New York Aortic Surgery Symposium 2010

Mohamad Bashir, Aaron Ranasinghe, David Quin,

Ben Holloway, Jorge Mascaro, Robert Bonser

The limited potential for hybridised thoracic endovascular aortic reconstruction in patients undergoing conventional aortic arch replacement

Introduction

• Thoracic endovascular aortic stent repair (TEVAR) is a rapidly developing technology in the treatment of aneurysms of the thoracic aorta

• Use of TEVAR in patients with aneurysmal disease in the aortic arch has the ability to either

– increase the number of potentially treatable patients

or– Compete with traditional arch repair

Objectives

• Review of the pre-operative anatomy and operative data to assess the potential suitability of patients with aneurysmal aortic arch disease undergoing conventional surgical repair for hybrid TEVAR

Methods

• Consecutive patients undergoing conventional aortic arch surgery between January 2005 and October 2009 were identified from our prospectively maintained database

• Pre-operative CT scans were sourced where available from our computerised hospital radiology database

• Operation notes and follow-up data were obtained on all patients

Methods

• CT scans were analyzed to assess maximal distal ascending and proximal descending aortic short-axis diameter

• Potential TEVAR landing zones were classified as a length of 20mm with a SAD < 40mm

Results

• 73 patients underwent conventional arch surgery during this time period

• 62 (85%) underwent total arch

• 11 (15%) underwent hemi-arch

• 71 (97%) had conservation of a three vessel cranial circulation

Pre-operative CT scans

• Available in 42 (58%)

• Median distal ascending SAD 5.4(4.2-6.5) cm

• Median proximal descending SAD 3.8(3.0-4.8) cm

• Of these only 17% and 19% had satisfactory zone 0 and zone 3 landing zones

Operative details• 34 had documented atheroma of the supra-aortic

vessels

• 71 required replacement of the ascending aorta

• 56 patients required additional proximal procedures– Aortic valve – 22– Root – 33– Mitral valve – 5– CABG – 16

• 7 required descending aortic replacement

• 39 had an elephant trunk procedure

Conclusions

1. Only a minority of patients were suitable for TEVAR without zone 0 creation

2. In this series the majority of patients undergoing aortic arch replacement required additional procedures

3. The role of hybrid TEVAR in management of aortic arch pathology remains to be defined