Presente e futuro negli aneurismi dell arco aortico
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1 Sessione Congiunta SICVE, SEACV, SCVE, SPACV Presente e futuro negli aneurismi dell arco aortico Roberto Chiesa Vascular Surgery, Vita-Salute University Scientific Institute San Raffaele Milano, Italy
2 Endovascular aortic arch repair Chimneys / Periscopes Sandwich technique
3 Endovascular aortic arch repair Chimneys / Periscopes ** ** ** Gutters
4 Endovascular aortic arch repair Single branched Medtronic Mona LSA WL Gore "Prototype
5 Endovascular aortic arch repair Double branched A-Branch Graft Cook Medical Double branch arch graft Bolton Medical
6 Total Endovascular approach
7 Inner branch arch repair results Mortality: 7.7%, Stoke: 13.8% Periop. Early experience Subsequent experience* Overall n=38 n=27 n=65 Mortality 5 (13.2%) 0 (0%) 5 (7.7%) Cerebrovascular events 6 (15.8%) 3 (11.1%) 9 (13.8%) Endoleaks 11 (28.9%) 3 (11.1%) 14 (21.5%) Systemic complications 17 (44.7%) 13 (43.3%) 30 (46.2%) F/U Mortality 4 (12.1%) 1 (3.7%) 5 (8.3%) Secondary procedures 3 (9.1%) 2 (7.4%) 5 (8.3%) Endoleaks 3 (9.1%) 2 (7.4%) 5 (8.3%) Overall mortality 9 (23.6%) 1 (3.7%) 10 (15.4%) 1. Aortic Centre, CHRU Lille, France, Vascular Surgery 2. Jikei University, Tokyo, Japan 3. German Aortic Center, University Heart Center Hamburg, Germany Spear et al. Eur J Vasc Endovasc Surg 2016*
8 OSR Preliminary Series (3 cases, Cook A-branch)
9 OSR Case (3 cases, Cook A-branch) To be continued
10 Total endo arch repair: PROBLEMS 1) Clinical limitations Waiting time: 12 weeks Available only on few referral centers (5 centers in all Europe)
11 11 Total endo arch repair: PROBLEMS Anatomical limitations Short ascending aorta Aortic mechanic valve SAT dissection Associated TAAA
12 12 Total Endo Arch Repair
13 Other approaches for Aortic Arch Pathologies
14 Open Surgery
15 Open surgery Authors N pts Mortality Stroke Strauch % 8% Matalanis 62 8% 15% Mortality: 10.8% Nakai % 17% Kikuchi 60 3% 3% Stroke: 10.6% Jakob 50 6% 10% Okita % 11%
16 Open surgery Trifurcated graft technique (continuous cerebral perfusion) Mortality: 4.3% Stroke: 5% Coselli JS et al, Ann Thor Surg 11
17 Hybrid Arch Surgery
18 Main concept Surgical supra-aortic vessels rerouting Stent-graft repair of aortic arch aneurysm
19 Hybrid arch repair Literature review > 25 cases ( ): 879 cases Authors N pts Mortality (%) Stroke (%) Narita H He X Kang WC Chiesa R Cao P Lofti S Murashita T Vallejo N Weigang E Gottardi R Wang M Czerny M Schumacher H Bergeron P Overall % 5.3%
20 Hybrid arch repair: OSR experience : 215 cases Zone 0 Zone 1 Zone 2 62 cases 39 cases 114 cases
21 Zone 0 Adjuncts Rapid pacing Clamping & SG deployment AA Side-clamping Off pump procedure TEE dissection
22 Zone 0 Easy in situ customization mm Bovine arch Right arch
23 Stroke prevention LSA management Plug before endo manipulation: stroke rate (p.04) Melissano, Chiesa et al. Eur J Vasc Endovasc Surg 2010
24 Cerebral filters Claret Medical s Sentinel embolic protection system Emboli following a TAVR procedure
25 Claret during TEVAR (Zone 2)
26 Perioperative results Zone 0 Zone 1 Zone 2 Total (62 pts) (39 pts) (114 pts) (215 pts) Mortality 6.6 % (4) 5.1 % (2) 1.7 % (2) 3.7 % Stroke 5.0 % (3) 2.6 % (1) 2.6 % (3) 3.3 % SCI % (2) 0.9 % Chiesa. et al. Multimed Man Cardiothorac Surg 2014 [Updated] Chiesa et al. J Endovasc Ther 2010 [Updated]
27 Late reinterventions causes 5 cases* Type I endoleaks Retrograde dissection Anastomotic pseudoaneurysm 1 case 3 cases 1 case* (Index procedure performed in another Center)
28 Arch cconclusions - More extended indications - Open surgery: acceptable results in fit patients - Hybrid: currently the best choice in mild / moderate risk patients - Total endo: future perspective
29
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