Pioneering EVAR techniques in aortic dissection

Pioneering EVAR techniques in aortic dissection Jianing Yue, Weiguo Fu Department of Vascular Surgery Zhongshan Hospital Fudan University Shanghai, China LINC Asia-Pacific 2016 March 8-10, 2016 Hong Kong ZHONGSHAN HOSPITAL FUDAN UNIVERSITY VASCULAR SURGERY DEPARTMENT INSTITUTE OF VASCULAR SURGERY FUDAN UNIVERSITY 1

Disclosure Speaker name:... I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest

Problems in Current TEVAR for Aortic Dissection Proximal sealing/landing Type A / retrograde type A dissection Braches in the landing zones Aortic Remodeling Distal entries Persist/retrograde FL perfusion Chronic thoracic and abdominal dilatation Rigid intimal tear in Chronic case Stentgraft-induced new entries

Extend the proximal landing zone TEVAR in ascending aorta Arch-debranching TEVAR Chimney techniques IN SITU FENESTRATED AORTIC ARCH ENDOGRAFTS CUSTOM-MADE FENESTRATED ENDOGRAFTS

Performed in 2015 TEVAR in ascending aorta

Chimney techniques this technique should be reserved only for the highlyselected cases or emergent setting

Arch debranching De Rango P. J Vasc Surg. 2014 Jan;59(1):107-14. Perioperative mortality/stroke risk Retrograde type A dissection

Branched Arch device Gore Branch TAG device Medtronic Valiant Mona LSA COOK Zenith inner-branch device

Inner Branched Arch Endograft (COOK) 2009-2013 Multicenter Study TAA & ctbad n = 38 Technichal success 84.2% 30-d mortality 13.2% Stroke/TIA 16% Haulon et al. 2014; J Thor Cardiovasc Surg 148:1709--16

Outer Branched Arch Endograft (Medtronic) Multicenter Study n = 9 Technichal success 100% 30-d mortality 0% Minor Stroke 33%

Performed in Zhongshan Hospital in 2013 Outer-branched device (Microport Inc. )

Outer-branched device (Microport Inc. ) 2009-2014 Multicenter Study 51 cases - 7 Type A - 22 Retrograde type A - 22 Type B All in the chronic phase (> 2w) Lu Q. J Thorac Cardiovasc Surg. 2015 Dec;150(6):1631-8

Fenestrated Arch device 2010-2011 N=383 (363 in zone 0) 19 types of precurved stent skeleton and 8 types of fenestration Technical success 95.8% 30d mortality 1.6% Stroke 1.8% Yokoi Y. J Thorac Cardiovasc Surg. 2013 Mar;145(3 Suppl):S103-9.

Tsilimparis et al. 2016; J Vasc Surg: submitted Presented by Tilo Ko lbel et al in LINC2016, Jan 26-29, Leipzig

Retrograde False Lumen Perfusion Presented by Matt Thompson in LINC2015, Jan 27-29, Leipzig, Germany. Mani K. Eur J Vasc Endovasc Surg. 2012 pr;43(4):386-91.

Induce False Lumen Thrombosis Prevent FL perfusion and negative remodeling PETTICOAT technique Access abdominal fenestrations occlude Fenestrated graft / branched graft! False lumen embolization techniques

Proximal descending aortic stentgraft plus distal bare metal stent (PETTICOAT Thechnique) Systematic review n=108 Technical success: 95.3% 30-d mortality: 2.7% Favorable aortic remodeling: a high rate of both false lumen regression and true lumen expansion Complete FLT at the thoracic level in 70.4% and at the abdominal level in 13.5% of patients Nienaber et al. J Endovasc Ther. 2006 Dec;13(6):738-46. Canaud L. Ann Cardiothorac Surg. 2014 May;3(3):223-33.

Distal Entry Occluder Performed in Zhongshan Hospital since 2009

The Candy-Plug Technique N=6 Technical success 100% FL thrombosis in all pts Ko lbel et al. 2013; J Endovasc Ther 20: 484-9

The Knickerbocker Technique Ko lbel et al. 2014; J Endovasc Ther 21: 117-22 N=8 Technical success 100% FL thrombosis in all pts

Other embolization options Plugs Glue Coils Idrees et al. J Vasc Surg 2014; 60:1507-1513

Stentgraft-induced new entries Reported incidence: 1.3-27% (3.4% in Zhongshan Hospital) Mortality may as high as 28.6% The mismatch between stentgraft size and distal TL diameter Inherent tendency to spring back to its initial straight status Tapered stentgraft More comfortable stentgraft Restrictive bare stent in the distal TL Dong Z, Fu W. J Vasc Surg. 2010 Dec;52(6):1450-7.

Ankura II endograft (Lifetech, Inc) Tapered 4mm, 6mm, 8mm Comfortable TAG (GORE) More compliant design

Restrictive bare stent in the distal TL Compared with the standard TEVAR, TEVAR + RBS was associated with a lower incidence of SINE (0% vs 2.9%; P =.033) and less secondary intervention (3.9% vs 9.3%; P =.040). Feng J. J Vasc Surg. 2013 Feb;57(2 Suppl):44S-52S.

With Courtesy: Prof. Wei Guo Performed by Prof. Guo in PLAGH in 2014 First reported in CEC2014, Beijing, Nov 27-30 2014 Octopus Technique

Take Home Messages Tubular stentgraft is sufficient in majority cases of TBAD Fenestrated and branched grafts may be feasible to extend the landing zone FL embolization techniques may have a role to optimize aortic remodeling Stentgraft-induced new entry should be taken into account during both device design and deployment technique, such as restrictive bare stent All these pioneering techniques are under investigation and need a significant learning curve

Pioneering EVAR techniques in aortic dissection Jianing Yue, Weiguo Fu Department of Vascular Surgery Zhongshan Hospital Fudan University Shanghai, China LINC Asia-Pacific 2016 March 8-10, 2016 Hong Kong ZHONGSHAN HOSPITAL FUDAN UNIVERSITY VASCULAR SURGERY DEPARTMENT INSTITUTE OF VASCULAR SURGERY FUDAN UNIVERSITY 27

Pioneering EVAR techniques in aortic dissection Jianing Yue, Weiguo Fu Department of Vascular Surgery Zhongshan Hospital Fudan University Shanghai, China LINC Asia-Pacific 2016 March 8-10, 2016 Hong Kong ZHONGSHAN HOSPITAL FUDAN UNIVERSITY VASCULAR SURGERY DEPARTMENT INSTITUTE OF VASCULAR SURGERY FUDAN UNIVERSITY 28