Antegrade Thoracic Stent Grafting during Repair of Acute Debakey I Dissection: Promotes Distal Aortic Remodeling and Reduces Late Open Re-operation
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1 Antegrade Thoracic Stent Grafting during Repair of Acute Debakey I Dissection: Promotes Distal Aortic Remodeling and Reduces Late Open Re-operation Vallabhajosyula, P: Szeto, W; Desai, N; Pulsipher, A; Moeller, P; Musthaq, S; Pochettino, A; Bavaria, JE Thoracic Aortic Surgery Program University of Pennsylvania, Philadelphia, PA
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3 Medtronic: Consultant; Co-Primary Investigator Talent Trial; Primary Investigator Valiant Valor II Trial, National CV PI Acute Type B Dissection trial W.L. Gore: Consultant; Primary Investigator TAG Trial; FDA PMA submission; Primary Investigator High Risk Trial, Dissection trial and Large Diameter 45 trial Cook Medical: Co-Primary Investigator TX2 Thoracic Aorta Trial, PI Post market TX2 trial Bolton Relay: PI TEVAR trial Jotec: Consultant; FDA E-Vita submission Vascutek: Aortic Symposium Director
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5 Cause of death Acute CHF due to AI Coronary malperfusion Cerebral malperfusion Free Ascending rupture Treatment Aortic valve resuspension Aortic root repair Arch replacement Asc aortic replacement
6 Note: Finished Product, Efficient Conduct of operation, good results
7 This is Consecutive All Comers with Immediate transfer to OR protocol 30 day Mortality 12.1% Intra-op mortality 2.3% NEW Stroke rate 4.5% Prior to 1992 Death/CVA 30-40%
8 Cause of death Acute CHF due to AI Coronary malperfusion Cerebral malperfusion Free Ascending rupture Treatment Aortic valve resuspension Aortic root repair Arch replacement Asc aortic replacement
9 Cause of death Acute CHF due to AI Coronary malperfusion Cerebral malperfusion Free Ascending rupture Treatment Aortic valve resuspension Aortic root repair Arch replacement Asc aortic replacement Fate of Distal Descending Aorta!
10 CT scans after Successful Type A Dissection surgery: No Reasonable distal Aortic Remodelling Mal-Perfusion Chronic Distal Dissecting aneurysm Chronic Complex Arch Dissecting aneurysm Residual 6.8 cm Dissecting Aneurysm after Type A Repair with Arch involvement
11 Senior Surgeon Series Bavaria et al, 2007 (USA), 26% Reoperation at 12 years Included Debakey II Ishihara et al, 2009 (Japan), 27% Aortic Events at 5 years Di Bartolomeo et al, 2001 (Italy), 27% Reoperation at 7 years Griepp et al, (USA), 16% reoperation at 8 years Included Debakey II Glauber and Murzi, 2010 (UK), 39% reoperation at 10 years (proximal and distal)
12 False lumen remains patent distal to the end of the stent grafts Courtesy: M. Grabenwoger, Vienna Courtesy: R. DiBartolomeo, Bologna Italy Note: H. Jakob, Essen Germany, ATS % Re-modeled Aorta in Type A Dissection with E-Vita
13 Type A (Debakey Type I) Dissection: Pre and Post Proximal Repair with E-Vita (type) Distal Graft Beijing, China
14 Aortic Event rate
15 77% of Stented Descending Aorta cases with Obliterated False Lumen vs only 25% for Standard hemi-arch Repair
16 Methods Analysis of 242 DeBakey I dissection repairs performed at the University of Pennsylvania from 2005 to 2012 Antegrade stent grafting of the Distal Arch/Proximal DTA performed during circulatory arrest starting in 2005 Comparison of a concurrent series of DeBakey I dissection repairs : open repair + antegrade stent grafting (Stented group) versus open repair (Standard group) Aortic Dissection Repair 1995 to 2012 (n=556) DeBakey I Repair 1995 to 2012 (n=398) DeBakey II Repair 1995 to 2012 (n=158) DeBakey I Repair 2005 to 2012 (n=242) Stented Group (n = 62) Standard Group (n=180)
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18 All parameters Non significant: No differences Stented Non-Stented P N Age N Male 40 65% % 0.52 Prior sternotomy 6 10% 19 11% 0.8 Prior AAA repair (open or EVAR) 1 2% 7 4% 0.7 Hypertension 51 82% % 1 Renal failure 3 5% 17 9% 0.42 Diabetic 8 13% 21 12% 0.82 Chronic Lung Disease 6 10% 18 10% 1 Preop Malperfusion 30 48% 70 39% 0.23
19 Stented (n=62) Standard (n=180) P Root Replacement 10 (16%) 36 (20%) 0.57 Root Reimplantation 0 (0%) 3 (2%) 0.57 Aortic Valve Replacement 8 (13%) 37 (21%) 0.22 Cardiopulmonary Bypass Time (minutes) Aortic Cross Clamp Time (minutes) Retrograde + Antegrade Cerebral Perfusion 8 (13%) 19 (11%) 0.64 Retrograde Perfusion 11 (18%) 117 (65%) <0.001 Antegrade Perfusion 43 (69%) 44 (24%) <0.001 Circulatory Arrest Time (minutes)
20 Stented (n=62) Standard (n=180) P In-hospital Mortality 6 (10%) 25 (14%) 0.51 Stroke 3 (5%) 15 (8%) 0.57 Permanent Paraplegia 0 (0%) 1 (1%) 1 Transient Spinal cord Ischemia 4 (6%) 3 (2%) 0.07 Ischemic Bowel 3 (5%) 7 (4%) 0.71 Prolonged Ventilation (>24 hours) 14 (23%) 69 (38%) 0.02 Renal Insufficiency/ Failure 13 (21%) 42 (23%) 0.86 w/ Hemodialysis 4 (6%) 21 (12%) 0.33 Reoperation for bleeding 7 (11%) 15 (8%) 0.45 Length of Stay (Days)
21 CTA follow-up Stent: 56/62 discharged, CTA follow-up on 55/56 (98%) Standard: 155/180 discharge, CTA follow-up on 120/155 (77%)
22 13/55 (23%) Stented mail.uphs.upenn.edu- 1.webloc 28/120 (23%) Controls
23 27/55 (49%) Stented 19/120 (16%) Controls
24 15/55 (28%) Stented 73/120 (61%) Controls
25 Combined Total Aortic and Thoracic Aortic Remodeling = 72% in Stented group and 39% in Standard Repair group (p=.001)
26 Stented Standard p = 0.58 N at risk Stented Standard
27 Stented Group (n=55) Standard Group (n=120) Stented Group (n=55) Total Distal Reinterventions (TEVAR + Open) Open Distal Reinterventions p = 0.26 p = 0.1 Standard Group (n=120) Reinterventions (11 patients) n = 11 Reinterventions (11 patients) n = 16 TEVAR n = 10 Open Distal Operation n = 1 TEVAR n = 5 Open Distal Operation n = 11 Redo Total Arch n = 1 Thoracoabdominal Repair n = 0 Redo Total Arch n = 3 Thoracoabdominal Repair n = 8
28 Stented Standard p= 0.1 N at risk Stented Standard
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30 p = Trend showing improved application of the Stent Procedure N at risk
31 Stent Standard p = 0.2 Trend towards improved survival in later cohort N at risk Stent Standard
32 Conclusions Antegrade stent grafting of the DTA during DeBakey I aortic dissection repair can be safely performed, without increasing morbidity and mortality over postoperative and midterm follow-up Antegrade stent grafting promotes aortic remodeling of the remnant dissected thoracoabdominal aorta by promoting false lumen thrombosis/ obliteration It also provides a platform that enables endovascular solutions for late aortic reinterventions This technique decreases morbidity over midterm follow-up, without increasing mortality Open distal reoperation rate was lower in the antegrade stent graft patients (1 open reintervention versus 11) There is a learning curve to the antegrade stent graft technique Outcomes were superior in patients who underwent this procedure during the late period (2009 to 2012) compared to the early period (2005 to 2008) Further follow-up may attest to the validity of this technique for potential long-term mortality and morbidity benefit
33 Thank You
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35 Stented Early (n=35) Stented Late (n=27) In-hospital death 5 (14%) 1 (4%) 0.21 Stroke 2 (6%) 1 (4%) 1 Paraplegia 0 (0%) 0 (0%) 1 Transient Spinal Cord Ischemia 3 (9%) 1 (4%) 0.62 Ischemic bowel 3 (9%) 0 (0%) 0.25 Prolonged Ventilation (>24 hours) 5 (14%) 9 (33%) 0.12 Renal Insufficiency 7 (20%) 6 (22%) 1 w/dialysis 2 (6%) 2 (7%) 1 Reoperation for bleeding 4 (11%) 3 (11%) 1 Length of Stay (Days) P
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