Total endovascular repair for thoraco Total endovascular repair for thoraco abdominal aortic aneurysmsabdominal aortic aneurysms

Michael Jacobs, Geert Willem Schurink

Maastricht University Medical Center, the Netherlands

University Hospital Aachen, Germany

Open surgery for TAAA has always been the

untill hybrid and endo techniques were introduced

TAAA Surgery: always some problem …

Is TEVAR already applicable for TAAA ?

Limited experience, mainly in high surgical risk patients

Complex technology, very expensive

Questionable longevity of material (interconnections)

Serious complications

Unclear indications

But, ……it will eventually dictate the future

Furthermore,….endosurgery of TAAA is more than introducing a device

Judging CT-MRA images

Performing adequate measurements

Designing an endovascular/hybrid plan

Execute the plan

Understanding and treating complications

Part of a multidisciplinary team

SHORT INFRARENAL NECK AND SHORT INFRARENAL NECK AND JUXTARENAL ANEURYSMSJUXTARENAL ANEURYSMS

Workstation is essentialWorkstation is essential

Axial versus MPR measurementsAxial versus MPR measurements

10-11mm distance 6mm distance

Clock positionClock position

9:30 hr 3:00 hr

Central Lumen Line reconstructionCentral Lumen Line reconstruction

Relative Central lumen line distanceAfstandRelative Central lumen line distanceAfstand

Distance Reference LineDistance Reference Line

LOWER COELIAC 00

MID SMAMID SMA

LOWER SMALOWER SMA

MID RIGHT RENALMID RIGHT RENAL

MID LEFT RENALMID LEFT RENAL

13131818

28283434

Thoracoabdominal Aortic AneurysmThoracoabdominal Aortic Aneurysm

ScallopScallop

FenestrationsFenestrations

Atrium V12 stent

Internal-external Branch

Helical Branch

SMA

Celiac axis

Right renalLeft renal

2 cm

Celiac axis

SMA

Right renalLeft renal

2 cm

8 Fr Flexor Sheath

12 Fr Flexor Shleath

Type I TAAAType I TAAA78 years; 78 years; Ø80mmØ80mm

Man (1940) Man (1940) TAAA IV (TAAA IV (Ø 70 mm) after aortic arch and Ø 70 mm) after aortic arch and

descending thoracic repairdescending thoracic repair

TAAA repairTAAA repair

� Mortality (30day) 13% 15% 5,4%

� Paraplegia 4,5% 8,4% 2,7%

� MI 3,6% ? 5,4%

� Dialysis 1,8% 4% 1,4%

1) Maastricht Open Experience. Jacobs et al. JVS 2006

2) St Mary’s/Heidelberg/Munich. Drinkwater et al. EJVES 2009

3) Cleveland Clinic, presented at AATS, 2006

Open repair(n=112)

Hybrid repair(n=107)

Endo repair(n=73)

ConclusionConclusion

Will total endovascular repair be the future for TAAA?

It needs to be ...It needs to be ...

FasterIn situ fenestration??

BetterMore flexible

Low(er) profile endoprostheses