Thoracic Endo-Vascular Aortic Repair Peter L. Birnbaum MD, MSc, FRCSC Cardiothoracic Surgeons St. Agnes Medical Providers

No Disclosures

Man beats odds, emergency stent plugs burst aorta When Robert Oberg got the news more than a decade ago that he

Open Surgical Repair • Left thoracotomy – – – –

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Clamp and sew technique Left heart bypass Reimplantation of intercostal vessels Interposition tube graft for descending thoracic aorta Hypothermic circulatory arrest for arch aneurysms Prolonged recovery

Complications of Open Repair Mortality Paraplegia Bleeding complications Neurologic complications • Intraabdominal complications

• • • •

Endovascular Approach

Objectives • Review aortic pathology and clinical

presentation • Diagnosis of aortic disease • Surgical Management • Thoracic Aortic Endovascular Repair: indications, device deployment, results

Thoracic Aortic Aneurysm • Incidence 6 in 100000

• most commonly in 6th & 7th decades • Males • Hypertension • Atherosclerosis • Risk of rupture 70% (size, age, smoking, COPD, HT, growth rate, renal failure) • Risk of death 95%

Aortic Pathology Acute Aortic Syndromes • Classic aortic dissection (classic intimal tear) • Intramural hematoma (cystic medial necrosis) • Penetrating aortic ulcer (ulceration of

atheromatous plaque that disrupts the internal elastic lamina and burrows deeply into the media)

Aortic Pathology • Aortic tear from blunt thoracic trauma • Aortic pseudo aneurysm • Distal to the Left subclavian takeoff • Mechanism: acceleration/deceleration at the ligamentum arteriosus compression from first rib

Classification of Acute Aortic Syndromes • Acute vs chronic • Stanford type A: • Stanford type B: aorta

( 5mm/yr Atherosclerotic ulcer > 10mm depth, > 20mm diameter

Patient Selection for Thoracic Stent Grafting • Adequate proximal and distal landing zones

• Minimal mural thrombus • Adequate aortic diameters compatible with device selection • Aneurysm localized to descending thoracic aorta • Adequate seal zone (2 cm)

• Adequate quality vascular access vessels to accommodate large-bore sheaths

Anatomical Inclusion Criteria

Anatomical Exclusion Criteria • Aneurysm/ulcer or angulation in the distal thoracic aorta that would preclude advancement of the introduction system • Inability to preserve the left common carotid artery and celiac artery

65 degrees

Unique Stent Graft Design 

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Graft allows unique Independent, stainless steel z-stent configuration provides adaptability to individual anatomy. Varied z-stent lengths and gage diameters promote secure graft/vessel apposition, columnar strength and graft flexibility.

Woven Polyester 

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A lightweight, strong, shrink/stretch resistant woven polyester used in both plastics and fibers. Historically used for open surgical TAA and AAA repairs.

Imaging Recommendations CTA • Great vessels through the femoral heads • Axial slices to assess diameters, calcium and thrombus Angiography May be done to assess lengths, angles and tortuosity 3D CTA Reconstructions CTA reconstructions using MMS, TeraRecon or 3-D imaging to accurately assess proximal and distal necks

Adequate Access Access vessel inner diameter …

… must accommodate introducer OD.

Neck Shape

TEVAR   

Heparin 100-150 units/kg ACT > 250 sec Spinal drainage

Thoracic Stent Graft Deployment • Device inserted over a

guidewire inside the aorta (femoral access) under fluoroscopic guidance. • Partial anti-coagulation with heparin to avoid embolization. • Identify the proximal landing zone using an angiogram. • 10-20% oversizing.

Thoracic Stent Graft Deployment • Deploy proximal

aspect of device at desired location. • BP decreased temporarily during deployment (SBP 80-100). • Multiple angiograms can be performed to confirm placement prior to full device deployment.

Thoracic Stent Graft Deployment • Completion

angiogram after deployment and/or ballooning. • Address incomplete seal (endoleak) as indicated. • Remove delivery system and repair access artery.

Endoleaks • Continued pressurization of • • • •

aneurysm sac Not an emergency Several different types Many endoleaks will resolve spontaneously Rarely involve re-intervention

30-day Morbidity – Neurological Events Event

TEVAR

OPEN

Stroke

2.5% (4/160)

8.6% (6/70)

Paraplegia

1.3% (2/160)

5.7% (4/70)

Paraparesis (weakness but able to walk)

3.8% (6/160)a

0% (0/70)

aOf

these six patients, five had complete resolution.

Conclusions: 1 year Data  

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Evaluation in a controlled trial: Overall and aneurysm-related survival are similar with TEVAR using TX2 compared to open repair. Major morbidity, severe morbidity, and clinical utility appear better with TEVAR. Sac enlargement, endoleak, migration, and other device issues were infrequent, but underscore the value of careful procedure planning and regular follow-up imaging before and after TEVAR. There were similar reintervention rates in both groups, and no ruptures or conversions in TEVAR group.

Results from the American Association for the Surgery of Trauma: Operative Repair or Endovascular Stent Graft in Blunt Traumatic Thoracic Aortic Injuries J of Trauma 64(3), March 2008

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Prospective multicenter study 125 SG vs. 68 OR Multivariate analysis adjusting for severe extrathoracic injuries, hypotension, GSC, age Lower mortality and blood transfusions in the SG pts Paraplegia: 2.9% OR, 0.8% SG 14.4% (18) endoleak (6 pts reqd open repair)

Conclusions   

TEVAR new technology Close follow up Long term data

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THORACIC ENDOVASCULAR AORTIC REPAIR FUTURE Traumatic cases Smaller grafts, smaller introducers Type B dissections IVUS Arch aneurysms Hybrid procedures Hybrid operating room

33yo meth addict with type B dissection (medically managed), hospital day 4 develops paralysis of the Lt leg. a) b)

c) d)

Consult neurology and neurosurgery Consult Interventional Radiology for fenestration of the dissection flap Consult CT surgery for TEVAR Spinal Drainage

60 yo presents with Lt sided stoke and back pain. Carotid U/S shows decreased velocity in the Rt ICA a) b) c)

d)

Consult neurology for thrombolytic therapy Consult Vascular surgery for CEA Obtain CTA and treat type A dissection with TEVAR Obtain CTA and treat type A dissection with open surgical repair with CP bypass and hypothermic circulatory arrest

Center for Aortic Surgery Cardiothoracic Surgeons St. Agnes Medical Providers • Peter Birnbaum MD • Steven Cummings MD • Richard Gregory MD • 450-7455