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Tilo Kölbel, Fiona Rohlffs, Stephan Haulon, Roger Greenhalgh
Stroke From Thoracic Endovascular Procedures: STEP-Findings
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Disclosure
Speaker name: Tilo Kölbel
has the following potential conflicts of interest to report:
• Research-grants, travelling, proctoring speaking-fees, IP, royalties
with Cook Medical.
• Consulting with Philips
• Consulting, Speaking fees from Getinge
• IP, Consulting with Terumo Aortic
• Shareholder Mokita-Medical GmbH
Speaker name: Fiona Rohlffs
• none
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Background of STEP
Incidence 3-11%
Anterior/posterior circulation
Silent undetected strokes up to 87%
Mortality 20%
Böckler et al. 2016; Eur J Vasc Endovasc Surg: in press
Feezor et al. 2007; J Endovasc Ther 14:568-73
Kahlert et al. 2014; Ann Thorac Surg 98:53-8
Perera et al. 2015; Br J Surg 102: s2: 5
Ullery et al. 2012; J Vasc Surg 56:1510-7
Stroke is a major concern in TEVAR
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Aim of STEP
To provide best practice for endovascular procedures forthe ascending aorta, aortic arch, great vessel branchesand high TEVAR to lower the risk of cerebral embolism
Zone 0
Zone1
Zone2
- Ascending aorta: tube grafts, scalloped stent-grafts
- Arch procedures: fenestrated and branched aortic arch
stent-grafts (Great vessel involvement)
- Descending aorta: high standard TEVAR procedures
landing in zone 2 (Ishimaru)
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Pathologies
Air
Particles / Plaque
Thrombus
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The STEP Collaboration
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The STEP Collaboration
Frank Arko
Carlos Bechara
Adam Beck
Dittmar Böckler
Martin Czerny
Michael Dake
Matthew Eagleton
Dennis Gable
William Jordan
Marwan Youssef
Ahmed Koshty
Gustavo Oderich
Jean Panneton
Geert Schurink
Santi Trimarchi
Rod White
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The STEP Advisors
Neurologist
Interventional Cardiologist
Cardiothoracic Surgeon
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Characteristics of the STEP Collaboration
Independent
All-encompassing
Open
Interdisciplinary
Built to learn from each other
Safe treatment for patients
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STEP Phase 1: Questionnaire to KOL
General Questions on experience to evaluate current practice
Pre-Procedural
Intra-Procedural
Post-Procedural
Key Findings
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STEP Results
Experience of KOL (n = 18)
Cumulativeyears of experience
- Zone 0 = 143 years(range 3 – 15)
- Zone 1 = 193 years(range 4 – 15)
- Zone 2 = 232 years(range 6 – 20)
Zone1,n=135(17%)
Zone0,n=171(21%)Zone2,
n=510(62%)
NumbersofproceduresperZoneandperyear
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STEP Results
Company Representatives
8
1
8
14
7
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ConsensusPre-Procedural
100%
Interdisciplinary team central to the final decision for treatment strategy
0
2
4
6
8
10
12
14
16
18
Zone 0 Zone 2Zone 1
0
2
4
6
8
10
12
14
16
18
100%
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ConsensusPre-Procedural
100% 100%
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NON-ConsensusPre-Procedural
How soon before the procedure should
the imaging be done (maximum tolerated)?
>1 – ≤ 3 months> 3 months ≤ 1 months
62 8
Procedure1: „depends on urgency“
1: „as soon as possible“
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Anticoagulation:
- Procedure should be done under anti platelet therapy
- Activated clotting time (ACT) should be 250 – 350s
Pre-Procedural
Intra-Procedural
Consensus
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Pre-Procedural
Intra-Procedural
NON-Consensus
Revascularisationof LSA
Routinely = 8Selectively = 10
• Prevention of spinal cord ischemia (all)• AV-Fistula (all)• LIMA Bypass (all)• Access for TEVAR procedure (n=3) • Other:
Elective vs emergent statusPrevention of stroke and arm ischaemiaDominant left armYoung patient
In advance = 9
Simultanously = 7
Case dependent = 2When?
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Pre-Procedural
Intra-Procedural
0
2
4
6
8
10
12
14
16
18
Zone 0
Use of Cardiac Output Reduction
100%
Consensus
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Pre-Procedural
Intra-Procedural
NON-Consensus
Zone 0
0
2
4
6
8
10
12
14
16
18
Zone 2Zone 1
Use of Cardiac Output Reduction
100%
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- Rapid Ventricular Pacing (RVP), n = 14
- Inferior Vena Cava Occlusion (IVCO), n = 1
- RVP or IVCO, n = 1
- Adenosine or RVP, n = 2
Pre-Procedural
Intra-Procedural
NON-Consensus
Cardiac Output Reduction Technique
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- Carotid Artery Clamping, n = 9
- CO2 flushing Technique, n = 6
- Other: - Minimize Arch wire and device manipulation, n = 1
- Place filters in supraaortic vessels, n = 0
Pre-Procedural
Intra-Procedural
NON-Consensus
Embolisation Prevention Techniques
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- CT Fusion Technique, n = 12
- Cone Beam CT in addition to final angiogramm, n = 9
- Intraoperative Monitoring of Brain Function routinely:yes = 12, no = 6:
- TCD, n = 4- NIRS, n = 11- Cerebral oyxmetry, n = 2- EEG, n = 3
Pre-Procedural
Intra-Procedural
NON-Consensus
Adjunctive Techniques
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Pre-Procedural
Intra-Procedural
Post-Procedural
Consensus
100%
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Pre-Procedural
Intra-Procedural
Post-Procedural
NON-Consensus
100%
When?:
- Pre discharge (few days after procedure), n = 13
- After 1 month, n = 3
- If urgent procedure pre-discharge, if elective procedureafter few weeks, n = 2
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Pre-Procedural
Intra-Procedural
Post-Procedural
Consensus
- Anti platelet therapy
- Postprocedural ICU: Zone 0 n = 18Zone 1 n = 15Zone 1 n = 14
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Pre-op MRIZone 0 + 1
mandatory = 4
never = 3
If needed = 11
Neurologic Evaluation
mandatory = 1
never = 0
If needed = 17Post-op MRIZone 0 + 1
Almost no expert neurologic testing, just 2 centers
Neurocognitiv testing is not established, just 1 center
Intraoperative monitoring of brain function is not standartised
Best method of brain function monitoring is not clear
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STEP Phase 2
Post-TEVAR evaluation of cerebral damage by DWMRI:
• Number, size and distribution of SBI
• Association with• Patient and procedural factors• Landing zone• Type of device (tubular, fenestrated, branched)• Protective techniques
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Summary
• TEVAR is plagued by continous high frequency of
stroke and SBI
• STEP-Initiative has collected current practice from 18
KOL in TEVAR from around the world.
• STEP phase 2 will study cerebral damage in real
world. First results to be presented at Charing Cross
Symposium 2019
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Tilo Kölbel, Fiona Rohlffs, Stephan Haulon, Roger Greenhalgh
Stroke From Thoracic Endovascular Procedures: STEP-Findings