The efficacy of debranching TEVAR for arch aneurysm in high risk patients.

Osaka UniversityOsaka University Department of Cardiovascular SurgeryDepartment of Cardiovascular Surgery


The efficacy of debranching TEVAR for arch aneurysm

in high risk patients.

Department of Cardiovascular surgeryOsaka university graduate school of medicine

Y Shirakawa, T Kuratani, K Shimamura, M Takeuchi, K.Kin, T.Yoshida

Y Sawa



Background

The traditional treatment of thoracic aortic aneurysms is open surgical graft replacement. Despite progressive surgical advances, conventional surgical repair is still associated with substantial morbidity and mortality, especially in elderly patients with other major medical conditions. Aortic arch aneurysms present a particular challenge to endovascular repair due to the involvement of supra-aortic vessels and the anatomic curvature of the arch. A variety of maneuvers have been recommended for thoracic endografting to address the landing zone limitations imposed by the arch vessels.



Objectives

This report presents the results of a review of our 10-year clinical

experience with endovascular treatment of aortic arch aneurysms

after debranching of arch vessels (debranching TEVAR).



Number of Patients : 90 cases (Jan. 1998 ～ Nov. 2009)

Sex : Male 65, Female 25Age : 68.9 ±11.7 （ 27 ～ 95 ） years oldpathology　　　 Type B dissection 37 cases （ acute case 10 ）　　　 Degenerative 44 cases （ rupture case 4 ） Infective/inflammatory 3 cases Traumatic 4 cases　　　 cancer invasion 2 casesco-morbidity

High age (over 80 y.o) 17 cases (18.8 %)COPD 30 cases (33.3 %)

Concomitant cancer 17 cases (18.8 %) CAD 12 cases (13.3 %) previous cardiac surgery 4 cases (4.4 %)

Debranching TEVAR

Logistic Euroscore : 15.93% +/- 9.77 % (2.76 ~ 43.67)



Proximal landing zone

10

19 61

Arch reconstruction procedure

Debranching TEVAR

Ao-rt.SCA-lt.CCA-lt.SCA bypass 9 bil.FA-rt.SCA-lt.CCA-lt.SCA bypass 1

Zone 0

rt.SCA-lt.CCA-lt.SCA bypass 19

Zone 1

Zone 2

rt.SCA-lt.SCA bypass 32lt.CCA-lt.SCA bypass 5Simple sacrifice of lt.SCA 24



Ao-rt.SCA-lt.CCA-lt.SCA bypass

Approach : Median sternotomy

Inflow : Side clamp of Ascending Aorta.

Prosthesis : 12mm Hemashield for rt. SCA 8mm Hemashield for lt.CCA & lt.SCA

Ao – rt. SCA bypass ~ avoid direct clamp of BCA



Debranching TEVAR

Primary success 97.8% (88/90)

type bⅠ ~ 1, type ~ 1Ⅱ

30 days Mortality 1.1 % (1/90)

due to iliac rupture

Postopeative Complication

Stroke 2 (2.2%) (Z2 ~ 2)

Respiratory failure 1 (1.1%)

Paraplegia 0

Early results



1 year 88.1 % 3 year 77.2% 5 year 69.5%10 year 69.5%


1 3 5 7 10

100

20

40

60

80

0

Late results

All cause survivalFreedom from aneurysm related death

1 3 5 7 10

100

20

40

60

80

0

(y) (y)

Debranching TEVAR

(%) (%)




Freedom from Aortic event

Re-TEVAR 3 distal enlargement 1 type b endoleak 2 Ⅰ in dissection case.Open conversion 1Graft infection 1Rupture 1

1 3 5 7 10

100

20

40

60

80

0

Debranching TEVAR

(y)

(%)



Discussion

Operative mortality : 4.3 %In-hospital mortality : 7.2 %Strokes : 5.8 %Paraplegia : 2.9 %

Freedom from Aortic events



Strategy for Arch Aneurysm

Debranched TEVAR

Arch and distal arch aneurysm

Open Surgery

High risk patientsFirst choice

Patients conditionAnatomical condition

First choice

Anatomical limitations• Proximal neck diameter 34 ~ 37mm, length 20mm diameter 23 ~ 33mm, length 15mm•Character of Aortic wall (ascending aorta)



Conclusion

Debranched TEVAR for aortic arch aneurysms appears to reduce the early mortality and morbidity and long-term durability is very acceptable.

Our results suggested that this procedure might be an alternative procedure for low risk patients.

In the future, ready made branched endoprostheses will be installed, which may expand the applications of this procedure.

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The efficacy of debranching TEVAR for arch aneurysm in high risk patients.

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