Thoracic Endovascular Aortic Stent Repair (TEVAR ... tevar.pdf · Thoracic Endovascular Aortic...

Thoracic Endovascular Aortic Stent

Repair (TEVAR): Outcomes and

Perioperative Managment Manfred D. Seeberger

EACTA President Department of Anesthesia & Intensive Care

Endovascular Repair of Descending Aortic Disease

Dake et al, N Engl J Med 1994

Endovascular Repair of Descending Aortic Disease

•  Stent-graft custom-made for each patient

•  Stainless steel endoskeleton

• Z shaped stent elements

• Woven Dacron graft material

Dake et al, N Engl J Med 1994

Endovascular Repair of Descending Aortic Disease

•  13 patients with descending thoracic aortic

aneurysm

•  Successful placement in all

•  Full (12) or partial thrombosis (1) of aneurysm

•  12 months follow-up

•  Surgery after 4 months in 1 patient (dilating arch)

•  No deaths

Dake et al, N Engl J Med 1994

Fontes-Carvalho et al, Rev Port Cardiol 2012

Two Decades Later

TEVAR: Full Evidence?

2009

  TEVAR technically feasible

 Early outcomes↑: paraplegia, mortality, hospital stay

  RCT needed: open-conversion, aneurysm exclusion, endoleaks, late mortality?

•  TEVAR vs. open surgery in pts with TAA

•  All RCT -October 2008, 2 reviewers

No RCT found!

J Thorac Cardiovasc Surg 2011;142:587-94

Cheng et al, J Am Coll Cardiol 2010; 55:986-1001

Hiratzka et al, JACC 2010;55:e27-129

1999-2009

Desai et al, J Thorac Cardiovasc Surg 2011;142:587-94

Other: Type A dissection (40), penetrating ulcer (7), pseudoaneurysm (14)

Desai et al, J Thorac Cardiovasc Surg 2011;142:587-94

•  Type A Dissection

• Surgery: Class 1, Level C

•  Asymptomatic aneurysm: surgery, if (Class 1, Level C)

• Aortic diameter >5.5 cm

• Marfan / genetic disease at diameter 4-5 cm

• Growth >0.5 cm/yr (even if aorta <5.5 cm)

• Aortic valve surgery and aortic diameter >4.5 cm

Hiratzka et al, JACC 2010;55:e27-129

Recommendations for ascending aortic disease

Aortic Diameter – Risk of Complication

Hiratzka et al, 2010 Guidelines on Thoracic Disease. JACC 2010

Growth rate / yr: 0.1 cm ≤0.2 cm

• Surgery: Class 1, Level C

Hiratzka et al, JACC 2010;55:e27-129

Recommendations for ascending aortic disease

Hiratzka et al, 2010 Guidelines on Thoracic Disease. J Am Coll Cardiol 2010

Cheng et al, J Am Coll Cardiol 2010; 55:986-1001

No single randomized study!

Cheng et al, J Am Coll Cardiol 2010; 55:986-1001

(n=2828)

Cheng et al, J Am Coll Cardiol 2010; 55:986-1001

Cheng et al, J Am Coll Cardiol 2010; 55:986-1001

Cheng et al, J Am Coll Cardiol 2010; 55:986-1001

Cheng et al, J Am Coll Cardiol 2010; 55:986-1001

Cheng et al, J Am Coll Cardiol 2010; 55:986-1001

Cheng et al, J Am Coll Cardiol 2010; 55:986-1001

(n=3060)

Anesthesia for TEVAR

Eur J Anaest 2010;27:91 (abstract)

Anesthesia for TEVAR

•  More frequently LA with increased experience

•  Promoted by non-surgical access (group A)

•  GA: more comfort and security for pts & doctors

•  LA: possibly lower morbidity and ICU LOS

The choice of anesthetic techniques and agents

should be tailored to

•  individual patient needs

•  facilitate surgical and perfusion techniques and

• monitoring of hemodynamics and organ function

Hiratzka et al, JACC 2010;55:e27-129

Recommendations for choice of anesthesia

Descending thoracic aortic aneurysm

•  Minimal co-morbidity, diameter >5.5: Surgery (Ib);

•  Aneurysm >5.5, degenerative, traumatic; saccular;

postoperative pseudoaneurysm >5.5 cm: TEVAR (1b)

•  Thoracoabdminal aneursm >6 cm, TEVAR not

feasible: consider open surgery (1c)

Hiratzka et al, JACC 2010;55:e27-129

Penetrating Ulcer

• No generally agreed first-lime treatment

• Uncomplicated: wait, follow-up

• Complicated by hematoma, pseudoaneurysm

or rupture: treat similar to aortic dissection

in the corresponding segment of the aorta Hiratzka et al, JACC 2010;55:e27-129

Traumatic aortic injury

Jonker et al, J Vasc Surg 2010; 51:565-71

• Conservative treatment: mortality >90%

Traumatic aortic injury

Jonker et al, J Vasc Surg 2010; 51:565-71