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Prof Dr Hakan PosacıoğluEge Üniversitesi Kalp ve Damar Cerrahisi
Prof Dr Hakan PosacıoğluEge Üniversitesi Kalp ve Damar Cerrahisi
VISCERAL DEBRANCHING FOR THE TREATMENT OF TAAAVISCERAL DEBRANCHING FOR THE TREATMENT OF TAAA
MANAGEMENT OF THE TAAA MANAGEMENT OF THE TAAA
- OPEN SURGERY- OPEN SURGERY
Mortality rates 2-20%(rates are higher for type II)
Complications of repair include -renal failure (2-12%) -cardiopulmonary (4-33%) -neurologic deficit (1-15%)
20-30% patients being dischargedto another instution rather than home
Mortality rates 2-20%(rates are higher for type II)
Complications of repair include -renal failure (2-12%) -cardiopulmonary (4-33%) -neurologic deficit (1-15%)
20-30% patients being dischargedto another instution rather than home
-ENDOVASCULAR-ENDOVASCULAR
-FENESTRATED OR BRANCHED STENT GRAFTS
-CHIMNEY OR SNORKEL TECHNIQES COMBINED WITH STENT GRAFT
-FENESTRATED OR BRANCHED STENT GRAFTS
-CHIMNEY OR SNORKEL TECHNIQES COMBINED WITH STENT GRAFT
-MULTI LAYERED FLOW MODULATER STENTS
-MULTI LAYERED FLOW MODULATER STENTS
-VISCERAL DEBRANCHING WITH STENT GRAFTS-VISCERAL DEBRANCHING WITH STENT GRAFTS
HYBRIDTAAA REPAIR
HYBRIDTAAA REPAIR
DEFINITION OF VISCERAL DEBRANCHING DEFINITION OF VISCERAL DEBRANCHING
EXTRA-ANATOMIC REVASCULARIZATION OF 1- CELIAC 2- SMA 3- RENAL ARTERIES
EXTRA-ANATOMIC REVASCULARIZATION OF 1- CELIAC 2- SMA 3- RENAL ARTERIES
THE KEY PRINCIPLES OF THIS HYBRID TAAA REPAIR
THE KEY PRINCIPLES OF THIS HYBRID TAAA REPAIR
-RETROGRADE FASHION REVASCULARIZATION
-COMPLETE EXCLUSION OF TAAA WITH STANDARD ENDOVASCULAR STENT GRAFTS
-RETROGRADE FASHION REVASCULARIZATION
-COMPLETE EXCLUSION OF TAAA WITH STANDARD ENDOVASCULAR STENT GRAFTS
VISCERAL HYBRID TAAA REPAIRVISCERAL HYBRID TAAA REPAIR
ADVANTAGES;
-REDUCED VISCERAL ISCHEMIC TIME AND SPINAL CORD ISCHEMIA
-NO AORTIC CROSS CLAMP
-AVOIDANCE OF THORACOTOMY, LESS PULMONARY COMPLICATIONS
-LESS HEMODYNAMIC INSTABILITY
-REDUCED HOSPITAL STAY
-LESS BLOOD LOSS/REDUCED TRANSFUSION REQUIREMENT
ADVANTAGES;
-REDUCED VISCERAL ISCHEMIC TIME AND SPINAL CORD ISCHEMIA
-NO AORTIC CROSS CLAMP
-AVOIDANCE OF THORACOTOMY, LESS PULMONARY COMPLICATIONS
-LESS HEMODYNAMIC INSTABILITY
-REDUCED HOSPITAL STAY
-LESS BLOOD LOSS/REDUCED TRANSFUSION REQUIREMENT
IN EMERGENCY CASES, THESE STENT GRAFTS ARE READILY AVAILABLE,UNLIKE FENESTRATED OR BRANCHED STENT-GRAFTS
IN EMERGENCY CASES, THESE STENT GRAFTS ARE READILY AVAILABLE,UNLIKE FENESTRATED OR BRANCHED STENT-GRAFTS
DETERMINATION OF INFLOW SITEDETERMINATION OF INFLOW SITE
1-EXTEND OF ANEURYSMAL DISEASE (IF RENAL ARTERIES ARE NOT INVOLVED ABDOMINAL AORTA CAN BE USED)
1-EXTEND OF ANEURYSMAL DISEASE (IF RENAL ARTERIES ARE NOT INVOLVED ABDOMINAL AORTA CAN BE USED)
2-PREVIOUS EVAR OR INFRA RENAL SURGERY FOR AAA REPAIR( affect the determination of inflowsite)
2-PREVIOUS EVAR OR INFRA RENAL SURGERY FOR AAA REPAIR( affect the determination of inflowsite)
3-COMMON AND EXTERNAL ILIAC ARTERY DIAMETER,PRE- EXISTENCE OF STENOSIS,TORTUOSITY AND KINKING ARE ALSO IMPORTANT FACTORS IN CHOOSING INFLOW SITE
3-COMMON AND EXTERNAL ILIAC ARTERY DIAMETER,PRE- EXISTENCE OF STENOSIS,TORTUOSITY AND KINKING ARE ALSO IMPORTANT FACTORS IN CHOOSING INFLOW SITE
**WE NEVER USE INFLOW ILIAC ARTERY AS A SITE FOR STENT GRAFT INSERTION
**WE NEVER USE INFLOW ILIAC ARTERY AS A SITE FOR STENT GRAFT INSERTION
GRAFT CHOICE GRAFT CHOICE
- HEPARIN BOUNDED PTFE GRAFT
- SMA OR CELIAC GRAFTS CONSTITUTE MAIN TRUNK THE OTHERS WERE ANASTOMOSED TO MAIN TRUNK END TO SIDE FASHION
- HEPARIN BOUNDED PTFE GRAFT
- SMA OR CELIAC GRAFTS CONSTITUTE MAIN TRUNK THE OTHERS WERE ANASTOMOSED TO MAIN TRUNK END TO SIDE FASHION
IF DOPPLER SIGNALS ARE SATISFACTORYIN THE BYPASS GRAFTS, NATIVE ARTERIES ARE LIGATEDTO PREVENT TYPE II ENDOLEAK .
IF DOPPLER SIGNALS ARE SATISFACTORYIN THE BYPASS GRAFTS, NATIVE ARTERIES ARE LIGATEDTO PREVENT TYPE II ENDOLEAK .
**THERE IS ONE EXCEPTION (CELIAC TRUNK). VERY DENSE VENOUS COLLATERALS AND LYMPHATICS MAKE THE DISSECTION AND LIGATION VERY DIFFICULT.CT LEFT UNLIGATED AND CLOSED WITH COILS OR VASCULAR PLUG 2-4 WEEKS AFTER OP.
**THERE IS ONE EXCEPTION (CELIAC TRUNK). VERY DENSE VENOUS COLLATERALS AND LYMPHATICS MAKE THE DISSECTION AND LIGATION VERY DIFFICULT.CT LEFT UNLIGATED AND CLOSED WITH COILS OR VASCULAR PLUG 2-4 WEEKS AFTER OP.
Coils and glue
HYBRID REPAIR OF TYPE II TAAA
HYBRID REPAIR OF TYPE II TAAA
OPERATIVE TECHNIQUEOPERATIVE TECHNIQUE
MIDLINE LAPAROTOMYMIDLINE LAPAROTOMY
1- CELIAC TRUNK EXPOSURE1- CELIAC TRUNK EXPOSURE
COMMON HEPATIC ARTERY(OUT FLOW FOR CELIAC REVASCULARIZATION)
COMMON HEPATIC ARTERY(OUT FLOW FOR CELIAC REVASCULARIZATION)
GASTRODUODENAL ARTERYGASTRODUODENAL ARTERY
WE PERFORM OUTFLOW ANASTOMOSIS FIRSTWE PERFORM OUTFLOW ANASTOMOSIS FIRST
ACCESS IS OBTAINED IN THE LESSER SAC, LEFT LOBE OF THE LIVER SLIGHTLY RETRACTED TO THE RIGHT, STOMACH AND PANCREAS HELD CAUDALLY
ACCESS IS OBTAINED IN THE LESSER SAC, LEFT LOBE OF THE LIVER SLIGHTLY RETRACTED TO THE RIGHT, STOMACH AND PANCREAS HELD CAUDALLY
PTFE GRAFT (USUALLY 6 MM) ANASTOMOSED COMMON HEPATIC ARTERY. PTFE GRAFT (USUALLY 6 MM) ANASTOMOSED COMMON HEPATIC ARTERY.
THE GRAFT IS TUNNELLED BETWEEN THE PANCREAS AND STOMACH TO THE RETROPERITONEUM
THE GRAFT IS TUNNELLED BETWEEN THE PANCREAS AND STOMACH TO THE RETROPERITONEUM
PANCREASPANCREAS
STOMACH STOMACH
COMMON HEPATICARTERY
COMMON HEPATICARTERY
2- SMA EXPOSURE2- SMA EXPOSURE
IT STARTS LIKE STANDARD INFRENAL ABDOMINAL AORTIC EXPOSURE
IT STARTS LIKE STANDARD INFRENAL ABDOMINAL AORTIC EXPOSURE
DUODENUM AND TREIZ LIGAMENT MOBILIZED. SMA TRUNK CAN BE FOUND 1 OR 1.5 CM ABOVE THE RENAL ARTERY ORIFICES
DUODENUM AND TREIZ LIGAMENT MOBILIZED. SMA TRUNK CAN BE FOUND 1 OR 1.5 CM ABOVE THE RENAL ARTERY ORIFICES
8MM PTFE GRAFT IS ANASTOMOSED TO SMA END TO SIDE FASHION 8MM PTFE GRAFT IS ANASTOMOSED TO SMA END TO SIDE FASHION
SMASMA
“LAZY C” GRAFT “LAZY C” GRAFT
COMMON HEPATIC GRAFT
COMMON HEPATIC GRAFT
3-LEFT AND RIGHT RENAL ARTERY EXPOSURE3-LEFT AND RIGHT RENAL ARTERY EXPOSURE
DURING LRA EXPOSURE ; WE PERFORM ANTERIOR APPROACH SIMILAR TO THAT USED FOR CONVENTIONAL AAA REPAIR. LEFT RENAL VEIN FREED AND SOME BRANCHES LIGATURED.
DURING LRA EXPOSURE ; WE PERFORM ANTERIOR APPROACH SIMILAR TO THAT USED FOR CONVENTIONAL AAA REPAIR. LEFT RENAL VEIN FREED AND SOME BRANCHES LIGATURED.
RIGHT RENAL EXPOSURE; IT REQUIRES LIMITED TAKE DOWN OF THE HEPATIC FLEXURE OF THE COLON .
RIGHT RENAL EXPOSURE; IT REQUIRES LIMITED TAKE DOWN OF THE HEPATIC FLEXURE OF THE COLON .
MOST DIFFICULT EXPOSURE AND ANASTOMOSIS IS THE RIGHT RENAL ARTERY;
1- EXTENSIVE DISSECTION
2-VERY DISTAL ANASTOMOSIS DUE TO VCI (4-5 MM RENAL ARTERY)
3-TUNNELING OF THE GRAFT TO THE INFLOW SITE IS DIFFICULT
4-SURGEON SOULD BE AWARE OF EARLY BRANCHING OR MULTIPLE RENAL ARTERIES
MOST DIFFICULT EXPOSURE AND ANASTOMOSIS IS THE RIGHT RENAL ARTERY;
1- EXTENSIVE DISSECTION
2-VERY DISTAL ANASTOMOSIS DUE TO VCI (4-5 MM RENAL ARTERY)
3-TUNNELING OF THE GRAFT TO THE INFLOW SITE IS DIFFICULT
4-SURGEON SOULD BE AWARE OF EARLY BRANCHING OR MULTIPLE RENAL ARTERIES
1-CEREBRO SPINAL FLUID DRAINAGE -POSTOP DAY 1 AND 2 ACTIVE DRAINAGE
- POSTOP DAY 3 JUST PRESSURE MONITORING
- POSTOP DAY 4 NO MONITORING BUT IT STAYS
1-CEREBRO SPINAL FLUID DRAINAGE -POSTOP DAY 1 AND 2 ACTIVE DRAINAGE
- POSTOP DAY 3 JUST PRESSURE MONITORING
- POSTOP DAY 4 NO MONITORING BUT IT STAYS
SPINAL CORD PROTECTION STRATEGYSPINAL CORD PROTECTION STRATEGY
2-MEAN ARTERIAL PRESSURE SHOULD BE ≥ 90-100mmHG
2-MEAN ARTERIAL PRESSURE SHOULD BE ≥ 90-100mmHG
3- HYPOXIA AND ACIDOSIS SHOULD BE AVOIDED
3- HYPOXIA AND ACIDOSIS SHOULD BE AVOIDED
4- HEMOGLOBIN SHOULD BE ≥ 10-12 mg/dl 4- HEMOGLOBIN SHOULD BE ≥ 10-12 mg/dl
EGE UNIVERSITY CARDIOVASCULAR SURGERY EXPERIENCEEGE UNIVERSITY CARDIOVASCULAR SURGERY EXPERIENCE
88 11 4422 33
PATIENTS : 18 (16 MALE)
CONTAINED RUPTURE: 4
MEDIAN AGE: 72±
CSF DRAINAGE: 16
INFLOW SITE: -INFRARENAL AA :2 -COMMON ILIAC: 16
FOLLOW UP:40±6 MONTHS
PATIENTS : 18 (16 MALE)
CONTAINED RUPTURE: 4
MEDIAN AGE: 72±
CSF DRAINAGE: 16
INFLOW SITE: -INFRARENAL AA :2 -COMMON ILIAC: 16
FOLLOW UP:40±6 MONTHS
NO MORTALITYNO MORTALITY
WHAT ABOUT GRAFT DURABILITY?WHAT ABOUT GRAFT DURABILITY?
WE ARE SURPRISED THAT EARLY AND MIDTERM GRAFTTHROMBOSIS RATE REMAINS VERY LOW
WE ARE SURPRISED THAT EARLY AND MIDTERM GRAFTTHROMBOSIS RATE REMAINS VERY LOW
RIGHTRENAL8/8(4 chimney)
RIGHTRENAL8/8(4 chimney)
SMA14/14
SMA14/14 LEFT
RENAL7/5
LEFTRENAL7/5
COMMANHEPATIC16/16(1 snorkel)
COMMANHEPATIC16/16(1 snorkel)
LEFT İLİACARTERY
LEFT İLİACARTERY
COMMON TRUNK2/2
COMMON TRUNK2/2
SMA
HEPATİC
SPLENIC
RESULTS: GRAFTS PATENCY: 95%RESULTS: GRAFTS PATENCY: 95%
TOTAL 42 GRAFTS 2 OCCLUSION
TOTAL 42 GRAFTS 2 OCCLUSION
PATIENT 1: 78 YEARS OLD MEN.TYPE 4 TAAA AND RENAL FUNCTIONS MODERATLY ELEVATED. ONE STAGE OPERATION CSF DRAINAGE +
PATIENT 1: 78 YEARS OLD MEN.TYPE 4 TAAA AND RENAL FUNCTIONS MODERATLY ELEVATED. ONE STAGE OPERATION CSF DRAINAGE +
PREOP CTPREOP CT
PATIENT 2: 75 YEARS OLD MALE PATIENT. TYPE 1 TAAA. PREVIOUS MULTIPLE PCI AND LOW EF. TWO-STAGE OPERATION CSF DRAINAGE +
PATIENT 2: 75 YEARS OLD MALE PATIENT. TYPE 1 TAAA. PREVIOUS MULTIPLE PCI AND LOW EF. TWO-STAGE OPERATION CSF DRAINAGE +
PREOP CTPREOP CT
POSTOP CT (5 YEAR)ENLARGEMENT OF DISTAL LANDING ZONE
POSTOP CT (5 YEAR)ENLARGEMENT OF DISTAL LANDING ZONE
EXTENSION OF CHIMNEY
EXTENSION OF CHIMNEY
EXTENSION OF STENT GRAFTAND RIGHT RENAL ARTERY CHIMNEY
EXTENSION OF STENT GRAFTAND RIGHT RENAL ARTERY CHIMNEY
PATIENT 3: 65 YEARS OLD WOMEN. BEHÇET’S DISEASE WITH VASCULAR INVOLVEMENT. TYPE 3 TAAA 3 MONTHS AGO BENTALL OPERATION TWO STAGE OPERATION - CSF DRAINAGE +
PATIENT 3: 65 YEARS OLD WOMEN. BEHÇET’S DISEASE WITH VASCULAR INVOLVEMENT. TYPE 3 TAAA 3 MONTHS AGO BENTALL OPERATION TWO STAGE OPERATION - CSF DRAINAGE +
PREOP CTPREOP CT
COMPLETE VISCERAL AND RENAL ARTERY DEBRANCHING** right renal artery very small
COMPLETE VISCERAL AND RENAL ARTERY DEBRANCHING** right renal artery very small
COMPLICATIONS:COMPLICATIONS:
GRAFT OCCLUSION: 2 (RENAL ARTERY)
DELAYED PARESTHESIA: 1(COMPLETE RECOVERY )
PROLONGED VENTIALATION: 1 (1 WEEK)
SMA DISSECTION AND TYPE II ENDOLEAK: 1
GRAFT OCCLUSION: 2 (RENAL ARTERY)
DELAYED PARESTHESIA: 1(COMPLETE RECOVERY )
PROLONGED VENTIALATION: 1 (1 WEEK)
SMA DISSECTION AND TYPE II ENDOLEAK: 1
GRAFT TO ENTERIC FISTULA:1GRAFT TO ENTERIC FISTULA:1
TYPE II ENDOLEAK : 4 ( 3 of them due to delayed occlusion of celiac trunk)TYPE II ENDOLEAK : 4 ( 3 of them due to delayed occlusion of celiac trunk)
GRAFTS WERE SOAKED WITH RIFAMPIN AND COVERED BY OMENTUM
GRAFTS WERE SOAKED WITH RIFAMPIN AND COVERED BY OMENTUM
CONCLUSIONCONCLUSION
-There are no pure comparative reports that demonstrate a definite advantageof hybrid TAAA repair. It may offer advantages in a selected population who are considered high risk for open repair.
-There are no pure comparative reports that demonstrate a definite advantageof hybrid TAAA repair. It may offer advantages in a selected population who are considered high risk for open repair.
Technology of fenestrated and branched stent grafts is still emerging. Imaging,sizing and graft construction all require time. In addition, the high cost of these stent grafts are prohibitive to many centers.
Technology of fenestrated and branched stent grafts is still emerging. Imaging,sizing and graft construction all require time. In addition, the high cost of these stent grafts are prohibitive to many centers.
Similar to conventional repair, results are likely to be better in higher volume centers with the necessary infrastructure.
Similar to conventional repair, results are likely to be better in higher volume centers with the necessary infrastructure.
Recommended