Cervical Debranching for Endovascular Arch
Repair:
Results, Tips and Tricks
ES Debus, Ch Vermeulen, A Larena, S Wipper, N Tsilimparis, T Kölbel
Department for Vascular Medicine
German Aortic Center Hamburg
University Heart Center Hamburg, Germany
Disclosure
Speaker name:
Univ.-Prof. Eike Sebastian Debus, FEBS, FEBVS
.................................................................................
I have no conflicts of interest to this lecture
Gold Standard for the Arch
Surgery for the aortic arch:
– Open repair
– Elephant trunk
– Frozen elephant trunk
Mortality rates 5-15%
Stroke: 4-12%
Sundt et al. 2008; Ann Thorac Surg 86:787-96
Minakawa et al. 2010; Ann Thorac Surg 90:72-7
Tsagakis et al. 2013 Ann Cardiothorac Surg 2:612-20
• n=38 (27 Zone 0, 11 Zone 1)
– Typ A und Typ B Dissection
– Aneurysm Aortic Arch
– TAAA
– Aortobronchial Fistula
• 84% Emergency
• 13.1% Stroke
• 2.7% Paraplegia
• n = 393
• 4.9% stroke, if LSA covered
• 0% stroke, if LSA-Plug before Arch
maneuver or Debranching before
Stenting
Cervical Debranching:
n=193 (2010-2015)
Surgery n additional
Carotid Subclavian
Bypass
139 CCA Interposition (6)
Subclavian
Transposition
26
Carotid Carotid Bypass 14
Vertebral Transposition 11
Subclavian Subclavian 4
Indications
TEVAR (including Ascendant Aorta &
Aortic Arch)
139
Stenosis/Occlusion (Steal or Ischaemia) 14
Ascendens / Arch 8
Subclavian Aneurysm 3
Kommerell Diverticula / Lusorian Artery 2
Trauma 2
Rec. TIA/CVA 1
Complications
Complications n %
Bleeding postop 14 7
Chylus fistula 4 2
Bypass Infection 3 1.5
Horner´s Syndrome 7 3.5
Recurrent Nerve palsy 6 3
Cerebral ischemia 4 2
Death 17 9
Horner´s Syndrome
Vertebral
Transposition
4/11 36%
Subclavian
Transposition
2/26 7.5%
Carotid Subclavian
Bypass
1/139 0.5%
Paresis Recurrent Laryngeal Nerve
Subclavian
Transposition
3/26 11.5%
Vertebral
Transposition
1/11 9%
Carotid Subclavian
Bypass
2/139 1%
Lessons learned:Technical Notes
In case of affection of
common carotid artery:
Common carotid artery
interposition graft
and carotid-subclavian
bypass
.
Lessons learned:Technical Note
for easy wire / graft
access to the
proximal CCA:
Avoid sharp proximal
angle Horizontal
Course of Subclavian-
Carotid Bypass (8 mm
Dacron)
Technical Note
To avoid bleeding:
Separate Open
Debranching from
TEVAR procedure
Reviews on Cervical Debranching…
Kotelis et al. Total vs hemi-aortic arch transposition for hybrid aortic arch repair. J Vasc Surg.
2011 Oct; 54(4):1182
Cao et al. Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections
and other arch diseases. J Thorac Cardiovasc Surg. 2012 Dec; 144(6):1286
Antoniou et al. Hybrid treatment of complex aortic arch disease with supra-aortic debranching
and endovascular stent graft repair. Eur J Vasc Endovasc Surg. 2010 Jun; 39(6):683
Different Diseases,
Different Techniques,
Different Vessels…..
In hospital mortality 6.5-15%
Paraplegia 0-1.5%
Stroke 3.7-12%
• Cervical Debranching: Portfolio for Aortic
Arch and thoracic Aorta Treatment
• Local Complication rates low in High Risk
Patients
• Indications have changed: „Service
Procedure“
• Different Techniques are associated with
different Complications
CONCLUSIONS
Forward. Together.
European Society for Vascular SurgerySpecialists in Vascular HealthCare
Join us in Lyon, France!Sept 19-22 2017
Cervical Debranching for Endovascular Arch
Repair:
Results, Tips and Tricks
ES Debus, Ch Vermeulen, A Larena, S Wipper, N Tsilimparis, T Kölbel
Department for Vascular Medicine
German Aortic Center Hamburg
University Heart Center Hamburg, Germany