THORACIC AORTIC PATHOLOGY

CHALLENGES AND SOLUTIONS

Thomas C. Naslund, M.D.Vanderbilt University Medical Center

CONFLICT OF INTEREST

WL Gore Investigator, Speaker, Consultant

Boston Scientific Consultant

LeMaitre VascularScientific Advisory Board

OFF LABEL USE

• WL Gore TAG

• Cook Zenith

• WL Gore Excluder

FREQUENTLY SEEN PATHOLOGY

• Aneurysm

-fusiform *

-saccular (concern for infection)

• Aortic Dissection – Type A* and B

• Traumatic transection

• Penetrating ulcer

• Intramural hematoma

*labeled use for TAG

*surgical management

PENETRATING ULCER

INTRAMURAL HEMATOMA

THORACIC AORTIC ANEURYSM

• Atherosclerosis of iliacs– 8-9 mm EI make most TEVAR easy

– 7-8 mm EI make some TEVAR difficult

– <6 mm EI is a clear danger zone (alternate access)• Dilation with serial dilators if EI normal

• KY jelly helps

• Extreme caution with dilators and atherosclerosis

• Tortuosity of iliacs and TA (arch)• Neck

– <2cm in straight distal attachment can work

– 2cm with angle in arch will not work

ACCESS FOR THE DISEASED ILIAC

• Conduit– Sutured to the CI artery end to side– Complete TEVAR via conduit– Consider anastomosis to CFA after completion

• May need secondary intervention• CFA may already be exposed/opened/damaged

• Direct CI/Abdominal Aorta Access– Transverse incision over rectus sheath– Retract rectus laterally/RP dissection– CI/terminal aorta easily exposed – Counter puncture in lower quadrant– Direct arterial closure

GOALS OF ENDOVASCULAR MANAGEMENT

Acute Type B Aortic Dissection

• Redirect flow into true lumen

• Cover entire descending thoracic aorta

• Provide satisfactory visceral flow

• Facilitate aortic healing

• Avoid surgical repair

DISSECTION TREATMENT ALGORITHM

• Type A- Medical Therapy &Emergency Cardiac Surgery Evaluation

• Type B- Medical therapy» Stent graft for complications in acute phase» Stent graft for aneurysm formation in late follow up» Long term follow up for all Type B to assess aneurysm

formation/stent graft

NECK PROBLEMS/SOLUTIONS

• Big (>36mm) – 45mm TAG in EU

• Small (<23mm)– 18-23mm diameter graft

• Short (< 2cm)– Debranching/fenestration

• Angled (>?)– Specific design/fenestration

LENGTHENING THE NECKCovering Branch Vessels

• Left Subclavian– Consider vertebrobasilar circulation

• Contralateral vertebral/carotid disease

• Celiac– Consider pancreaticoduodenal and gastroduodenal

• SMA disease

• Coiling typically not needed– Subclavian for Type II leak

• Transbrachial– Celiac

• Flow robust– Catheterize, cover celiac/trap catheter, coil

SURGICAL DEBRANCHING

• Viscerals– Celiotomy

• Midline gets all 4

• Left flank gets 3,maybe 4

• Arch– Left subclavian to carotid transposition– Carotid-carotid bypass (retroesophageal)– Aortoinnominant & carotid bypass

ARCH REPAIR

TRAUMATIC TRANSECTION

• Deceleration injury–MVA

–falls

• Sudden movement of aortic arch

• Circumferential tear of arterial intima and media

• Survivors have intact adventitia and possibly some media

TRAUMATIC TRANSECTION

• Innominate artery second most common site

VANDERBILT SERIESOpen Repair 1987

• 41 Patients

• 5 Died without repair– 3 preoperatively

– 2 en route with emergency thoracotomy

• 5/36 Repaired died during operation– 3/5 associated with aortic clamping

• 2/36 Paraparesis

TRANSECTION PRE OP MEDICAL MANAGEMENT

• Beta Blockade

• BP/HR control

• Discontinue after repair

STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION

n = 20

• Since 2005

• Age 35 (15 – 72)

• Mortality 1/20 (5%) – 72 yo MSOF

STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION

n = 20• Mean procedure time 103min

• Mean blood loss 390ml

• Mean intraoperative transfusion 1 unit

• Grafts utilized– TAG - 9

– Cook Iliac extenders- 9

– Excluder aortic cuffs - 2

STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION

n = 20

• Technical success 100%– graft exclusion of injured

segment

– No deaths pre operatively

• Operative complications– groin access site – 2

– TAG graft collapse – 2

– spinal cord injury – 0

– dialysis – 0

LATE FOLLOW UP

• Erosions – 0

• Endoleaks/aneurysm – 0

• Access site false aneurysm – 0

• Paraplegia – 0

• Secondary interventions – 0

USE OF COOK ILIAC LIMB EXTENDER

• Aorta diameter too small for TAG prosthesis (<23mm)

• 55 mm length (satisfactorily covers entire area of injury)

• Z stent design (no collapse)

• Requires manual loading into long sheath to reach aortic arch

ZENITH Delivery and Deployment

USE OF ABDOMINAL AORTIC CUFF EXTENDERS

• 33 – 36 mm length

• Reported in several series with success

• Requires 3 or more individual cuffs to bridge injured region

• Requires inventory of substantial numbers of aortic cuffs

• Cook, Medtronic, and Gore

TIGHT ARCH

• Typical of adolescence and young adults

• Implant can either poorly oppose the inner arch and collapse

FOLLOW UP

• Interval CT in 1 – 3 days (renal function considerations)

• Follow up CT 1 -3 months after discharge

• Annual CT • Eventually CT each 3-5

years • Emphasis on permanent

life-long follow up

LATE CONCERNS

• Erosion

• False aneurysm formation

• Infections

MINIMAL AORTIC INJURY

• Focal-non-circumferential intimal disruption

• No false aneurysm

• No periaortic hematoma

• Suitable for medical therapy and CT follow up rather than intervention– Healing typical in 3-6 months– Persistent fixed lesions identified after 1 year

followup