treatment of thoracoabdominal aortic aneurysms. surgery alone or hybrid
TRANSCRIPT
Lenox Hill Heart and VascularInstitute of New York
Treatment of Thoracoabdominal Aortic Aneurysms. Surgery alone or Hybrid.
Konstadinos A Plestis, MD
Associate Professor
Director of Aortic Surgery
Department of Thoracic and Cardiovascular Surgery
Lenox Hill Hospital, NY
Lenox Hill Heart and VascularInstitute of New York
The Risk of ParaplegiaCrawford Classification (n = 1509)
I II III IV
15% 31% 7% 4%
Svensson LG, Crawford ES: J Vasc Surg 1993; 17:357-370
Lenox Hill Heart and VascularInstitute of New York
Open Surgical Treatment
Extensive Operations
Need of CPB + DHCA
Risk of Paraplegia
Post-operative Mortality and Morbidity
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Endovascular Treatment
Decreases Access Trauma
Decreases Blood Loss
Reduces Morbidity and Mortality?
Improves long term outcomes?
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Spinal Cord Protection
Cerebral Protection
Visceral Organ Protection
Goals during Open Repair of TA Aneurysms
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Current Lenox Hill Technique
Mild systemic hypothermia, 32°C
Distal perfusion
CSF drainage
Monitoring of SSEP and MEP
Spinal cord perfusion pressure (SCPP) monitoring
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DHCA: Indications
Proximal clamping is not feasible
Need to clamp above the left subclavian
Type II Aneurysms?
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CSF Drainage Technique
CSF catheter : L4-L5 or L3-4
CSF pressure < 10mmHg
CSF drainage: 10 cc/h
CSF drainage for 2-3 days
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Current Lenox Hill Technique
Mean BP: 85-95mmHg
CSF drainage for 72-96 hr
CSF drainage at 10 cc/hr
SCPP monitoring
Steroids for 48 hrs
Postoperative Management
Lenox Hill Heart and VascularInstitute of New York
Motor-evoked potential (MEP) amplitudes
baseline MEP MEP amplitude disappearance
MEP amplitude recovery
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CASE PRESENTATION
42 yo patient
Distal Arch/ Type I TAAA
Lenox Hill Heart and VascularInstitute of New York
BUN
23.7
30.4
17.04
20.4
38.1
24.2
19.3
40.5
26.2
Pre OP Highest End
NO DHCA
BUN (all cases)
DHCA
=p<.05
Lenox Hill Heart and VascularInstitute of New York
CREATNINE
1.49
2.03
1.431.48
2.92
2.06
1.48
2.83
1.98
Pre OP Highest End
NO DHCA
Creatnine (all cases)
DHCA
Lenox Hill Heart and VascularInstitute of New York
AMYLASE
54
428
194
61
175
7962
148
62
Pre Op Highest End
DHCA
Amylase (all cases)
NO DHCA
Lenox Hill Heart and VascularInstitute of New York
Total Bilirubin
0.65
2.75
1.23
0.66
2.85
1.170.68
3.46
0.81
Pre OP Highest End
NO DHCA
T. Bilirubin (all cases)
DHCA
Lenox Hill Heart and VascularInstitute of New York
SGOT
16
344
3722
137
3323 102
36
Pre OP Highest End
DHCA
SGOT (all cases)
NO DHCA
Lenox Hill Heart and VascularInstitute of New York
16
220
54
19
84
362062
33
Pre OP Highest End
DHCA
SGPT (all cases)
NO DHCA
SGPT
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Visceral Perfusion
Dilute Blood
Rate at 100-200 cc/min
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Case Presentation
67 yr old patient
Type IV TAAA
Previous Descending TA repair
Symptomatic
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Stroke Prevention
Cannulation TechniquesLeft Axillary CannulationAscending Aorta CannulationArch cannulation
Stage I Elephant Trunk
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62 yr old patient
Type I TAAA
Grade V aortic arch
Stenosis of the Celiac, SMA
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January 2002 – July 2011
Total Cases 219
male 112 51%
female 107 49%
Age 66 + 13
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Etiology: N=219
0
10
20
30
40
50
60
70
80
90
Medial
Degen.
Ather. Chr.
Diss.
Acute
Diss.
Other
38%
23%
27%
3%
9%
Lenox Hill Heart and VascularInstitute of New York
Presentation: N=219
ElectiveRuptureUrgent
66%
19%
15%
Lenox Hill Heart and VascularInstitute of New York
Aneurysm Type:N=219
0
10
20
30
40
50
60
70
80
Type I Type II Type III Type IV
36%
20%
23% 21%
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No Distal perfusion 29 13%
Femoral-Femoral 87 40%
Atrial-Femoral 103 47%
DHCA 41 19%
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Operative variables
Aortic X time 49 (14-173)
CPB time 87 (17-320)
DHCA time 31 (22-56)
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Post- Op Bleeding 8 4%
Stroke 6 3%
Embolic 3
Hemorrhage 3
Operative Complications
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New Onset Renal Complications:Cr>2.5
New onset renal insufficiency 51 24%
New Onset Hemodialysis 8 4%
Ventilation>48h 51 23%
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Survival and Dissection
Dissection
Non Dissection
p =0.015
5863 54 32 20 1058 51 33 16 10
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Open – Demographics Plestis2011
N=219
Schephens199
N=258
Gambria2002
N=337
Coselli2007N=2286
Conrad-2007N=445
Age 66 65 70 66 71
Extent I + II 56% 58% 44% 64% 42%
Rupture 19% 15% 13% 6% 11%
Hybrid – Demographics Kuratani2009N=86
Choong2009N=70
Donas2009
N=58
Kabbani2010
N=36
Chiesa2009N=31
Age 71 67 64.5 71 70
Extent I + II 27% 56% 14% 31% 45%
Rupture 3% 4% 14% N/A N/A
Lenox Hill Heart and VascularInstitute of New York
Open
HybridKuratani2009N=86
Choong2009N=70
Donas2009
N=58
Kabbani2010
N=36
Chiesa2009N=31
Mortality 2.3% 16% 25% 8.3% 19.4%
SCI 1.2% 10% 3.4% 3% 8.6%
Dialysis 2.3% N/A N/A 11% 6.4%
Endoleak 10% N/A 17% 27% N/A
Plestis2011
N=219
Schephens199
N=258
Gambria2002
N=337
Coselli2007N=2286
Conrad-2007N=445
Mortality 6% 10% 8% 7% 8%
SCI 2% 11% 11% 4% 13%
Dialysis 4% 10% 13% 6% 21%
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Follow Up Survival -Open
Kuratani2009
Kabbani2010
Chiesa2009
Bockler2008
Survival1 year3 years5 years 70%
80% 60%70%
Follow Up Survival -Endovascular
Plestis2011
Schephens2010
Conrad2007
Kouchoukos2011
Survival1 year5 years10 years
70%51%
83%63%34%
54%29%
55%%23%
Lenox Hill Heart and VascularInstitute of New York
Conclusions
Both open and hybrid operations in the thoracoabdominalaorta remain extremelly complex operations
The results of open repair of TAAA have improved significantly over the last decade in centers of excellence
The long term outcomes of hybrid operations have not been determined yet.
Open TAA repair remains the procedure of choice in appropriately selected candidates
Lenox Hill Heart and VascularInstitute of New York
Extent and Mortality
0
10
20
30
40
50
60
70
80
90
Type I TypeII TypeIII TypeIV Descending
Mortality
6%
0%
13%
6%
6%P>0.05
N
Lenox Hill Heart and VascularInstitute of New York
Mortality and Distal Perfusion
0
20
40
60
80
100
120
Atriofemoral Femoral Femoral None
Mortality
No Mortality"
6%
7%
10%
P>0.05
Lenox Hill Heart and VascularInstitute of New York
Mortality and Aneurysm Type
0
20
40
60
80
100
120
140
160
1 2
No
5%
6%P>0.05
TAAA DTA
Lenox Hill Heart and VascularInstitute of New York
0
20
40
60
80
100
120
140
160
180
1 2
No
Ventilation<48h Ventilation>48h
Mortality and Ventilation>48h
2.5%
13%
P<0.05
Lenox Hill Heart and VascularInstitute of New York
0
50
100
150
200
250
1 2
Mortality and HemodialysisNo
4%
19%
P<0.05
No Hemodialysis Hemodialysis
Lenox Hill Heart and VascularInstitute of New York
0
50
100
150
200
250
1 2
40%
4%
Stroke and Mortality
StrokeNo Stroke
P<0.05
Lenox Hill Heart and VascularInstitute of New York
Survival
TAAA Dissection
DTA Non Dissection
DTA Dissection
TAAA non Dissectionp =0.038
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Survival
TAAA
DTA
44 40 29 15 9 5 79 65 50 21 11 7
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Questions
Does endovascular surgery treat the same patients as open surgery ?
Does endovascular surgery treat the same extent of aorta?
Does endovascular surgery deliver the same long-term outcomes?
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Infrarenal replacement + debranching
Bockler et al
Lenox Hill Heart and VascularInstitute of New York
MEP and SSEP guided intercostal artery reimplantation
Avoidance of subclavian artery clamping
Operative Management
Lenox Hill Heart and VascularInstitute of New York
Is it reasonable to search for a single segmental artery whose preservation will prevent paraplegia? NO
Is it reasonable to monitor spinal cord integrity in the perioperative period and treat cord ischemia when it occurs? YES
Do we yet have a strategy to assure preservation of spinal cord integrity through the perioperative period of thoracic and thoracoabdominal aortic aneurysm resection? NO
Has the neurological outcome of thoracic and thoracoabdominal aortic surgery improved markedly in the past decade? YES