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Edward B. Diethrich, MD Phoenix, Arizona The Future of Aortic Repair Malmo, Sweden June 18, 2010
What Perspective? How? Where? Who? What?
How? Where? Who? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Infrarenal AAA ,[object Object],[object Object],[object Object],[object Object],What Perspective?
Bown MJ et al.Br J Surg 2002;89:7 14-30. Visser  P 2005 Perioperative Period: Surgical mortality still elevated : 40 – 50% range Open Repair Overall mortality of 75 to 80%
Acute Type B Descending Dissection Asymptomatic What Perspective? Medical Rx Endograft Controversy Waiting for studies Our Data Symptomatic (malperfusion) Endovascular technology with some hybrid combinations
Acute Type A Dissection ,[object Object],[object Object],[object Object],[object Object],What Perspective? Progressive dissection not inconsequential
Mortality Ruptured Cases All Pathologies TAA Intraop Death 4 (5.5%) 3(12.5%) < 30 Days 9 (12.3%) 5 (20.8%)
Conclusion ,[object Object],[object Object]
Natural History ,[object Object],[object Object],Advance in Vasc Surg. St Louis, Mosby 1998, pp 17-36
Success
Success
Remodeling Changes Continues Post-op 6 months P/3 M/3 D/3 Retrograde Flow
Observations ,[object Object],[object Object],[object Object],[object Object],flow FL  thrombosis/ patency depend on several factors
[object Object],Results Flow
Incidence of Aneurismatic Dilatation ,[object Object],[object Object]
Observations Pre-Op Post-Op 1 month 24 months 6 months ,[object Object],[object Object],[object Object],[object Object],J Vasc Surg 2009;49:20-8.
Post-Op 6 months 24 months Case #3 P/3 D/3
Type B Dissection, Regardless of Symptoms, Should Be Treated By Endografting to Prevent Future Complications?
[object Object],[object Object],Inclined to Treat Non-complicated  TBD with ELG
[object Object]
[object Object],[object Object],[object Object],Limitations at Present Example?
[object Object],[object Object],[object Object],[object Object],Our Series: Open vs Endograft
30-Day Mortality ,[object Object],[object Object],[object Object],[object Object],When comparing those  EVAR  cases with combined use of local anesthesia at initiation of procedure and use of supra-celiac occlusive balloon to those receiving general anesthesia and no balloon ,  the mortality reduced from 27.8% to 11.1 % (p=0.40)
Conclusions ,[object Object],[object Object]
Conclusions ,[object Object]
Z0 Z1 Z2 Z3 Z4 The Real Challenge: Conquering Zone Zero
[object Object],[object Object],[object Object],[object Object],64 Slice CT Oblique Coronal Images Showing the 4 Diameter Measurements of Aortic Root
Acute Dissection Ascending Aorta Hematoma High Risk Patient for Open Procedure Balloon Occluding Device L. Coronary Artery Sheath with Positioning of ELG Aortic Valve Dissection
Dissection and Hematoma Sealed
24 ° Post-Op CT
1.  Vortex velocity control in aneurysm 2.  Laminates the flow in collaterals 3.  Accelerates shear stress flow in the vessel Multi-Layered Stent Key Principles
Human Experience (All OUS) Thoraco Abdominal Aneurysm
1 Month Follow-Up Aneurysm excluded All visceral arteries open
 
 
 
Future Potential for  Endovascular ??? Aortic Stenosis Ascending Arch Aneurysm Aortic Stenosis
Neuro Protection Devices Ascending Endoluminal Graft Coronary Inserts Percutaneous Aortic Valve Special Stent to Correct Kink Arch/ Descending Endoluminal Graft with Three Branches
Horizon Looks Favorable…. Training Government FDA CMS Industry
We are the heritage of our undaunted medical forefathers. Our young physicians are the genetic products of those great pioneers. Let their fate be the product of those positive, energetic, inquisitive, creative, and adventurous epigenoms which have the ability to overcome all adversity and bring ultimate success to all endeavers.
 
In All Aspects of Cardiovascular Therapy, the Pendulum is Swinging to Less Invasive Endovascular Approaches CABG Angioplasty Arrhythmia EP Aneurysm Endograft PVD Balloon & Stent ??? Carotid
Evolution of Endovascular Therapies has Created Expanded Opportunities- Created Uncertainties for the Future
Role of the Cardiothoracic Surgeon?
Cardiovascular care is rapidly moving toward catheter-based technologies Surgeons lack skill set Obstacles Even more importantly they often do not recognize the complexity of endovascular
Often not available  to surgeons- High-Quality Imaging is Imperative for High-Quality Results
The No Workshop Phenomenon Portable, suboptimum imaging will not be satisfactory for high performance outcomes Catheterization Laboratory
Hybrid Operating Rooms Arizona Heart Hospital
[object Object],[object Object]
Many CT surgeons are now seeking education and training in endovascular surgery!
Percutaneous Aortic Valve Multi-Disciplinary Team
Retroperitoneal Conduit Approach Special Training Required
Hybrid Operating Rooms Hybrid Training Programs Hybrid Procedures A hybrid is a combination of two or more different things, aimed at achieving a particular objective or goal
 
 
Ascending Aorta and Aortic Arch are the Next Generation of Challenges for Endoluminal Grafting
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Surgery is Effective- But Significant morbidity and mortality
Endovascular Techniques for Ascending & Aortic Arch Will be Coming Branched and Fenestrated Devices Not a Simple Process Other New Concepts
J. L. Andersen, Australia Innovative Endovascular Grafting
J. L. Andersen, Australia
Initial Approach: Concentrate on Distal Arch and Transition into Ascending Aorta
Intent of Hybrid Approaches:   Expand the Landing Zone for Endoluminal Grafting by Rerouting Arterial Branches ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Surgical Endovascular
Thoracic Aortic Pathologies Offer Unique Opportunities for Hybrid Procedures Classical Endovascular
57 Year Old Female. Could Not Swallow Without Choking. Esophageal Compression Aberrant RSA
Anomalous Origin Right Subclavian Artery Dysphagia Lusoria
 
[object Object],[object Object],Therapeutic Plan
Cannulation of Aberrant RSA Retrograde  Femoral No branches between right vertebral and descending aorta
Occluder Placement in RSA
Left Radial Subclavian Stump RSA Anastamosis to Right CCA  Proximal RSA Ligated
No Compression
Post-Op
[object Object],[object Object],[object Object],37 Years Ago
37 Years Later Pseudoaneurysm Degenerated Graft
L. Subclavian A. Bovine  Arch Graft to transposed aberrant right subclavian artery (37 yrs ago) Pseudoaneurysm Aberrant right subclavian artery with previous graft
L. C-S bypass Right C-S  bypass Ligation of degenerated graft ELG deployment
Right  C-S  bypass L. C-S bypass Endoluminal graft Thrombosed pseudoaneurysm
Pathologies Encroaching Aortic Arch Options Left C-S Bypass Left SC transposition
Areas of Controversy:  Covering the Left Subclavian Artery Indications for Left  C-S Bypass or Transposition ,[object Object],[object Object],[object Object],[object Object],[object Object],No Consensus * *
Hybrid Example Subclavian aneurysm Previous coarctation repair Large associated aneurysm
C-S graft bypass Resection subclavian aneurysm Operative exposure
Endoluminal graft deployed at left CCA Simultaneous: ,[object Object],[object Object],[object Object]
Previous Type A Dissection Aberrant right subclavian artery Left CCA dissection Distal arch dissection False channel expansion Left subclavian  dissection Left CCA dissection
Hybrid Treatment Plan Rt. subclavian- carotid bypass Vertebral LCCA stent deployed  retrograde Rt. aberrant  subclavian closed proximally Lt. carotid-  subclavian bypass
Extra Anatomic Procedures in  Preparation  for Thoracic Endograft
LCCA stent Rt. subclavian- carotid bypass Lt. C-S bypass Rt. aberrant  subclavian closed
Rollover vehicle accident 15 years ago, multiple injuries Recent TIA,  Dx innominate artery aneurysm
Bovine arch Initial plan ELG Innominate artery aneurysm  (source of emboli) Inadequate  landing zone LCCA Compromise LCCA
Coiled  aneurysm Transposition of Rt.  subclavian artery  Carotid-carotid  bypass Coiled  aneurysm Transposition of Rt.  subclavian artery  Carotid-carotid  bypass Ligation  distal innominate Retrograde femoral approach
Expanding ascending aneurysm Dissection False lumen True lumen Previous ascending graft for type I dissection
Requires Partial Cardiopulmonary Support Femoral Artery-Femoral Vein Bypass Insufficient Graft Length
Ascending graft Left common carotid bypass Innominate bypass Radiopaque marker for ELG landing zone
Ascending graft ELG ascending, arch, descending  To left carotid, innominate Bifurcated graft Original ascending graft for type A repair To innominate
Ascending Aorta and Contiguous Arch Present Specific Challenges
I.  Aortic Valve II.  Coronary Arteries III.  Aortic Root IV. Ascending Aorta  and Trunk Vessels
Current Potentials for Rx of Ascending Aortic Pathologies I. Degenerative Aneurysms Proximal landing length Distal landing length Proximal-distal discrepancies
II. Dissections Current Potentials for Rx of Ascending Aortic Pathologies Initial Tear 1-3cm Type II Extensive  Dissection
Anatomic Challenge Larger Diameter Ascending Curvature Short Deployment Area Extremely Friable Tissue
Overcoming Systemic Pressure
[object Object],[object Object],[object Object],Overcoming Systemic Pressure
Balloon Occlusion of Cardiac Venous Return Right Atrium IVC SVC ,[object Object],[object Object]
Double Balloon Occluding Catheter
130/80 mmHg Balloon  deflates SVC balloon  inflates 110/60 IVC  balloon  inflates 60/20
Right Atrium Inflated IVC Inflated SVC BP 130/80 mmHg 60/20 mmHg
 
A Better Answer to Stent Graft Expansion or Remodeling The “UnBalloon”
Current Potentials for Rx of Ascending Aortic Pathologies ,[object Object],[object Object],[object Object],[object Object],[object Object],III. Complications of Previous Interventions
Investigation of Ascending Endovascular Therapy Bypass Occluded Pseudoaneurysm of Ascending Aorta
Coil Embolization
Coils failed to close entry point Aneurysm expanded from 6-10cm in 4 months
Endoluminal Graft Exclusion of Pseudoaneurysm
1 Year Follow-up
3 Months  Post Mitral Valve Replacement 9cm aneurysm 8mm Channel Measured by IVUS Option
Amplatz Occluder Retrograde femoral delivery Disc Diameter Ranges Small 12mm-30mm Large 14mm-32mm
Aneurysm Excluded
5 Month Follow-Up Preop Small Disc Size 26mm Large Disc Size 30mm
Dissection Ascending  Aorta Enlarging Dissection Ascending  Aorta
Dissection JR4 catheter across dissection entry point
Occluder
Is Endovascular Possible? Aortic Insufficiency Arch Aneurysm
Extending Endovascular Even Further with Hybrid Procedures ,[object Object],[object Object],[object Object],Case History No thrombus, no antegrade flow, loss of motor and sensory function to entire right lower extremities Result
Arch dissection Celiac Left iliac dissection Rt. iliac occlusion CT Examination After Right Groin Exploration Celiac
Femoral-femoral bypass  graft (Acute ischemia with  paralysis) Emergent Fem-Fem Bypass
Ascending tube graft Type A Dissection Cardiopulmonary bypass Mild hypothermia Retrograde left femoral cannulation (above fem-fem)
Transposition of brachiocephalic and left common carotid arteries Bifurcated graft with conduit Ascending tube graft Off cardiopulmonary bypass
240cm wire to left iliac artery 9 Fr  sheath
Snare retrieval of conduit wire to left femoral sheath
Conduit-Femoral Wire The Banjo Concept
Conduit-Femoral Wire ,[object Object],[object Object],[object Object],[object Object]
Completion After 2 nd  ELG Deployed Antegrade ELG Delivery Across Aortic Arch
Ct 3 Days Post ELG exclusion of arch and descending thoracic dissection Bifurcated graft Stump of conduit
5 Year Follow-Up No Symptoms, Ready to Fly
Captain Federal Aviation Administration (FAA) Thank You Edward B. Diethrich

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Notas del editor

  1. Running, H
  2. Elwell, Anne
  3. Hathaway Line 1- 2001 Line 2- 2003 Line 3- 2004