Aortic Pathologies State of the art surgical interventions - today and tomorrow. Canadian CardioVascular Nurses Spring Meeting Calgary, Alberta
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1 Aortic Pathologies State of the art surgical interventions - today and tomorrow Canadian CardioVascular Nurses Spring Meeting Calgary, Alberta May 6, 2017 Jehangir Appoo Division of Cardiac Surgery Libin Cardiovascular Institute Cumming School of Medicine University of Calgary
2 Purpose Today I. Tour of recent and future treatment for: I. Descending Aortic Anuerysms II. Type B Dissections III. Aortic Coarctation IV. PDA V. Type A Dissection VI. Ascending aorta/arch I. Infrastructure II. Unsolved Problems
3 Fathers of Aortic Surgery 1953 Cooley and Debakey repaired the first descending thoracic aortic aneurysm using homografts s Stanley Crawford major technical improvements 30/30 club 1970 s-1980 s Randall Griepp refinements of techniques neuro/spinal protection
4 Evolution of Aortic Surgery
5 Evolution of Aortic Surgery Highly morbid operations Significant risks Pain syndrome
6 Evolution of Aortic Surgery
7 Purpose Today I. Tour of recent and future treatment for: I. Descending Aortic Anuerysms II. Type B Dissections III. Aortic Coarctation IV. PDA V. Type A Dissection VI. Ascending aorta/arch I. Infrastruture II. Unsolved Problems
8 Descending Thoracic Aortic Aneurysms Risk of dissection or rupture of the Descending Aorta Elefteriades et al., Yale database
9 Endovascular surgery improves morbidity & mortality Mortality 2% vs. 11% Spinal Cord ischemia 3% vs. 14% ICU, hospital LOS vascular cxs re-interventions
10 37y.o mother of 3 Presents with a cough Open & Endovascular options 2011
11 1.5 inch groin incision Home 2 1 week
12 Distal Arch Aneurysms TEVAR with left carotidsubclavian bypass (2011)
13 81y.o male March 2016 Endovasc revasc of left subclavian artery with snorkel technique
14 Purpose Today I. Tour of recent and future treatment for: I. Descending Aortic Anuerysms II. Type B Dissections III. Aortic Coarctation IV. PDA V. Type A Dissection VI. Ascending aorta/arch I. Infrastruture II. Unsolved Problems
15 Type B dissection Evolving controversy surrounding mgmt of uncomplicated vs. complicated type B
16 Complicated Type B Dissection
17 Endovascular Treatment of Type B dissection
18 Complicated Acute Type B Dissection 56yo male Seen 12 hrs post presentation Severe Malperfusion: Ischemic leg Ischemic gut Renal failure
19 Rt. Iliac SMA Rt. Renal Artery
20 Management Emergent OR Multidisciplinary team Right groin access 42mm x 216mm Cook Zenith TX2 Proform device from left CCA to mid descending aorta (Prox LZ=36mm) Device unsheathed distal to ostium of Left Carotid Artery
21 Lower extremity, visceral & renal malperfusion resolved
22 Hospital Survival with Acute Type B Dissection In Hospital Mortality: Medical Rx-10% TEVAR -10% Open surgery-34% Fattori R et al. J Am Coll Cardiol Intv 2008;1:
23 Purpose Today I. Tour of recent and future treatment for: I. Descending Aortic Anuerysms II. Type B Dissections III. Aortic Coarctation IV. PDA V. Type A Dissection VI. Ascending aorta/arch I. Infrastruture II. Unsolved Problems
24 2007 Primary Adult Coarct Male Early 30 s Bicuspid Aortic Valve
25 2007
26 2013 Primary Adult Coarct Male Early 30 s Bicuspid Aortic Valve
27 2013
28 2013
29 PDA Closure
30 PDA Closure
31 PDA Closure
32 Recent Evolution Descending Thoracic Aortic Aneurysm Type B Dissection Coarctation Patent Ductus Arteriosus
33 Purpose Today I. Tour of recent and future treatment for: I. Descending Aortic Anuerysms II. Type B Dissections III. Aortic Coarctation IV. PDA V. Type A Dissection VI. Ascending aorta/arch I. Infrastruture II. Unsolved Problems
34 Is there a role for endovascular therapy of acute type A aortic dissection?
35 2017 Debate Emerging on: Hemi-arch vs. Extended Arch
36 Why not Total Arch for ATAAD? Dissection process can involve all first order branches of the aorta and consequently perfusion of ALL ORGANS
37 Why not Extended Arch ± TEVAR?
38 Why not Extended Arch ± TEVAR? Sample Case: June 2016 OSH 65y.o male car accident 2 o CVA Hemiplegic Pulseless, mottled left leg Acute Type A 5cm Asc Ao
39 Occluded R carotid Visceral malperfusion Renal malperfusion Occluded left common iliac
40 Occluded R carotid 4 organ system malperfusion : GERAADA data suggests >50% operative mortality Visceral malperfusion Renal malperfusion Occluded left common iliac
41 Our patient June 2016: On-Table completion angio after Total Arch and TEVAR: Post op CTA: R carotid perfusion Renal perfusion nephrograms Iliac flow restored
42 Our evolution of acute Type A repair
43 In the future: What % of pts would be eligible for isolated endovascular repair of acute type A dissection? Which patients benefit from conventional surgery vs. hybrid surgery vs. endovascular?
44 Purpose Today I. Tour of recent and future treatment for: I. Descending Aortic Anuerysms II. Type B Dissections III. Aortic Coarctation IV. PDA V. Type A Dissection VI. Ascending aorta/arch I. Infrastruture II. Unsolved Problems
45 Ongoing/Future Evolution
46 Takumi Principle Perceptive, Thoughtful surgeons in new era of skill
47 Zone 0:
48 2013 Chronic Dissection 64 y.o male Type A repair 2009 Complicated course Aorta growing at rate of 1cm/year Arch dissected Large residual primary intimal tear in arch True lumen effaced
49 Total endo arch Custom built branched arch graft
50
51 Complexity
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53 2013- VR image 3 months post op
54 80 yo male Saccular distal arch aneurysm Recent VATS for non small cell lung ca with clear margins Being considered for novel endovascular total arch graft
55 Nexus Branched Arch Device
56
57 Future evolution of acute Type A repair?? FDA Trial April Zone 2 Implants 8 Zone 0 implants Dissection Trial starting
58 Future Evolution of closed chest zone 0 -new devices on horizon
59 Purpose Today I. Tour of recent and future treatment for: I. Descending Aortic Anuerysms II. Type B Dissections III. Aortic Coarctation IV. PDA V. Type A Dissection VI. Ascending aorta/arch I. Infrastructure II. Unsolved Problems
60 The Latest and Greatest
61 The Latest and Greatest Tools and Techniques
62 TEAM Surgeons Interventional Radiologists Diagnostic Radiologists CV Anesthetists Nursing & DI staff CV ICU Advanced NP Biomedical Engineering Pathology Neurology Admin
63 Cardiac Hybrid Operating Suitea State of the Art Centre Conventional operating theatre & Diagnostic suite opened 2014 Multimodality Multidisciplinary team Avoid patient transfer Improved results
64 Precise Imaging
65 Minimally invasive Aortic therapy is: Safer More effective More efficient Less invasive/better tolerated Innovative
66 Vessel Navigator allows reuse of 3D vascular anatomical information from existing CTA and MRA datasets as a 3D roadmap overlay on a live X-ray image. With its excellent visualization, Vessel Navigator provides an intuitive and continuous 3D roadmap to guide you through vasculature during the entire procedure. Phillips website Overlay of CTA data onto fluoroscopic image
67 Vessel Navigator Synchronization of CTA and Fluoroscopy Data CTA Volume Rendered 3D Image
68 Vessel Navigation Software Game Changer 51yo male with aneurysmal growth and compromised flow to visceral vessels 2 yrs post acute Type A Dissection repair March 2016 redo Total Arch Zone 2 Technique April 2016 Endovascular repair of thoraco-abdominal aorta
69 Purpose Today I. Tour of recent and future treatment for: I. Descending Aortic Anuerysms II. Type B Dissections III. Aortic Coarctation IV. PDA V. Type A Dissection VI. Ascending aorta/arch I. Infrastructure II. Unsolved Problems
70 Unsolved Problems in Aorta Easy to make perfect decisions with perfect info. Medicine asks you to make perfect decisions with imperfect info. Siddharta Mukherjee Laws of Medicine: Field Notes from an Uncertain Science, 2015
71 Research Interests: Assessing efficacy of inovation Decreasing morbidity and mortality of aortic interventions Understanding Aortic Dissections Risk stratification of Aortic Aneurysms Indolent but Catastrophic Why do Aneurysms Rupture? Size & growth rate not great predictors of rupture/dissection Need more science
72 Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing Voltaire,
73 Why understanding aortic behaviour is important? Intervention is invasive has some risks Dilemma: aneurysms of time Young patients with small aneurysms are running into trouble vs. Denominator is very large many patients have large aortic that are stable for prolonged periods If we operated on every dilated aorta, we may do more harm than benefit
74 * Aortic root Asc Aorta
75
76
77 Summary of Guidelines for Prox Ao Intervention: Asc Ao > 5.5cm Asc Ao > 5.0cm with some risk factors (rate of growth, family history of dissection, hypertension, patient preference ) Asc Ao cm for Connective Tissue Disease Probably don t need to be more aggressive if bicuspid valve
78 Summary of Guidelines on Prox Aortic Intervention: Level of scientific evidence is poor no randomized data no large non randomized studies small, retrospective studies consensus opinions aortic Lots of room for flexible interpretation including patient preference, shape, rate of growth, patient size
79 Aug y.o VACTERL Syndrome R sided aortic arch Bicuspid valve with mild stenosis Asymptomatic Petite stature Does she have an indication for surgery?
80
81 The Asc Ao is 2.7x the size of desc aorta! Do the Guidelines convince us that this 29 y.o is safe?
82 July y.o active female BSA 1.53m2 Bicuspid valve with mild to moderate AI asymptomatic normal lv size and function family history of bicuspid valve and ascending aortic aneurysm repair (brother) Does she have an indication for surgery?
83
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85 According to Guidelines does this 50y.o have an indication for surgery? <5.5cm <5.0cm no known history of rapid growth family history of elective aneurysm repair no family history of dissection indexed to BSA: 3.24! one publication suggests >2.75cm/m2 is high risk
86 How robust are the natural history data of Ascending Aortic Aneurysms? A Systematic Review CCC 2016 Search Strategy
87 Conclusions of our systematic review: No single study reported all of: aneurysm growth rate, size at dissection or rupture, incidences of dissection or rupture, predictors of increase rate of growth, rupture and dissection, and overall survival. Discrepancies between results from different studies Data not robust enough to do a meta-analysis on topic
88 NASA: SvS N. American Study of Ascending Aorta: Surgery vs. Surveillance Proposed Multicentre Randomized Study of surgery vs surveillance for ascending aortic aneurysms cm Objectives: Describe natural history Establish core CT lab Determine a NNT for asc ao aneurysms Risk profile aneurysms beyond size Forum for prospective trials
89 NASA: SvS Letters of Intent to participate from Cardiac Surgeons at 15 Canadian institutions Memorial University of Newfoundland New Brunswick Heart Centre Laval University Royal Victoria Hospital, McGill University Montreal Heart Institute Queens University Ottawa Heart Institute Toronto General Hospital Northern Ontario School of Medicine London Health Sciences Centre University of Manitoba University of Calgary University of Alberta St. Paul s Hospital, University of British Columbia Royal Jubilee Hospital, University of British Columbia
90 NASA: SvS N. American Study of Ascending Aorta: Surgery vs. Surveillance Raised $75,000 via Libin, EFW and U of Ottawa $50,000 Seed Grant applied April 2017 Study Protocol currently being worked U of Ottawa & U of Calgary
91 Biomechanical Engineering Analysis as a tool to determine Aortic fingerprint
92 Aneurysms rupture/dissect when wall stress > wall strength 2010 Mar 2011 Dec 2012 Dec 1 st Principal Stress (N/cm 2 ) Collaboration with Biomedical Engineering, Histo-Pathology & Imaging colleagues
93 3D Growth Multidimensional growth estimation Non linear growth measure post operation D i D i follow-up g i d 1 t D log( D follow-up post operation i i ) Post operation 1 year follow-up 100 observations AATS Aortic Symposium 2014
94 3D Growth Results Maximum growth Maximum diameter Growth rate (mm/y) Outer diameter (mm) AATS Aortic Symposium 2014
95 Aorta at Risk Ongoing Project Personalized Medicine fingerprint Prospective tissue sample from asc ao aneurysms Multimodality imaging HistoPath analysis Tissue strength testing Tissue stiffness testing Once we understand properties of asc ao can we determine a non invasive risk profile?
96 Screening How can we appropriately screen a population to prevent disasters? Cavaet: Will also discover a lot of aortas that may not benefit from treatment
97 March y.o male abdo pain Lap Appendectomy at Rural Hospital Repeat CT POD4 for CP/unwell Died prior to transfer
98 March 2016 In retrospect, root dilatation and abdo aortic dissection could be appreciated on preop CT at time of abdo pain presentation Questions: What kind of systematic screening program can identify him early? How did aorta get to 8cm in young man without rupturing?
99 Sept y.o Type A and GI bleed died prior to transfer from RGH
100 Screening at FMC: Working with DI to develop White Papers incidental finding of aortic aneurysms screening of first degree relatives
101 Future: 1.Prospective multicentre randomized trials of ascending aortic aneurysms 2.Biomechanical assmt may help stratify risk assessment along with size, growth rate, indexed size, pt. age, biomarkers to develop a FingerPrint 3.Appropriate Screening protocols are to be determined
102 Purpose Today I. Tour of recent and future treatment for: I. Descending Aortic Anuerysms II. Type B Dissections III. Aortic Coarctation IV. PDA V. Type A Dissection VI. Ascending aorta/arch I. Infrastructure II. Unsolved Problems
103
104
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106 Come a long way...journey continues
107 Calgary Thoracic Aortic Program,
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