THORACIC AORTIC PATHOLOGY
CHALLENGES AND SOLUTIONS
Thomas C. Naslund, M.D.Vanderbilt University Medical Center
CONFLICT OF INTEREST
WL Gore Investigator, Speaker, ConsultantBoston Scientific ConsultantLeMaitre VascularScientific Advisory Board
OFF LABEL USE
• WL Gore TAG
• Cook Zenith
• WL Gore Excluder
FREQUENTLY SEEN PATHOLOGY
• Aneurysm-fusiform *-saccular (concern for infection)
• Aortic Dissection – Type A* and B• Traumatic transection• Penetrating ulcer• Intramural hematoma
*labeled use for TAG *surgical management
PENETRATING ULCER
INTRAMURAL HEMATOMA
THORACIC AORTIC ANEURYSM
• Atherosclerosis of iliacs– 8-9 mm EI make most TEVAR easy– 7-8 mm EI make some TEVAR difficult– <6 mm EI is a clear danger zone (alternate access)
• Dilation with serial dilators if EI normal• KY jelly helps• Extreme caution with dilators and atherosclerosis
• Tortuosity of iliacs and TA (arch)• Neck
– <2cm in straight distal attachment can work– 2cm with angle in arch will not work
ACCESS FOR THE DISEASED ILIAC
• Conduit– Sutured to the CI artery end to side– Complete TEVAR via conduit– Consider anastomosis to CFA after completion
• May need secondary intervention• CFA may already be exposed/opened/damaged
• Direct CI/Abdominal Aorta Access– Transverse incision over rectus sheath– Retract rectus laterally/RP dissection– CI/terminal aorta easily exposed – Counter puncture in lower quadrant– Direct arterial closure
GOALS OF ENDOVASCULAR MANAGEMENT
Acute Type B Aortic Dissection• Redirect flow into true lumen• Cover entire descending thoracic
aorta• Provide satisfactory visceral flow• Facilitate aortic healing• Avoid surgical repair
DISSECTION TREATMENT ALGORITHM
• Type A- Medical Therapy &Emergency Cardiac Surgery Evaluation
• Type B- Medical therapy» Stent graft for complications in acute phase» Stent graft for aneurysm formation in late follow up» Long term follow up for all Type B to assess aneurysm
formation/stent graft
NECK PROBLEMS/SOLUTIONS
• Big (>36mm) – 45mm TAG in EU
• Small (<23mm)– 18-23mm diameter graft
• Short (< 2cm)– Debranching/fenestration
• Angled (>?)– Specific design/fenestration
LENGTHENING THE NECKCovering Branch Vessels
• Left Subclavian– Consider vertebrobasilar circulation
• Contralateral vertebral/carotid disease • Celiac
– Consider pancreaticoduodenal and gastroduodenal • SMA disease
• Coiling typically not needed– Subclavian for Type II leak
• Transbrachial– Celiac
• Flow robust– Catheterize, cover celiac/trap catheter, coil
SURGICAL DEBRANCHING
• Viscerals– Celiotomy
• Midline gets all 4• Left flank gets 3,maybe 4
• Arch– Left subclavian to carotid transposition– Carotid-carotid bypass (retroesophageal)– Aortoinnominant & carotid bypass
ARCH REPAIR
TRAUMATIC TRANSECTION
• Deceleration injury–MVA –falls
• Sudden movement of aortic arch
• Circumferential tear of arterial intima and media
• Survivors have intact adventitia and possibly some media
TRAUMATIC TRANSECTION
• Innominate artery second most common site
VANDERBILT SERIESOpen Repair 1987
• 41 Patients• 5 Died without repair
– 3 preoperatively– 2 en route with emergency thoracotomy
• 5/36 Repaired died during operation– 3/5 associated with aortic clamping
• 2/36 Paraparesis
TRANSECTION PRE OP MEDICAL MANAGEMENT
• Beta Blockade• BP/HR control• Discontinue after repair
STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION
n = 20
• Since 2005• Age 35 (15 – 72)• Mortality 1/20 (5%) – 72 yo MSOF
STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION
n = 20• Mean procedure time 103min• Mean blood loss 390ml• Mean intraoperative transfusion 1 unit• Grafts utilized
– TAG - 9– Cook Iliac extenders- 9– Excluder aortic cuffs - 2
STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION
n = 20
• Technical success 100%– graft exclusion of injured
segment– No deaths pre operatively
• Operative complications– groin access site – 2– TAG graft collapse – 2
– spinal cord injury – 0– dialysis – 0
LATE FOLLOW UP
• Erosions – 0• Endoleaks/aneurysm – 0• Access site false aneurysm – 0• Paraplegia – 0• Secondary interventions – 0
USE OF COOK ILIAC LIMB EXTENDER
• Aorta diameter too small for TAG prosthesis (<23mm)
• 55 mm length (satisfactorily covers entire area of injury)
• Z stent design (no collapse)• Requires manual loading into long sheath to
reach aortic arch
ZENITH Delivery and Deployment
USE OF ABDOMINAL AORTIC CUFF EXTENDERS
• 33 – 36 mm length• Reported in several series with success• Requires 3 or more individual cuffs to bridge
injured region• Requires inventory of substantial numbers of
aortic cuffs• Cook, Medtronic, and Gore
TIGHT ARCH
• Typical of adolescence and young adults
• Implant can either poorly oppose the inner arch and collapse
FOLLOW UP• Interval CT in 1 – 3
days (renal function considerations)
• Follow up CT 1 -3 months after discharge
• Annual CT • Eventually CT each 3-5
years • Emphasis on permanent
life-long follow up
LATE CONCERNS
• Erosion
• False aneurysm formation
• Infections
MINIMAL AORTIC INJURY
• Focal-non-circumferential intimal disruption• No false aneurysm• No periaortic hematoma• Suitable for medical therapy and CT follow up
rather than intervention– Healing typical in 3-6 months– Persistent fixed lesions identified after 1 year
followup
