False Lumen Occlusion Techniques in CAD:
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1 University Heart Center Hamburg GERMAN AORTIC CENTER False Lumen Occlusion Techniques in CAD: What is ist role? How is it done? Tilo Kölbel Fiona Rohlffs, Nikos Tsilimparis, Sebastian Debus German Aortic Center University Heart Center Hamburg
2 Disclosures! Research-grants, travelling, proctoring speaking-fees, IP with Cook.! Discussion of investigational devices, which are not FDA-aprooved.
3 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
4 TEVAR in Chronic Type B False Lumen Perfusion No Aortic Remodelling Death Mani et al. 2012; Eur J Vasc Endovasc Surg 43:
5 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!
6 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% Song et al. 2007; JACC 50:
7 Direct False Lumen Occlusion
8 Direct False Lumen Occlusion! TEVAR-extension to CA! Embolisation or Knickerbocker! Seperates aortic FL-compartments!! Does not restrict further distal techniques like fenestrated EVAR Bulkhead
9 When/Why Are They Needed?! Open surgery in CTBAD reserved to good risk patients.! TEVAR in CTBAD fails in 1/3 of patients.! False lumen occlusion needed if proximal thoracic aorta expands or diameter requires immediate occlusion.
10 Filters, Balloons, Thrombin! 2 Cases 1. FL-TAA-occlusion with:! 2 Greenfield filters! 6 detachable balloons! 5ml thrombin 2. FL-TAA-occlusion with:! 24mm Talent occluder Loubert et al. 2003; J Endovasc Ther 10: 244-8
11 Coils, Plugs, Glue Preop. CT Intervention Postop. CT
12 Iliac Occluder Idrees et al. 2014; J Vasc Surg 60:
13 Candy-Plug 50mm 22mm Amplatzer plug II 22mm ZIP iliac-occluder Kölbel et al. 2013; J Endovasc Ther 20: 484-9
14 Candy-Plug Kölbel et al. 2013; J Endovasc Ther 20: 484-9
15 Kölbel et al. 2014; J Endovasc Ther 21: Knickerbocker-Technique
16 Kölbel et al. 2014; J Endovasc Ther 21: Knickerbocker-Technique
17 Kölbel et al. 2014; J Endovasc Ther 21: Knickerbocker-Technique
18 Kölbel et al. 2014; J Endovasc Ther 21: Knickerbocker-Technique
19 What Are The Complications?! Risk for spinal cord ischemia:! Observation! SF-drainage! BP-control! 1 anecdotal case in ruptured CTBAD and surgeon-modified candyplug Knickerbocker:! Risk for FL-rupture:! 1case: salvaged by additional coil and glue embolisation.
20 What Is The World Experience? Recently collected data, all Cook-Medical CMDs! Knickerbocker:! German Aortic Center Hamburg, Germany! Fabio Verzini, University of Perugia, Italy! Andrew Holden, Auckland City Hospital, New Zealand! Carla van Rijswijk, Leiden UMC, Netherlands! Anders Wanhainen, Uppsala UniversityHospital, Sweden! Candyplug:! German Aortic Center Hamburg, Germany! Matt Thompson, St. Georges Hospital London, Great Britain! Joachim Florek, Helios-Klinikum Freital, Germany! Hence Verhagen, Erasmus UMC Rotterdam, Netherlands
21 Candy-Plug! N=18! Technical success 18/18! No rupture! No SCI! No mortality! 3 reinterventions for continous perfusion! Secondary FLthrombosis all patients
22 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:
23 fevar in Chronic Type B Courtesy of Stephan Haulon, Lille
24 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; J Vasc Endovasc Surg 48: 641-8
25 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! World experience promising, but future role to be defined.
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