Ascending Aorta: The Endovascular Approach

Transcription

1 University Heart Center Hamburg GERMAN AORTIC CENTER Ascending Aorta: The Endovascular Approach Tilo Kölbel, MD, PhD University Heart Center Hamburg University Hospital Eppendorf

2 Gold Standard for Ascending Aorta Open Surgery:! Sternotomy, CPB! Ascending replacement! With/without aortic valve! Hemiarch/elephant trunk Krüger et al. 2012;Brit J Surg 99:

3 Gold Standard for Ascending Aorta But... Octogenerians Patients with! Old age! Severe comorbidities! Previous cardiac surgery!... Piccardo et al. 2009, Ann Thor Surg 88:491-7 Previous cardiac surgery p = 0.07 Estrera et al. 2010, Ann Thorac Surg 89:

4 Gold Standard for Ascending Aorta But... Patients with! Old age! Severe comorbidities! Previous cardiac surgery!... are often turned down for open surgery and might benefit from a less invasive therapy. Bonser et al. 2011, JACC 58:

5 Gold Standard for Ascending Aorta But... Rylsky et al. 2014,Ann Thor Surg 97:

6 Endovascular Treatment of the Ascending Aorta Is there room for Endovascular techniques in ascending pathology?

7 Endovascular Treatment of the Ascending Aorta Pathologies to be treated:! Lesions post surgery:! Pseudoaneurysm! Postsurgery bleeding! Residual Dissection! Lost TAVI! Ascending aneurysm! Type A dissection

8 Pseudoaneurysm

9 Postsurgery Bleeding

10 Residual Dissection

11 Transapical Through & Through

12 Ascending Aneurysm! Most are conical and lack proximal landing zone.! Endovascular exclusion usually not possible in native vessel Kolvenbach et al. 2011; J Vasc Surg 53:

13 Ascending Aneurysm

14 Ascending Aorta and Arch:!

15 Endovascular Repair of Type A Aortic Dissection So, is there room for Endovascular techniques in acute Type A Aortic dissection?

16 Type A Aortic Dissection Epidemiology:! Incidence: 2-3/ persons/year! 2/3 of thoracic dissection! Male/female: 3/2! Age: 60-65y! 14d-mortality 50% Tsai et 1l. 2005, Circulation 112:

17 Acute Type A Dissection Sobocinski et al 2011, EJVES 42: 442-7

18 Anatomical Suitability University Heart Center Hamburg! s te! Entry-tear tear distal to sino-tubular tubular junction " 38mm " % 0 5 t o p a i t en! 20mm! a d! Proximali and distal landing d n zone!! 20mm a lc! True lumen diameter " " 38mm! Total lumen diameter " " 46mm! Appropriate access vessels! No significant Aortic regurge Sobocinski et al 2011, EJVES 42: 442-7

19 Patients denied surgical therapy for Type A Dissection 28% of patients with acute type A aortic dissections are considered unfit for open surgery and receive only medical management The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:

20 But.things happen! Coverage of coronary arteries! Perforation of ventricle with tip of graft! Ventricular pseudoaneurysm! Misplacement distally, covering of supraaortic branches! Delivery system retention! Conversion to open surgery

21 Literature Review Endo-Repair of Type A N! 13 Acute Type A Ronchey et al. 2013, Eur J Vasc Endovasc Surg 45:

22 Chronic Type A Dissection Dorros et al. 2000, JEVT 7:

23 Chronic Type A Dissection! Subacute / chronic! n = 6! Technical success 5/6! Mortality 1/6 Nienaber et al. 2011; J Vasc Endovasc Surg (It) 18:

24 Acute Type A Dissection Metcalfe et al. 2012, J Vasc Surg 55: 220-2

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26 Endograft Choice Cook Zenith Ascend

27 Results Cook Ascend Indication for treatment n %! Hamburg, Lille, Rochester, Aarhus Type A Dissection 5 50% Aneurysm/Pseudoan eurysm 4 40%! N=10; ! 5 male Fixation of a dislocated Aortic Valve 1 10%! Age: 67y (26-90)! ASA III-IV: n=9 Tsilimparis et al. 2016; J Vasc Surg 63:

28 Endograft Choice! Length: measure at outer curve 6-10cm! Diameter: measure on Centerline! Tapered grafts! Reverse tapering! On-table customization

29 Endograft Choice 77-81mm Cook Zenith TBE ProForm

30 !"#$%&'#'&(!"#$%&'$()&*+,+-$./&01+ Toward Endografting of the Ascending Aorta: Insight into Dynamics Using Dynamic Cine-CTA Joffrey van Prehn, MD 1 ; Koen L. Vincken, PhD 2 ; Bart E. Muhs, MD, PhD 3 ; Gijsbrecht K. W. Barwegen, BS 1 ; Lambertus W. Bartels, PhD 2 ; Mathias Prokop, MD, PhD 4 ; Frans L. Moll, MD, PhD 1 ; and Hence J. M. Verhagen, MD, PhD 1,5 J ENDOVASC THER 2007;14: Departments of 1 Vascular Surgery and 4 Radiology and the 2 Image Science Institute,

31 Limitations of Femoral Access! Distance to ascending and arch! Tortuosity and kinking! Left ventricular wire-position! Difficult true lumen access! Apposition

32 Transapical TEVAR! Casereports! Well established Access! Hybrid OR! Cardiac Surgeon/Endovascular specialist! Preoperative imaging/workstation Kölbel et al 2012, Vascular 19:

33 Acute Type A Dissection Transapical TEVAR Kölbel et al. 2013; Ann Thor Surg 95:694-6

34 Acute Type A Dissection Transapical TEVAR Kölbel et al. 2013; Ann Thor Surg 95:694-6

35 Transapical TEVAR

36 Acute Type A Dissection Transapical TEVAR 12h postop. Kölbel et al. 2013; Ann Thor Surg 95:694-6

37 Acute Type A Dissection Transapical TEVAR 24m postop.

38 Ascendens Stentgraft

39 Reimplanted and Bypassed Coronary Arteries!

40 Hamburg Experience with Stentgrafts in the ascending Aorta N=20! Study period : 6 years, urgent=13 (65%)! 13!, mean age 70±15years, 29-90y! 16 cases treated with Zenith Ascend device! 4 with modified/standard thoracic endografts Tsilimparis et al. 46. Jahrestagung der DGTHG - Leipzig

41 Hamburg Experience with Stentgrafts in the ascending Aorta Indication n % Type A dissection 12 60% Fixation of a dislocated aortic valve Pseudoaneurysm of the ascending aorta Relining after fen- TEVAR 2 10% 4 20% 1 5%! Access! Transfemoral n=14! transapical n=5! A. subclavia=1 Tsilimparis et al. 46. Jahrestagung der DGTHG - Leipzig

42 Early Outcomes! Technical success: 100% (20/20)! Proper implantation at intended level! Clinical Success: 95% (19/20)! 1 failed proximal and distal seal! In-hospital survival: 80% (16/20)! One aortic related death! 3 deaths due to general complications (Pneumonia=1, stroke =1, Sepsis =1)! MAEs: 1 major stroke, 1 myocardial infarction, 1 post-tevar aortic valve insufficiency " TAVI

43 In-hospital death case! Post TAVR dissection of the ascending aorta! Non operable! Emergent bail-out procedure with ascend graft as ultima ratio! Stent graft obviously undersized in aneurysmatic ascending aorta

44 Case: Endo-bentall Post Ascendens Graft aortic Insufficiency dislocated valve

45

46 Endo-bentall

47 Late Outcomes! Mean Follow-up: 12 months (range 3-36 months)! 2 late re-interventions for distal endoleaks! No migration! 2 late non-aortic related deaths! No late aortic related death

48 Percutaneous Transapical Access Jelnin et al. 2011, JACC Cardiovasc Interv 8:

49 Percutaneous Transapical TEVAR

50 Valved Conduit Endo-Bentall? Courtesy of E. Dietrich, Arizona Courtesy of C. Nienaber, Rostock

51 Summary! Endovascular Treatment of ascending aorta potentially beneficial in selected patients.! Postsurgery lesions and Type A dissection work.! Ascending aneurysms in native vessel do not.! Transfemoral delivery challenging, transapical access route potentially easier.! Currently available stent-grafts do not meet requirements.! Role of endovascular treatment in the ascending aorta yet to be defined.