Surgical Considerations of TEVAR

Surgical Considerations of TEVAR University of Alberta, June 14 th, 2013 Jehangir Appoo Libin Cardiovascular Institute University of Calgary,

Today: Lesions/Pathology amenable to TEVAR On label Off label Future Directions Controversies in TEVAR Open vs. Endo Management of LSCVa.

On label indications: descending thoracic aortic aneurysm acute, complicated type B dissection traumatic aortic disruption

In Theory:

In Reality:

DTA: decreased mortality 2% vs. 11% decreased cord ischemia 3% vs. 14% similar CVA risk decreased ICU, hospital LOS increased vascular cxs increased re-interventions

Indications for DTA surgery:? Elefteriades et al., Yale database Indications changing? Evolving? Rightly or wrongly?

On label Indications 1. DTA 2. Blunt Traumatic Aortic Injury Fabian et al. J Trauma 2007 274 pts open repair, 50 Trauma centres Mortality 31% Paraplegia 8.7%

18 y.o female in motorcycle accident

On label Indications 1. DTA 2. Blunt Traumatic Aortic Injury 3. Acute, complicated type B dissection 44y.o female: chest pain, hypotension, Hgb 65

Hospital survival with acute type B Dissection is poor even worse if open surgery is required In Hospital Mortality: Medical Rx-10% TEVAR -10% Open surgery-34% Fattori R et al. J Am Coll Cardiol Intv 2008;1:395-402

On label indications: descending thoracic aortic aneurysm acute, complicated type B dissection traumatic aortic disruption Other indications aortic coarctation IMH PAU arch aneurysms ascending aortic aneurysms/pseudoaneurysms aortomegaly type A dissections mycotic aneurysms

2007 2013

Off Label Indications often involve encroachment of arch and into ascending aorta

Distal Arch Aneurysms

Isolated Ascending Aortic Pseudoaneurysm

Why Zone 0 TEVAR? Complex Patients Diffuse aortic disease Generally need 2 stage procedures with total arch replacement and elephant trunk Often redo setting

Etz, Grieppe et al. Eur J. CT Surg 2008 Surgeon Year ET1 Mortality ET2 Mortality Interval Mortality Rx Mortality Svensson 2004 2% 8.5% 14% 18% Safi 2007 6.3% 9.6% 10% 13.3% Lemaire/Coselli 2006 12% 4% 25% 36% Kouchoukos 2007 7.2% -- -- 7.2% Grieppe 2008 6% 7% 12% 24.5% Even in centres of experience, operative mortality with 2 stage elephant trunk technique is high

Surgical Principles of our Type II Hybrid Arch Technique On CPB Axillary Cannulation 28-30 degrees Celcius Cross Clamp

Brachiocephalic Trunk Branch Left Common Carotid and Left Subclavian Branches Endovascular System Delivery Branch 28 mm Tube Graft

Hybrid Arch sternotomy ascending aortic replacement arch debranchment & TEVAR Rx combination ascending, arch, and desc pathology Bavaria et al. J Thorac Cardiovasc Surg 2013; 145:S85-90

2010 11 yrs post TypeA 2012 2 yrs post Hybrid Arch

Calgary Zone 0 Follow up at up to 47 months 8176 days of cumulative radiological follow up Early endoleak 1/15 Graft buckling 1/15 Late endoleak 0/15 Graft migration 0/15 Graft fracture 0/15 Retrograde Type A Dissection 0/15 CCC 2012

Acute Type A Aortic Dissection Primary Intimal Tear in Mid or Distal Arch Arch Aneurysm Visceral/Renal/Extremity Malperfusion Radiologic risk factors for future aneurysm formation

Positive Lessons from Hybrid Arch Experience stent graft can navigate angulation of arch stent graft appears stable in high force area of ascending aorta diffuse aortic pathology can be treated in one stage without prolonged circulatory arrest strategies endovascular technology can be applied to chronic type B dissections...remains a highly invasive operation involving sternotomy, multiple anastomosis, bleeding...

Future likely involves closed chest total arch repair Branched arch grafts Fenestrated grafts Insitu graft fenestration Chimney grafts Flow modulating grafts

Closed Chest Total Arch: 1. Cook Branched Arch Fenestrations for arch vessel stents L carotid subclavian bypass 40 cases world wide Custom made Need landing zone in asc aorta

2013 64 y.o male Type A repair 2009 Complicated course Aorta growing at rate of 1cm/year Arch dissected Large residual primary intimal tear in arch True lumen effaced

Closed Chest Total Arch 2. Modular branch graft Off the shelf device First in man: 2013/2014

Closed Chest Arch 3. Chimney Technique Off the shelf conventional devices Concern with gutter endoleaks & branch compression Main indication: emergencies when customized devices unavailable but being used electively in parts of world

Closed Chest Total Arch 4. Najuta graft Precurved fenestrated arch graft in various configurations off the shelf Used in over 300 aneurysm cases in Japan Concern re: risk of stroke

Closed chest total arch 5. Flow Modulating devices Paradigm change: Not about aneurysm exclusion Scaffold to allow thrombus deposition, flow pattern modulation while maintaing side branch patency Laminar vs. turbulent flow

Closed Chest Total Arch Flow Modulating devices Global registry 243 pts treated thoracoabdominal, arch acute type B 1 yr f/u of first 55 pts: no aneurysm rupture All 202 side branches patent J Endovasc Ther 2013;20:366-377 * aneurysm rupture reported by others

Controversies Lots Open surgery vs. TEVAR risk stratification vs. quality of life Mgmt of Left Subclavian artery CT disorders Use in dissections, chronic dissections does it work? Significance of endoleaks Indications/Benefit indolent but catastrophic disease Palliative therapy mycotic aneurysm Cancer sx Branch vs. fenestrated.vs. flow modulating Use of CSF drain

TEVAR vs. Open Surgery Advantages less Invasive cosmetic quicker recovery decrease periop mort decreased SCI single stage faster for emerg cases

TEVAR vs. Open Surgery Disadvantages? durability so far good endoleaks re-intervention follow up similar concerns with PCI 25 yrs ago??

TEVAR vs. Open Surgery Costs device costs are high may come down surgical grafts not without cost ICU/hospital costs are less survival is increased. Increases costs to system cost of follow up imaging re-intervention costs

TEVAR in young patient has different considerations 37 y.o female Size of normal aorta growth of aorta over time/decades Pros/Cons of Open Surgery Follow Up Future options

26mm x 10cm ctag & 26-21 x10cm ctag

Discharged home 3 days post op Back at work on 7th post op day No chest scar 1 year f/u aneurysm sac shrinking in size

Management of left subclavian artery Can be sacrificed in an emergency in most cases Elective revasc may decrease stroke balance vs. risk of procedure likely decreases SCI complete thoracic coverage compromised internal iliacs

Management of left subclavian artery Mandatory revascularization dominant left vertebral artery patent LITA graft Strongly suggested revascularization dialysis fistula dominant left arm

Management of left subclavian artery Mandatory revascularization dominant left vertebral artery patent LITA graft Strongly suggested revascularization dialysis fistula dominant left arm

Management of left subclavian artery Carotid perfusion for branched/fenestrated grafts Ax-Ax-L carotid bypass sometimes simpler than having 3 separate branches

59 y.o male 6.5cm aortic root 4+ AI 8cm LVEDD with Severe LV Dysfunction NYHA Class IV CHF 6cm Descending Thoracic Aortic Aneurysm

59 y.o male 6cm Descending Thoracic Aortic Aneurysm Neck at Left Carotid allows Zone 2 Landing Issues with carotid-subclavian at same time as proximal root operation in ill patient with 4+ aortic insufficiency

Staged approached: Axillary Mechanical Composite Root & Aorto-Left bypass with L Axillary inflow TEVAR post op with ctag

?

Pigtail catheter in true lumen Obliteration of false lumen in arch & prox descending aorta

What happens to the stent graft in the angulated arch over time?

What happens to the stent graft in the angulated arch over time? At 4 years: Current genereation of grafts appear stable in ascending aorta Accommodates sharp curves & forces of ascending aorta and arch

The Evolution of Endovascular

The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney/Snorkel technique Sandwich technique

The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney/Snorkel technique Sandwich technqiue

The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney/Snorkel technique Sandwich technique

The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney/Snorkel technique Sandwich technique

The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney/Snorkel technique Sandwich technique

The Evolution of Endovascular Stentgrafts Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease Fenestrated Custom / pre-fabricated In-situ Branched grafts Chimney technique Sandwich technique

The Evolution of Endovascular While these novel hybrid endovascular approaches do show promise, there are significant limitations High cost and lag time (custom fabricated devices) Branch thrombosis 1 Need for high volume centers of excellence 2 Similar spinal cord and visceral (renal failure) complication rates compared with surgical techniques 2 1. Fenestrated Endovascular Grafting : The French Multicenter Experience. Eur J Endovasc Surg 2010;39:537-44 2. Branched Endografts for Thoracoabdominal Aneurysms. J Thorac Cardiovasc Surg 2010;140:S171-8

The Evolution of Endovascular

Minimally invasive

In Theory:

In Reality:

Understanding of Zone 0 physiology & biomechanics will lead to improvements in technology will tackle problems of: conformability access landing zone issue branch issues This will allow more patients to have safe, high quality treatment

Multilayer Flow Modulating Stents Global Independent MFM Registry 1 172 implanted world-wide Report on 1 st 26 cases from 7 countries Crawford TAAA (11 type II, 9 type III, 6 type IV) 16/26 redo (prior TEVAR) 3/26 redo (prior juxtarenal EVAR) 2/26 rupture 5/26 elective 1. J Vasc Endovasc Surg 2012;19:1-14

Multilayer Flow Modulating Stents Global Independent MFM Registry No aneurysm related death (6mo) Visceral branch patency Reintervention 2/26 due to stent foreshortening Maximal sac diameter and volume 0-3mo 10%/6% increase, stabilized 3-6mo, reduction >6mo 1. J Vasc Endovasc Surg 2012;19:1-14

Multilayer Flow Modulating Stents Global Independent MFM Registry FEA Improved laminar flow Transfer of shear stress from aortic wall to stent 55% reduction in aneurysm wall stress 1. J Vasc Endovasc Surg 2012;19:1-14