Techniques For Endovascular Aortic Arch Repair. Mario Lachat, MD University Hospital of Zurich Matteo Orrico, MD San Camillo-Forlanini Hospital, Rome
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1 Techniques For Endovascular Aortic Arch Repair Mario Lachat, MD University Hospital of Zurich Matteo Orrico, MD San Camillo-Forlanini Hospital, Rome
2 Disclosure Speaker name: Mario Lachat Endospan, Jotec, Medtronic, Gore
3 Agenda Paralell Grafts Hybrid Repair Arch devices
4 Parallel Grafts TECH chimney
5 N= 14 Mean follow-up of 27 months (range 9 37) «Periscope»
6 3 or 4 Parallel Grafts (chimney, periscope)
7 Sizing with PG
8
9 Actual Sizing PG TECH USZ Diameter Aorta + 20% + ½ diameter PG Example: (Aorta 30mm) and PG to LSA (13mm) Regular sizing aortic stentgraft= 36mm Sizing aortic stentgraft with PG=45 (30+6+6,5= 42.7mm)
10 GUTTERS AREA OSIRIX EVALUATION Oversizing & A: STENT 8 mm B: STENT 11 mm C: STENT 9 mm (ostio dei TSA)
11 Technique to reduce diam of PG and/or aortic stress
12 Intended PG size: 13mm
13 Intended PG size: 13mm 10mm PG parked ASG parked
14 Intended PG size: 13mm 10mm PG parked ASG parked ASG deployed
15 Intended PG size: 13mm 10mm PG parked ASG parked ASG deployed 10mm PG deployed
16 Intended PG size: 13mm 10mm PG parked ASG parked ASG deployed 10mm PG deployed Extension with 13mm PG
17 Intended PG size: 13mm 10mm PG parked ASG parked ASG deployed 10mm PG deployed Extension with 13mm PG Primary relining with wallstent
18 Summary 2 different SG sizes -As small as possible in aortic LZ -10% oversize in target vessel
19 Primary relining with wallstent -To reinforce PG -To reduce endoluminal infolding (2nd PG)
20 Similar approach for all SAV
21 Moulding ASG
22 Moulding PG
23 CHIMNEY ORIENTATION VESSELS TAKE-OFF REDUCE INTERACTION IN THE ASCENDING
24 GUTTERS Longer chimney reduce EL (gutters ) Bad landing zone curvature/graft LZ
25 RETROGRADE TYPE A
26 RETROGRADE TYPE A Day 4 sudden death
27 DO THEY WORK? TECHNICAL SUCCESS 39/39 100% MORTALITY % PROCEDURE REL COMPLICATIONS % MINOR STROKE (2 RUPT-1 ELECT) 3 PARAPARESIS 1 EARLY TYPE I EL 0
28 Median FUP of 36 months
29 95 PTS 48 EMERGENCY TECHNICAL SUCCESS 89.5% 30 DAYS MORTALITY 9.5% (NONE AORTA RELATED) MAJOUR STROKE 2% TYPE I EL 10.5% (SOLVED SPONTANEOUSLY 50%) PRIMARY PATENCY 98% REINTERVENTION RATE 5.8%
30 Parallel Grafts (all Gore TAG/Viabahn/Excluder) n 30d mortality CVA/SCI EL 68 12% 9% 18% 40% acute patients 49% redo thoracic aorta
31 USZ Long-Term Study 41 first ARCH PG-EVAR patients treated up to May 2014
32 Mean FUP 22 (0-65; 17) months Pt at risk
33 Mean FUP 22 (0-65; 17) months months Pt at risk
34 Parallel Grafts - Conclusions Parallel grafts used in the aortic arch Off-The-Shelf repair technique Safe in selected patients Behave durable up to 3 years mean follow-up Taking into account substantial number of reinterventions to maintain seal or branch patency
35 ARCH devices
36 Aortic Arch Devices: 30days Fabric n 30d mortality CVA/SCI EL Gore 30 Zone % NA Zone % 22% Medtronic 9 Zone % 0 Bolton 34 Single Branch 8 25% 13% 17% Double Branch 26 12% 4% 22% Cook 38 Arch 38 5% 16% 11%
37 Nexus Innominate branch Nexus Main Module Ascending Module «Oriented»
38 Fixation zone of the ascending module (3cm) Separation forces of the modules: mean 20N (SD 3) [ref 10N]
39 Sealing zone of the ascending module (2cm)
40 RO Markers «B» markers for orientation (3) Dot markers for position (8) Ring marker for connection (1)
41 + Supraaortic Fenestration
42 Delivery system 20 Fr Pre-curved, Pre-shaped Delivery system and tip Nexus Main Module (NMM) Nexus Ascending Module (NAM)
43 Implantation technique Trough & Trough GW 20 Fr sheath Heparin bolus 300 IU/kg BW (ACT>300 ) Anti-Trendelenburg for deployment
44 Implantation technique Rapid Pacing
45 Clinical History 61 y Male Former Smoker Hypertension Dislypedimia IRC CAD TIA (15 y ago, unknown)
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62 From screening to Implantation
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65 Patients (31) Male 25 (80%) Age 73 years (52-85, SD:9) Aortic pathology Aneurysm 17 (55%) Dissection Type A 14 (45 %, all chronic) 10 (9 post ascending repair) Type B 3 Non-A-Non-B 1 Max Aneurysm Diameter: 63 mm (46-105; SD:13)
66 our center 5 4 monobranch Male 100 % Age 69 years Aortic pathology Aneurysm 3 Dissection 2 Type A 1 ( post ascending repair) Type B 1 1 Paraparesis (regressive) 1 Type II Endoleak (Uneffective LSA occl) Mortality 0% Type I EL 0%
67 N (31) 26 5
68 Results n 30d mortality 30d CVA/SCI 30d EL I/III 31 (Z0) 13% 10% 13% I I I 100% technical success rate (conversion free implantation) Mean FUP 12 months (SD9; 1-29) Aneuryms sac behavior Survival
69 Nexus - Conclusions Nexus is a promising alternative for total EV aortic arch repair Good Technical Outcomes and clinical outcomes Branch + Fen design is more challenging Precannulated fenestration could be an alternative
70 Hybrid Repair
71 Patient selection Stépan Haulon. EVT Nov. 2014
72
73 Zone Zero unfit for TEVAR (ectasy)
74 Ascending TD >35mm
75 The wrapping TECH Prolen mesh premarked to circumference = π x intended diameter 11cm for ID of 35mm
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77 SA debranching -Generally BCT and LCCA
78 SA debranching -Generally - BCT E/E or E/S running suture - LCCA with VORTEC
79 TAG Zone 4 And LSA PG sandwich
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81 66yo male Wrap & SADB 3.5h (teaching case) No transfusion PG-TEVAR 0.5h No transfusion
82 Hybrid TEVAR w. PG N= 26 30d M: 8% Mean follow-up 34 (SD 20] months
83 Modified less invasive Type II HR
84 When ever possible!!! -»Normal root» -»normal» AV function -Ascending diam < 7omm
85 Author Year Pts (n) 30-day results Long-term results Hybrid Repair mortality (%) Stroke (%) Mean (months) Survival Tokuda (2.6) % reinterv-free at 2 years Canaud (0) 1 (14.3) 41 No complication Kang (5.7) 2 (5.7) 35.4 Surv: 83.3% at 3 years Ren (2.2) 1 (2.2) 26 Surv 93.2% at mean fup Ockert (12.8) secondary EL 8.5%, Survival 70% Iba (2) 3(6) 24 Surv 81% & 80% FFR at 3 years Chiesa (4.5) 6 (3.4) 27.3 Clinical success 92.2% De Rango Survival 71% t 5 years Bavaria (8) 3 (8) 30 Surv 48% at 5 years Canaud Surv: 71.8 at 2 y Andersen (16) 3 (4.5) 28.5 Reintervention in 10 cases. Vallejo (23.7) 2(4.2) 28.1 Surv 50% ay 2 y Czerny (9.1) 3(4.5) 25 Surv 72% at 5 y Ma (2) 5(2) Gelpi (7) 0(0) m OK Canau (7) 2(5.9) m: surv 70% Gottardi (6.8) 1(1.4) 37 Surv 72% at 5 years Total 889 5% 2.6% 33±8 72±12%
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87 Hybrid Tech- Conclusions HR techniques and results significantly improved during last years More recent series show lower mortality & morbidity rates and repair durability Valuable option in selected patients
88 Conclusions Hybrid, PG tech & Arch devices are three safe means to treat arch pathology Superiority cannot be shown for none of them due to different target population Wise indication selection/ capability to combine the technique is probably the way to go
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