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Edward B. Diethrich, MDEdward B. Diethrich, MDPhoenix, ArizonaPhoenix, Arizona
The Future of The Future of Aortic RepairAortic Repair
Malmo, SwedenMalmo, SwedenJune 18, 2010June 18, 2010
What Perspective?What Perspective?
How?How?
Where?Where?Who?Who?
What?What?
How?How?
Where?Where?
Who?Who?• Classical• Endovascular• Robotic• Laparoscopic• Hybrid
• Classical• Endovascular• Robotic• Laparoscopic• Hybrid
• Cathlab• OR• Radiology Suite• Hybrid
• Cathlab• OR• Radiology Suite• Hybrid
• Vascular Surgeon
• Interventional Cardiologist
• Interventional Radiologist
• CT Surgeon• Hybrid
• Vascular Surgeon
• Interventional Cardiologist
• Interventional Radiologist
• CT Surgeon• Hybrid
Infrarenal AAAInfrarenal AAA
• Local anesthesia• Percutaneous• Maybe outpatient• Anyone
• Local anesthesia• Percutaneous• Maybe outpatient• Anyone
What Perspective?What Perspective?
Bown MJ et al.Br J Surg 2002;89:7 14-30.Visser P 2005
Bown MJ et al.Br J Surg 2002;89:7 14-30.Visser P 2005
Perioperative Period:Perioperative Period:Surgical mortality still elevated : Surgical mortality still elevated : 40 – 50% range40 – 50% range
Perioperative Period:Perioperative Period:Surgical mortality still elevated : Surgical mortality still elevated : 40 – 50% range40 – 50% range
Open RepairOpen Repair
Overall mortality of Overall mortality of 75 to 80%75 to 80%Overall mortality of Overall mortality of 75 to 80%75 to 80%
Acute Type B Acute Type B Descending Descending DissectionDissection
AsymptomaticAsymptomatic
What Perspective?What Perspective?
Medical RxMedical Rx EndograftEndograft
ControversyControversy
Waiting for studiesWaiting for studies Our DataOur Data
Symptomatic(malperfusion)Symptomatic(malperfusion)
Endovascular technology with some hybrid
combinations
Endovascular technology with some hybrid
combinations
Acute Type A Acute Type A DissectionDissection
• No AI• Limited to zone 0
[endovascular treatment]• Type I arch/descending• Ascending tube
• No AI• Limited to zone 0
[endovascular treatment]• Type I arch/descending• Ascending tube
What Perspective?What Perspective?
Progressive dissection not inconsequential
Progressive dissection not inconsequential
MortalityMortality
Ruptured CasesRuptured Cases
All PathologiesAll Pathologies TAATAA
Intraop DeathIntraop Death 4 (5.5%)4 (5.5%) 3(12.5%)3(12.5%)
< 30 Days< 30 Days 9 (12.3%)9 (12.3%) 5 (20.8%)5 (20.8%)
ConclusionConclusion
• TEVAR should be the first option of treatment in high risk patients and those with anatomical restraints in order to increase survival.
• Neuro-deficit is decreased when compared to open repair.
• TEVAR should be the first option of treatment in high risk patients and those with anatomical restraints in order to increase survival.
• Neuro-deficit is decreased when compared to open repair.
Natural History
False Lumen at 2 - 5 years
Subject to Aneurismal Dilatation in 20% to 40%
Advance in Vasc Surg. St Louis, Mosby 1998, pp 17-36
SuccessSuccess
SuccessSuccess
Remodeling Changes Continues
Post-op
6 months
P/3 M/3 D/3
Retrograde Flow
ObservationsObservations
a. Retrograde flow at viscerals 17.7% (19pts)
b. Retrograde flow at D/3 18.7% (20pts)
c. Retrograde flow at M/3 1.8% (2pts)d. Retrograde flow at P/3 1.8% (2pts)
flow
FL thrombosis/ patency depend on several factors
Flow
• Complete thrombosis of FL of TA without evidence of antegrade or retrograde flow – 69 pts (65.1%)
Results
Incidence of Aneurismatic Dilatation
Incidence of Aneurismatic Dilatation
• Incidence is 20-40% over 5 year period
• Risk of extending dissection and potential complications including visceral and limb malperfusion 26%
• Incidence is 20-40% over 5 year period
• Risk of extending dissection and potential complications including visceral and limb malperfusion 26%
Observations Pre-Op
Post-Op
1 month
24 months
6 months
Remodeling Changes• True lumen gain volume
• False lumen decrease in diameter
• Whole lumen expand
J Vasc Surg 2009;49:20-8.
Post-Op
6 months
24 months
Case #3P/3 D/3
Type B Dissection, Regardless of Symptoms, Should Be Treated
By Endografting to Prevent Future Complications?
Exceptions ?•Asymptomatic patient without significantly collapsed true lumen, <50%.
Inclined to Treat Non-complicated TBD with ELG
• Endograft is well indicated in aortic dissection type B since the natural history demonstrated high degree of success and positive remodeling changes.
• Endograft is well indicated in aortic dissection type B since the natural history demonstrated high degree of success and positive remodeling changes.
•No commercial products for many of the pathologies encountered
•Frequent customization required
•Complexity of pathology restricts broad training and experience
•No commercial products for many of the pathologies encountered
•Frequent customization required
•Complexity of pathology restricts broad training and experience
Limitations at PresentLimitations at Present
Example?Example?
Our Series: Open vs Endograft
June 1998 and June 2009Retrospective Review
Presented with a rAAA
69 (65.2%) -- Open Repair
36 (33.6%) -- EVAR
30-Day Mortality
• Overall was 29.5% (31)
• 34.8% (24) for Open
• 19.4% (7) for EVAR
(p=0.12) When comparing those EVAR cases with combined use of local anesthesia at initiation of procedure and use of supra-celiac occlusive balloon to those receiving general anesthesia and no balloon, the mortality reduced from 27.8% to 11.1 % (p=0.40)
Conclusions• EVAR in ruptured AAAs has reduced
mortality.
• Supraceliac occlusive balloon, based on CT findings of large retroperitoneal hematoma, initiated under local anesthetic, can prevent circulatory collapse.
Conclusions
• Availability of graft to treat larger caliber necks and low profile devices are some of the technology changes that we need.
Z0Z0
Z1Z1 Z2Z2
Z3Z3
Z4Z4
The Real Challenge:Conquering Zone Zero
The Real Challenge:Conquering Zone Zero
1. Level of the annulus of the aortic valve
2. Sinus of Valsalva3. Sinotubular junction4. Ascending aorta at the
level of pulmonary trunk
1. Level of the annulus of the aortic valve
2. Sinus of Valsalva3. Sinotubular junction4. Ascending aorta at the
level of pulmonary trunk
64 Slice CTOblique Coronal Images Showing the 4 Diameter Measurements of Aortic Root
64 Slice CTOblique Coronal Images Showing the 4 Diameter Measurements of Aortic Root
Acute Dissection Ascending AortaAcute Dissection Ascending Aorta
DissectionDissection HematomaHematoma
High Risk Patient for Open ProcedureHigh Risk Patient for Open Procedure
Balloon Occluding
Device
Balloon Occluding
Device
L. Coronary Artery
L. Coronary Artery
Sheath with Positioning of
ELG
Sheath with Positioning of
ELG
Aortic ValveAortic Valve
Dissection and Hematoma Sealed
Dissection and Hematoma Sealed
24° Post-Op CT24° Post-Op CT
1. Vortex velocity control in aneurysm
2. Laminates the flow in collaterals
3. Accelerates shear stress flow in the vessel
1. Vortex velocity control in aneurysm
2. Laminates the flow in collaterals
3. Accelerates shear stress flow in the vessel
Multi-Layered StentKey Principles
Multi-Layered StentKey Principles
Human Experience(All OUS)
Human Experience(All OUS)
Thoraco Abdominal Aneurysm
Thoraco Abdominal Aneurysm
1 Month Follow-Up
Aneurysm excludedAll visceral arteries openAneurysm excludedAll visceral arteries open
Future Potential for Endovascular ???Future Potential for Endovascular ???
Aortic Stenosis
Aortic Stenosis
Ascending Arch AneurysmAscending Arch Aneurysm
Aortic StenosisAortic Stenosis
Neuro Protection Devices
Neuro Protection Devices
Ascending Endoluminal
Graft
Ascending Endoluminal
Graft
Coronary Inserts
Coronary Inserts
Percutaneous Aortic Valve
Percutaneous Aortic Valve
Special Stent to Correct
Kink
Special Stent to Correct
Kink
Arch/ Descending Endoluminal Graft
with Three Branches
Arch/ Descending Endoluminal Graft
with Three Branches
Horizon Looks Favorable….Horizon Looks Favorable….
TrainingTraining
GovernmentGovernment
FDAFDA
CMSCMS
IndustryIndustry
We are the heritage of our undaunted medical forefathers. Our young physicians
are the genetic products of those great pioneers. Let their fate be the product of
those positive, energetic, inquisitive, creative, and adventurous epigenoms which
have the ability to overcome all adversity and bring ultimate success to all endeavers.
We are the heritage of our undaunted medical forefathers. Our young physicians
are the genetic products of those great pioneers. Let their fate be the product of
those positive, energetic, inquisitive, creative, and adventurous epigenoms which
have the ability to overcome all adversity and bring ultimate success to all endeavers.
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