Endovascular Management of Thoracic Aortic Pathology Stéphan Haulon, J Sobocinski, B Maurel, T Martin-Gonzalez, R Spear, A Hertault, R Azzaoui Aortic Center, Lille University Hospital, France
Disclosures Research support, Consulting, IP Cook Medical, GE Healthcare
Simple Aneurysms Minimal tortuosity Short + Straight Long fixation zones Good sealing Good access
Iliac Access EIA diameter >7mm Iliac tortuosity/calcification
Which Graft Is Better? There is no ideal graft for the thoracic aorta All grafts are acceptable for simple aneurysms of the mid-descending aorta Aneurysms Dissections Coarctation traumatic rupture There will be no comparison studies
Zenith Alpha Thoracic
Zenith Alpha Thoracic Two-piece modular system Nitinol stents Graft diameters: 18-46 mm 16-20 Fr (ID) introduction system
Chronic Dissections Challenging Procedures Proximal and Distal Sealing Narrow true lumen Target vessels perfused by false lumen Limited experience
Early Complication After TEVAR for Chronic Dissection - 70 year-old man - Acute Type B dissection February 2013 - Medical treatment
CT Scan Follow-Up Rapid Growth 2013 2014
LSA
LSA
Entry tear
TL FL
Surgical approach Left Carotid-LSA bypass Thoracic endovascular aortic repair: Left subclavian artery embolisation Amplatzer Vascular Plug II 16 mm Thoracic device: ZTEG-2P-38-202-PF
Left Carotid-LSA bypass
LSA Catheterization
Thoracic device
ICU Chest pain 24 hours after surgery CT scan Type A dissection
IATROGENIC TYPE A
Retrograde aortic dissection after thoracic endovascular aortic repair. Canaud L 1, Ozdemir BA, Patterson BO, Holt PJ, Loftus IM, Thompson MM. Ann Surg. 2014 Aug;260(2):389-95. OBJECTIVE: To provide data regarding the etiology and timing of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR). METHODS: Details of patients who had RTAD after TEVAR were obtained from the MOTHER Registry supplemented by data from a systematic review of the literature. Univariate analysis and binary logistic regression analysis of patient or technical factors was performed. RESULTS: In MOTHER, RTAD developed in 16 of the 1010 patients (1.6%). Binary logistic regression demonstrated that an indication of TEVAR for aortic dissection (acute P = 0.000212; chronic P = 0.006) and device oversizing (OR 1.14 per 1% increase in oversizing above 9%, P < 0.0001) were significantly more frequent in patients with RTAD. Data from the systematic review was pooled with MOTHER data and demonstrated that RTAD occurred in 1.7% (168/9894). Most of RTAD occurred in the immediate postoperative (58%) period and was associated with a high mortality rate (33.6%). The odds ratio of RTAD for an acute aortic dissection was 10.0 (CI: 4.7-21.9) and 3.4 (CI: 1.3-8.8) for chronic aortic dissection. The incidence of RTAD was not significantly different for endografts with proximal bare stent (2.8%) or nonbare stent (1.9%) (P = 0.1298). CONCLUSIONS: Although RTAD after TEVAR is an uncommon complication, it has a high mortality rate. RTAD is significantly more frequent in patients treated for acute and chronic type B dissection, and when the endograft is significantly oversized. The proximal endograft configuration was not associated with any difference in the incidence of RTAD.
No Compromise on Proximal Seal - Open Surgery
ELEPHANT TRUNK
Post Type A Repair Branched Arch Endograft
Late Complication After TEVAR for Chronic 61-year old woman Dissection Acute type B aortic dissection (2004) Left renal stenting TEVAR+ LSA occlusion (2005) Iatrogenic type A dissection Ascending aorta + aortic valve replacement (Bentall)
Checking position of wire in the true lumen
Late Complication TEVAR for Chronic Dissection
Distal Extension August 2011 Non complicated Type B dissection BMT
2 nd CTA performed 5 days after admission Rapid growth of descending thoracic aorta Dynamic compression of visceral segment with Renal hypoperfusion Thoracic endograft 34x220mm distal LSA
Follow-up Acute Type B dissection with rapid growth: TEVAR Aneurysmal evolution of DTA: 70mm at endograft level 56mm below
Narrow true lumen Perfusion of all visceral vessels by true lumen, right renal artery by both lumen Plan: Access true lumen Endograft distal extension in true lumen
True lumen above CT: Dead-end with no communication with the endograft
Fenestration with12x40mm balloon to create a re-entry tear
Catheterisation of the re-entry tear and the endograft lumen Exchange for a stiff wire Dilation with an 18x40mm balloon
Deployment of 38x202mm TX2
Early FU Renal failure Creatinine: 186 µmoml/l (base: 97 µmoml/l) Oliguria < 500 ml/24h BP control SBP between 150 et 210 mmhg Required 6 anti-hypertensive drugs
Renal artery US Symetric reduced intra-renal flow Resistance index 0.64 CTA
Second procedure Stainless Steel stent Palmaz P4014 (16x40mm balloon)
Follow-up BP SBP between 120 and 140mmHg 3 anti-hypertensive drugs Normal renal function Creatinine 89 µmol/l Renal artery US Normal kidney perfusion Resistance index 0.5
False Lumen Perfusion by Visceral Vessels
Fenestrated Distal Extension?
GE Discovery IGS 730
GE DISCOVERY IGS 730
GE DISCOVERY IGS 730
GE DISCOVERY IGS 730
SMA Perfused by False Lumen
TRUE LUMEN FALSE LUMEN
Left Renal Perfused by (2) False Lumen
CT SMA
True lumen Expansion Post TEVAR Post FEVAR
Expansion of true lumen
Expansion of true lumen Post TEVAR Post FEVAR
Post TEVAR Post FEVAR
Staged Approach 50 yo patient Step 1 (2009): Acute type A dissection with ascending aortic replacement Step 2 (2013): Redo sternotomy Tirone David + Arch repair and elephant trunk
Step 3 TEVAR (2013) Angiography = Confirmation True/False lumen
TEVAR
Step 3: TEVAR from Elephant Trunk and CT
Step 4 Aorto Bi-Iliac Open Repair Goal: Perfusion of - Both Internal Iliac - Distal lumbar arteries
Step 5: Fenestrated Endograft
Small tear in front of the right renal
Tear inflation
3D-CT
Expansion of true lumen Post TEVAR Post FEVAR
Post TEVAR Post FEVAR
Post TEVAR Post FEVAR
Post TEVAR Post FEVAR
Expansion of true lumen
Post operative type 1b-2 endoleak
DATA
Age Aneurysm Connective Previous Previous Visceral In-hospital Early major Reinterventi Technical (years) median diameter disorder aortic endovascular target mortality adverse ons(n, %) success [min-max] (mm) (n, %) repair exclusion artery (n, %) events (n, %) median (n, %) (n, %) strategy (n, %) [min-max] manage ment (n, %) Aortic arch aneurysm n=7 63[37-73] 67[64-76] 1, 14% 7, 100% 1, 14% 0 1, 14% 2, 28.5% 2, 28.5% 5, 71% TADAA n=16 64.5[46-84] 61.5[55-79] 2, 8.7% 14, 87.5% 12, 75% 4, 25% 1, 6% 3, 19% 2, 12.5% 16, 100% Total n=23 64[37-84] 64[55-79] 3, 13% 21, 91% 13, 57% 4, 17% 2, 8.7% 5, 22% 4, 17% 21, 91%
CONCLUSIONS Simple to very complex 3D WS analysis No compromise