Endovascular treatment of the ascending aorta –are there indications?

Hans Krankenberg

Hamburg, Germany

L E I P Z I GI N T E R V E N T I O N A L

C O U R S E28-31 January 2020

Disclosure

Speaker name: Hans Krankenberg

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

X I do not have any potential conflict of interest

50%

29,7%

5,1%

4,2%

2,5%8.5

Typ A dissection

Pseudoaneurysm

Aneurysm

Ulcer

Rupture

Other

Endovascular interventions - ascending aorta1995 - 2017

Systematic review, 46 publications, 118 patients

Muetterties et al. 2018 J Vasc Surg 67(1):332-42

Muetterties et al. 2018 J Vasc Surg 67(1):332-42

Access

• femoral 63%

• transapical 14%

• A. carotis 13%

• axillary 7%

Complications (FU Ø 17 months)

• Typ I Endoleak 19%

• Reintervention 9%

• Conversion to surg. 3%

• Cerebrovask. compl. 3%

• Mortality 15%

• Aorta 5%

Endovascular interventions - ascending aorta1995 - 2017

Systematic review, 46 publications, 118 patients

Indication for grafts

• Lesions post surgery:• Pseudoaneurysm

• Postsurgery bleeding

• Residual Dissection

• Lost TAVI

• Ascending aneurysm

• Type A dissection

10 - 30% of patients are not accepted for surgery

TEVAR is an additional optionin 30 to 50% of the patients

Nienaber et al. 2017

Eur J Cardiothorac Surg 2019:55 (1) 133-62; Courtesy of Czerny and Schmidli, MAC 2018

Consensus EACTS/ESVS

Eur J Cardiothorac Surg 2019:55 (1) 133-62; Courtesy of Czerny and Schmidli, MAC 2018

Consensus EACTS/ESVS

Octogenerian patients after surgeryn=57

Total

Without preoperat. moribunde

Piccardo et al. Ann Thor Surg 2009

Surgical ATAAD Repairn=49 (ATAAD after cardiac surgery)

n=281 (spontaneous ATAAD)

Estrera et al. Ann Thor Surg 2010

ATAAD after previous cardiacsurgery

SpontaneousATAAD

Octogenerian patientsacute type A aortic dissection

Rylski et al. Ann Thor Surg 2014;97:1582-9

previous surgery No previous surgery

Mortality Survival

Mortality after type A aortic dissection in patientswith previous cardiac surgery

Kolvenbach et al. 2011; J Vasc Surg 53: 1431-8

• Most are conical• No proximal landing zone

Ascending aneurysm – anatomical limitations

• Endovascular exclusion usuallynot possible in native vessel

Graft geometry

• Undersizing (5% oversizing max.)

• Tapert stent graft (bigger diameter prox.)

Aortic anatomy

• Aortic sinus/coronary arteries (suitable: dissection distal to thesinu-tubular junction)

Kreibich et al. J Vasc Surg 2018;4:69, Courtesy of Roselli

• Consider kinking

• Curved stent graft

• Supraaortal vessels: possible fenestration/arms

Anatomical suitability

• Entry-tear > 10 mm distal to sino-tubularjunction

Kolvenbach et al. J Vasc Surg 2011:53;1431-8Lu et al. JACC 2013;61 (18):1917-24; Sobocinski J et al. EJVS 2011;42:442-7Nordon EJVES 2012; 44:406-10; Moon et al. J. Vasc Surg 2011, Sobocinski et al. J Vasc Endovasc Surg 2011

• Proximal and distal landing zone ≥ 20 mm

• True lumen diameter ≤ 38 mm

• Total lumen diameter ≤ 46 mm

• Suitable access vessels

• No significant aortic regurgitation

• No connective tissue disease, no CAD

Preconditions for TEVAR30-50% of patients eligible

Summary

• Endovascular treatment of ascending aorta is potentially beneficial in selected patients.

• Patients older than 80 years and patients with prior cardiac surgery may benefit

• The anatomy of the ascending aorta has to be matched by dedicated devices

Endovascular treatment of the ascending aorta –are there indications?

hans.krankenberg@web.de