TEVAR for Ascending Aortic Aneurysm with Minimalist Approach

TEVAR for Ascending Thoracic Aortic Aneurysm (ATAA) with Minimalist Approach Abdelkader Almanfi, MD, MRCP-UKInterventional cardiology FellowTexas Heart Institute

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Nothing to disclose related to this presentation

Disclosures

Clinical Presentation A 79-year-old male patient was referred to us by cardiothoracic surgery for endovascular repair for saccular aneurysm ATAA due to his risk comorbidities

Aortogram showed a saccular ascending thoracic aortic aneurysm

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Initially, he was diagnosed with ATAA after he sustained a cardiac arrest, ventricular fibrillation, he was cardioverted by paramedics and was admitted to the hospital

He underwent Coronary Angiography which revealed no evidence of CAD, Aortogram showed a saccular ATAA

ICD was implanted for secondary prevention of SCD

PMH: HTN, h/o SBE with Mitral regurgitation, atrial fibrillation, cardiac arrest, ventricular fibrillation, recent ICD obesity, MV repair

Computed Tomography Angiography (CTA) of the chest revealed a saccular ascending aortic aneurysm originating approximately 3 cm from the left coronary artery and ending 3 cm from the origin of the Innominate artery.

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Our Plan

Due to high surgical risk and comorbidities including previous mitral surgery, recent cardiac arrest and the anterior location of the aneurysm and close proximity to the sternum, we decided to proceed with

endovascular repair of ascending aortic thoracic aneurysm under local anesthesia, conscious sedation, percutaneous approach with RV pacing

Procedural Technique

The procedure was done in the endovascular suiteAccess :A percutaneous access using micropuncture technique in both CFAs and 6 Fr sheaths were placed in the right and left CFAsVenous access in the left CFV with 6 Fr Sheath, used for temporary pacemaker of the RV for rapid RV pacing during deployment A 10 Fr Prostar device was used to preclose the right CFA, and 6 Fr Proglide was used to preclose the left CFA.

Left common femoral vein access -> 6 Fr x 75 cm long sheath was advanced over the wire and fluoroscopy guidance to the right atrium. Through this sheath, 5 Fr Balloon tipped Pacemaker catheter was introduced and advanced to the apex of the RV for rapid pacing. The pacemaker was connected and tested for rapid pacing during graft deployment at later stage. Afterwards, the patient's AICD was temporarily turned off.

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Prostar XL Technique

Aortic Angiogram

A 5 Fr. marker pigtail (20 markers) was then introduced under fluoroscopic guidance into the thoracic aorta and placed at the right coronary sinus.

A 50 cc injection was performed with digital imaging to assess the aneurysm and determine the anatomical relationship with the left coronary artery and the Innominate artery.

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From the Right CFA access, the aortic valve was crossed using regular J wire and JR5 Catheter.

The wire then was exchanged with .035 Lunderquist that was positioned inside the LV cavity.

Progressive dilatation of the ipsilateral side with 14, 16, 18 Fr sheaths was performed successfully.

A 22 Fr. Medtronic sheath was placed with no complications.

Next, 5 Fr Pigtail catheter was advanced through Left CFA and advanced to the ascending aorta for marking the innominate artery at the time of deployment.

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advancement & positioning of a (44 mm D x 80 mm L)Valiant Medtronic stent graft

Next, we advanced Valiant (44 mm x 44 mm x 80 mm length) stent graft to the ascending aorta. The device was deployed under fluoroscopy guidance and rapid ventricular pacing to 180 BPM to reduce cardiac output and stabilize the graft, keeping in mind the distance from the left main coronary artery.

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First stent graft deployed in the ascending aorta

Angiography obtained after the deployment of the endograft revealed a significant foreshortening of the endograft and presence of small endoleak; 11

Second Valiant (44 mm x 80 mm length) stent graft overlapped with first graft Angiography after deployment of the endograft revealed a significant foreshortening and presence of small endoleak

Angiography obtained after the deployment of the endograft revealed a significant foreshortening of the endograft and presence of small endoleak; We advanced second Valiant (44 mm D x 80 mm L) stent graft to the ascending aorta, and the device was deployed under fluoroscopy guidance and rapid ventricular pacing to 180 BPM to reduce cardiac output and stabilize the graft, keeping in mind the distance from the innominate artery which was protected using pigtail catheter.

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Final angiogram showing total exclusion of the aneurysm and patency of coronary and the Innominate arteries.

Angiogram documenting patency of the innominate artery

Our patient had uneventful post-op course and was discharged home next morning

CTA after one month follow up

Learning points To the best of our knowledge, we are reporting the first case of endovascular repair of ATAA under local anesthesia, conscious sedation, percutaneous approach with RV pacing. The current standard treatment of ATAA is the surgical approach as endovascular repair is very challenging due to the anatomical complexities including the origin of aortic arch vessels, hemodynamic forces, respiratory motion, angulation of the inner aortic curvature and proximity to the coronary/Innominate arteries and the aortic valve. There are no specific devices designed and approved for this purpose.

In our patient, a successful repair of ascending aortic aneurysm has been performed under local anesthesia, and that combination of TEVAR of ascending aorta with local anesthesia & conscious sedation is what makes this case unprecedented and could be used in the future in the appropriate settings as an alternative to more invasive approaches.

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Thank you