Combined Endovascular and Surgical Repair of Thoracoabdominal Aortic Pathology: Hybrid TEVAR
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1 Combined Endovascular and Surgical Repair of Thoracoabdominal Aortic Pathology: Hybrid TEVAR William J. Quinones-Baldrich MD Professor of Surgery Director UCLA Aortic Center UCLA Medical Center Los Angeles, California
2 Disclosures Speaker / consultant W.L. Gore Endologix Medtronic
3
4 Hybrid Approach to Aortic Pathology Surgical component -Debranching of visceral or extracranial vessels - Other Endovascular component - Adequate seal zone either present or created Rationale Decrease magnitude of procedure No thoracotomy required No high aortic cross-clamping required Ischemia time of each visceral organ limited to time required to do distal anastomosis; simultaneous ischemia to all visceral organs avoided Can be staged
5 Hybrid Approach to Thoraco-abdominal Pathology: Results 17 series with 10 or more patients as of 2011 (most considered unsuitable for open repair) Mortality 0 to 31 % ; 14% average Morbidity 30 % Paraplegia 5 % Cardiac complications 5 % Renal insufficiency / failure 12 % Results have lead some to recommend as preferred approach and others to consider it a poor option Poor choice for ruptures or emergency repair Interval aneurysm rupture is a risk
6 high risk patients 40 TAA 8 II, 23 III, 9 IV 5.8 % mortality - 2 interval aneurysm ruptures Paraplegia 2/40 at risk (5 %); II,III 1/31 (3.2%) 2/8 (25%) Single Stage ; 1/32 (3%) Two Stage
7 Staged Approach. Expanded!
8 Staging Decreases Risk
9 Staged retroperitoneal debranching, endovascular repair of type III TAA; observation of proximal DTA: Stage 1: Ilio celiac, SMA, L renal bypass Stage 2: R ilio-renal bypass, conduit, TEVAR
10 Staged retroperitoneal debranching, endovascular repair of type III TAA; observation of proximal DTA: Stage 1: Ilio celiac, SMA, L renal bypass Stage 2: R ilio-renal bypass, conduit, TEVAR
11 Type A D s/p Arch, Elephant trunk and TEVAR: Reversed Hybrid
12 Infrarenal Aortic Replacement as Part of Debranching Pledgeted proximal anastomosis Graft size to match available endograft May require distal tapering
13 Lumbar/Sacral artery revascularization
14 Lumbar/Sacral artery revascularization
15 Subcutaneous Conduit: Two stage approach Conduit passed through retrocolic tunnel Closure of peritoneum
16 Combined Endovascular and Surgical Approach to Thoraco-abdominal Pathology: Conduit placement (1rst stage) and thrombectomy (2 nd stage)
17 Chronic Dissection = Thick restrictive septum
18 False lumen is where aneurysm forms after dissection
19 51 y/o woman Known Type B aortic dissection s/p left thoracotomy and descending thoracic aortic repair on L heart bypass Radiation therapy L breast for cancer Presented with left chest and back pain Renovascular HTN Pulmonary fibrosis
20 Hybrid repair for type B dissection with False Lumen Intentional Placement (FLIP)
21 Type B Dissection with proximal DTA Aneurysm significant hypertension and LLE claudication
22 FLIP Intravascular Ultrasound
23 Type B Dissection with proximal DTA Aneurysm and renal malperfusion and LLE claudication: Hybrid TEVAR w FLIP
24 FLIP From false lumen to true lumen
25 FLIP Preservation of intercostal flow
26 FLIP: Anatomic Requirements Proximal landing zone in the true lumen Proximal undissected aorta Proximal surgical or endovascular graft Elephant trunk Access from the false lumen to the true lumen Proximal tear Distal landing zone Distal false lumen (staged repair) Infra-renal graft with retrograde de-branch
27 Infrarenal Aortic Repair With or Without False Lumen Intentional Placement (FLIP) of Endografts for Hybrid Management of Complex Aortic Pathology Between 2006 and 2016, 27 patients with TAAA underwent open infrarenal aortic replacement combined with endovascular repair in a single or multiple stage procedure 16 patients (59% ) also had AD Transient spinal cord ischemia occurred in 3 patients (11%) ; All 1 stage procedures. Peri-operative mortality was 3.7% One patient died due to interval rupture
28 Infrarenal Aortic Replacement and Abdominal Debranching for Aortic Dissection 16 patients with type A or B aortic dissection 15 chronic; 1 sub-acute 8 with Juxta or infrarenal AAA 13 with proximal DTA aneurysm 5 malperfusion 10 done in 2 or more stages 5 False lumen Intentional placement of endograft (FLIP) 3 have not required proximal repair Decompression of false lumen?
29 False Lumen Intentional Deployment (FLIP) for Endovascular Repair of Aortic Dissection Allows full expansion of endograft Improves distal perfusion May preserve intercostal / lumbar flow Excludes weaker false lumen IVUS / Trans esophageal echo is critical Limited Experience F/U to determine if behavior of false lumen is altered (Decompression?)
30 Durable?
31 Durable? Combined Endovascular and Surgical Approach (CESA or Hybrid Approach) 13 yr follow up
32 Durable Combined Endovascular and Surgical Approach (CESA or Hybrid Approach) 19 yr follow up
33 Combined Endovascular and Surgical Repair of Thoracoabdominal Aortic Pathology: Hybrid TEVAR Open surgery and endovascular alternatives are complementary Patient selection is critical Hybrid repair of aortic pathology should be in the armamentarium of all caring for patients with aortic pathology
34 UCLA Aortic Center Thank you aorticcenter.ucla.edu 310-AORTAFIX ( )
Challenges. 1. Sizing. 2. Proximal landing zone 3. Distal landing zone 4. Access vessels 5. Spinal cord ischemia 6. Endoleak
Disclosure I have the following potential conflicts of interest to report: Consulting: Medtronic, Gore Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s)
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