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““Shaggy aorta” is a highly dangerous sign of Shaggy aorta” is a highly dangerous sign of TEVAR for aortic arch aneurysmTEVAR for aortic arch aneurysm

Department of Cardiovascular SurgeryDepartment of Cardiovascular Surgery

Fukushima Medical University, School of MedicineFukushima Medical University, School of Medicine

Fukushima, JAPANFukushima, JAPAN

Shinya Takase, Hirono Satokawa, Yoichi Sato, Shinya Takase, Hirono Satokawa, Yoichi Sato,

Hiroki Wakamatsu, Yoshiyuki Sato, Hiroyuki Kurosawa,Hiroki Wakamatsu, Yoshiyuki Sato, Hiroyuki Kurosawa,

Takashi Igarashi, Akihito Kagoshima, Tsuyoshi Yamabe,Takashi Igarashi, Akihito Kagoshima, Tsuyoshi Yamabe,

Hitoshi YokoyamaHitoshi Yokoyama

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BackgroundBackground

•Conventional surgery for thoracic aortic aneurysm still has high Conventional surgery for thoracic aortic aneurysm still has high

morbidity and mortality.morbidity and mortality.

•In this condition, stentgraft is applied to descending thoracic aortic In this condition, stentgraft is applied to descending thoracic aortic

disease more than graft replacement.disease more than graft replacement.

•For arch aorta, stentgraft is only deployed to high risk patients in For arch aorta, stentgraft is only deployed to high risk patients in

general. However, in TEVAR for this lesion, stroke is concerned general. However, in TEVAR for this lesion, stroke is concerned

because of atheromatous embolization.because of atheromatous embolization.

•Conventional surgery for arch aortic aneurysm even with severe Conventional surgery for arch aortic aneurysm even with severe

atherom induces catastrophic complication followed by early death.atherom induces catastrophic complication followed by early death.

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PurposePurpose

This paper is to explore whether TEVAR This paper is to explore whether TEVAR

for aortic arch aneurysm with “shaggy for aortic arch aneurysm with “shaggy

aorta” is acceptable or not.aorta” is acceptable or not.

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Severely atheromatous aortaSeverely atheromatous aortaDefinition of “Shaggy aorta”

NoramlIntimal thickness(IT) < 2mmNo irregularity

Intimal thickness > 2mmNo irregularity

Irregularity (+)

IT>2mm + Irregularity but not projected

IT>2mm + Irregularity with projection

ASCVTS 2011 Shaggy aorta & TEVAR

Case 4Case 4 77 y.o. male,77 y.o. male,True aortic arch aneurysm, AnginaTrue aortic arch aneurysm, Angina

ASCVTS 2011 Shaggy aorta & TEVAR

Case 1Case 1 ；； 82y.o. female 82y.o. female Arch Aneurysm with aberrant arteryArch Aneurysm with aberrant artery

ASCVTS 2011 Shaggy aorta & TEVAR

Treatment StrategyTreatment Strategy Indication of Conventional Surgery?Indication of Conventional Surgery?

PossiblePossible ImpossibleImpossible

•Age>75 y.o., Age>75 y.o.,

•Severity of co-morbiditySeverity of co-morbidity•Concomittant Procedure (CABG, Valve Surgery)?Concomittant Procedure (CABG, Valve Surgery)?

CSCS

Concomittant Proc.Concomittant Proc.

Difficult Treans-femoral AccessDifficult Treans-femoral Access

YesYes NoNo

debranched SGdebranched SG

Zone0~1Zone0~1 Zone2Zone2

SGSGFenestrated SGFenestrated SG

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SGSG deploymentdeployment•Examination

•MD-CT ＞ Angiography•Endoluminal Stentgraft (tailered made)

•GiantrucoZ 　 stent ; 　 d30-40X l 50-75mm •UBE Ultrathin graft ; d28-40X l 50-150mm

•Delivery system (Pull through)•COOK Guiding Sheath (straight / bending)•0.035” 　 Super stiffness / TERMO J type 　 230cm

•Deployment•Hypotension (60-80mmHg) / ATP 0.2-0.4mg/kg / •Rapid pacing 120-140 ppm

•Monitoring•INVOS / MEP ( in some cases)

ASCVTS 2011 Shaggy aorta & TEVAR

Fenestrated ＳＧ for aortic arch aneurysm

Max diameter;42mmMax diameter;42mm

Saccular typeSaccular type

ASCVTS 2011 Shaggy aorta & TEVAR

(Debranching) + Transaortic SG (Debranching) + Transaortic SG

1) Branched Graft

2) Side clamping and

anastomosis

3) Reconstruction of cerebral arteries

(debraching)

4) Trans-aortic SG

SG (22F Guiding Sheath) over the wire

5F Pigtail

8X16mm Y-graft

8mm

10mm

8mm

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PatientsPatients

Jan., 2001Jan., 2001 ～～ May, 2010May, 2010

SG repair for aortic arch aneurysmSG repair for aortic arch aneurysm

(Non-dissecting aneurysm) (Non-dissecting aneurysm)

2323 CasesCases

Male:Female = 19Male:Female = 19 ：： 4,4,

Age ; 74±7Age ; 74±7 y.o.,y.o.,

Observation ; 30Observation ; 30 ～～ 32193219 （（ 848±1058848±1058 ） ） daysdays

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Patients’ Profile with “Shaggy aorta” or notPatients’ Profile with “Shaggy aorta” or not

Shaggy aorta, n(%) Non “Shaggy aorta”, n(%)

n=23 n=8 n=15

Male:Female 7:1 12:3 0.65

Age 75±6 73±7 0.59

HT 8(100) 15(100) 1.00

HL 6(75) 10(67) 0.67

DM 1(13) 0(0) 0.35

Cerebrovascular diseases 2(22) 5(33) 0.12

Cardiac disorders 3(38) 3(20) 0.62

Respiratory dysfunction 2(50) 3(53) 1.00

Renal insufficiency 2(25) 3(20) 1.00

PAD 4(50) 1(7) 0.033

Multiple aortic aneurysm 2(25) 2(13) 0.59

Logistic EuroSCORE 30.1±24.6 23.1± 20.1 0.76

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Postoperative OutcomePostoperative OutcomeShaggy aorta, n=8 Non Shaggy aorta, n=15

Approach from aorta 5(63) 4(27) 0.18

CPB use 1(13) 2(13) 1.00

Debranching 5(63) 7(47) 0.67

SG top;Zone0/1/2/3 3(38)/3(38)/0(0)/2(25) 2(13)/3(20)/5(33)/5(33) 0.19

Primary Outcome

Endoleak 2(25) 2(13) 0.59

Surgical conversion 0(0) 1(7) 1.00

Additional SG 1(13) 0(0) 0.35

Access trouble 1(13) 2(13) 1.00

Aorta injury 1(13);dissection 1(7); aorta rupture* 1.00

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Postoperative OutcomePostoperative OutcomeShaggy aorta, n=9 Non Shaggy aorta, n=14

Cerebral infarction 1(13) 0(0) 0.35

Respiratory failure 3(38) 2(13) 0.30

Pneumonia 2(25) 0(0) 0.11

Renal dysfucntion 3(38) 1(7) 0.10

Hemodialysis 3(38) 1(7) 0.10

Bowel ischemia 0(0) 0(0) 1.00

Gastric bleeding 0(0) 1(7) 1.00

Paraparesis 2(25) 0(0) 0.11

Any morbidities 5(63) 2(13) 0.026

MOF 1(13) 0(0) 0.35

Death in 30days 1(13) 1(7) 1.00

Hospital death 4(50) 2(13) 0.13

*MOF;1, Pneumonia;2, AAA rupture;1,

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Actual SurvivalActual Survival

1515

Log-rank 　 p=0.13

50%

71%

Shaggy

Non-shaggy

ASCVTS 2011 Shaggy aorta & TEVAR

SummarySummary

• SG treatment for aortic arch aneurysm is technically SG treatment for aortic arch aneurysm is technically successful with debranching and/or fenestrated SG. successful with debranching and/or fenestrated SG.

• There were no differences in preoperative co-There were no differences in preoperative co-morbidities between patients group w/ and w/o morbidities between patients group w/ and w/o “shaggy aorta”.“shaggy aorta”.

• Embolim was induced around 50% in the group with Embolim was induced around 50% in the group with “shaggy aorta”, whereas it was 0% in that without “shaggy aorta”, whereas it was 0% in that without “shaggy aorta”.“shaggy aorta”.

• As the result, once one or more organ dysfunctions As the result, once one or more organ dysfunctions were occurred in such high risk patients, it led to were occurred in such high risk patients, it led to death.death.

• Once the patients with “shaggy aorta” can tolerate Once the patients with “shaggy aorta” can tolerate this treatment, they could survive in long time period.this treatment, they could survive in long time period.

ASCVTS 2011 Shaggy aorta & TEVAR

ConclusionConclusion

““Shaggy aorta“ is a dangerous sign.Shaggy aorta“ is a dangerous sign.

Special caution of handling in this procedure is Special caution of handling in this procedure is

required.required.

Adequate informed consent to such patients is also Adequate informed consent to such patients is also

required. required.

Invention of completely preventive measures against Invention of completely preventive measures against

embolism is aspired.embolism is aspired.