TEVAR for Aneurysmal

Disease

Grayson H. Wheatley III, M.D.

Arizona Heart Institute

Phoenix, Arizona

AATS 2012 San Francisco April 29, 2012

Disclosures

W.L. Gore & Associates – Scientific Advisory Board,

Consultant

Medtronic – Consultant

Bolton Medical – Research Grant (RELAY Trial)

Atherosclerotic Aneurysm

Acute Dissecting Aneurysm with Vascular Compromise

Chronic Dissection with Expansion

Aortic Ulcer with Embolization

Adult Coarctation

Pseudo Aneurysm Associated with Previous Repair

Acute Transection Secondary to Trauma

Potential opportunities for endoluminal treatment of thoracic aortic pathologies

“There is one thing

stronger than all the

armies in the world,

and that is an idea

whose time has

come.” Victor Hugo

General Sizing and Recommendations

Diameter: Oversize 20% (2-4mm over)

2cm

Left subclavian

Celiac 2cm

On-Label

Celiac Axis

Left Subclavian

Left Common Carotid

Descending Thoracic

Aorta

Z0

Z1 Z2

Z3

Z4

Compiled Data

TEVAR for Thoracic Aneurysms

Overview

Key topics

Outcomes

Stroke

Spinal cord ischemia/protection

Dealing with the Left subclavian

Arch Aneurysms

Hybrid Repair

Pre-Operative Planning

Components of Thoracic

Endografting Pre-operative

History and Physical

• pulses

Imaging

• CXR

• Helical CT scan (1-3mm slices minimum)

• Angiogram

Pre-operative planning

• 3D reconstruction (M2S/TeraRecon)

• Vascular access issues

• Proximal and Distal landing zones

• Device selection

• Spinal drain

Components of Thoracic

Endografting

Operative

– Spinal drain (if necessary)

– Imaging equipment

– Patient Positioning

– Imaging

• Angiogram

• Intravascular Ultrasound

– Vascular Access

• Femoral

• Retroperitoneal conduit

– Sheath Delivery

Thoracic Aorta Morphology AHI Classification

Level 1 Level 2 Level 3 Level 4

Operative (continued)

– “Roadmapping”

– Device delivery

– Device deployment

– Ballooning

– Endoleaks

– Sheath removal

– Repair of vascular

access

Components of Thoracic

Endografting

Post-Operative

– BP issues

– Spinal cord protection

– Graft Surveillance

Components of Thoracic

Endografting

Conformable GORE TAG

COOK Zenith TX2 Pro-Form

Medtronic Valiant Stent-Graft

Bolton Relay Thoracic Stent-Graft

INVESTIGATIONAL

Stent Deployment Considerations

Flexibility of stent

Length of the stent

Radial strength

Expansion characteristics

Endografts Do Fail…

Surveillance!

Chest CT Post-op

1 month

3 months

6 months

12 months

Annually

TEVAR for Thoracic Aneurysms

Overview

Key topics

Outcomes

Stroke

Spinal cord ischemia/protection

Dealing with the Left subclavian artery

Arch Aneurysms

Hybrid Repair

TEVAR for Thoracic Aneurysms

Overview

Key topics

Outcomes

Stroke

Spinal cord ischemia/protection

Dealing with the Left subclavian artery

Arch Aneurysms

Hybrid Repair

TEVAR for Thoracic Aneurysms

Overview

Key topics

Outcomes

Stroke

Spinal cord ischemia/protection

Dealing with the Left subclavian artery

Arch Aneurysms

Hybrid Repair

TEVAR for Thoracic Aneurysms

Overview

Key topics

Outcomes

Stroke

Spinal cord ischemia/protection

Dealing with the Left subclavian artery

Arch Aneurysms

Hybrid Repair

Thoracic Single Side Branch Device

Device Description

Thoracic component

flexibility provides

conformance to the

inner curve of the

aortic arch

W.L. Gore & Associates

Thoracic Single Side Branch Device

Device Description

Inner docking lumen

provides anchoring and

sealing for modular side

branch component

W.L. Gore & Associates

Thoracic Single Side Branch Device

Device Description

Modular side

branch component

accomodates a

variety of vessel

diameters

W.L. Gore & Associates

Thoracic Single Side Branch Device

Porcine Animal Model Deployment

W.L. Gore & Associates

Thoracic Single Side Branch Device

Porcine Animal Model Deployment

Retrograde perfusion of thoracic

branch in porcine animal model W.L. Gore & Associates

TEVAR for Thoracic Aneurysms

Overview

Key topics

Outcomes

Stroke

Spinal cord ischemia/protection

Dealing with the Left subclavian

Arch Aneurysms

Hybrid Repair

Distal Aortic Arch Aneurysm

Excluded with Endoluminal Graft and Carotid-Subclavian Bypass

TEVAR for Thoracic Aneurysms

Overview

Key topics

Outcomes

Stroke

Spinal cord ischemia/protection

Dealing with the Left subclavian

Arch Aneurysms

Hybrid Repair

New Hybrid Classification System

Hybrid Type I Hybrid Type II

Summary

TEVAR for thoracic aneurysms

has evolved in the 7 years post-

approval

Outcomes have shown an

improvement for high-risk

patients

Incidence of complications and

key clinical issues have room

for improvement

TEVAR for Aneurysmal

Disease

Grayson H. Wheatley III, M.D.

Arizona Heart Institute

Phoenix, Arizona

AATS 2012 San Francisco April 29, 2012