EVAR and TEVAR: Extending Their Use for Rupture and Traumatic Injury Bruce H. Gray, DO MSVM FSCAI Professor of Surgery/Vascular Medicine USC SOM-Greenville Greenville, South Carolina none Conflict of Interest Hypotensive shock 1
Aortic Dissection Arteriogram TEVAR 2
Embolization Outcomes in 1,150 Type B Dissections In-Hospital Outcomes Overall Medical TEVAR p Value In-hospital mortality 104 (9.2) 74 (8.7) 30 (10.9) 0.273 Complications CVA 15 (1.4) 9 (1.1) 6 (2.3) 0.217 Coma 5 (0.5) 4 (0.6) 1 (0.4) 1.000 Spinal cord ischemia 10 (1.0) 7 (1.0) 3 (1.3) 0.712 Acute renal failure 164 (15.6) 99 (12.5) 65 (25.3) <0.001 Extension of dissection 72 (6.9) 46 (5.8) 26 (10.2) 0.016 Died while awaiting surgery 3 (1.7) 3 (2.8) 0 (0.0) 0.275 Frattori R, etal. JACC:CVI 2013;6:876 Ascending Aortic PSA 3
RA Occlusion Balloon & TEE Completion 2.5 year CTA 4
Aortic Injury Aortic Injury more challenging in younger patients since: Smaller radius of aortic curvature & aortic diameter Smaller iliac or femoral access vessel diameter Aortic disruption typically located immediately distal to the left subclavian artery, in contrast to patients with thoracic aneurysms, which can occur in any segment of the thoracic aorta Blunt Aortic Injury Scale Degree of Transection Grade I aortic injury Grade II aortic injury Grade III aortic injury Grade IV aortic injury Description Aortic intimal tear or flap Aortic intramural hematoma without change in external contour of aorta Contained aortic pseudoaneurysm with concurrent increase in external contour of the aorta but without extravasation of intravenous contrast Full-thickness aortic injury resulting in rupture with extravasation of intravenous contrast on imaging Aortic Transection Subclavian artery takeoff & aortic tear just distal Grade III injury 5
Blunt Aortic Injury: General Outcomes 75% die before reaching the hospital 50% of those who arrive alive, die early Concomitant injuries predict M/M: 29% have major abdominal injury 31% have major head trauma Most have multiple fractures including those of sternum, ribs, spine that impacts open surgery 6
TEVAR vs. Open 84 y/o in ER with abdominal pain Emergent EVAR Local Anesthesia of both CFA s 7
Persistent Type I Leak Prompt Aortic Control Permissive hypotension until CFA sheath insertion under local anesthesia 12 Fr, 45 cm long sheath reaches to descending thoracic aorta for balloon support Expand compliant Coda balloon Resuscitate Place main EVAR body to renal arteries then move balloon down below into graft Instruct team: Avoid GA to begin with No urinary catheter Limited scrubbing Infiltrate both groins with local anesthesia Prepare aortic occlusion balloon (AOB) Step-by-Step EVAR Patient stable Don t inflate AOB but, keep ready Deploy stent graft Patient in shock 12-16 Fr sheath in aorta Inflate balloon above T12 Support sheath Deploy main SG Use 2 nd balloon inside SG and withdraw AOB Deploy contra limb Can perform test with AOB in patient with shock, No recovery then abort procedure 8
Ruptured AAA Fifty percent never make it to the hospital. Of those who arrive at a health care facility, fifty percent do not survive Starnes, et. al, 2010 (2002-2009) N = 187 patients Implementation of raaa protocol Total N N died in 30 days 30 day mortality Pre-Protocol (2002-2007) 128 74 57.8% Post-Protocol Combined (2007-2009) 51 18 35.3% Post Protocol EVAR 27 5 18.5% Post-Protocol OSR 24 13 54.2% IMPROVE Trial-Ruptured AAA 613 English patients randomized to EVAR or open strategy after CT scan in >90% Endo group (n=316) EVAR: 154 pts (54%) Open: 112 pts (40%) Death before repair: (6%) Open group (n=297) EVAR: 36 pts (13%) Open: 219 pts (80%) Death before repair: (7%) 30 day Mortality Rate Subgroup EVAR Open Odds Ratio All Ruptures Ruptures repaired 100/275 36% 84/259 32% 106/261 41% 87/242 36% Br Med J 2014:348;f6771 0.84 0.86 Subgroup Observations Lowest BP prior to OR 30 day mortality < 70 mmhg 51% 70-83 mmhg 38% 84-98 mmhg 46% 99-119 mmhg 29% >120 mmhg 25% Anesthetic type 30 day mortality General 34% Local then general 31% Local only 13% Local only advantageous BP < 100 mmhg Carries highest risk Br J Surg 2014;101:216-224 9
Other issues from IMPROVE Mortality similar in EVAR and Open groups Women may benefit more with EVAR 94% of EVAR pts discharged to home 77% of Open pts discharged to home Reinterventions similar in both groups Shorter LOS with EVAR did not overcome excess cost of graft Br J Surg 2014;101:216-224 Fenestrated Stent Grafts Introduced in 1996 Allow to seal graft through branched segments of aortic arch and infrarenal aorta Limited availability Requirements Careful planning Individualized graft Experienced endovascular team Used in high risk patients Complication: loss of side branches Fenstrations 10
3D Printing Juxtarenal AAA Fenestrated Placement 11
Follow-up CT Embolization of side branches Chimneys Periscopes Snorkels Open repair Ancillary Techniques Cardiac Risk Assessment Bertges DJ, etal., J Vasc Surg 2010;52:674 12
Conclusions TEVAR and EVAR are emerging technologies for acute aortic emergencies, be prepared Organization & experience of the team is key Surgeon, interventionalist, anesthesiologist, nursing and support personel Preoperative imaging is not always possible, but good OR imaging is a must Great post-operative care and surveillance can provide excellent long-term results Storm clouds coming into Pensacola 13