Dr R H Stables

Cardiothoracic CentreLiverpool, UK

Thoracic Aortic Stent Grafting

Introduction

• Pathology of the thoracic aorta

• Referred to cardiologists / cardiac surgeons

• Investigated and treated in cardiac units

• Conventional surgical treatment associated with

• High mortality

• Significant morbidity (including paraplegia)

• ? improved Tx with endovascular techniques

• Requires genuine collaborative working

‘Liverpool cardiologist dies in drive-by shooting’

Collaborative Working

• Cardiologists / Interventional radiologists

• Interventional radiologists have much to offer

• Equipment and techniques

• More related to peripheral intervention

• (Unlike carotid stenting !)

• Experience with abdominal aortic procedures

Collaborative Working

• Cardiologists / Interventional radiologists

• Vascular surgeons / Cardiothoracic surgeons

• Vascular surgical skills

• Issues of vascular access

• Femoral / Iliac / Aorta

• Complications related to device passage

• Iliac vessels

• Cardiothoracic techniques

• Conversion to open procedure

Collaborative Working

• Cardiologists / Interventional radiologists

• Vascular surgeons / Cardiothoracic surgeons

• MRI / CT Imaging specialists

• Radiographic and surgical facilities

• Availability of open surgical conversion

• Anaesthesia ITU Post op - care

• Industrial partners

Thoracic Stent Grafting

• Developing treatment strategy

• Mainly descending aorta

• Indications

• Aneurysm

• Dissection

• Transection

• Perforation

• Open surgical graft procedures (may include Type A)

• Coarctation of the aorta

MRI Image – Thoracic Aneurysm

MRI Image – Thoracic Aneurysm – Post Stent

Angio Images – Thoracic Aneurysm

Slides courtesy of Prof. Rousseau

Mrs MB

• Female 56 years

• CRF - Failing renal transplant (after 20 years)

• Recent return to haemodialysis

• Subclavian dialysis line - septicaemia

• Staph Aureus - Tx Antibiotics through line

• Readmitted with back pain Ix Osteoporosis

• Vomits bright red blood

• Endoscopy and CT scan

• Transfer to CTC Liverpool

Mrs MB

• 3 x simultaneous blood infusions

• Hb 5.4 g/dl

• Left haemothorax PaO2 = 8 kPa on 40% O2

• Infected dialysis line in situ

• No immediate evidence of septic shock

• CT scan imaging

• Emergency thoracic stent procedure

Peripheral Vessel Anatomy

Leaking (x2) Thoracic Aneurysm

Sizes 26, 28, 30, 32, 34, 38, 42, 44, 46 mm

Nitinol rings

Dacron graft

Talent LPS Thoracic Stent Graft System

Thoracic Delivery System

Stent Device (TALENT) Before Deployment

Acute Result

Subacute EndoLeak / Perforation

Use of Forming Balloon

Deployment of Additional Proximal Stent

Deployment of Additional Distal Stent

Final Result

Thoracic Stent Grafting

• Complications• Problems with peripheral vascular access• Low incidence of paraplegia• Migration• Endo-leaks and perforation

• Multiple stents common• Post implant syndrome

Thoracic Stent Grafting

• Initial case series reports

• Many cases surgical contraindication ? Risk

• Acute success 80 - 90%

• 3 year event-free survival 50 - 70%

Questions and Discussion

Angio Images – Thoracic Aneurysm

Slides courtesy of Prof. Rousseau