Ascending Aorta: Is The Endovascular Approach Realistic? Tilo Kölbel, MD, PhD University Heart Center Hamburg University Hospital Eppendorf
Disclosures Research-grants, travelling, proctoring speaking-fees, IP with Cook. Research-grant, travelling, speaking-fees with Cordis Research-grant, proctoring with Atrium
Gold Standard for Ascending Aorta Open Surgery: Sternotomy, CPB Ascending replacement With/without aortic valve Hemiarch/elephant trunk Krüger et al. 2012;Brit J Surg 99:1331-44
Gold Standard for Ascending Aorta But... Octogenerians Patients with Old age Severe comorbidities Previous cardiac surgery... Piccardo et al. 2009, Ann Thor Surg 88:491-7 Previous cardiac surgery p = 0.07 Estrera et al. 2010, Ann Thorac Surg 89:1467 74
Gold Standard for But... Ascending Aorta Patients with Old age Severe comorbidities Previous cardiac surgery... are often turned down for open surgery and might benefit from a less invasive therapy. Bonser et al. 2011, JACC 58: 2455-73
Gold Standard for But... Ascending Aorta Rylsky et al. 2014,Ann Thor Surg 97: 1582-9
Endovascular Treatment of the Ascending Aorta Is there room for Endovascular techniques in ascending pathology?
Endovascular Treatment of the Ascending Aorta Pathologies to be treated: Lesions post surgery: Pseudoaneurysm Postsurgery bleeding Residual Dissection Lost TAVI Ascending aneurysm Type A dissection
Pseudoaneurysm
Postsurgery Bleeding
Residual Dissection
Transapical Through & Through
Ascending Aneurysm Most are conical and lack proximal landing zone. Endovascular exclusion usually not possible in native vessel Kolvenbach et al. 2011; J Vasc Surg 53: 1431-8
Ascending Aneurysm
Ascending Aorta and Arch:
Endovascular Repair of Type A Aortic Dissection So, is there room for Endovascular techniques in acute Type A Aortic dissection?
Acute Type A Dissection Sobocinski et al 2011, EJVES 42: 442-7
Anatomical Suitability Entry-tear distal to sino-tubular junction Proximal and distal landing zone 20mm True lumen diameter 38mm Total lumen diameter 46mm Appropriate access vessels No significant Aortic regurge Sobocinski et al 2011, EJVES 42: 442-7
Patients denied surgical therapy for Type A Dissection 28% of patients with acute type A aortic dissections are considered unfit for open surgery and receive only medical management The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897 903.
But.things happen Coverage of coronary arteries Perforation of ventricle with tip of graft Ventricular pseudoaneurysm Misplacement distally, covering of supraaortic branches Delivery system retention Conversion to open surgery
Literature Review Endo-Repair of Type A N 13 Acute Type A Ronchey et al. 2013, Eur J Vasc Endovasc Surg 45: 475-80
Chronic Type A Dissection Dorros et al. 2000, JEVT 7: 506-12
Chronic Type A Dissection Subacute / chronic n = 6 Technical success 5/6 Mortality 1/6 Nienaber et al. 2011; J Vasc Endovasc Surg (It) 18: 187-91
Acute Type A Dissection Metcalfe et al. 2012, J Vasc Surg 55: 220-2
Zenith Ascend ZTLP-A Type A Dissection Low Profile (16-20F) Proximal and distal Barestents Length: 65mm/83mm Controlled Deployment: ProForm 100cm Sheath length 28mm 46mm Diameter
Fig. 1 Fig. 2 Fig. 3 Fig. 4 Endograft Choice Cook Zenith Ascend
Endograft Choice Length: measure at outer curve 6-10cm Diameter: measure on Centerline Tapered grafts Reverse tapering On-table customization
Endograft Choice 77-81mm Cook Zenith TBE ProForm
Pulsatility
Limitations of Femoral Access Distance to ascending and arch Tortuosity and kinking Left ventricular wire-position Difficult true lumen access Apposition
Transapical TEVAR Casereports Well established Access Hybrid OR Cardiac Surgeon/Endovascular specialist Preoperative imaging/workstation Kölbel et al 2012, Vascular 19: 308-12
Acute Type A Dissection Transapical TEVAR Kölbel et al. 2013; Ann Thor Surg 95:694-6
Acute Type A Dissection Transapical TEVAR Kölbel et al. 2013; Ann Thor Surg 95:694-6
Transapical TEVAR
Acute Type A Dissection Transapical TEVAR 12h postop. Kölbel et al. 2013; Ann Thor Surg 95:694-6
Acute Type A Dissection Transapical TEVAR 24m postop.
Ascendens Stentgraft
Reimplanted and Bypassed Coronary Arteries!
Hamburg Experience Ascend device n=10 Ishimaru N=7 N=1 N=2 Study period : 4 years, dringlich=2 7, mean age 74y, (53-90y) received a Zenith Ascend device All patients were ASA III-IV (n=10) and poor candidates for open surgery. Indication for treatment n % Type A Dissection 3 30% Residual dissection of ascending and arch Fixation of a dislocated Aortic Valve Type 1 Endoleaks post TEVAR Ascending Pseudoaneurysm 3 30% 1 10% 2 20% 1 10%
Operative Characteristics Simultanous Procedures One fenestrated Arch Device (f-tevar) (Fig A) One Arch Branch Device (b-tevar) (Fig B) One Ascend Graft with fenestration for the Innominate artery (Fig C) A B C
Results - Outcome All endografts were deployed properly at the intended level Technical success: 100% Clinical success: 90% In-hospital survival: 90% One death due to progression of type A dissection following TAVR in a patient with aneurismatic ascending aorta Mean Follow-up: 20 months (4-40months) One late death unrelated to endograft repair One re-intervention due to endoleak
Acute Type A Dissection Branched Arch Endograft
In-hospital death case Post TAVR dissection of the ascending aorta Non operable Emergent bail-out procedure with ascend graft as ultima ratio Stent graft obviously undersized in aneurysmatic ascending aorta
Is the Endovascular Approach Realistic? Yes, in selected cases. Remaining problems: Pulsatility, movement of aortic arch Impact of endografts on AV unknown Proximal seal Patient selection Best access Referral and interdisciplinarity Most beneficial after previous surgery: Higher risk in Redo-surgery Safe proximal landing.
Percutaneous Transapical Access Jelnin et al. 2011, JACC Cardiovasc Interv 8: 868-74
Percutaneous Transapical TEVAR
(min) Percutaneous Transapical TEVAR 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 PAP / MAP - ratio T0 T1 transseptal T2 transapikal T3 T4 120 100 80 60 40 20 0 Operating time TSA TAA TFA TSA TAA TFA 3,5 LAP / CVP - ratio 120 Deployment time 3 100 2,5 2 1,5 1 80 60 40 20 TSA TAA TFA 0,5 0 T0 T1 T2 T3 T4 transseptal transapikal 0 TSA TAA TFA Wipper et al. 2013, submitted
Percutaneous Transapical Arch-Repair 8 pigs Complete percutaneous antegrade transapical single branch arch graft Hemodynamics, perfusion, operating-time, fluoro-time Wipper et al. 2014, submitted
Percutaneous Transapical Arch-Repair Successful in 6/8 1 Graft-rotation causing IA-coverage 1 cardiac arrest at wire insertion Operating time 233 ± 12min Fluoro time 28.2 ± 6.2min No significant impact on hemodynamics Wipper et al. 2013, manuscript
Summary Endovascular Treatment of ascending aorta potentially beneficial in selected patients. Postsurgery lesions and Type A dissection work. Ascending aneurysms in native vessel do not. Transfemoral delivery challenging, transapical access route potentially easier. Currently available stent-grafts do not meet requirements. Role of endovascular treatment in the ascending aorta yet to be defined.