Update on Open and Endovascular Therapeutic Option for Aortic Repair CENTRE CARDIO-TORACIQUE DE MONACO Friday November 7 th, 2014 THORACOABDOMINAL AORTIC ANEURYSMS HYBRID REPAIR Roberto Chiesa Vascular Surgery, Università Vita-Salute Scientific Institute San Raffaele Milan, Italy
Conflict of interest - PI / Co-PI for several thoracic and abdominal aortic stent graft trials (Cook, Inc, Cordis Corporation, Bolton Medical) - Proctor and lecturer at symposia hosted by Cook, Inc., Bolton, W.L. Gore and Associates, Jotec and Medtronic, Inc. - Educational grants from Cook, Inc.
Open TAAA repair Extensive aortic aneurysm is a complex problem, but it can be managed safely Safi et al., Ann Surg 2014
Alternative strategies?
Total endovascular repair No thoracotomy No laparotomy No aortic cross-clamping No LHBP / ECC Branched stent-graft (Zenith t-branch TM ) Chimney-graft (Gore c-tag + Viabahn & Fluency)
Total endovascular repair Selected cases Anatomic suitability Material availability Costs X-rays exposure Late rupture Follow up? Eagleton, Greenberg, Sem Vasc Surg 2009
Third option?
Hybrid surgery Open Surgery + Endovascular Repair The way to a wider application of endovascular technology for management of complex aortic disease Hollier LH. J Endovasc Surg 1998
Operative technique Stage 1 Visceral arteries rerouting
Operative technique Stage 2 TAAA stent-graft repair
Selection criteria OSR experience Systemic conditions Advanced age Severe COPD Ejection fraction CAD Valvulopathy Oxygen therapy / Dilated ventricle Local conditions Frozen chest Redo TAAA No BEVAR / FEVAR Redo thoracotomy
Case reports
#1 Dissecting type II TAAA Female, 22 Marfan syndrome Previous multiple thoracic aortic interventions Thoracic wall infection Collapsed true lumen
#1 Dissecting type II TAAA Celiac trunk Pancreas Infrarenal aortic grafting with custom made graft Trans-peritoneal vessels exposure
#1 Dissecting type II TAAA Pre-op Post-op (Stent-graft in FL) Patent debranching grafts In-graft landing zones (Cook TX2)
#2 Visceral aortic patch aneurysm Male, 68 Severe COPD, left nephrectomy Previous TAAA III open repair Previous aorto-bifemoral bypass Tshomba, Chiesa et al., J Vasc Surg 2008
#2 Visceral aortic patch aneurysm CT Inflow: iliac prosthetic SMA branch Sequential bypass RRA SMA CT Medtronic Valiant Tshomba, Chiesa et al., J Vasc Surg 2008
#3. Type II TAAA (Alternative in-flow) Male, 59 Previous left lung resection ( frozen chest ) Retroperitoneal fibrosis Previous TAAA IV open repair Hypotrophic left kidney Chiesa et al., Eur J Surg Endovasc Surg 2009
#3. Type II TAAA (Alternative in-flow) Ascending ao Diaphragm CT RRA SMA Chiesa et al., Eur J Surg Endovasc Surg 2009
#3. Type III TAAA (Alternative in-flow) Cook TX2 Chiesa et al., Eur J Surg Endovasc Surg 2009
Gore Hybrid Vascular Graft (GHVG) Sutureless distal anastomosis
#3. Type II TAAA (Gore Hybrid Vascular Graft)
#3. Type II TAAA (Gore Hybrid Vascular Graft)
OSR series 1993-2014 Thoracic aorta 1516 patients Arch DTA TAAA Open ( 93-14) 81 384 522 (987 pts 65.1%) 56 Hybrid TEVAR ( 98-14) 203 261 65 (529 pts 34.9%) 9 FEVAR/BEVAR Tot: 1516 pts 284 645 587 65
TAAA hybrid repair: 56 patients 30-day results N patients (%) Mortality 7 (12.5) Multiorgan failure 2 (3.6) Myocardial infaction 2 (3.6) Coagulopathy 1 (1.8) Bowel infarction 1 (1.8) Pancreatitis 1 (1.8)
TAAA hybrid repair: 56 patients 30-day results N patients (%) Complications 15 (28.8) Renal failure 5 (8.9) Pancreatitis 3 (5.8) Respiratory failure 3 (5.3) Transient paraparesis 2 (3.6) Paraplegia 1 (1.7) Dysphagia 1 (1.7)
TAAA hybrid repair: 56 patients Mid-term results (mean follow-up 36.3±19 mts) N patients (%) Related mortality 4 (7.1) Aortic rupture 2 (3.6) Visceral graft occlusion 2 (3.6) Non-related mortality 9 (16.0) Complications 9 (16.0) Endoleak/migration 5 (8.9) Visceral bypass stenosis/kinking 2 (3.6) Renal failure 1 (1.7) Pancreatitis 1 (1.7) Graft occlusion 9.8% (16/163) Assisted patency 15.6% (23/147 grafts)
Visceral bypass long-term patency 6-months FU: SMA anastomosis angulation 12-months FU: SMA stenting, graft to CT occlusion Chiesa et al., J Cardiovasc Surg 2010
Discussion Chiesa et al., Eur J Vasc Endovasc Surg 2009
Technical issues 1. CT revascularization 2. Renal protection 3. Intraoperative angiography 4. Timing
1. CT revascularization Associated CT and SMA revascularization SMA CT Always when possible!
1. CT revascularization Graft to CT Acute pancreatitis Retro-pancreatic routing 20 days later
1. CT revascularization CT Ante-pancreatic routing
Custodiol 2. Renal protection (Histidine-Tryptophan-Ketoglutarate) Significantly reduced acute kydney injury compare to Ringered Lactated solution during TAAA repair Tshomba, [ ], & Chiesa. J Vasc Surg 2013
3. Intraoperative angiography Intraoperative quality check SMA CT LRA RRA
4. Timing SIMULTANEOUS Single anesthesia Bleeding Coagulopathy Risk of paraplegia STAGED Operative time/bleeding Invasiveness Spinal cord conditioning Intersurgical rupture Strategy to be chosen patient by patient
TAAA hybrid repair Metanalysis 2000-2011 19 publications - 507 cases % 30-day mortality 12.8 Irreversible paraplegia 4.5 Renal failure 8.8 Visceral graft patency 96.5 Moulakakis, Liapis et al., Circulation 2011
TAAA hybrid repair Emergency TAAA treatment (2007-2013) 30 patients % 30-day mortality 26.7 Irreversible paraplegia 10 Chronic hemodialysis 6.7 One-year graft patency 97.3 Gkremoutis A, et al., Eur J Vac Endovasc Surg 2014
TAAA hybrid repair Conclusions Current highly selective indications Technical challenge Good long-term grafts patency Careful follow-up
Milano, December 11th - 13th, 2014 Waiting for you