TEVAR. (Thoracic Endovascular Aortic Repair) for Aneurysm and Dissection. Bruce Tjaden MD Vascular Surgery Fellow

Department of Cardiothoracic & Vascular Surgery McGovern Medical School / The University of Texas Health Science Center at Houston TEVAR (Thoracic Endovascular Aortic Repair) for Aneurysm and Dissection Bruce Tjaden MD Vascular Surgery Fellow

Disclosures I have no relevant financial disclosures.

TEVAR Definitions

Definitions TEVAR Thoracic Endovascular Aortic Repair Deploying an impermeable graft on a metal scaffold (stent-graft) inside the thoracic aorta to exclude a diseased segment of the aortic wall from arterial pressure and flow

Definitions Aneurysm Dilation of an arterial segment to >150% of its normal size Dissection Tear in the inner-most layer of the arterial wall (intima) allowing blood flow into a false channel (lumen) blood flow within the arterial wall

TEVAR for Aneurysm

Thoracic Aortic Aneurysms (review) Can be divided anatomically into aneurysms involving the ascending aorta, the transverse arch, or the descending aorta. In general, ascending aneurysms are treated by Cardiac surgeons In general, arch and descending aneurysms may be treated by either Vascular or Cardiac surgeons

Descending Thoracic Aortic Aneurysms Natural History Risk of rupture directly related to size 5cm = 5.5% risk of rupture or dissection within 1 yr 5.5cm = 7.2% risk of rupture or dissection within 1 yr 6cm = 9.3% risk of rupture or dissection within 1 yr..

TEVAR for Descending Thoracic Aortic Aneurysms Open Surgical Outcomes Operative mortality 8.5% Cardiopulmonary complications 44% Permanent paraplegia 5% 5 year survival 68% TEVAR Outcomes Operative mortality 2% Cardiopulmonary complications 16% Permanent paraplegia 1.6% 5 year survival 67%

TEVAR for Descending Thoracic Aortic Aneurysms 1. Who to treat? Size >6.0-6.5cm Rapid growth (>1cm/yr) Symptoms Chest pain Back pain Compression of adjacent structures (airway)

TEVAR for Descending Thoracic Aortic Aneurysms 2. When to treat? Immediately for rupture Urgently for symptoms or rapid enlargement Electively for size criteria

TEVAR for Descending Thoracic Aortic Aneurysms 3. Goals of Repair Exclude the aneurysm Land in normal-sized aorta Minimize risk of spinal ischemia

TEVAR for Descending Thoracic 4. Technique Lumbar drain placed if possible (unless hostile back anatomy or rupture with major hemodynamic instability) Percutaneous approach usually (no incisions) Oversize device 10-20% Aortic Aneurysms If coverage of the LSA is required, it is usually performed only after a pre-emptive LSA revascularization (transposition or bypass)

TEVAR for Descending Thoracic 5. Complications Spinal Cord Ischemia Branch vessel coverage end-organ Ischemia Stroke Endoleaks Aortic Aneurysms Retrograde Type A dissection

TEVAR for Dissection

Thoracic Aortic Dissections

Thoracic Aortic Dissections Acute Dissections < 2 weeks old Subacute Dissections 2-12 weeks old Chronic Dissections >12 weeks old Uncomplicated Dissections No evidence of endorgan ischemia or rupture Complicated Dissections Evidence of endorgan ischemia or rupture pick one descriptor from each box

TEVAR for Type B Dissections Difficult to summarize evidence, significant heterogeneity (acute, subacute, chronic, complicated, uncomplicated) But in summary TEVAR is associated with better perioperative outcomes, similar long term survival, but increased need for reintervention compared to open surgery.

TEVAR for Type B Dissections 1. Who to treat? Medical therapy for uncomplicated dissections TEVAR for complicated dissections TEVAR for uncomplicated dissections with highrisk features Any aortic diameter >44mm False lumen diameter >22mm Age >60 Borderline malperfusion (chronic n/v, ileus, fluctuating pulse exams, refractory pain, refractory HTN)

TEVAR for Type B Dissections 2. When to treat? Immediately for acute complicated with malperfusion or rupture After 2 weeks for acute uncomplicated dissections with high risk features (allows septum to thicken, aorta to stabilize) As needed for chronic dissections that degenerate into aneurysms, rupture, or develop late malperfusion

TEVAR for Type B Dissections 3. Goals of Repair Close proximal entry tear Land in normal aorta proximally Improve true lumen flow / decrease false lumen flow Promote aortic remodeling Address malperfusion fasciotomies, ex-lap, etc.

TEVAR for Type B Dissections 4. Technique Lumbar drain placed if possible (unless hostile back anatomy or concern about severity of malperfusion makes it too timeintensive) Percutaneous approach usually (no incisions) Intravascular ultrasound to determine location of tear and aid in sizing Minimize device oversizing proximally Don t hesitate to cover LSA / down to diaphgram / cover celiac if needed in order to treat the malperfusion in complicated cases If required in acute dissections, coverage of the LSA is usually performed without revascularization during that same operation patients are followed postop to determine the need for LSA bypass / transposition

TEVAR for Type B Dissections 5. Complications Retrograde Type A dissection More likely in acute dissections, large aortas, larger proximal landing zones, bare metal stents proximally, ballooning Stent-graft Induced New Entry (SINE) tears tear at trailing edge of stent-graft leading to more false lumen flow at that location may require extension or fenestration Spinal Cord Ischemia Branch vessel Ischemia Stroke Endoleaks Persistent False Lumen Flow

References Ray HM, Durham CA, Ocazionez D, Charlton- Ouw KM, Estrera AL, Miller CC, et al. Predictors of intervention and mortality in patients with uncomplicated acute type B aortic dissection. J Vasc Surg. 2016;64(6):1560 8. Trimarchi S, Eagle KA, Nienaber CA, Pyeritz RE, Jonker FHW, Suzuki T, et al. Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2010 Sep;122(13):1283 9. Thompson M. The VIRTUE registry of type B thoracic dissections - Study design and early results. Eur J Vasc Endovasc Surg [Internet]. 2011;41(2):159 66. Available from: http://dx.doi.org/10.1016/j.ejvs.2010.08.016 Heijmen R, Fattori R, Thompson M, Dai-Do D, Eggebrecht H, Degrieck I, et al. Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: The VIRTUE Registry. Eur J Vasc Endovasc Surg [Internet]. 2014;48(4):363 71. Available from: http://dx.doi.org/10.1016/j.ejvs.2014.05.007 Canaud L, Ozdemir BA, Patterson BO, Holt PJE, Loftus IM, Thompson MM. Retrograde Aortic Dissection After Thoracic Endovascular Aortic Repair. Ann Surg [Internet]. 2014;260(2):389 95. Available from: http://content.wkhealth.com/linkback/open url?sid=wkptlp:landingpage&an=00000658-201408000-00030 Liu L, Zhang S, Lu Q, Jing Z, Zhang S, Xu B. Impact of Oversizing on the Risk of Retrograde Dissection After TEVAR for Acute and Chronic Type B Dissection. J Endovasc Ther [Internet]. 2016;23(4):620 5. Available from: http://journals.sagepub.com/doi/10.1177/152 6602816647939 Chen Y, Zhang S, Liu L, Lu Q, Zhang T, Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis. J Am Heart Assoc [Internet]. 2017;6(9):e004649. Available from: http://jaha.ahajournals.org/lookup/doi/10.11 61/JAHA.116.004649%0Ahttp://www.ncbi.nlm.nih.gov/pubmed/28939705%0Ahttp://www.p ubmedcentral.nih.gov/articlerender.fcgi?arti d=pmc5634245 Furlough CL, Desai SS, Azizzadeh A, Lawrence PF. Adjunctive technique for the use of ProGlide Vascular closure device to improve hemostasis. J Vasc Surg. 2014;60(6):1693 4. Estrera AL, Sheinbaum R, Miller CC, Azizzadeh A, Walkes J-C, Lee T-Y, et al. Cerebrospinal fluid drainage during thoracic aortic repair: safety and current management. Ann Thorac Surg. 2009 Jul;88(1):9 15; discussion 15. https://www.valleyheartandvascular.com/th oracic-aneurysm-program/hybrid- Procedures.aspx http://www.surgery.usc.edu/cvti/graphics/a orticdissection01.jpg http://www.huntervascular.com/thoracicaortic-aneurysm https://www.inkling.com/read/cronenwett- rutherfords-vascular-surgery-2-volume-set- 8th/chapter-136 http://circ.ahajournals.org/content/132/17/1 620 Davies RR, Goldstein LJ, Coady MA, Tittle SL, Rizzo JA, Kopf GS, Elefteriades JA. Yearly rupture or dissection rates for thoracic aorticaneurysms: simple prediction based on size. Ann Thorac Surg. 2002;73:17 27. Coady MA, Rizzo JA, Hammond GL, Mandapati D, Darr U, Kopf GS, Elefteriades JA. What is the appropriate size criterion for resection ofthoracic aortic aneurysms? J Thorac Cardiovasc Surg. 1997;113:476 491. https://www.inkling.com/read/cronenwett- rutherfords-vascular-surgery-2-volume-set- 8th/chapter-138/ https://www.ncbi.nlm.nih.gov/pubmed/2881 1003 http://www.internationaljournalofcardiology. com/article/s0167-5273(17)34002-0/pdf https://www.sciencedirect.com/science/arti cle/pii/s1726490115000039

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Case #1 A 56 year-old man presented with an acute complicated TBAD with visceral and left lower extremity malperfusion. Medical Therapy? Open Surgery? TEVAR?

Treated with TEVAR. The pre-tevar images demonstrate poor filling of the mesenteric vessels, while the post- TEVAR images show brisk filling throughout the reno-visceral segment as well as through both iliac arteries. Mild preop lactic acidosis resolved. No laparotomy required.

Case #2 A 55 year-old woman initially presented with acute uncomplicated TBAD. She was managed medically, but developed renal malperfusion during the subacute phase, mandating repair. left subvclavian through retrograde vertebral flow, exclusion of the diseased aorta, and brisk distal true lumen filling. She was followed expectantly, and did not require left subclavian revascularization.

TEVAR Case #2 During TEVAR, angiography revealed interval development of a contained rupture (left image). IVUS confirmed the dissection extended into the distal aortic arch.

The operative plan was modified, and an endograft was deployed with intentional left subclavian artery coverage. Completion angiogram revealed adequate filling of the left subvclavian through retrograde vertebral flow, exclusion of the diseased aorta, and brisk distal true lumen filling (right image). She was followed expectantly, and did not require left subclavian revascularization. Case #2

Case #3 67M w/ Symptomatic Descending Thoracic Aortic Aneurysm beginning at the distal edge of the left subclavian artery. Prior EVAR with bilateral internal iliac artery occlusions. Medical therapy? Open surgery? TEVAR with LSA coverage alone? TEVAR with LSA coverage and revasc?

Case #3 TEVAR w/ LCC LSA bypass and plug

Case #4 85F w/ descending thoracic aortic aneurysm -?world record?

Case #4 TEVAR w/ extensive spinal coverage no spinal ischemia LD removed POD#1 d/c d home.

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