How to Determine Tolerance for Branch Vessel Coverage
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1 How to Determine Tolerance for Branch Vessel Coverage Venita Chandra, MD Clinical Assistant Professor of Surgery Division of Stanford Medical School, Stanford, CA PNEC May 25 th, 2017
2 DISCLOSURES Venita Chandra, MD No relevant financial relationship reported
3 Disclosures Clinical Consultant: Endologix, Cook Educational Grants: Cook
4 Branch Vessels Innominate Carotids Subclavian Mesenteric Vessels Celiac SMA IMA Renals Accessory Renals Lumbars/intercostals Internal Iliac Artery
5 General Approach to Branch Vessel Coverage Complete understanding of clinical picture Complete understanding of branch collaterals Assessment of health of neighboring vessels
6 Branch Vessel Coverage
7
8 Branch Vessel Coverage
9 How to Determine InTolerance for for Branch Vessel Coverage?
10 Subclavian Coverage Potential Complications Upper extremity ischemia Subclavian steal (VBI) Stroke Paraplegia MI (LIMA) Loss of ax-fem bypass or AVF B.G. Peterson et. al.j Vasc Surg, 43 (2006), pp
11
12
13 LSA Coverage Intolerance Absent right vertebral artery Termination of left vertebral artery into PICA Incomplete Circle of Willis LIMA bypass Relative: AVF/AVG of left arm Prior infrarenal aortic repair Long segment coverage Hypogastric artery occlusion
14 Recommendation 1: In patients who need elective TEVAR where achievement of proximal seal necessitates overage of the left subclavian, we suggest routine preoperative revascularization Recommendation 2: In selected patients who have an anatomy that compromises perfusion to critical organs, routine preoperative LSA revascularization is strongly recommended Recommendation 3: In patients who need urgent TEVAR for life-threatening acute aortic syndromes where achievement of proximal seal necessitate cover of the left subclavian artery, we suggest that revascularization should be individualized and addressed expectantly on the basis of anatomy, urgency and availability of surgical expertise
15 Celiac Artery Occlusion Inadequate distal landing zone during TEVAR 4.4%* Celiac revascularization has complications and may be unnecessary Due to rich collateral network coverage of celiac to facilitate landing may be feasible** *Leon LR, et al. Vasc Endovasc Surg 43:51-60, 2009 **Appleby LH: Cancer 6: , 1953
16 Arch of Bühler
17 Celiac Artery Coverage Tolerance Well-developed pancreaticoduodenal collaterals between celiac and SMA Replaced right hepatic artery (originating from SMA) Pre-existing celiac artery stenosis Well developed SMA
18 How to Determine Celiac Coverage Tolerance? CT angio Looking for collaterals Conventional Angio Celiac Occlusion Test +/- duplex SMA anatomy Consider treatment of concomitant SMA stenosis
19 Celiac Coverage Tolerance
20 Celiac Artery Coverage InTolerance Prior pancreatic/gastric surgery Embolization of GDA Stenosis or occlusion of SMA Portal vein occlusion Liver dysfunction
21 Inadequate Distal Seal Zone CTA with 3D reformat Inadequate Collaterals Noted On CTA Adequate Collaterals or Aberrant Anatomy Noted on CTA Intraoperative Angiogram +/- Celiac Balloon Occlusion Test YES Coil/Plug occlusion of celiac and TEVAR coverage NO Branch/fenestrated graft or other revascularization
22 17 articles- non-randomized retrospective case reports/series 93 patients Majority TAAs Overall mortality: 9.7% Foregut related: Mortality: 3% Complications: 7.5%
23 In Conclusion Impossible to predict Best to focus on determining intolerance Pre-operative imaging key Avoid branch coverage as much as possible Branched devices/chimney snorkel cases, vs. open repair
24 Thank You! vascular.stanford.edu
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