Total endovascular arch repair: what...

Total endovascular archrepair: what welearned so far?

Ciro Ferrer, MDFisiopatologia Chirurgica ad Interesse Vascolare

Sapienza Università di Roma

Disclosure

Speaker name:

Ciro Ferrer

I do not have any potential conflict of interest

OPEN REPAIR

- Mediansternotomy

- Hypothermia

- Cardiopulmonarybypass

- Antegrade cerebralpurfusion

- Massive heparinization

ENDOVASCULAR REPAIR

Car-Subclbypass/transposition

DOUBLE INNER BRANCHENDOGRAFT

Arch branched stentgraftOPERATIVE DETAILS

VASCULAR ACCESSES:

- R femoral a (aortic main body)- L femoral a (angiography)- L femoral v (pacing)- R axillary (innominate stent)- L brachial (L carotid stent)

X X

X

X

X

J Vasc Surg 2011

30 patients screened: 75% conical shapewithout a proximal landing zone

BUILDING A DURABLE ARCH REPAIR

- Avoid landing in diseased ascending aorta Ectatic ascending aorta (>38mm)

Male, 78 yo

CT scan @ 24h

Chronic type B dissection

40 mm

Ascending aorta replacement + total debranching + TEVAR

Dacron graft of at least

5 cm in length

09/2009 – 09/2015

TEVAR n = 483Arch TEVAR n = 181

16 mm

Middle-distal arch disease

5 mm shrinkage @ 24 monthsafter Branched Arch TEVAR

More stable sealingfor a potentiallyfeasible zone 1 repair

Double branch stentgraft

2012 – 2016

Arch branchedprocedures: 14

Bolton (n=9) Cook (n=5)

Single branch: 2/14Double branch: 12/14Technical success: 14/1430-day mortality: 3/1430-day stroke: 2/14

#Implant

DateDevice Age Sex Pathology

Intraoperative

Complication

Perioperative

ComplicationAlive

1 25/06/13 Bolton 70 M TAA N Stroke - death N

2 19/09/13 Bolton 83 M TAA N N Y

3 17/03/14 Bolton 84 M TAA N N Y

4 29/04/14 Bolton 79 M Dissection N N Y

5 22/07/14 Bolton 72 M TAA N N Y

6 06/11/14 Cook 76 M TAA N N Y

7 12/01/15 Cook 64 M DissectionCoverage of L vertebral

artery by vascular plug Stroke Y

8 16/02/15 Bolton 84 M TAA NRetrograde

dissection - deathN

9 05/06/15 Cook 77 M TAA N N Y

10 24/09/15 Cook 75 M TAA N N Y

11 06/02/16 Cook 83 M TAA N N Y

12 21/11/16 Bolton 78 M TAA N N Y

Double inner branch N=12

Arch aneurysmpost type A repair

Dissection ofInnominate artery

Dissection ofR common carotid

Dissection ofLSA

Double branch stentgraft

R car to RSAtransposition

L car - LSAbypass

Car-subcl bypass + LSA emboliz (Plug) + Branched Arch TEVAR

Elongation of Plug due to LSA dissection

Partial coverage of L Vertebral artery

Posterior Stroke

LSA re-entry tear

RCCA re-entry tear

Arch aneurysmpost type A repair

Deployment of a 10-mm V-12 stentgraft in the LSA and a 6-mm Vascular Plug in the false lumen

Deployment of a 9-mm Viabahnstentgraft in the RCCA

Post-op CTA afterSPOT STENTINGtechinique

Male, 86 yo70 mm arch aneurysmThoracic painHorsenessRespiratory distress

LIMA to LADpatent bypass

Persistent aneurysmperfusion

Journal of Endovascular Therapy 2016

2 patients with acute type A aortic dissection treated with

combination of tubular and branched stentgrafts

RelayBranch off-the-shelf device

PROX DIAMETER32 · 34 ∙ 36 ∙ 38 ∙ 40 ∙

42 ∙ 44 ∙ 46 ∙ 48

DISTAL DIAMETER22 · 24 ∙ 26 ∙ 28 ∙ 30 ∙32 ∙ 34 ∙ 36 ∙ 38∙ 40 ∙

42 ∙ 44 ∙ 46 ∙ 48

MAIN BODY LENGTH45 · 60

TOTAL MAIN BODY LENGTH250 · 270

WINDOWLENGTH

50

WINDOWWIDTH

26 ∙ 32 ∙ 38TUNNEL DIAMETER12

PROX DIAMETER13

PROX DIAMETER13

DISTAL DIAMETER8 · 9 ∙ 10 ∙ 11 ∙ 12 ∙ 13

DISTAL DIAMETER14 · 16 ∙ 18 ∙20 ∙ 22 ∙ 24

TOTAL BRANCH LENGTH70 · 80 · 90 · 100

110 · 120 · 130 · 140

Conclusion

Endovascular approach is a valid alternative to open surgery for all patients when morphologically feasible

Identification of a suitable proximal landing zone remains a major concern in TEVAR for arch disease

Dacron ascending aorta is the safest landing zone

An arch branched endograft should be at most 42 mmin proximal diameter (ascending aorta no larger than 38 mm)

Off-the-shelf solutions will be the future for extending the treatment also to emergency