Toward Total Endovascular Therapy of the Aorta Adam W. Beck, MD Associate Professor of Surgery Division of Vascular Surgery and Endovascular Therapy University of Alabama at Birmingham
Disclosures Grant Support: Cook Medical, Medtronic Inc, W.L. Gore & Associates, Consultant Cook Medical, Medtronic, Inc, Physician Education Cook Medical, Terumo All proceeds to UAB **Off label use of devices will be discussed
Historical Perspective There is no disease more conducive to clinical humility than aneurysm of the aorta. -Sir William Osler
Aortic Aneurysm
Endovascular Revolution
Juan Parodi (1991) Endovascular Revolution
Endovascular Revolution TEVAR: 1994: First successful TEVAR 2005: Gore TAG approved for use in the U.S.
How Does A Stent Graft Work? Synergy of Form and Function Form Function Stent Graft Seal Fixation
Infrarenal Aortic Devices (2000)
Devices (2017) 6 Commercially available devices ~70% of AAAs amenable to repair (within IFU)
Anatomic Challenges to EVAR Neck Iliac Anatomy Access
Juxtarenal Fenestrated EVAR FDA approved 2013
Anatomic Challenges to EVAR
Open Repair of TAA and TAAA Mortality 10-25% Morbidity Pulmonary: 30-50% Cardiac: 10-25% Renal: 10-20% Paralysis/Paraplegia: 5-40% Stroke: 5-10%
Open Repair of TAA and TAAA Current Adjuncts CSF Drainage Distal Aortic Perfusion Intercostal Reimplantation Expeditious Surgery Hypothermia Spinal Cooling Neuroprotective drugs SCI: 5-20%
Pioneers and Investigational Device Exemptions Roy Greenberg Tim Chuter
Thoracoabdominal Aneurysm Repair Open Repair Hybrid Debranching Repair Endovascular Repair Parallel ( Chimney ) stents Fenestrated/Branched Endografts Physician-modified Custom devices - requires Investigational Device Exemption
Alternatives? Hybrid TAAA Repair
Second stage (TEVAR) sometimes not completed Physiologic impact similar to open TAAA Largely Abandoned
Alternatives? Parallel stents: Chimneys
406 TAAA Patients!
ACTIVE SPONSOR-INVESTIGATOR F/BEVAR IDE STUDIES Matt Sweet and Ben Starnes University of Washington Tim Chuter UC-San Francisco San Francisco, CA David Kuwayama U. Of Colorado Denver, CO Gustavo Oderich Mayo Clinic Rochester, MN Matt Eagleton Cleveland Clinic Cleveland, OH Adam Beck, MD UABMC Birmingham, AL Darren Schneider Cornell University New York, NY Mark Farber UNC-Chapel Hill Chapel Hill, NC Andy Schanzer U. Massachusetts Worcester, MA Carlos Timaran UT-Southwestern Dallas, TX Anthony Lee Lynn Heart and Vascular Institute Boca Raton, FL
Challenge: Spinal Cord Ischemia Achilles Heel?
Endovascular Repair: Acute Spinal Cord Ischemia Aortic coverage/intercostal Thrombosis Hemodynamics (Hypotension) Intercostal, Subclavian, Hypogastric, Lumbar Arterial coverage/ligation
SCI: Spinal Cord Perfusion Artery of Adamkiewicz T9 - T12/L1
UF Branched/Fenestrated Spinal Cord Ischemia No SCI Any SCI N=243 60 50 1.67% 31.7% In-house mortality: N=10 (4.1%) 40 17.9% 30 20 43 52 53 54 33 10 0 14.3% 8 Juxtarenal Suprarenal IV III II I *Unpublished Data
UF Branched/Fenestrated Spinal Cord Ischemia Temporary vs. Permanent Recovered Function Permanent SCI 40 35 30 4.9% 10.71% 25 20 15 0% 10 5 0% 0 Juxtarenal Suprarenal IV III II I
Spinal Cord Ischemia
Spinal Cord Ischemia
Implications of SCI 12-Month survival (TEVAR) With SCI: 25% Without SCI: 80%
UF/UAB SCI Prevention Protocol
Spinal Cord Ischemia Rate (%) SCI Rate Before and After Protocol 20 15 10 5 * p =.007 * p =.004 0 Pre Post Pre Post All Patients High Risk Patients
Challenge: Urgent/Emergent Presentations
Custom Endografts
Urgent/Emergent ~30% of UAB Aortic Practice ~20% of endovascular practice Frequently complex anatomy Custom devices not available
Acute Complex Aortic Emergencies Traumatic transection Complicated Dissection Symptomatic Aneurysms Ruptured Aneurysms
Chimneys, Periscopes, Snorkels..ChimPS?
Thoracoabdominal: Zenith TAAA Branch This prototype is under development.
Branched Endografts
Surgeon-modified Fenestrated Endograft
Surgeon-modified Fenestrated Endograft
Emergent Presentations
83yo EVAR 85yo revision 87yo Failure Twelve!!!
Continued Dilation, endoleak
6 months Follow-Up
Challenge: Radiation/Operative Length
Planning
Modern Hybrid Operating Room
Advanced Intraoperative Imaging
Intraoperative Fusion Imaging
Methods: Branch vessel access
Intraop 3D CT
Challenge: The Arch/Ascending Aorta
Anatomic Challenges
Challenge: Aortic Arch
Future Technologies
Proximal LZ Management
Transverse Arch Devices
Transverse Arch
Endograft Failures Future Challenges Connective tissue disorders Graft infections Ascending Aorta Aneurym No proximal seal zone (annulus combine with TAVR?) Coronary branches? Type I Dissection Entry tears usually (>80%) within first 4cm Combined coronary disease Combined valvular dysfunction
Thank You