Should We Be Doing This? Sealing Dissections: Thoracic Stenting Dr Peter Wilde – Consultant Cardiac Radiologist Dr K Balachandran – Cardiology SpR Mr A

Should We Be Doing This?

Sealing Dissections: Thoracic Stenting

Dr Peter Wilde – Consultant Cardiac RadiologistDr K Balachandran – Cardiology SpRMr A Bryan – Consultant Cardiac Surgeon

Dr A Baumbach – Consultant Cardiologist

Bristol Royal Infirmary

Should We Be Doing This?

Sealing DissectionsSealing Leaks

Closing AneurysmsRepairing Transections

P Wilde - BCIS Autumn Meeting Bristol – 30th September 2005

Stanford Type B Dissection(Intramural haematoma)


Aneurysms


Penetrating atherosclerotic

ulcer


Transection


Acute or chronic?

Acute ( <2 weeks) Recent chest painEvidence of bleedingEvidence of recent expansion

ChronicSlow increase in sizeAbsolute size of aneurysmMass effects


What about surgery?


Acute type B dissection

Surgical mortality 30-80%

Medical treatment mortality 10-15%

20-30% have a complication requiring intervention

No clear case for surgery in the majority


Nienaber, Zanetti et al., Am Heart J 2003

Cumulative survival of subacute type B dissection with medical therapy


Thoracic aortic aneurysm resection

Elective surgical mortality at least 10%

Higher mortality in complex cases

Paraplegia rate 5-10%


Acute post traumatic transection

Surgical mortality at least 15%, may be much more

Associated major trauma, especially head injury

Lower incidence of paraplegia


Surgery on the Thoracic Aorta

Operations frequently last 5-7 hours

Partial cardiopulmonary bypass or circulatory arrest required

Prolonged intensive care required

Surgeons hate operating on the descending thoracic aorta


Thoracic Aortic Stent Grafting (TASG)

First performed in 1994 – immediate clinical benefitsthere are no controlled trials available yet (INSTEAD)



Rationale for an INvestigation of STEntgrafts in Aortic Dissection (INSTEAD)-study

Hypothesis

Should the concept of stent-graft induced aortic remodeling be applied to stable dissection?

Mid-term outcomes of stent-graft placement in type B dissection?

Improvement of the natural course of type B dissection?

Design

MC, prospective, randomized

Endpoints

Outcomes at 1 & 2 years, events, remodeling of aorta


Literature review of TASG (‘meta analysis’)

15 publications 1996 – 2005632 patientsSeries from 12 to 110 patientsFull range of indicationsApprox. 30% acute casesOverall early mortality 5.1%Paraplegia only 1.3% ( 0.8% recovered)


Guy’s Hospital Results 1997 – 2005(Courtesy Dr J Reidy)

143 patients (66% Male)

Age 17-90 yr (mean 72)

Many non-surgical or poor surgical risk

33% for acute indications

Overall 30 day mortality 7.7%

11% acute, 6.2% chronic

Paraplegia 4.9% ( 3.5% recovered)

Late mortality 15% (mean f/u 34m)


TASG Indications

Traumatic rupture Strong indication for TASG – anatomy usually favourable – long term results?

AneurysmIntervene over 5.5cm assess on a case by case basis according to anatomy

Type B dissection

Currently only indicated in ‘active’ cases (continuing pain, expansion, bleeding) but……..

Emerging evidence begins to suggest all Type B dissections

Penetrating atherosclerotic ulcerStrong indication if bleeding and anatomy is suitable


Nienaber, Zanetti et al., Am Heart J 2003

Medical therapy Elective stent graft

Cumulative survival of subacute type B dissection: Stent graft v. historical group with medical therapy


Complications of TASG

Paraplegia

Stroke

Vascular complication (femoral/iliac)

Device migration

EndoleakType 1 – marginal leakType 2 – external collateral fillingType 3 - Device leak/failure


Technical aspects of TASG (Bristol)

High quality imaging is essential for planning

Preliminary high resolution CT angio

3D reconstruction for assessment of anatomy and measurements

Evaluate vascular access

Aortograms during procedure in chosen projection


Technical aspects of TASG (Bristol)

Catheter laboratory environment

General anaesthesia (blood pressure and heart rate control)

25F devices - surgical access (combined surgery/interventional team approach) Y-graft approach

Additional right radial catheter for check angios

Have CSF drainage as an available option









Case 1

BK

27 y Female

RTA

Severe injuries including multiple pelvic fractures in external fixation







BK follow up

Well and leading a normal life 1 year

later


Case 2

AE

81 y Male

Mycotic aneurysm (salmonella) of descending thoracic aorta with haemoptysis and dysphagia

Previous CABG







AE follow up

Well and leading a normal life 2 years later (oral antibiotic

prophylaxis)


Bristol Experience 2002-2005

11 patients (7 male)

Age 27-81 yr (mean 63)4 chronic aneurysm

3 type B dissection (2 Marfan)

2 traumatic rupture

1 haemorrhagic ulcer

1 mycotic aneurysm

1 failed deployment (vascular access)

No early mortality, 1 late mortality (9 mths ? cause)

CT follow up so far in 8, no endoleaks

1 transient paraplegia (treated CSF drainage)

1 transient renal failure (trash embolisation)


What do we need to do this?

Most importantly a committed team who are prepared to work togetherRadiology and/or cardiology, cardiac surgery and/or vascular surgery, anaesthesia, cath lab team, operating theatre team

High quality imaging

Institutional commitmentFinancial support, clinical governance support (new techniques)

TimeTo learn the technique (visits etc.) To organise each case (small numbers, high complexity)

FacilitiesCath lab/ vascular angio lab (of operating theatre standard) or operating theatre (very high quality image intensifier)


Should we be doing this?

Yes definitely

but…..

A lot of planning is required Protocols for indications and technique requiredGood access to high quality imagingFunding issues are substantial


Call yourselves interventionists?This is a REAL stent!

Documents

Should We Be Doing This? Sealing Dissections: Thoracic Stenting Dr Peter Wilde – Consultant Cardiac Radiologist Dr K Balachandran – Cardiology SpR Mr A