Taming The Aorta. David Minion, MD Program Director, Vascular Surgery University of Kentucky Medical Center Lexington, Kentucky, USA
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1 Taming The Aorta David Minion, MD Program Director, Vascular Surgery University of Kentucky Medical Center Lexington, Kentucky, USA Faculty Disclosure Consulting: Endologix, Cook 1
2 Objectives Review the presentation of the three most common diseases affecting the aorta aneurysms, dissection, and occlusive disease. Discuss the appropriate work up and indications for repair of aortic pathology. Describe the latest endovascular treatment for complex aortic pathology. Aortic Aneurysm Defined as Dilation to at least 1.5 times the Diameter of Normal Vessel Normal abdominal Aorta = Approximately 2 cm. 2
3 Presentation Incidental/Screening 3
4 Rupture/Symptomatic Atheroembolism 4
5 Avoiding Rupture Aortic Aneurysm Screening USPSTF Guidelines Men aged who have smoked (at least 100 cigarettes in their lifetime.) Society of Vascular Surgery Guidelines for Screening All men age 65 or older Men with a family history as early as age 55 Women age 65 or older with a family history of AAA or who have smoked 5
6 Interpreting the Scan Annual Risk of Rupture Diameter < 4.0 cm = < 0.5 % Risk Diameter cm = % Risk Diameter cm = 3 15 % Risk Diameter cm = % Risk Diameter cm = % Risk Diameter < 8.0 cm = % Risk 6
7 Surveillance for Smaller AAAs Aorta < 2.6 cm = no further imaging Aorta 2.6 to 2.9 cm = repeat in 5 years Aorta 3.0 to 3.4 = repeat in 3 years Aorta 3.5 to 4.4 = repeat in 1 year Aorta 4.5 to 5.4 = repeat in 6 months Indication for Repair Symptomatic patients Size 5.5 cm or greater for males 4.5 to 5 cm for females? Growth of 1 cm in one year or 7 mm in 6 months Consider earlier repair in younger, healthy patients or saccular morphology 7
8 Saccular Aneurysm The Thoracic Aorta 8
9 Normal Diameters Mid Ascending Aorta (#3): Females/Males ~2.9 cm Mid Descending Aorta (#7): Females: cm Males: cm Aortic Root (#1): Females: cm Males: cm Diaphragmatic (#8): Females: 2.4 cm Males: cm ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Recommendations for Aneurysm Repair Ascending Aorta/Arch: Isolated: 5.5 cm (or 0.5 cm/yr growth) With AVR: 4.5 cm CTD: 4 5 cm Descending Aorta/TAA: Open: 6.0 cm TEVAR Candidate: 5.5 cm CTD or Dissection: 5.5 cm Hiratzka, et al. JACC 2010;55:
10 Endovascular Aneurysm Repair (EVAR) The Basic Steps for EVAR Access Delivery of the Endograft Deployment of Main Body Cannulation of Gate Deployment of Limbs Seating of the Graft 10
11 The Finished Product Seal in Normal Vessel Impervious Tube David J Minion, MD What Could Possibly Go Wrong? 11
12 Short Neck Reverse Taper 27 mm 23 mm 27 mm 30 mm 12
13 Calcified Neck Angled Neck 13
14 Double Angle Thrombus 14
15 Compromised Distal Seal Zone Compromised Distal Seal Zone 15
16 Access Issues Endoleaks Type I: Attachment site leaks IA = Proximal IB = Distal Type II: Retrograde Branch leaks Type III: Graft defect IIIA = Junctional leak IIIB = Fabric disruption Type IV: Graft fabric porosity Type V: Endotension White et al., J Endovasc. Surg. 1998;5(4):
17 Type II Endoleaks IMA via the Arc of Riolan Iliolumbar (Retiform) Iliolumbar (Inosculated) Type I Endoleak 17
18 Type III Endoleak Endovascular versus Open Repair of Abdominal Aortic Aneurysms 1252 Patients Randomized to EVAR vs Open 30 Day Mortality EVAR = 1.8% Open = 4.3% No Late Survival Benefit (at 5 years) UK EVAR Trial Investigators. N Engl J Med 2010;362:
19 Endovascular versus Open Repair of Abdominal Aortic Aneurysms UK EVAR Trial Investigators. N Engl J Med 2010;362: Endovascular versus open repair of abdominal aortic aneurysm in 15 years follow up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial Patel R, et al. for the EVAR Trial Investigators. Lancet 2016;388:
20 We Need More Seal Options for More Seal Fenestrated Graft Parallel Grafts David J Minion, MD 20
21 Parallel Endografts Juxtarenal Aneurysm 21
22 Marginal Seal Parallel Endografts 22
23 The Pericles Registry 517 patients from 13 centers. Mean Follow up of 17 Months 94% Primary Patency of 898 Chimney grafts Mean Sac Regression = 4.4 mm No aortic ruptures Overall survival of 79% Type IA Endoleaks Intra operative = 7.9% Late/Persistent = 2.9% Gutter Leak Imperfect Apposition 23
24 Standard Parallel Endograft Poor Apposition and Large Gutters Lens Shaped Parallel Endograft Perfect Apposition and No Leak 24
25 Urgent Type IA David J Minion, MD Urgent Type IA Minimal Paravisceral Thrombus Type IA David J Minion, MD 25
26 Urgent Type IA Short Seal Zone Distal to RRA/SMA Upward Oriented LRA with No Infrarenal Seal Zone David J Minion, MD Operative Approach Cannulate LRA (6x59 icast) From Rt Groin David J Minion, MD 26
27 Operative Approach Cannulate LRA (6x59 icast) From Rt Groin Cannulate RRA (5x38 icast) and SMA (7x38 icast) from Left Arm David J Minion, MD Operative Approach Cannulate LRA (6x59 icast) From Rt Groin Cannulate RRA (5x38 icast) and SMA (7x38 icast) from Left Arm Deploy 1st Cuff David J Minion, MD 27
28 Operative Approach Cannulate LRA (6x59 icast) From Rt Groin Cannulate RRA (5x38 icast) and SMA (7x38 icast) from Left Arm Deploy 1st Cuff Complete Retro Sandwich in LRA David J Minion, MD Operative Approach Cannulate LRA (6x59 icast) From Rt Groin Cannulate RRA (5x38 icast) and SMA (7x38 icast) from Left Arm Deploy 1st Cuff Complete Retro Sandwich in LRA Extend Above SMA and RRA David J Minion, MD 28
29 Eye of the Tiger Technique A. Deploy B. Over Dilate C. Crush D. Partially Re Expand David J Minion, MD Operative Approach Cannulate LRA (6x59 icast) From Rt Groin Cannulate RRA (5x38 icast) and SMA (7x38 icast) from Left Arm Deploy 1st Cuff Complete Retro Sandwich in LRA Extend Above SMA and RRA Over dilate LRA icast to 10 mm David J Minion, MD 29
30 Operative Approach 6 mm Balloon Cannulate LRA (6x59 icast) From Rt Groin Cannulate RRA (5x38 icast) and SMA (7x38 icast) from Left Arm Deploy 1st Cuff Complete Retro Sandwich in LRA Extend Above SMA and RRA Over dilate LRA icast to 10 mm Exchange for original 6 mm balloon David J Minion, MD Operative Approach Cannulate LRA (6x59 icast) From Rt Groin Cannulate RRA (5x38 icast) and SMA (7x38 icast) from Left Arm Deploy 1st Cuff Complete Retro Sandwich in LRA Extend Above SMA and RRA Over dilate LRA icast to 10 mm Exchange for original 6 mm balloon Crush LRA stent with CODA David J Minion, MD 30
31 Operative Approach Cannulate LRA (6x59 icast) From Rt Groin Cannulate RRA (5x38 icast) and SMA (7x38 icast) from Left Arm Deploy 1st Cuff Complete Retro Sandwich in LRA Extend Above SMA and RRA Over dilate LRA icast to 10 mm Exchange for original 6 mm balloon Crush LRA stent with CODA Re inflate LRA with 6 mm balloon David J Minion, MD Operative Approach Cannulate LRA (6x59 icast) From Rt Groin Cannulate RRA (5x38 icast) and SMA (7x38 icast) from Left Arm Deploy 1st Cuff Complete Retro Sandwich in LRA Extend Above SMA and RRA Over dilate LRA icast to 10 mm Exchange for original 6 mm balloon Crush LRA stent with CODA Re inflate LRA with 6 mm balloon IVUS David J Minion, MD 31
32 Operative Approach Cannulate LRA (6x59 icast) From Rt Groin Cannulate RRA (5x38 icast) and SMA (7x38 icast) from Left Arm Deploy 1st Cuff Complete Retro Sandwich in LRA Extend Above SMA and RRA Over dilate LRA icast to 10 mm Replace with original 6 mm balloon Crush LRA stent with CODA Re inflate LRA with 6 mm balloon IVUS Completion Angio David J Minion, MD Operative Approach Cannulate LRA (6x59 icast) From Rt Groin Cannulate RRA (5x38 icast) and SMA (7x38 icast) from Left Arm Deploy 1st Cuff Complete Retro Sandwich in LRA Extend Above SMA and RRA Over dilate LRA icast to 10 mm Replace with original 6 mm balloon Crush LRA stent with CODA Re inflate LRA with 6 mm balloon IVUS Completion Angio David J Minion, MD 32
33 Standard Approach 8 mm Parallel Seal David J Minion, MD Post CTA Recon 8 mm Parallel Seal 10 mm True Seal 10 mm True Seal 30 mm Parallel Seal 33
34 Transgluteal Embolization of Type II Transgluteal Embolization of Type II 34
35 Transgluteal Embolization of Type II Post op CTA 35
36 Extending the Techniques Case 2 36
37 Aneurysmal Type B Dissection Aneurysmal Type B Dissection 37
38 Aneurysmal Type B Dissection 38
39 Post op CT Aneurysmal Type B Dissection 39
40 Ahead of the Curve 40
41 Case 3 The trifurcated endograft technique for hypogastric preservation during EVAR Minion, et al. JVS 2008;47:
42 Trifurcated graft Trifurcated Graft 42
43 Prototype for the first FDA approved device Thoracoabdominal Endografts Feasibility Study
44 Case 4: 72 YO Female Lateral View Anterior View Operative Exposure th 4th Type: ciii, civ, cv Type: ci & cii 44
45 Fenestrated Endovascular Aneurysm Repair Fenestrated Endovascular Aneurysm Repair 45
46 Fenestrated Endovascular Aneurysm Repair Fenestrated Endovascular Aneurysm Repair 46
47 Fenestrated Endovascular Aneurysm Repair Fenestrated Endovascular Aneurysm Repair 47
48 Fenestrated Endovascular Aneurysm Repair Fenestrated Endovascular Aneurysm Repair 48
49 Fenestrated Endovascular Aneurysm Repair Fenestrated Endovascular Aneurysm Repair 49
50 Fenestrated Endovascular Aneurysm Repair 50
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