ischemia

39 Implications of SCI 12-Month survival (TEVAR) With SCI: 25% Without SCI: 80%

40 UF/UAB SCI Prevention Protocol

41 Spinal Cord Ischemia Rate (%) SCI Rate Before and After Protocol * p =.007 * p = Pre Post Pre Post All Patients High Risk Patients

42 Challenge: Urgent/Emergent Presentations

43 Custom Endografts

44 Urgent/Emergent ~30% of UAB Aortic Practice ~20% of endovascular practice Frequently complex anatomy Custom devices not available

45 Acute Complex Aortic Emergencies Traumatic transection Complicated Dissection Symptomatic Aneurysms Ruptured Aneurysms

46 Chimneys, Periscopes, Snorkels..ChimPS?

47 Thoracoabdominal: Zenith TAAA Branch This prototype is under development.

48 Branched Endografts

49 Surgeon-modified Fenestrated Endograft

50 Surgeon-modified Fenestrated Endograft

51 Emergent Presentations

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58 83yo EVAR 85yo revision 87yo Failure Twelve!!!

59 Continued Dilation, endoleak

60 6 months Follow-Up

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62 Challenge: Radiation/Operative Length

63 Planning

64 Modern Hybrid Operating Room

65 Advanced Intraoperative Imaging

66 Intraoperative Fusion Imaging

67 Methods: Branch vessel access

68 Intraop 3D CT

69 Challenge: The Arch/Ascending Aorta

70 Anatomic Challenges

71 Challenge: Aortic Arch

72 Future Technologies

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74 Proximal LZ Management

75 Transverse Arch Devices

76 Transverse Arch

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89 Endograft Failures Future Challenges Connective tissue disorders Graft infections Ascending Aorta Aneurym No proximal seal zone (annulus combine with TAVR?) Coronary branches? Type I Dissection Entry tears usually (>80%) within first 4cm Combined coronary disease Combined valvular dysfunction

90 Thank You

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