Donald AdamDonald AdamConsultant Vascular and Endovascular SurgeonConsultant Vascular and Endovascular Surgeon

Total endovascular repair Total endovascular repair of thoracoabdominal aortic of thoracoabdominal aortic

aneurysmsaneurysms

Disclosure

Preceptor for Cook Medical's fenestrated, Preceptor for Cook Medical's fenestrated, TAAA branch and t-branch EVAR devicesTAAA branch and t-branch EVAR devices

Unrestricted research funding from Cook MedicalUnrestricted research funding from Cook Medical

Current status of TAAA repairCurrent status of TAAA repair

Open repairOpen repair

Performed in small number of hospitals Performed in small number of hospitals Low-risk patients (extent IV, young, CTD) Low-risk patients (extent IV, young, CTD)

High turn-down rateHigh turn-down rate

Endovascular repairEndovascular repair

Performed in small number of hospitalsPerformed in small number of hospitalsHybrid visceral debranching and TEVARHybrid visceral debranching and TEVAR

Fenestrated / Branch EVARFenestrated / Branch EVARHigh-risk (unfit) patientsHigh-risk (unfit) patients

Fenestrated EVARFenestrated EVAR Branch EVARBranch EVAR

TBRANCH-34-18-202TBRANCH-34-18-2023 proximal sealing stents 3 proximal sealing stents

4 branches at 1:00, 12:00, 3:00, 10:004 branches at 1:00, 12:00, 3:00, 10:00

Tick, anterior and branch markersTick, anterior and branch markers

Diameter-reducing tiesDiameter-reducing ties

22 Fr, 60 cm Flexor22 Fr, 60 cm Flexor®® introducer introducer

Distal body Distal body UNIBODY-22-81, 22-98, 22-115, 22-132UNIBODY-22-81, 22-98, 22-115, 22-132

20 Fr, 40 cm Flexor20 Fr, 40 cm Flexor® ® introducerintroducer

34 mm

18 mm

202 mm

81, 98, 115, 132 mm

22 mm

F-EVAR / B-EVAR for TAAA

220 patientsMean diameter = 7cm

Mean age = 75 yrs50% extent IV TAAA

40% previous aortic surgery50% coronary artery disease

50% COPD25% renal failure

F-EVAR / B-EVAR for TAAA

30-day mortality 8%Spinal cord ischaemia 9%

Renal failure 5.8% (50% RRT)Mean ITU stay 3 days

Mean post-op stay 6.5 days

Branch patency 95% @ 12m

_____________________________________________________________________

Chuter 1 100% 0% -Anderson 4 75% 25% 75%Simi 1 100% - -Roselli 73 93% 5% 81%Chuter 22 100% 9% 77%Gilling-Smith 6 100% 0% 100%Ferreira 11 - 24% 76%Bicknell 8 100% 0% -Verhoeven 30 93% 7% 76%Haulon 33 94% 9% 82%Clough 31 100% 10% 80%_____________________________________________________

F-EVAR / B-EVAR for TAAAN= Technical success 30d mortality 1-yr survival

c. 80% 1-year survival

F-EVAR / B-EVAR for TAAA

406 patients54% extent IV TAAA

30-day mortality 4%

Estimated 2-year survival 75%JTCS 2010;140:S171-8JTCS 2010;140:S171-8

CCF 2006 - 2010

Birmingham TAAA EVAR program

Commenced June 2007

High-risk patients unsuitable for OR due to physiological or anatomical factors

Exclusions from this analysis: 65 FEVAR / BEVAR for juxtarenal AAA

10 surgeon-modified FEVAR for acute TAAA45 FEVAR / BEVAR proctored in other hospitals

Patients

June 2007 - February 2014June 2007 - February 2014

8686 high-risk patients high-risk patients [73 men; median 73 (range 54-84) years][73 men; median 73 (range 54-84) years]

Asymptomatic (n=81), acute symptomatic (n=5)Asymptomatic (n=81), acute symptomatic (n=5)

Crawford extent I-III (n=43), extent IV (n=43)Crawford extent I-III (n=43), extent IV (n=43)

Fenestrated (n=49), branch EVAR (n=37)Fenestrated (n=49), branch EVAR (n=37)

PatientsCrawford Extent I 4 (5%)

Extent II 9 (10%)

Extent III 30 (35%)

Extent IV 43 (50%)

Previous aortic surgery * 26 (30%)

Thoracic aortic surgery 3 (3%)

Thoracic EVAR 1 (1%)

Abdominal aortic surgery 19 (22%)

Abdominal EVAR 5 (6%)

* 1 pt – open AAA + TEVAR; 1pt – open AAA + TAAA repair* 1 pt – open AAA + TEVAR; 1pt – open AAA + TAAA repair

Procedures320 target vessels 320 target vessels

coeliac axis (71), superior mesenteric (83), renal (154), arch branches (7), internal iliac artery (4)

scallops (16), branches (102), fenestrations (202)

297 stent-grafted target vessels297 stent-grafted target vesselscoeliac axis (55), superior mesenteric (81), renal (151),

arch branches (6), internal iliac artery (4)

4 target vessels occluded intra-operatively4 target vessels occluded intra-operativelycoeliac axis (1), renal (3)no clinical consequences

Early outcome

Outcome Total (n=86) I-III (n=43) IV (n=43)

30-day mortality 2 (2.3%) 1 (2.3%) 1 (2.3%)

Spinal cord ischaemia * 4 (4.7%) 3 (7%) 1 (2.3%)

Unplanned permanent RRT 0 (0%) 0 (0%) 0 (0%)

Non-fatal CVA 2 (2.3%) 0 (0%) 2 (4.7%)

Myocardial infarction 1 (1.2%) 0 (0%) 1 (2.3%)

Early re-operation 3 (3.5%) 1 (2.3%) 2 (4.7%)

Spinal cord ischaemia

First 40 proceduresSCI = 4 (10%)

Staged procedures introduced for extent I-III Spinal cord protection protocol without CSF drainage

Next 46 procedures 27 extent I-III

SCI = 0

Spinal cord protection protocol

Preserve spinal cord collaterals (LSA, IIA)Preserve spinal cord collaterals (LSA, IIA)

Minimize embolisationMinimize embolisation

Staged procedures for extent I-III TAAAStaged procedures for extent I-III TAAA

Stop anti-hypertensives 3 days pre-operativelyStop anti-hypertensives 3 days pre-operatively

HDU care for at least 36 hours post-operativelyHDU care for at least 36 hours post-operatively

Maintain MAP Maintain MAP >> 80mmHg 80mmHg

Maintain patient lying at 30 degrees for 36 hrs Maintain patient lying at 30 degrees for 36 hrs

Maintain CVP < 15mmHgMaintain CVP < 15mmHg

Maintain oxygen delivery (Hb > 10, pOMaintain oxygen delivery (Hb > 10, pO2 2 > 9, SaO> 9, SaO22 > 95%) > 95%)

Staged proceduresStaged procedures

Stage 1: Complete SMA and RA branches Stage 1: Complete SMA and RA branches Stage 2: Complete CA branch Stage 2: Complete CA branch

Stage 1: Deploy proximal device landing above CA Stage 1: Deploy proximal device landing above CA Stage 2: Complete FEVAR/BEVARStage 2: Complete FEVAR/BEVAR

Stage 1: Complete proximal FEVAR / BEVARStage 1: Complete proximal FEVAR / BEVAR Stage 2: Complete distal repair / limb extensionStage 2: Complete distal repair / limb extension

Allow remodelling of spinal collateralsAllow remodelling of spinal collaterals

Mid-term outcomePatient survivalPatient survival

1 year = 91%1 year = 91%3 years = 88%3 years = 88%5 years = 81%5 years = 81%

Freedom from re-interventionFreedom from re-intervention3 years = 95%3 years = 95%

Late target vessel occlusion = 2Late target vessel occlusion = 2

ConclusionsFenestrated / branch EVAR is associated with good

early and medium-term outcomes in high-risk patients with TAAA

Staged procedures have contributed to a significant reduction in spinal cord ischaemic injury

Patients with TAAA should be evaluated by multidisciplinary teams who are capable of offering

open and endovascular repair