Redo treatment and open conversion after TEVAR

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Redo treatment and open conversion after TEVAR Roberto Chiesa Vascular Surgery, Vita-Salute University Scientific Institute San Raffaele Milan, Italy

Number of procedures Off-Label indications for TEVAR Approved indications Off-label indications Time following approval Russell et al. J Interven Cardiol 2006

The domino effect Experience with endovascular devices has evolved Application expanded to more complicated cases Reports of complication has increased Increased secondary endo procedure and open conversion

TEVAR: Long-term results Real world results Authors Year N TEVAR Open Conversions % Geisbüsch P. 2011 264 11 4.1 % Dumfarth J. 2011 421 21 5.0 % Miyahara S. 2013 147 16 10.8 % Canaud L. 2013 236 14 5.9 % Scali S.T. 2014 585 46 7.9 % Roselli E. 2014 _ 50 _ Nozdrzykowski M. 2015 371 25 6.7 %

Thoracic aortic experience 1993-2015 Arch DTA TAAA OPEN (1993 2015) 1227 pts 75 381 771 TEVAR (1999 2015) 567 pts 208 304 55 Total: 1794 283 685 826

OSR experience 1999-2015 Thoracic reinterventions 156 Our series = 76 (49%) Other Institutions = 80 (51%)

Indications to reintervention Endoleak 86 Stent-graft migration 35 Stent-graft failure 17 Infection / fistulization 12 Retrograde dissection 6

Redo treatment strategies Endo-Procedures N = 85 (54%) Open conversion N = 59 (38%) Hybrid approach N = 12 (8%)

Case #1 Endoleak, 68 years 68 mm 1998: AAA open repair 2009: TEVAR for DTA (Medtronic Talent) 2011: Sudden back pain Endoleak (1b) CT: endoleak, sac growth

Case #1 Open conversion Thoracoabdominal aorta exposure

Case #1 Visceral perfusion Previous AAA graft Previous DTA stent-graft

Case #1 Visceral perfusion 6-cm long (no anatomic feasibility for branched-evar

Case #1 Reconstruction

Case #2 TEVAR failure, 65 years Multiple aortic interventions (other Institutions) - AAA open repair - Zone 0 arch debranch. + TEVAR - Re-TEVAR for endoleak - 3 multi-layer stents in DTA - Re-TEVAR for endoleak - Distal platinum bare-stent Endofit Talent Zenith Cardiatis Cardiatis Cardiatis CP-stent

Case #2 Complete aneurysm perfusion Type III endoleak (from Cardiatis ML stents) 95 mm

Case #2 Open conversion Arch aneurysm TAAA

Case #2 Hypothermic CC arrest Proximal graft-to-stentgraft anastomosis

Case #2 Stent-grafts explantation Mural thrombosis of ML stents only in overlapping regions Reperfusion branch

Case #2 Reconstruction Distal anastomosis Visceral perfusion

Case #3 Fenestrated-EVAR failure, 70 years Previous F-EVAR for type IV TAAA Progressive sac enlargement 67 mm Cook fenestrated graft

Case #3 F-EVAR failure Endoleak (Type III) SMA stent fracture

Case #3 Open conversion

Case #3 Removal of fenestrated-sg SMA stent (left in situ)

Case #3 Final reconstruction Gore Hybrid (LRA)

Case #4 Stent-graft infection / AEF, 67 years TEVAR for saccular TAA 14 months later: hematemesis Close contact with the esophagus Tracer captation at PET/CT 2 Medtronic Valiant

Case #4 Open conversion Left thoracotomy - Intercostal muscle flap preparation

Case #4 Open conversion Endograft removal

Case #4 Reconstruction Evidence of AEF In situ repair with silver-coated graft

Case #4 Reconstruction Esophageal repair Intercostal muscle interposition

Results Open conversion N pts (%) Total 59 Mortality (30-days) 10 (17%) Major morbidity Respiratory failure 15 (25%) Renal failure 8 (14%) Paraplegia 2 (3%)

Mortality x Etiology 59 open conversions Indication to conversion 30-days Mortality Endoleak (25) 1 (4%) Endograft migration + failure (16) 2 (12%) Retrograde dissection (6) 2 (33%) Infection/fistulization (12) 5 (42%)

Who performs open conversions? US Medicare database (763 hospitals, 3554 open repairs and 3517 TEVARs) 2004 2007 Hospitals performing TEVAR 24% 76% Hospitals performing OPEN repair 95% 57% Patel et al, J Vasc Surg 2013

In-hospital Mortality (%) In-hospital Mortality (%) Who performs open conversions? Mortality of OPEN repair depends from the hospital volume / experience Annual hospital volume Annual surgeon volume Patel et al, J Vasc Surg 2013

Importance of teaching open surgery 1958: OR during a De Bakey s operation

to avoid this scenario in the future! I m the only who performs OPEN surgery Surgeo-matic V2.5

Conclusions Close follow-up after TEVAR Open conversion Technical challenge Acceptable results in High Volume Centers Increased mortality in case of retrograde dissection and infection

Redo treatment and open conversion after TEVAR Roberto Chiesa Vascular Surgery, Vita-Salute University Scientific Institute San Raffaele Milan, Italy

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