Fenestrated Implantation: How I do it. Tara M Mastracci, FRCSC, FACS, FRCS, MSc Royal Free London

Transcription

1 Fenestrated Implantation: How I do it. Tara M Mastracci, FRCSC, FACS, FRCS, MSc Royal Free London

2 Disclosures Cook Medical Inc -- Proctorship and Consultation All speaking and consultation fees are donated to the Royal Free Trust Aortic Charity (Fund 187)

3 Fenestrated Planning Postprocessing software is essential Greater accuracy and precision Flexibility to manipulate the planes Axial Corrected

4 Dedicated Planning Software

5 Calculations Distances between visceral arteries Radial or clock positions Vessel diameters Sealing zone diameter Graft length

6 Determine Seal Zone Fenestrated device planning begins by determining where the proximal sealing stent will reside. Choose the lowest aortic segment that will provide adequate seal Be cautious in the setting of angulated anatomy Seal zone should be > 20 mm and proximal to the aneurysm

7 How do you pick a Sealing Zone???

8 What s Really Happening In The Conical Neck? ASCULAR SURGERY ber 2 Diehm et al 427 JOURNAL OF VASCULAR SURGERY Volume 48, Number 2 Normal 430 Long Neck Diehm et al 429 JOURNAL OF VASCULAR SURGERY August 2008 Fig 2. Van Gieson s elastic stains from control (left) and two neck regions from patients with infrarenal abdominal aortic aneurysm (center and right). The center picture from a patient with low scores of destruction shows beginning scarification of the outer media (asterisk) and substantial loss of elastin in the inner media. The example in the right image from a severely affected aortic neck illustrates almost complete loss of continuous sheets of elastin throughout the media. The age-matched control on the left has a normal medial structure except for a few interrupted lamellar units near the adventitia.. Schematic depiction of tissue sampling in AAA patients undergoing open repair. A, In 5/22 (23%) AAA ts with infrarenal neck lengths "15 mm, the aorta was clamped suprarenally and a tissue stripe spanning from the differences between tissues were similar after the adjustscopically nonaneurysmal segment distal to the renal arteries to the level of the maximally dilated aortic sac was ment for age, gender, and type of sampling (Table III). ed. B, In 17/22 (77%) AAA patients with infrarenal neck lengths!15 mm, the aorta was clamped infrarenally issue stripe spanning from the macroscopically nonaneurysmal segment distal to the renal arteries to the Restricting level of the analyses to tissues obtained to tissues obaximally dilated aortic sac was retrieved. hemidoc (BioRad, Hercules, Calif) and anati One software (BioRad). The intensities of ve bands were normalized to GAPDH. A was extracted for real-time reverse polymerion (PCR) using the Fibrous tissue Mini kit ncia, Calif). RNA integrity was assed by the alyzer (Agilent Technologies, Santa Clara, icrograms of RNA were reverse transcribed Diehm et al Conical Neck tained through intraoperative sampling, we found results much the same (data available on request). Real- time PCR DNase-treated RNA sample. Gene expression was quantiindicated fied using the!!ct method normalizing against the meanthat gene expression of MMP-9 was higher in CT of the set of housekeeping genes.22 AAA sacs compared with necks and controls (P for trend! For zymography, proteins were resolved by electrotable III). Using immunohistochemistry, we found phoresis in 10% SDS polyacrylamide slab.002, gels (Sigma, G1890, St. Louis, Mo). After electrophoresis, gels were MMP-9 and p-jnk expression in et AAA and sac specidiehm al,neck 2008 incubated overnight at 37 C in the zymography developmens, with prominent staining in smooth muscle cells, ing buffer. Following staining with Coomassie blue R-250 tion.10 These findings suggest that continuing aortic neck dilatation is a perpetuation of a proximal aneurysmal disease process. Thickness of the aortic media at the infrarenal level has been described to be 640 " 180 #m in control individuals.38 The increased media thickness in the present study may be explained by samples obtained proximally to those described previously.38 The decrease in the number of elastic lamellar units along the course of the thoracic to the infrarenal aorta is well-known.38,39 The number of elastic

9 Anatomic Predictors: Vertebral Tortuosity Index VTI=(Actual/Straight-1)*100 Morris et al, Circulation 2011

10 Anatomic Predictors: Vertebral Tortuosity Index 66 patients, age 71 yrs VTI not associated with acute presentation Did increase with Age Higher than controls (16) Virgilio et al, EJVES 2016

11 Heritable Diseases of the Aorta Brown, Greenberg, Wong, Eagleton, Mastracci, Hernades, Rigelsky and Moran; JVS 2013

12 Family History Predicts Outcomes Van de Luijtgaarden et al, JVS 2014

13 Family History Predicts Complications Van de Luijtgaarden et al, JVS 2014

14 Metabolic Environment Matters Shalaby et al, JAMA Surgery 2015

15 Inflammation and Complications Shalaby et al, JAMA Surgery 2015

16 Cause of Death After Aneurysm Repair 619 patients over After first 30 days, no difference in mortality rate between rupture and intact aneurysms 157 deaths after 30 days Bastos Gonçalves et al, JVS 2016

17 Cause of Death After Aneurysm Repair Other 32% 35% Cardiovascular Aortic Related 4% 29% Cancer Related Bastos Gonçalves et al, JVS 2016

18 New Paradigm for Evaluating Technology

19 What Device Do I Use??? Age Comorbidities Metabolic Environment Family History Preferred Length of Sealing zone Ease of Reintervention Global Experience with Device

20 An IFU is not a Substitute for Vascular Surgery Training

21 History of the Sealing Zone >4cm

22 Common Landing Zones Never trust a Distal Aorta Group IV Juxtarenal

23 CA SMA RRA LRA

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25 What would you Do? Infrarenal EVAR with anticipated poor outcomes and plan for fenestrated conversion in a few years? Open Infrarenal? Fenestrated repair?

26 Parallel Walled Aorta Is Important Post Op Year 1 Year 2

27 gacek

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29 Owens

30 Endoleak Rate: Learning Curve O Callaghan et al, JVS 2015

31 Technique & Design are subject to a learning curve Mastracci et al, JVS 2015

32 Endoleak Over Time: Technical Success Durability EASE OF IMPLANTATION SHOULD NOT DRIVE DESIGN O Callaghan et al, JVS 2015

33 Choosing Graft Diameters The diameter of the graft is typically chosen to be 10-25% larger than the proximal implantation site. The attachment sites for distal implantation are oversized by approximately 15-35%. In vessels with diameters greater than 16 mm, oversizing can be increased.

34 Clock Positions Clock positions should be performed on corrected views (MPR).

35 Effects of Angulation

36 Inner Vessel Diameter Determines where the fenestrations will be located More critical for fenestrations than scallops Not to include thrombus

37 Access Vessel Proper alignment of fenestrations requires the ability to readily rotate the device. Access vessels must be evaluated with respect to: - Tortuosity - Diameter - Stenosis - Calcification - Length Quality of access vessel influences the ability to manipulate the proximal body while aligning the fenestrations.

38 Access Vessel Graft Diameters mm Proximal Body (20 Fr) 8.1 mm Minimum Access Vessel Diameter Distal Body (20 Fr) 8.1 mm 9 16 mm ZSLE Leg extension (14 Fr) 5.4 mm mm ZSLE Leg extension (16 Fr) 6.0 mm Calcification and existing stents severely limit rotational ability.

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40 Access 2 o clock 8 o clock 4 o clock

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60 Zenith Fenestrated Experience patient-specific precision.