The Current Status Of Endovascular Repair Of Ascending Aorta And Aortic Arch

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The Current Status Of Endovascular Repair Of Ascending Aorta And Aortic Arch Tilo Kölbel German Aortic Center Dpt. of Vascular Medicine University Heart Center Hamburg

Disclosures Research-grants, travelling, proctoring speaking-fees, IP, royalties with Cook Medical. Consultant with Philips Speaking fees from Getinge IP, Consultant with Terumo Aortic Shareholder Mokita-Medical GmbH

Indication for Ascend Grafts Lesions post surgery: Pseudoaneurysm Postsurgery bleeding Residual Dissection Lost TAVI Type A dissection Ascending aneurysm

Acute Type A Dissection Metcalfe et al. 2012, J Vasc Surg 55: 220-2

Ascending TEVAR for TAAD 2009-2011 n=15 Intervall: 26days Technical success: 15 Open conversion: 1 Mortality: 0 Li et al. 2016; J Am Coll Cardiol 68:1944-54

Ascending TEVAR Hamburg Experience 2010-2017: Cases: 24 Dissection: 15 Pseudoaneurysm: 5 Dislocated TAVI: 2 Other: 2 Urgent/emergent 14 Access: Transfemoral: 18 Transapical: 4 Transsubclavian: 2 30d-mortality: 5 (21%) 1y-mortality: 6 (25%) Stroke: 3 (13%) Tsilimparis et al. 2018; J Vasc Surg accepted

Endograft Choice Length: measure at outer curve 6-10cm Diameter: measure on Centerline Tapered grafts Reverse tapering On-table customization

Oversizing Native aorta or graft Gated or non-gated CT Systolic or diastolic Age Bloodloss... Generally: 15-25%

Inner Curve Apposition 77-81mm Cook Zenith TBE ProForm

Gore ARISE Study Early human feasibility trial Acute TAAD Courtesy of H.Patel, Ann Arbor Staged release Active control system 7/10 patients included Courtesy of Michael Dake

Ascending TEVAR Indications: Lesions post surgery: Pseudoaneurysm Postsurgery bleeding Residual Dissection Lost TAVI Ascending aneurysm Type A dissection

Valved Conduit Porcine study: Bolton NBS ascending SG Symetis valve Courtesy of Martin Czerny, Freiburg Rylski et al. 2014; J Card Surg 29:371-6

Valved Conduit Endo-Bentall? Courtesy of E. Dietrich, Arizona Courtesy of C. Nienaber, Rostock Courtesy of M. Czerny, Freiburg

Combined Ascend + Branched Arch Endograft in acute TAAD Kölbel et al. 2017, J Endovasc Surg 24: 75-80

Combined Ascend + Branched Arch Case series n=5 Technical success 5/5 1y mortality 2/5 (ataad) Law et al. 2018; J Endovasc Surg 25:561-5

Complex Arch Endografts Branched SG Fenestrated SG

Cook Branched Arch Endograft Hamburg Experience 2012-2017: Cases: 54 Aneurysm/PAU: 28 Residual dissection: 24 Acute Type A: 2 30d-Mortality: 3 (5.5%) Clinical stroke: 4 (7%) Tsilimparis et al. 2018, J Vasc Surg: epub

Milne et al. 2016; Ann Thor Surg; epub Post TAAD-Repair N=73; 2009-2015 Type 1 AD Eligibility for B-TEVAR Access, diameter, angulation 70% anatomically suitable

Anatomical Suitability Suitable:70% Graft too short: 21% Major Kink: 7% Sobocinski et al. 2016; Ann Thorac Surg102:2028 35

Post TAAD-Repair

Residual Dissection

Residual Dissection Bilateral carotid-subclavian bypass Axillo-axillary bypass

Chronic TAAD Multicenter Experience Chronic TAAD : 13 Centers, 9 countries, 2012-2018 Patients: 70 Male 50 Age 69y Technical success 68 (97%) Stroke: 2 (3%) 30d-Mortality: 2 (3%) 1y-mortality 8 (11%) Verscheuren et al. Unpublished data.

Cook Branched Arch with 3 Inner Branches N=3; 2016-2017 Technical success all 3 Procedure time 3h All 3 uncomplicated course Spear et al. 2017; J Endovasc Surg 24:534-8

Fenestrated Arch Repair

Fenestrated Arch Anatomical Suitability Diameter 38mm 38mm Proximal landing zone 20mm Appropriate access vessels Landing zone in mid-arch

Fenestrated Arch Endograft Hamburg Experience 2011-2017: Cases: 40 Aneuysm: 25 Chronic dissection: 8 PAU: 7 30d-Mortality: 4 Stroke: 4

Fenestrated Arch Endograft Multicentre Japan; n=383 Zone 0: n=363 Technical success: 99% 30d mortality: 1.6% Stroke: 1.8% Yokoi et al. 2013; J Thorac Cardiovasc Surg 145:S103-9

Summary Endovascular Treatment of ascending and aortic arch aorta beneficial in selected patients. Postsurgery lesions and post Type A dissection work best. Ascending aneurysms in native vessel do not. Significant progress in device development recently.

The Current Status Of Endovascular Repair Of Ascending Aorta And Aortic Arch Tilo Kölbel German Aortic Center Dpt. of Vascular Medicine University Heart Center Hamburg

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