Evolution of Thoracic Aortic Surgery A Rapidly Advancing Paradigm. October 15 th, 2014 Family Practice Evening Course University of Calgary
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1 Evolution of Thoracic Aortic Surgery A Rapidly Advancing Paradigm October 15 th, 2014 Family Practice Evening Course University of Calgary Jehangir Appoo Division of Cardiac Surgery Libin Cardiovascular Institute University of Calgary
2 Today: Story: Recent Evolution of Thoracic Endovascular Repair Descending Thoracic Aortic Aneurysms Complicated Type B Aortic Dissections Aortic Coarctation Future Evolution of Thoracic Endovascular Repair Aortic Arch Ascending Aorta Infrastructure/Research Paradigm Few Tools for Primary Care Physicians
3 Fathers of Aortic Surgery 1953 Cooley and Debakey repaired the first descending thoracic aortic aneurysm using homografts 1970 s Stanley Crawford major technical improvements 30/30 club 1970 s-1980 s Randall Griepp refinements of techniques neuro/spinal protection
4 Highly morbid operations Significant risks Pain syndrome
5 Evolution of Aortic Surgery
6 Recent Evolution of Thoracic Endovascular Repair Descending Thoracic Aortic Aneurysms Complicated Type B Aortic Dissections Aortic Coarctation Current/Future Evolution of Thoracic Endovascular Repair Infrastructure Research Aortic Arch Ascending Aorta
7 Descending Thoracic Aortic Aneurysms Risk of dissection or rupture of the Descending Aorta Elefteriades et al., Yale database
8 Endovascular surgery improves morbidity & mortality Mortality 2% vs. 11% Cord ischemia 3% vs. 14% ICU, hospital LOS vascular cxs re-interventions
9 37y.o mother of 3 Presents with a cough Open and Endovascular options
10 1.5 inch groin incision Home 2 1 week
11 Recent Evolution of Thoracic Endovascular Repair Descending Thoracic Aortic Aneurysms Complicated Type B Aortic Dissections Aortic Coarctation Current/Future Evolution of Thoracic Endovascular Repair Aortic Arch Ascending Aorta Infrastructure Research
12 Type B dissection Evolving controversy surrounding mgmt of uncomplicated vs. complicated type B
13 Complicated Type B Dissection
14 Endovascular Treatment of Type B dissection
15 Complicated Acute Type B Dissection 56yo male Seen 12 hrs post presentation Severe Malperfusion: Ischemic leg Ischemic gut Renal failure
16 Rt. Iliac SMA Rt. Renal Artery
17 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
18 Lower extremity, visceral & renal malperfusion resolved
19 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:
20 Recent Evolution of Thoracic Endovascular Repair Descending Thoracic Aortic Aneurysms Complicated Type B Aortic Dissections Aortic Coarctation Current/Future Evolution of Thoracic Endovascular Repair Aortic Arch Ascending Aorta Infrastructure Research
21 2007 Primary Adult Coarct Male Early 30 s Bicuspid Aortic Valve
22 2007
23 2013 Primary Adult Coarct Male Early 30 s Bicuspid Aortic Valve
24 2013
25 2013
26 Recent Evolution Descending Thoracic Aortic Aneurysm Type B Dissection Coarctation
27 Recent Evolution of Thoracic Endovascular Repair Descending Thoracic Aortic Aneurysms Complicated Type B Aortic Dissections Aortic Coarctation Current/Future Evolution of Thoracic Endovascular Repair Aortic Arch Ascending Aorta Infrastructure Research
28 Ongoing/Future Evolution
29 Takumi Principle Perceptive, Thoughtful surgeons in new era of skill
30 Why Zone 0 TEVAR? How did we get started? 11 yrs post Type A dissection repair
31 Why Zone 0 TEVAR? Complex Patients Diffuse aortic disease Generally need 2 stage procedures with total arch replacement and elephant trunk Often redo setting
32 Etz, Grieppe et al. Eur J. CT Surg 2008 Surgeon Year ET1 Mortality ET2 Mortality Interval Mortality Rx Mortality Svensson % 8.5% 14% 18% Safi % 9.6% 10% 13.3% Lemaire/Coselli % 4% 25% 36% Kouchoukos % % Grieppe % 7% 12% 24.5% Even in centres of experience, operative mortality with 2 stage elephant trunk technique is high
33
34 2010- Zone 0 Novel Approach Follow up at 2 years
35 Zone 0:
36 Is there a role for endovascular therapy of acute type A aortic dissection?
37
38 Pigtail catheter in true lumen Obliteration of false lumen in arch & prox descending aorta
39 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? Strategies Surgical asc ao replacement followed by branch grafts?
40 Is it safe to place an endograft in the ascending aorta? Clinical & Radiologic Follow up Zone 0 Thoracic Endovascular Aortic Repair Jehangir Appoo, Eric Herget, William Kent, & Jason Wong University of Calgary Canadian Cardiovascular Congress October 28 th, 2012
41 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
42 Total endo arch Custom built branched arch graft
43
44 Complexity
45
46 2013- VR image 3 months post op
47 Evolution of Zone 0
48 Future Evolution of closed chest zone 0 -new devices on horizon
49 Closed Chest Total Arch Modular branch graft Off the shelf device FDA trial: 10 cases done at 4 sites in US Oct 2014
50 Closed Chest Arch Chimney Technique Off the shelf conventional devices Concern with gutter endoleaks & branch compression Main indication: emergencies when customized devices unavailable but being used electively in parts of world
51 Closed Chest Total Arch Najuta graft Precurved fenestrated arch graft in various configurations off the shelf Used in over 300 aneurysm cases in Japan Concern re: risk of stroke
52 Evolution of Endovascular MultiLayer Aortic Stent Grafts The
53 Closed chest total arch Flow Modulating devices Paradigm change: Not about aneurysm exclusion Scaffold to allow thrombus deposition, flow pattern modulation while maintaing side branch patency Laminar vs. turbulent flow
54 Recent Evolution of Thoracic Endovascular Repair Descending Thoracic Aortic Aneurysms Complicated Type B Aortic Dissections Aortic Coarctation Current/Future Evolution of Thoracic Endovascular Repair Aortic Arch Ascending Aorta Infrastructure/Research
55 Infrastructure Team Equipment Research
56 TEAM Surgeons Interventional Radiologists CV Anesthetists Nursing & DI staff CV ICU Advanced NP Biomedical Engineering Pathology Neurology Research Nurse Clinician
57 Cardiac Hybrid Operating Suitea State of the Art Centre Conventional operating theatre & Diagnostic suite Multimodality Multidisciplinary team Avoid patient transfer Improved results
58 Precise Imaging
59 Minimally invasive Aortic therapy is: Safer More effective More efficient Less invasive/better tolerated Innovative
60 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
61 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
62 3D Growth Multidimensional growth estimation Non linear growth measure D i post operation 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
63 3D Growth Results Maximum growth Maximum diameter Growth rate (mm/y) Outer diameter (mm) AATS Aortic Symposium 2014
64 Today: Story: Recent Evolution of Thoracic Endovascular Repair Descending Thoracic Aortic Aneurysms Complicated Type B Aortic Dissections Aortic Coarctation Future Evolution of Thoracic Endovascular Repair Aortic Arch Ascending Aorta Infrastructure/Research Paradigm Few Tools for Primary Care Physicians
65
66 Increased risk of Aortic complications: large size ( 5cm) rapid growth (>0.5cm/yr) concomitant aortic valve disease uncontrolled hypertension smoking history
67
68 Some discrepancies between 2010 US & 2014 Canadian Guidelines *Reasonable to screen first degree relatives of patients with acute aortic syndrome, thoracic aortic aneurysm, and bicuspid aortic valves *Screening tool: Echo ±CTA/MRA chest...indolent but Catastrophic...
69 * If thoracic aorta is 6cm worth having a conversation about driving
70 Come a long way...journey continues
71
72
73
74 The Evolution of Endovascular
75 The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney/Snorkel technique Sandwich technique
76 The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney/Snorkel technique Sandwich technqiue
77 The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney/Snorkel technique Sandwich technique
78 The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney/Snorkel technique Sandwich technique
79 The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney/Snorkel technique Sandwich technique
80 The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney technique Sandwich technique
81 The Evolution of Endovascular While these novel hybrid endovascular approaches do show promise, there are significant limitations High cost and lag time (custom fabricated devices) Branch thrombosis 1 Need for high volume centers of excellence 2 Similar spinal cord and visceral (renal failure) complication rates compared with surgical techniques 2 1. Fenestrated Endovascular Grafting : The French Multicenter Experience. Eur J Endovasc Surg 2010;39: Branched Endografts for Thoracoabdominal Aneurysms. J Thorac Cardiovasc Surg 2010;140:S171-8
82 The Evolution of Endovascular
83
84 Distal Arch Aneurysms
85 Foothills Medical Centre University of Calgary
86
87
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