endovascular repair of thoracic arch aneurysms postgraduate course southern association for vascular...
TRANSCRIPT
Endovascular Repair of Thoracic Arch Aneurysms
Postgraduate CourseSouthern Association for Vascular Surgery
H. Edward Garrett, Jr. M.D.Professor of Surgery
University of Tennessee Health Sciences CenterMemphis, TN
Financial & Regulatory Disclosure
• Principal investigator for – Gore TAG post-approval study and – Medtronic VALOR Trials (Talent thoracic stent
graft system)
• W.L. Gore sponsors the University of Tennessee Vascular Conference and the Edward Garrett Sr. Midsouth Vascular Society
Surgical results for open repair of aneurysms involving the aortic arch:
• 30 day mortality 15%• Neuro events 10-15%• 5 year survival 75%• Death primarily related to neurological and cardiac
events• Many patients denied open surgical treatment because
of comorbidities Kirklin/Barratt-Boyes Cardiac Surgery, Third Edition , N.T. Kouchoukos et
al
Landing zones in the thoracic aorta
Coverage of the left subclavian artery:Carotid-subclavian bypass or not?
• Gore TAG IFU: “If occlusion of the left subclavian artery ostium is required to obtain adequate neck length for fixation and sealing, transposition of the left subclavian artery should be considered.”
• Vertebral circulation must be evaluated. ?Impact on paraplegia
• Presence of internal mammary artery graft to LAD mandates revascularization
• Debatable whether left subclavian bypass necessary
LIMA bypass graft off the left subclavian artery
pre-implant post-implant
Arizona Heart Institute
• 255 thoracic endograft pts reviewed (2/00-12/05)• LSA covered in 71 pts; partially covered in 47 pts• 15 of 71 pts had pre-stent bypass → 1
CVA (this pt also had car-car bypass)• 3 of 56 pts without pre-stent bypass had
complications: 2 TIA’s, 1 paraparesis (full recovery)• 1 of 56 pts without pre-stent bypass had lt arm
claudication → car-SC bypass• Many other high volume centers are aggressive about
subclavian revascularization -Data used with permission of Grayson Wheatley III, MD
Results of subclavian revascularization
• Prosthetic carotid-subclavian bypass:
– Patency: 85% @ 7 yr– Mortality: 0-2%– Stroke rate: 1-5%
• Carotid-subclavian transposition:
– Patency: 100% @ 7 yr– Mortality: 1-2%– Stroke rate: 0-2%
Rutherford, Vascular Surgery
Coverage of left carotid &/or innominate arteries not included in IFU
but allows expansion of endovascular technique.Debranching the aortic arch mandates some type
of reconstruction:
• Carotid-carotid bypass • Ascending aorta to innominate &
carotid bypass• Proximal carotid stenting• Femoral-axillary bypass• Chuter graft
Ascending aorto – innominate &/or carotid bypass
• Patency 100% at 7 years• Mortality 5%
• Stroke 7%
Crawford et al, Surgery 1983;94:781-791
Ascending aorta to innominate & carotid bypass (Saleh & Inglese, JVS 2006;44:461)
Results of surgical carotid-carotid and aorto-innominate / left carotid
(Y-graft) bypass
Selected case reports
Carotid-
Carotid
30d Mortality /
CVA
Aorto-innominate/
L carotid
30d Mortality /
CVAOther
Kato et al 1 0 / 0 2 1 / 1(same pt)
Bergeron
et al
15 1 / 1 11 1 / 1 1 retro type A dissection
Czerny et al 9 0 / 0 2 0 / 0
Mangialardi et al
1 0 / 0
Zhou et al 16 1 / 0
Saleh & Ingles
15w/ Ao banding
1 / 0
Buth at al 1(Ao-L car-LSC
0 / 0
TOTAL 26 1 / 1 47 4 / 2
Carotid stenting (T. Larzon et al, Eur J Vasc Endovasc Surg 2005;30:148)
Chuter GraftChuter et al, JVS 2003;38:861
Chuter GraftChuter et al, JVS 2003;38:861
Hybrid techniques(Zhou et al, JVS 2006;44:691)
Hybrid techniques(Zhou et al, JVS 2006;44:691)
Hybrid techniques( Diethrich at al, J Endovasc Ther 2005;12:663 )
Case Study: 77 y/o WF with 6.3cm saccular TAA
• Evaluation of left vocal cord paralysis → CT of chest Feb 2006 → large saccular TAA off lateral aspect of distal arch
• History of extensive spinal surgery in 2004 (Harrington rods at lumbar spine); surgical repair of perforated gastric ulcer in May 2005
Baseline CTA – 3D
Baseline CTA
Baseline arch & cerebral arteriogram
Operative procedures
• Right to left carotid-carotid, left carotid-subclavian bypass using 8mm ringed Goretex graft
• Right common iliac artery conduit using 10mm Hemashield graft
• 34 mm x 15 cm Gore TAG deployed just distal to innominate via 22 Fr sheath
• No spinal drain due to previous lumbar surgery and hardware
Intraoperative aortogram
1-month CTA
Open surgical repair still an option
Case study:
• 41 y/o WM s/p patch repair of thoracic aortic coarctation 23 yr ago
• Severe AI and MR; no sig CAD
• CTA of chest 3/06: recurrent coarctation w/ marked aneurysmal dilatation distally
Left carotid-subclavian bypass and attempted endovascular repair
Persistent type I proximal endoleak 4 days post-op → open chest repair
5 days post tube graft repair
Fenestrated Graft: Is This the Future Solution?
Questions?