how to manage aortic arch pathology: open, hybrid, chimney
TRANSCRIPT
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How to manage aortic arch pathology:
Open, Hybrid, Chimney or Fenestration
Director & Prof. of Vascular Surgery Center
1. National Center for Cardiovascular Diseases,
Fuwai Hospital, CAMS & PUMC, Beijing, China
2. The Second Xiangya Hospital,
Central-South University, Changsha, China
Chang Shu MD. PhD
Email:
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I do not have any potential
conflict of interest.
Disclosure of Conflicts
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Current Approaches for Arch
➢ Open Repair
Total arch replacement
➢ Hybrid Techniques
Hybrid arch replacement
Debranching + TEVAR
Extra-anatomic bypass + TEVAR
➢ Total Endo Techniques
Fenestrated stent-graft
Branched stent-graft
Chimney technique
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1997-2018 Volume of Aortic Surgery in Fuwai Hospital
Outcomes of Fuwai Hospital
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2018 Aortic Surgery for Different Aortic Segment in Fuwai Hospital
Outcomes of Fuwai Hospital
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TEVAR in Fuwai Hospital & Second Xiangya
Hospital (Nov2015-Nov2018)
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Total arch replacement
—Long operation time with huge trauma
four branch prosthesis vessel implantation LCCA reconstruction
proximal anastomosis
heart resuscitationLSA IA reconstruction procedure completed
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Case characteristics:
➢ Entry tear near the LSA;
➢ Diameter of the ascending aorta was 4.6cm
➢ Aortic valve disfunction
Hybrid Arch Replacement
Strategy:
➢ Avoided DHCA, regular CPB
➢ Extended landing zone in prosthetic graft,
reduce retrograde TAAD
➢ Antegrade and retrograde delivery could be
selected
➢ Reduced complication compare with total
arch replacement
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Hybrid Arch Replacement
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Hybrid Ⅱ:Debranching + TEVAR
Extra bypass+ TEVAR
Advantages
1. Extension of landing zone for healthy aorta
2. One-stage repair supra-aortic branches pathologies
Ascending - Supra Aortic
Branches Transposition
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Branched Stent-grafts
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Fenestration Technique
Fenestration
In Vitro
Fenestration
In Situ
Fenestration
Customized
Fenestration
On-the-table
Fenestration
In Situ Needle
Fenestration
In Situ Laser
Fenestration
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Advantage:
✓ Reduce the operation time: < 45 minutes
✓ More fit to the anatomy of the aortic arch
✓ Less endoleak
On-the-table Fenestration
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Fenestration for Aortic dissection combined with
Aberrant subclavian artery
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Case characteristics:
➢ Entry tear close to the LSA
➢ LSA close to LCCA(Easily covered by chimney graft)
Small fenestration and balloon expansion
to make accurate fenestration size
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Double fenestration for both the
LCCA and LSA
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Double fenestration for both the
LCCA and LSA
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➢ Aneurysm combined with local dissection
➢ Whole aortic arch involved
Triple Fenestration
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Balloon expandable puncture needle
In-situ Fenestration
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In-vitro Fenestration for LCCA
and In-situ Fenestration for LSA
➢ LSA was involved by the huge aneurysm
➢ LCCA was close to the LSA
➢ Stent-graft should be placed proximal to the LCCA
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✓ The aneurysm was well sealed without endoleaks
In-vitro Fenestration for LCCA
and In-situ Fenestration for LSA
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Triple Fenestration
✓ In-vitro Fenestration for IA and LCCA
✓ In-situ Fenestration for LSA
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Fenestration technique, branched stent-graft are
promising, what can we use before that?
Search for a method featured:
➢ Easy to accomplish by current device
➢ Could be used in bailout situation
➢ Minimal invasive
➢ Less complication
Chimney Approach
Special designed Skirt-Stenting Graft
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Chimney + Snorkel
Case characteristic:
➢ 80 years old man
➢ Thoracic aortic aneurysm
➢ Type III aortic arch
➢ LSA stenosis
Chimney for LCCA
and Snorkel for LSA
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Chimney is very useful for aged patients
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Single/Double Chimney
2017 JVS & J Endovasc Ther
122 cases reported from our center
Overall results:
Technical Success Rate:98.6%
84.2% free from any EL
80.6% free from any adverse events
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Chimney in
Marfan Syndrome Patients
Case Characteristic:
➢ Female, Marfan Syndrome
➢ Previous Bentall surgery,
recurrence of back pain
after 8 years
➢ The entry of tear is located
at the opening of the LSA
TEVAR + Chimney for LCCA
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Fenestration in
Marfan Syndrome Patients
Case Characteristic:
➢ Male, Marfan Syndrome
➢ Previous Bentall surgery,
recurrence of B-type
dissection after 5 years
➢ The entry of tear is located
at the opening of the LCCA
TEVAR + Fenestration for IA & LCCA
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Chimney with Endoleaks
Endoleaks can be observed for a few months
6 months 18 months later
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Newly designed chimney graft
The Skirt Stent-graft
➢ Designed for eliminating the endoleak of parallel stent
➢ Multi-center clinical trial is about to begin
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First In Man Cases
May 14th 2018 in Indonesia
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First In Man Cases
May 14th 2018 in Indonesia
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First In Man Cases
Performed in Yunnan Fuwai Hospital
August 21th 2018
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Conclusions
➢ Conventional open surgery has gradually been replaced.
➢ Hybrid technique could be chosen for pathologies involving the
ascending aorta or the aortic root.
➢ Fenestration technique is well-accepted, while Chimney is still
a promising method, branch stent-graft is in developing.
➢ Total endovascular repair to treat aortic arch pathologies is the
wave of the future.
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The 4th China Vascular
Congress (CVC 2019)
Sept. 2019
Beijing, China
Welcome You!
Thanks for your attention!
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How to manage aortic arch pathology:
Open, Hybrid, Chimney or Fenestration
Director & Prof. of Vascular Surgery Center
1. National Center for Cardiovascular Diseases,
Fuwai Hospital, CAMS & PUMC, Beijing, China
2. The Second Xiangya Hospital,
Central-South University, Changsha, China
Chang Shu MD. PhD
Email: