Technique and Outcome of Laser Fenestration For Arch Vessels
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1 Technique and Outcome of Laser Fenestration For Arch Vessels Jean M. Panneton MD, FRCSC, FACS Professor of Surgery Chief & Program Director Division of Vascular Surgery Eastern Virginia Medical School Norfolk, VA
2 Disclosures Consultant: Arsenal, Cook Medical, Bolton Medical, Medtronic Inc, Volcano, WL Gore Speakers Bureau: Bolton Medical, Medtronic Inc., WL Gore Scientific Advisory Board: Medtronic Inc. Eastern Virginia Medical Center
3 Case study 78 year old male patient Ruptured 8cm arch aneurysm Hypotensive, transferred to hybrid room On table CPR
4 Case study Predeployment arch study with laser in LCA and endograft in the arch for Zone 1 Endograft deployed and retrograde angiogram of the laser fenestrated and stented LCA Completion arch study with patent LCA fenestration and no endoleaks Patient discharged neurologically intact and now at 1 year and 3 months follow up without reinterventions
5 Technique Endograft is deployed, retrograde sheath & Laser in contact Laser Balloon 6 x 40 7 Fr Sheath Expandable covered stent 8-10 x guidewire Balloon 14 x 20
6 Technique Laser Orientation Deployment view 48 o LAO Barrel view 37 o RAO
7 Technique Laser Activation Guidewire into ascending aorta
8 Technique Predilation: over stiff guidewire with 6x40 balloon
9 Technique Stenting of the fenestration Retrograde angiogram with balloon expandable covered stent across the fenestration and proximal to the vertebral artery origin
10 Technique LCA fenestration after LSA to LCA transposition Completion aortogram
11 Pitfalls The anatomy of the arch and the supraaortic vessels dictates the feasibility Type III arch Other criteria of the arch vessels Short innominate Low Vertebral artery origin SATs involved by dissection SATs too dilated
12 Pitfalls: Acute take off Acute takeoff May be facilitated by using steerable sheath to modify the angle
13 Results: Initial Experience 22 patients with successful LSA fenestration during emergent TEVAR Operative mortality: 4.5% (1/22) No stroke No major fenestration related complications or type I or III endoleaks 100% patency of LSA stents J Vasc Surg 2013;58:1171-7
14 Results: Current Experience July 2009 December 2017 N = 59 patients Mean Age of 61.3 yrs 55 LSA & 3 LCA & 1 Inn All Thoracic aortic pathologies: Aortic Dissection, IMH, BTAI, Thoracic aneurysms or TAAA ( including 16 ruptures [ 27% ] )
15 Results: Early Outcomes Operative Mortality = 5.1% ( 3 /59 ) 1 ruptured acute TBAD resp failure 1 ruptured IMH resp failure 1 acute TBAD malperfusion - stroke Neurologic Complications: Stroke : 2 (3.4%) ( ruptured IMH & Acute TBAD ) SCI : 5 (8.5%) ( 3 paraplegia; 2 Paraparesis ) ( 3 permanent; 2 transient ) Mean Length of Stay = 9.5 days
16 Results: Late Outcomes Modes of Failure No type III endoleak; No stent occlusion Fenestration related reintervention rate = 5.1% ( 3/59 ) 1 early type Ic endoleak requiring coiling around LSA stent 2 late type Ic endoleaks: LSA distal restenting at 17 & 30 mo Mean clinical follow up of 2.5 years ( range years )
17 Summary In situ laser fenestration can safely and effectively revascularize arch branches during TEVAR and imaging surveillance has documented the mid term durability of this innovative technique
Jean M Panneton, MD Professor of Surgery Program Director Vascular Surgery Chief EVMS. Arch Pathology: The Endovascular Era is here
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TECHNICAL NOTE Use of covered stents and endograft as a rescue treatment in a patient with a complex form of recurrent aortic coarctation Juan C. Parodi, MD, Luis Mariano Ferreira, MD, Horacio Faella,