branched arch tevar : the march to zone 0 · branched arch tevar : the march to zone 0. january 26....
TRANSCRIPT
Branched Arch TEVAR :The March to Zone 0
January 26th, 2014STS TechCon
Orlando, Florida
Jehangir AppooDivision of Cardiac Surgery
Libin Cardiovascular InstituteUniversity of Calgary
Disclosures
Consultant Gore Medical
Investigational devices
Futuristic license
Outline
Why is Arch TEVAR important?
Options for Arch TEVAR
Demonstrate a case
Descending thoracic aortic surgery has transitioned to endovascular treatment
Why is Arch TEVAR important?
Technically some isolated ascending aortic surgery can be done endovascularly
Why is Arch TEVAR important?
So… what’s left to solve….?
Image courtesy of Dr. C. Abraham – Montreal, Canada
If arch can be solved …
…Implications?
Why is Arch TEVAR important?
Classification of Zone 0 endovascular options
Open Chest – Hybrid Operations
Closed Chest - Endo Total Arch
Sternotomy
Arch Debranching
Antegrade Deployment
Single Stage Repair
Hybrid Arch proposed as lower risk alternative for diffuse thoracic aortic pathology
Avoidance of prolonged circ arrest
Mild hypothermia
Challenging distal operation converted to proximal anastomosis
122 pts with acute Type A dissection
Open placement of triple branched stent graft into descending aorta and arch vessels
4.9% operative mortality
Closed Chest Options as Futuristic Treatment Modality
Multi-layer aortic repair systems
Fenestrated graftsinsitu fenestration
Chimney technique
Branched arch graftsmulti branch graftssingle branch grafts
Multi-Layer Aortic Repair Systems
383 patients @ 35 sites in Japan1.6% Mortality1.8% Stroke
Customized fenestrated device
19 types precurved stent body8 types fenestrations for arch vessels
Chimney Technique
Using standard devices
Multibranch arch Single branch arch
Carotid-subclavian bypass preop
Main body deployed transfemorally
Head vessels cannulated from above
Cook Multibranch Arch Graft is custom made for alignment of patient’s arch vessels
Narrower body in arch
40-50 selected cases worldwide
1st 38 cases – stroke and mortality rates < 10% (unreported)
64 y.o maleType A repair 2009
Complicated course
Aorta growing at rate of 1cm/year
Arch dissectedLarge residual primary
intimal tear in archTrue lumen effaced
2013
Total endo arch Custom built branched arch graft
Complexity
VR images 3 months post op
Single Branch Arch Devices
Gore FDA study6 sites enrolling in US1st patient-Jan 2014
Medtronic FDA study7 pts at 2 US Sites
Off the shelf devicesDesigned for LSADual wire lumens
Single Branch Arch Grafts potentially could be combined with extra-anatomic carotid carotid bypass for full arch reconstruction
ConclusionsDynamic Evolution in treatment of thoracic aortic disease
Summary:
Hybrid open chest operations
vs.
Closed chest aortic arch
Branched arch graftssingle vs. multi branchoff the shelf vs. custom
Fenestrated arch graftsChimney graftsMultilayer aortic stent grafts
ConclusionsDynamic Evolution in treatment of thoracic aortic disease
Future is likely to be less invasive
Investigational process to determine pros/cons of each of the closed chest arch operation
Different therapies applicable for different anatomy
Exciting opportunity to be involved with ongoing evolution
ConclusionsDynamic Evolution in treatment of thoracic aortic disease
Once algorithm for endovascular approach to arch is defined…could ”routine” ascending aortic replacement potentially be envisioned as part of the armamentarium of endovascular surgeons?
Paradigm shift: Are CT surgeons ready to be endovascular specialists?
Thank You
Surgeon Year ET1 Mortality
ET2 Mortality
Interval Mortality
Rx Mortality
Svensson 2004 2% 8.5% 14% 18%
Safi 2007 6.3% 9.6% 10% 13.3%
Lemaire/Coselli 2006 12% 4% 25% 36%
Kouchoukos 2007 7.2% -- -- 7.2%
Grieppe 2008 6% 7% 12% 24.5%
Etz, Grieppe et al. – Eur J. CT Surg 2008
Even in centres of experience, operative mortality with 2 stage elephant trunk technique is high