The SPIDER-Graft for Thoracoabdominal Aortic Repair a feasability study in pigs Wipper S, Kölbel T, Manzoni D, Duprée A, Sandhu H, Nelis V, Debus ES University Heart Center Hamburg University Heart Center Hamburg German Aortic Center
Disclosures The experimental study was supported by VASCUTEK 2
Background Solely endovascular treatment is not possible in all patients (e.g. connective tissue disease, difficult anatomy with kinked or atherosclerotic access vessels, no landing zone, accessory renal arteries, ) Risk of spinal cord ischemia (no reimplantation of radicular arteries) 3 Courtacy Prof. Oderich
Background Open thoracoabdominal aortic repair using Crawford access and extracorporeal circulation is still challenging ECC related complications Thoracotomy required Reimplantation of thoracic/ lumbar arteries to reduce spinal cord ischemia possible Hybrid repair with endovascular treatment of the thoracic aorta and open repair of the abdominal aorta might reduce perioperative risk 4
Idea of the study Frozen elefant trunk in aortic arch repair to provide landing zone in the descending aorta for future endovascular treatment Reversed modified frozen elefant trunc for hybrid repair of thoracoabdominal aortic aneurysm??? 5
Idea of the study Modification of a frozen elefant trunk for retrograde delivery to descending thoracic aorta Developed of a six-branched hybrid graft for thoracoabdominal aortic replacement Avoiding thoracotomy by endovascular treatment of the thoracic part Avoiding extracorporeal circulation by perfusion of the visceral branches via transient distal aortic anastomosis Retrograde delivery into the descending thoracic aorta Save fixation in the proximal landing zone Side armes for reimplantation of renal and visceral arteries 6
Aim of the study Experimental evaluation in a pig model: Six-branched hybrid graft for thoracoabdominal aortic replacement with endovascular treatment of the thoracic aorta avoiding thoracotomy and extracorporal circulation and open repair of the abdominal aorta including visceral reimplantation 7
Study protocol 6 domestic pigs (75-85kg) Technical feasibility Hemodynamic parameters (HD) Blood-flow (Transit-Time flow measurement) Ischemic time of related organs Angiography Swan-Ganz Catheter: CVP, PAP, LAP, PVR, BGA Post Mortem CT angiography PiCCO: MAP, HR, CO, SVR, GEDV, BGA Transit-Time flow measurement (TTFM): Coeliac trunc, superior mesenteric artery, left renal artery, Iliac arteries
SPIDER graft deployment 9
Anastomosis of iliac sidebranch 10
Insertion of thoracic stentgraft In-flow occlusion Aortic clamp distal to CT Clamp on CT 11
Retraction of sheath 12
Stentgraft deployed 13
Release of proximal fixation wire 14
Release of introducer system 15
De--airing of the SPIDER graft De 16
Release of iliac clamp and perfusion of visceral arteries 17
Stepwise rere-implantation of visceral and iliac carteries 18
Surgical Procedure 19
Results Successful graft deployment in all 6 animals 20
Results Successful fixation of graft in proximal landing zone Modificatoin of Delivery System for easier retraction necessary Thoracic graft implantation 4.2±1min Ischemic time (min) TTFM Base (ml/min) TTFM post (ml/min) TC 11.5±2.3 585±65 534±110 SMA 9.0±2.1 492±113 722±115 RRA 13.4±3.8 LRA 21.2±4.0 246±97 163±97 RIA 9.0±3.3 565±192 326±67 LRA 15.6±6.5 592±156 400±127 21
Summary Hybrid graft implantation is technically feasable in pigs Crossclamping time and visceral and renal ischemia can be kept in a short limit Extracorporeal circulation can be avoided Thoracotomy can be avoided Prothesis has to be further modified Further experimental studies are necessary Hybrid graft might be a useful treatment option for selective cases
Future perspective Modification of nose cone for delivery system difficult to extract Over the wire implantation Modification of the graft for reimplantation for thoracic or lumbar arteries for spinal cord perfusion Better orientation of side arms for retroperitoneal access Actual experimental studies for evaluation of Organ perfusion Comparision to conservative prothesis Evaluation of spinal cord perfusion 23
Future perspective E.S. Debus, MD 2nd Generation 3rd generation
Thank you for your attention
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