Distal Arch and Descending Aorta: What Is the Optimal Therapy in 2017?

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Transcription:

Distal Arch and Descending Aorta: What Is the Optimal Therapy in 2017? Eric E. Roselli, MD Chief, Adult Cardiac Surgery Director, Aorta Center Heart and Vascular Institute, Cleveland Clinic

Disclosures Bolton Cook Cryolife Edwards Gore LivaNova Medtronic St Jude Vascutek Consultant, Investigator Speaker, Investigator Consultant Consultant, Investigator Consultant, Investigator Speaker, Investigator Consultant, Investigator Speaker, Investigator Speaker, Investigator

Options for Zone 2 Landing Zone (+) TEVAR (-) Open LSA: 1) Cover 2) Bypass 3) Stent Total Endo Arch ET FET Debranching +/- staged TEVAR

TEVAR Options for the LSA Cover Bypass Emergencies Current Standard Endovascular Revascularization In Situ Laser Fenestration Off-Label Parallel Grafting Off-Label Branched Grafts Investigational Medtronic Mona LSA Gore TBE

Open Options for the Distal Arch Conventional Elephant Trunk Platform Hybrid (open plus stentgraft) Frozen Elephant Trunk Hybrid Debranching

70 y/o Male s/p Type A Dissection 2007 Emergency ascending and hemiarch Sternal infection on chronic suppressive abx Malignant lymphoplasmacytic lymphoma Obesity (BMI 37), Ventral hernia, Sleep Apnea, Barrett s esophagus, Hyperlipidemia, Glaucoma, h/o retinal detachment, restless leg syndrome, depression

Recent Growth Distal Arch FL

Plan for TEVAR Spinal drain, Cover to Celiac Size between LCC and LSA, minimal oversizing (3D CT) Always use IVUS U/S guidance for brachial access U/S guidance for Perclose also helpful Beware dissected LSA

IVUS

Laser Fenestration and LSA Stenting

Completion CT

Malalignment an Issue

Key Points for Laser Fen + Stenting Understand the Anatomy Visualization LAO, RAO, Cr/Cau Thru and thru wire Balloon waist confirmation LSA angio guidance from above

Chimneys, Periscopes, Snorkels (ChimPS) Alternative

Branch Challenge: Endoleaks, Patency? Beaufort H, et al. JVS, 17.

Fenestrated Devices Yokoi Y, et al. Tokyo, Japan Presented at 2012 AATS Aortic Symposium Azuma T, et al. EJCTS, 2013

Beware the Dissected LSA

Arch Single Branch Devices MonaLSA TBE

Procedure

Post-Op CTA Image

GORE TAG Thoracic Branch Endoprosthesis Inner portal Side branch anchors

Potential Use of Single Branch Device Zone 2 Zone 1 Zone 0

LSA Branched Graft Commonalities Double Wire Access Through and through wire optimizes alignment Avoid wire wrap RAO visualization Over the wire snaring Minimize manipulation within the arch Wire Snaring in distal aorta when possible Know the LSA and limitations of devices

Hybrid Arch Classification Type I Type II Type III Beating Heart Cardiac Arrest Only Circulatory Arrest On or Off Pump (incl FrozenET and EEC) Single (s) or Two (d) stage

81y/o acute hoarseness, CP CAD + Ruptured Arch Aneurysm Inferior wall ischemia Cath 70% PLCx and RCA CT Large arch aneurysm, Leak s/p PPM, Jehovah s Witness Hybrid Arch Type 1s Beating heart debranching, Antegrade TEVAR

CABG and Debranching 1st

Antegrade Delivery 2nd

Completion CT

Hybrid Arch Type 1 Issues Side-biting clamp on diseased ascending Ascending diameter disparity - often large Landing zone less reliable, relatively short Partial/full sternotomy Extra-anatomic bypass patency Limited options for multi-component procedure

Arch Double Branch Devices Cook Bolton Nexus

Arch Branches Improving

Ascending Often Dilated / ing Type 1 Endoleak ~ 10% (up to 19%)

Proximal / Retrograde Dissection Post TEVAR ~ 1-8% especially dissection and CTD Higher Post Hybrid: 11% native, Andersen, Hughes, et al. JVS 13 24% h/o dissx, Cochennec, et al. JVS 13

Type A after previous Type B Retrograde Dissection or Disease Progression?

Should we limit hybrid debranching to those with an ascending graft?

Or Kinked Grafts Often Short Or Tortuous

Sternotomy Circ Arrest +SABP Frozen Elephant Trunk Isabella, Roselli. OpTechThorSurg, 13.

86y/o asc an, chronic dissx

Completion CT

Newer Devices

S.A.F.E.R. Technique Single Anastamosis Frozen Elephant trunk Repair Roselli EE, et al. J Thorac Cardiovasc Surg, 2012.

Evolving Procedure: B-SAFER 2009 2012 2015 Roselli EE, et al. Annals Thoracic Surgery, 2017, In Press.

Branched Frozen Elephant Trunk Acute: B-SAFER Chronic: Modified Roselli EE, et all. STS 2017 poster Roselli EE, et al. EurJCTSurg, 2017.

Open Advantages and Limitations + Widely applicable Durable Safe with SAnteBP - Invasive Long, complex op Too much for some Hybrid Less Mech Circ Support Commercial devices Endo Least invasive Still big operation Device complications Stroke, Endoleaks, retro dissx Unknown Durability Device availability Proximal seal?

Which will win out? Tailored Therapy for Each Patient

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