Total endovascular archrepair: what welearned so far?
Ciro Ferrer, MDFisiopatologia Chirurgica ad Interesse Vascolare
Sapienza Università di Roma
Disclosure
Speaker name:
Ciro Ferrer
I do not have any potential conflict of interest
OPEN REPAIR
- Mediansternotomy
- Hypothermia
- Cardiopulmonarybypass
- Antegrade cerebralpurfusion
- Massive heparinization
ENDOVASCULAR REPAIR
Car-Subclbypass/transposition
DOUBLE INNER BRANCHENDOGRAFT
Arch branched stentgraftOPERATIVE DETAILS
VASCULAR ACCESSES:
- R femoral a (aortic main body)- L femoral a (angiography)- L femoral v (pacing)- R axillary (innominate stent)- L brachial (L carotid stent)
X X
X
X
X
J Vasc Surg 2011
30 patients screened: 75% conical shapewithout a proximal landing zone
BUILDING A DURABLE ARCH REPAIR
- Avoid landing in diseased ascending aorta Ectatic ascending aorta (>38mm)
Male, 78 yo
CT scan @ 24h
Chronic type B dissection
40 mm
Ascending aorta replacement + total debranching + TEVAR
Dacron graft of at least
5 cm in length
09/2009 – 09/2015
TEVAR n = 483Arch TEVAR n = 181
16 mm
Middle-distal arch disease
5 mm shrinkage @ 24 monthsafter Branched Arch TEVAR
More stable sealingfor a potentiallyfeasible zone 1 repair
Double branch stentgraft
2012 – 2016
Arch branchedprocedures: 14
Bolton (n=9) Cook (n=5)
Single branch: 2/14Double branch: 12/14Technical success: 14/1430-day mortality: 3/1430-day stroke: 2/14
#Implant
DateDevice Age Sex Pathology
Intraoperative
Complication
Perioperative
ComplicationAlive
1 25/06/13 Bolton 70 M TAA N Stroke - death N
2 19/09/13 Bolton 83 M TAA N N Y
3 17/03/14 Bolton 84 M TAA N N Y
4 29/04/14 Bolton 79 M Dissection N N Y
5 22/07/14 Bolton 72 M TAA N N Y
6 06/11/14 Cook 76 M TAA N N Y
7 12/01/15 Cook 64 M DissectionCoverage of L vertebral
artery by vascular plug Stroke Y
8 16/02/15 Bolton 84 M TAA NRetrograde
dissection - deathN
9 05/06/15 Cook 77 M TAA N N Y
10 24/09/15 Cook 75 M TAA N N Y
11 06/02/16 Cook 83 M TAA N N Y
12 21/11/16 Bolton 78 M TAA N N Y
Double inner branch N=12
Arch aneurysmpost type A repair
Dissection ofInnominate artery
Dissection ofR common carotid
Dissection ofLSA
Double branch stentgraft
R car to RSAtransposition
L car - LSAbypass
Car-subcl bypass + LSA emboliz (Plug) + Branched Arch TEVAR
Elongation of Plug due to LSA dissection
Partial coverage of L Vertebral artery
Posterior Stroke
LSA re-entry tear
RCCA re-entry tear
Arch aneurysmpost type A repair
Deployment of a 10-mm V-12 stentgraft in the LSA and a 6-mm Vascular Plug in the false lumen
Deployment of a 9-mm Viabahnstentgraft in the RCCA
Post-op CTA afterSPOT STENTINGtechinique
Male, 86 yo70 mm arch aneurysmThoracic painHorsenessRespiratory distress
LIMA to LADpatent bypass
Persistent aneurysmperfusion
Journal of Endovascular Therapy 2016
2 patients with acute type A aortic dissection treated with
combination of tubular and branched stentgrafts
RelayBranch off-the-shelf device
PROX DIAMETER32 · 34 ∙ 36 ∙ 38 ∙ 40 ∙
42 ∙ 44 ∙ 46 ∙ 48
DISTAL DIAMETER22 · 24 ∙ 26 ∙ 28 ∙ 30 ∙32 ∙ 34 ∙ 36 ∙ 38∙ 40 ∙
42 ∙ 44 ∙ 46 ∙ 48
MAIN BODY LENGTH45 · 60
TOTAL MAIN BODY LENGTH250 · 270
WINDOWLENGTH
50
WINDOWWIDTH
26 ∙ 32 ∙ 38TUNNEL DIAMETER12
PROX DIAMETER13
PROX DIAMETER13
DISTAL DIAMETER8 · 9 ∙ 10 ∙ 11 ∙ 12 ∙ 13
DISTAL DIAMETER14 · 16 ∙ 18 ∙20 ∙ 22 ∙ 24
TOTAL BRANCH LENGTH70 · 80 · 90 · 100
110 · 120 · 130 · 140
Conclusion
Endovascular approach is a valid alternative to open surgery for all patients when morphologically feasible
Identification of a suitable proximal landing zone remains a major concern in TEVAR for arch disease
Dacron ascending aorta is the safest landing zone
An arch branched endograft should be at most 42 mmin proximal diameter (ascending aorta no larger than 38 mm)
Off-the-shelf solutions will be the future for extending the treatment also to emergency