Aortic Arch/ Thoracoabdominal Aortic Replacement

Transcription

1 Aortic Arch/ Thoracoabdominal Aortic Replacement Joseph S. Coselli, M.D. Vice Chair, Department of Surgery Professor, Chief, and Cullen Foundation Endowed Chair Division of Cardiothoracic Surgery Baylor College of Medicine AATS International Cardiovascular Symposium 2017 Session 13: Live in Box Complex Cardiac Scenarios São Paulo, Brazil Saturday, December 9, 2017

2 Disclosure Medtronic, Inc Vascutek Terumo WL Gore & Associates Bolton Medical PI Clinical Trials Consultant Consultant PI Clinical Trials Royalties Coselli branched graft PI Clinical Trials Consultant PI Clinical Trials

3 Followed successful 1956 ascending aortic repair with CPB Wanted to move away from all of the "shunt" anastomoses and shorten operative time (perfused for 43 minutes) Early Aortic Arch Replacement First successful attempt Homograft Cardiopulmonary bypass used to perform early antegrade cerebral perfusion Felt 60 minutes CPB was safe No hypothermia DeBakey et al SGO 1957

4 Profound Hypothermic Circulatory Arrest (HCA) 1 st time profound HCA used to protect the brain during repair Profound: 14 C 4 patients 3 survivors (75%) Mainstay of arch repair for > 4 decades Griepp et al J Thorac Cardiovasc Surg C esophageal temperature 18 C rectal temperature

5 Complex Aortic Repair Hemiarch Total arch + ET Trifurcated (Y) Graft Aortic arch repair Reimplant brachiocephalic arteries Almost always use hypothermic circulatory arrest (HCA) to protect brain Type of repair varies (pathology) Hemiarch Total (full) arch Total arch + elephant trunk (ET) Hybrid/endovascular options Experimental/off-label Debranch arch vessels

6 Arch Repair Hemiarch Replaces lesser curvature of arch Blood to brain interrupted Less risk than total arch Branching arteries are left intact Often used in cases involving acute aortic dissection or if pathology is limited

7 Total Arch Reconstruction Island Branched Y-graft Y-graft ET Single branch ET Island ET

8 Total Arch Beyond the Arch Frozen ET ET

9 Trifurcated Approach: Extensive Repair Early results using trifurcated graft technique compare favorably to traditional approaches 7/150 (4.7%) early death Spielvogel 2007 ATS Enables effective delivery of SCP axillary perfusion Minimizes unprotected cerebral ischemic time Facilitates the full arch approach of extensive repair

10 Y-Graft Approach Bilateral ACP: 9 Fr balloon perfusion catheter During Cooling: Left common carotid and left subclavian arteries are transected, ligated, and bypasses onto prefabricated Y-graft Cooled to C: Once target temperature attained, flows are reduced to ml/kg/min and the innominate artery is snared

11 Head Y-Graft Approach Distal anastomosis of graft collar: Collar helps reduce tension on graft and aids hemostasis

12 Head Bilateral ACP: Flow rate 10-15mL/kg/min Y-Graft Distal perfusion: Side branch Approach Proximal anastomosis of main graft complete: Proximal anastomosis of trifurcated graft underway

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14 Elephant Trunk (Island)

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16 Elephant Trunk + TEVAR Repair

17 Mortality of Elephant Trunk Cumulative Mortality Table Summary Range of Percentages from Authors Reporting Elephant Trunk Surgical Outcomes 1 st Stage Mortality Interval or Nonreturning Mortality 2 nd Stage Mortality All Cause Total Mortality % % % % Etz et al, 2008 LeMaire et al, 2006 Svensson et al, 2004 Heinemann et al, 1995 Safi et al, 2005 Sundt et al, 2004

18 Frozen Elephant Trunk Repair

19 Cannulation Sites Femoral artery Axillary artery Innominate artery Ascending aorta Carotid artery Subclavian artery Brachiocephalic trunk Apical (apex) All above sites are in contemporary use Alternate cannulation sites useful in cases of redo surgery and acute aortic dissection

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21 Preventza et al 2013 ACTS [Coselli]

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23 Frozen Elephant Trunk: Devices Thoraflex Evita plus

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25 Hemiarch + Antegrade TEVAR Only a small part of the transverse arch is native Unlike frozen elephant trunk (FET), not a total arch replacement

26 Evolution of Open Aortic Arch Femoral cannulation Axillary/Innominate cannulation Retrograde cerebral perfusion Bilateral antegrade cerebral perfusion Profound hypothermia Moderate hypothermia Island technique Y-graft technique Elephant trunk Collared grafts

27 2026 Open Arch Repairs Consecutive from January 1999 to November 2017 Preoperative characteristics n (%) Age, years 60±14 Male 1341 (66%) Heritable thoracic aortic disease 217 (11%) Marfan syndrome 149 (7%) Bicuspid aortic valve 410 (20%) Acute/subacute aortic dissection 384 (19%) Chronic aortic dissection (redo or previously unrepaired) Includes data on 138 hybrid arch repairs 454 (22%)

28 2026 Open Arch Repairs Consecutive from January 1999 to November 2017 Operative Details n (%) Elective repair 1414 (70%) Urgent repair 280 (14%) Emergent repair (including salvage) 332 (16%) Repeat sternotomy 626 (31%) HCA + ACP only 1630 (80%) HCA alone 134 (7%) Lowest mean temperature, C 20.8±4.1 Includes data on 138 hybrid arch repairs

29 2026 Open Arch Repairs Consecutive from January 1999 to November 2017 Operative Details n (%) Concomitant root or valve procedure 1519 (75%) Valve-sparring ARR 134 (7%) Hemiarch 1486 (73%) Full arch 515 (25%) Full arch with elephant trunk 319 (16%) Y-graft approach to full arch 185 (9%) Cannulation: innominate artery 627 (31%) Cannulation: right axillary artery 934 (46%) Includes data on 138 hybrid arch repairs

30 2026 Open Arch Repairs Consecutive from January 1999 to November 2017 Select 30-Day Mortality Rates n (%) Overall 30-Day death 141 (7%) Elective repair (n=1414) 75 (5%) Emergent repair (n=332) 44 (13%) Redo sternotomy (n=626) 65 (10%) Acute aortic dissection (n=345) 43 (12%) Heritable thoracic aortic disease (n=217) 11 (5%) Total arch (with or without ET) (n=515) 53 (10%) 30-day death is death within 30 days at any location including after discharge Includes data on 138 hybrid arch repairs

31 Hybrid Aortic Arch Surgery

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33 138 Hybrid Arch Repairs Consecutive from January 1999 to November 2017 Operative Details n (%) Zone 0 44 (32%) Zone 1 2 (1%) Zone 2 11 (8%) Zone 3 78 (57%) Zone 4 3 (2%) Above zones use Criado classification

34 138 Hybrid Arch Repairs Consecutive from January 1999 to November 2017 Early Outcomes n (%) Early death (hospital + 30-day) 18 (13%) 30-day death 16 (12%) Early death includes all deaths during entire period of hospitalization (including any transfer) as well as any 30-day death (within 30 days at any location including after discharge)

35 Complex Aortic Repair Thoracoabdominal aortic repair Reimplant visceral arteries Use of adjuncts varies (pathology) Repair itself risks ischemic damage to downstream organs Spinal cord Kidneys Visceral organs Hybrid/endovascular options Experimental/off-label Debranch visceral vessels

36 Evolving TAAA Repair Crawford 1509 TAAA repairs Svensson et al. J Vasc Surg 1993 Lifetime Experience I 378 patients II 442 patients III 343 patients IV 346 patients Svensson J Vasc Surg 1993;17:357 Cited as reference ~600 times (SCOPUS) 31-year experience 1960 to 1991 n (%) Early death 123 (8%) Paraplegia 105 (7%) Renal dialysis 136 (9%) GI complications 101 (7%) For extent II TAAA repair, the rate of paraplegia or paraparesis increased to 31%

37 Evolution of Open TAAA Repair No use of heparin Moderate heparinization Clamp-and-sew Selective use left heart bypass Selective use of CSF drainage Selective use visceral perfusion Whenever possible cold renal perfusion Island technique Selective use branched grafts Select reattachment of intercostals Aggressive reattachment of intercostals Improved Outcomes

38 Intraoperative Strategies All extents Moderate heparinization Permissive mild hypothermia Aggressive reattachment of segmental arteries Cold renal perfusion whenever renal ostia can be accessed Expeditious repair Extent I and II repairs Cerebrospinal fluid drainage Left heart bypass Selective celiac/sma perfusion

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41 Left Heart Bypass Left inferior pulmonary vein Distal descending thoracic aorta

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44 Cold Crystalloid Renal Perfusion We have performed 2 randomized clinical trials regarding cold renal perfusion Cold renal perfusion was found to benefit patients and reduce postoperative renal failure over normothermic P=0.03 [Köksoy 2002] Cold crystalloid and cold blood provide equivalent renal benefit P=1.0 [LeMaire 2009] LeMaire et al J Vasc Surg 2009

45 Cold Renal Perfusion 9-Fr Pruitt catheters LR g/l Mannitol mg/l methylprednisolone

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52 Isothermic centrifugal circuit

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58 Outcomes of 3309 Thoracoabdominal Aortic Aneurysm Repairs? Coselli et al JTCVS th Annual Meeting, American Association of Thoracic Surgery (AATS) Plenary Scientific Session: Abstract 1 Seattle, Washington Monday, April 27, 2015

59 3309 Open TAAA Repairs October 1986 to December 2014 n=914 n=1066 n=660 n=669 Coselli JTCVS 2016 ~30 year experience 1986 to 2014 n (%) Operative death 249 (7.5%) 30-day death 159 (4.8%) Permanent paraplegia 97 (2.9%) Permanent paraparesis 81 (2.4%) Renal failure (dialysis) 189 (5.7%) Gastrointestinal ischemia 31 (0.9%)

60 3522 Open Thoracoabdominal Aortic Aneurysm Repairs Repairs performed between 1986 and November 2017 Patient Characteristics n (%) Median age, y [IQR]; range 10y to 92y 67 [59-73] Heritable thoracic aortic disease 364 (10%) Marfan syndrome 318 (9%) Aortic dissection involving distal aorta 1266 (36%) Acute or subacute dissection 179 (5%) Chronic dissection 1087 (31%) Symptomatic 2254 (64%) Rupture 184 (5%)

61 3522 Open Thoracoabdominal Aortic Aneurysm Repairs Repairs performed between 1986 and November 2017 Early Outcomes n (%) Operative mortality 283 (8%) 30-day death 186 (5%) Persistent* Paraplegia 109 (3%) Paraparesis 78 (2%) Stroke 87 (2%) Renal failure necessitating dialysis 211 (6%) Adverse event (composite endpoint) 526 (15%) *Persisting to the time of hospital discharge or early death

62 Conclusions Contemporary Arch/TAAA repair is highly varied multitude of approaches Good-to-excellent outcomes in experienced centers Variety of techniques/adjuncts have lowered risk in contemporary practice Many options for your patient

63 Obrigado!

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