Tips and Tricks to Deliver a Stengraft to the Ascending Aorta
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1 Tips and Tricks to Deliver a Stengraft to the Ascending Aorta Tilo Kölbel, MD, PhD University Heart Center University Hospital Eppendorf Hamburg, Germany
2 Disclosures Research-grants, travelling, proctoring speaking-fees, IP with Cook. Research-grant, travelling, speaking-fees with Cordis Research-grant, proctoring with Atrium
3 Clinical Relevance Type A Dissection Ascending aneurysm Re-Do after open surgery Adjunct to endovascular arch repair
4 Type A Dissection: Approachability for Endovascular Repair Sobocinski et al 2011, EJVES 42: 442-7
5 Endovascular Limitations in the Ascending Aorta Distance from transfemoral access Length and diameter of endograft Tortuosity and kinking Left ventricular wire-position Hemodynamic forces of the ascending aorta Apposition
6 Distance from Transfemoral Access Length of sheath: 75-95cm can be too short Individual distance on preop-ct Conduit access Alternative access routes Subclavian Antegrade
7 Graft-Specifications Brand Cook Zenith TX2 ProForm Medtronic Valiant Captivia Diameter (mm) Length (mm) System- Length (mm) Sheath- Diameter ID (F) Gore CTAG Bolton Relay x Jotec Evita 3G
8 Endograft Length and Diameter Length: measure at outer curve 6-10cm Diameter: measure on Centerline Tapered grafts Reverse tapering On-table customization
9 Endograft Length and Diameter Length: measure at outer curve 6-10cm Diameter: measure on Centerline On-table customization Tapered grafts
10 Graft-Specifications Brand Cook Zenith TX2 ProForm Medtronic Valiant Captivia Diameter (mm) Length (mm) System- Length (mm) Sheath- Diameter ID (F) Gore CTAG Bolton Relay x Jotec Evita 3G
11 Endograft Length and Diameter 77-81mm Cook Zenith TBE ProForm
12 Zenith Ascend ZTLP-A Type A Dissection Low Profile (16-20F) 100cm Sheath length 28mm 46mm Diameter Length: 65mm/83mm Proximal and distal Barestents Controlled Deployment: ProForm Not available, No CE-mark, Not FDA-approved
13 Zenith Ascend Not available, No CE-mark, Not FDA-approved
14 Zenith Ascend Not available, No CE-mark, Not FDA-approved
15 Tortuosity and Kinking Stiff Buddy wire Throughwire-access: Transbrachial Transseptal Transapical Alternative access routes: transcardiac, subclavian artery
16 Transapical Through & Through
17
18 Transseptal Through & Through
19
20 Left ventricular wire-position Crossing the aortic valve: Preop echocardiography: AV-stenosis, opening-area Long,soft hydrophilic wire Prevent perforation: Stiff double precurved wire Position well into the left ventricle Constant observation
21 Hemodynamic forces Windsocket effect Proximal fixation Throughwire-access Cardiac output reduction Pulsatility 15% in the ascending aorta Cardiac Output reduction: Adenosine Rapid Pacing IVC balloon occlusion Kasirajan et al; J Vasc Surg 2010
22 Hemodynamic forces Windsocket effect Proximal fixation Throughwire-access Cardiac output reduction Pulsatility 15% in the ascending aorta Arch movements Cardiac cycle Breathing Cardiac Output reduction: Adenosine Rapid Pacing IVC balloon occlusion Kasirajan et al; J Vasc Surg 2010
23 Apposition
24 Alternative Access Routes Subclavian Artery Transapical Access Transseptal Access
25 Transsubclavian Access
26 Transsubclavian Access Straight access in mature arches May require conduit Stroke risk
27 Transapical Access
28 Transapical TEVAR Short, straight route Well established Access Cardiac axis
29 Transapical TEVAR in Acute Type A Dissection
30 Transapical TEVAR in Acute Type A Dissection
31 Transapical TEVAR in Acute Type A Dissection
32 Transapical TEVAR in Acute Type A Dissection 12h postop.
33 Percutaneous Transapical TEVAR
34 Transseptal Access
35 Transseptal TEVAR
36 Summary Stent-graft delivery to the ascending aorta can be challenging because of distance, tortuosity and hemodynamic differences. Currently available stent-grafts do not meet requirements. Alternative access routes can provide improved control. Role of endovascular treatment in the ascending aorta yet to be defined.
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