Surgery for Failed (T)EVAR
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Surgery for Failed (T)EVAR
- 1. Surgery for Failed TEVAR Dicky A.Wartono Cardiovascular Surgeon - NCC Harapan Kita Jakarta
- 2. ā¢ Disclosure : none
- 3. ā¢ Thoracic endovascular aortic repair (TEVAR) has been emerging as an attractive treatment modality for aortic disease ā¢ TEVAR has proven durability in strict indications and experienced hands & The incidence of secondary surgical conversions is low ā¢ Current series prove feasibility of these operations; however, mechanisms of failure are not yet addressed. ā¢ The aim of the study was to evaluate mechanisms of failure and outcome of secondary surgical interventions after TEVAR.
- 4. n = 13 Demographics Age, mdian 65 49 - 72 Male Gender 7 53.8% Indication for TEVAR Aneurysm 4 30.8% Dissection 7 53.8% PAU 2 15.4% In hospital TEVAR assessment Zone 2 Emergency 6 46.2% Comorbidity 7 53.8% Indication for Conversion Infected Stent 1 4.5% Retrograde type A 10 86.5% Endoleak type 1A 2 9% Surgical Procedure Total Arc Replacement 11 91% Descending Aorta Replacement 1 4.5% Arch Debranching 1 4.5% Specific outcome Time to Conversion (mo) 6 4 - 9 Mortality 3 13.5%
- 5. 77 yo Female, Aortic Arch Debrancing + Stent Insertion for Endoleak type 1 6 month after TEVAR
- 7. Interactive CardioVascular and Thoracic Surgery, Volume 24, Issue 3, 1 March 2017, Pages 450ā459
- 11. Why Do TEVAR Grafts Fail?
- 12. STENT GRAFT INFECTIONS -most complex indication for conversion to open repair after TEVAR -half of them died from intermediate complications. -medically. -additional stent grafts -Stent -multistaged repair - extra-anatomic bypass, debridement of the infected field (which may include esophagectomy and diversion), and later, reconstruction. Chaudhary SB, Roselli E, Steinmetz M, Mroz TE. Thoracic aortic dissection and mycotic pseudoaneurysm in the setting of unstable upper thoracic type b2 fracture. Global Spine J. 2012;2:175-182.
- 13. PERSISTENT FALSE LUMEN PERFUSION IN CHRONIC DISSECTION -uncertainty of thromboexclusion of the false lumen ,approx 70% -converted to a hybrid distal reconstruction. 30% -TEVAR and open repair should be considered complementary options a -later open repair may be as high as 25% to 30%. 1. Roselli EE, Abdel-Halim M, Johnston DR, et al. Open aortic repair after prior thoracic endovascular aortic repair. Ann Thorac Surg. 2014;97:750-757. 6. Subramanian S, Roselli EE. Thoracic aortic dissection: long- term results of endovascular and open repair. Semin Vasc Surg. 2009;22:61-68. 7. Kang W, Greenberg RK, Mastracci T, et al. Endovascular repair of complicated chronic distal aortic dissections: intermediate outcomes and complications. J Thorac Cardiovasc Surg. 2011;142:1074-1083. 8. Arafat A, Idrees J, Roselli EE. Should endovascular therapy be recommended for descending thoracic aortic dissections? Interv Cardiol. 2013;5:627-638.
- 14. TYPE I ENDOLEAKS ā¢most common indications for secondary surgical intervention after TEVAR. (38%). These may be proximal (14 of 19 in our series) or distal (5 of 19 in our series) ā¢had shorter-than- landing zones or another use of the stent graft that was considered off-label. ā¢proximal endograft extension ā¢transpose or debranch the arch ā¢āelephant trunkā operation 1. Roselli EE, Abdel-Halim M, Johnston DR, et al. Open aortic repair after prior thoracic endovascular aortic repair. Ann Thorac Surg. 2014;97:750-757. 2. Chaudhary SB, Roselli E, Steinmetz M, Mroz TE. Thoracic aortic dissection and mycotic pseudoaneurysm in the setting of unstable upper thoracic type b2 fracture. Global Spine J. 2012;2:175-182. 3. Roselli EE, Soltesz EG, Mastracci T, et al. Antegrade delivery of stentgrafts to treat complex thoracic aortic disease. Ann Thorac Surg. 2010;90:539-546. 4. Andersen ND, Williams JB, Hanna JM, et al. Results with an algorithmic approach to hybrid repair of the aortic arch. J Vasc Surg. 2013;57:655-667.
- 15. RETROGRADE DISSECTION -2% -8% -The key to saving these patients is timely diagnosis and transfer to a center where the techniques of hypothermic circulatory arrest are commonly practiced. Canaud L, Ozdemir BA, Patterson BO, et al. Retrograde aortic dissection after thoracic endovascular aortic repair. Ann Surg. 2014;260:389-395
- 16. CONCLUSION ā¢ (< 3%) have required conversion to open repair. ā¢ Although hospital survival has been good in our experience with open conversion after TEVAR, late survival was less than favorable, and 42% of patients required additional operations. ā¢ Conversion may be indicated for ā¢ type I endoleak, ā¢ retrograde dissection, ā¢ chronic aortic dissection with persistent false lumen perfusion and growth, ā¢ Graft infection ā¢ the majority of these events could have been avoided by a more strict indication. Thereby, further critical evaluation and respecting limitations of TEVAR will help to reduce the need for these operations.
- 17. ā¢ The first important mechanism being easily prevented is the length of the proximal and distal landing zone. ā¢ It was interesting to observe that proximal or distal endoleak formation was ā if more than one stent- graft was used- always accompanied by type III endoleak formation, ā¢ In addition, respecting anatomy is a crucial issue. Despite potential sufficient landing zones, disrespecting angulations may lead to failure.
- 18. ā¢ retrograde type A dissection. ā¢ proximal bare springs ā¢ steep angulated aortic arches ā¢ intrinsic disease of a morphologically normal proximal aorta as well as com- pliance mismatch between the stent-graft and the native aortic wall ā¢ Interestingly, this event may happen even years after TEVAR. ā¢ Distal aneurysm formation ā¢ The length of the covered segment ā¢ Multisegmental downstream apposition of the dissecting membrane to the adventitia may turn out as a decisive factor for prevention of late aneurysmal formation
- 19. ā¢ mycotic aneurysm ā¢ TEVAR may be a most valuable bridge to definitive therapy. ā¢ Aorto-esophageal or aorto-bronchial ā¢ Mortality in this series was substantial. ā¢ In non-infective thoracic or thoracoabdominal replacement- according to the individual situation and the clinical need- stent-grafts may be left in place or may be merely partially resected. This may easen surgery. Clamping of the stent-graft can be done easily as nitinol returns into its natural position after declamping. ā¢ infective situations, surgery may be more demanding as conventional alloplastic vascular material may not be used without a certain risk of recurrence of infection
- 20. ā¢ due to our current state of knowledge, we will not- except in emergency situations as a bailout- electively perform TEVAR without a landing zone of at least 3cm ā¢ with an angula-tion of more than 90%, we will make a careful risk-benefit ratio and apply TEVAR only if the angulation may be anatomically used as a hypomochlion and not as poten- tial fixation segment. ā¢ The issue of retrograde type A dissection remains unpredictable
- 31. Thank You
Editor's Notes
- Thoracic endovascular aortic repair (TEVAR) has been emerging as an attractive treatment modality for acute and chronic aortic disease [1ā4]. TEVAR has proven durability in strict indications and experienced hands [5ā7]. The incidence of secondary surgical conver- sions is low [8ā10]. Current series prove feasibility of these operations; however, mechanisms of failure are not yet addressed. The aim of the study was to evaluate mechanisms of failure and outcome of secondary surgical interventions after TEVAR.
- My aortic surgery pactise were started on 2014, it is ess than 5 years ago Only after last 2 year, we tryto operate on failed tevar So this data were release on tha last to year 2017-July 2018 Dissection n PAU are most founding pathology There were 13 pasien which was had 12% mortality, which far beyond our āfreshāpatient, about 6% in dissection and 1% in aneurysm Retrograde type, is the most found indication for convertion there for, total arch replacement are the most common proc.
- Total arch debranching, without ECC
- This if our most common surgical pro Replace entire arch, in 1 pts we have to remove the stent, which was difficult But most ly we just replace the archm and repair the endoleak by primary sututr w/o teflon
- Descending aorta surrounded by infected thrombus with an air pocket within the aneurysm sac. The right arrow shows the esophagus, the left arrow shows air in the aneurysm sac, and the bottom arrow shows the descending aortic aneurysm with an endograft. Pts dien POD 25 severe sepsis
- most complex indication for conversion to open repair after TEVAR half of them died from intermediate complications. If the infection has not compromised the integrity of the aorta and the imaging does not demonstrate obvious air around the device, we first try to manage these patients medically. If the infection is due to a process occurring in the periphery of the lung, it can usually be treated with the placement of additional stent grafts to control hemoptysis and prolonged organism-specific intravenous antibiotics followed by oral antibiotics, sometimes for life. If the esophagus or more central airways are involved, then the infected devices must be removed to control the infection, and this usually needs to be done urgently. If the patient is young and can tolerate a multistaged repair, then they may stand a chance at survival with a clear plan for extra-anatomic bypass, debridement of the infected field (which may include esophagectomy and diversion), and later, reconstruction.
- PERSISTENT FALSE LUMEN PERFUSION IN CHRONIC DISSECTION The use of stent grafts to treat chronic dissections in the setting of an aneurysm is currently controversial because of the uncertainty of thromboexclusion of the false lumen (Figure 2).6 An increasing body of data suggests that the rate of false lumen thrombosis in the treated segment is approximately 70% and may be predicted by the extent of aorta dissected.7,8 If the endovascular therapy does not achieve the desired reverse remodeling, then the patients can safely be converted to a hybrid distal reconstruction.1 This indication for open conversion represented one-third of the cases in our series. In that regard, TEVAR and open repair should be considered complementary options for the treatment of patients with chronic aortic dissection and aneurysm (Figure 3). As such, we will explain to our patients who are undergoing TEVAR for chronic dissection that the chances of them needing a later open repair may be as high as 25% to 30%.
- One option for patients with proximal endoleak isto transpose or debranch the arch by creating bypasses originating from the ascending aorta, extending the endovascular repair more proximally into the arch or distal ascending aorta. The stent graft may be delivered in a retrograde or an antegrade fashion.3 Although we have performed this procedure in select patients, several authors have demonstrated that this is still a high-risk procedure, with a significant risk of persistent endoleak or retrograde dissection in up to 11% of patients.4 More often, we have chosen to convert these patients by using the āreverse frozen elephant trunkā operation (Figure 1). This is performed using cardiopulmonary bypass, hypothermic arrest, and selective antegrade brain perfusion via cannulation of the right axillary artery with a side graft.5 Once the distal circulation is arrested, the arch is opened, and the previously placed stent graft may be directly sutured into the aortic arch. If the old stent graft is too distal in the aorta for direct suturing, then an additional device may be added to bring the repair more proximal and facilitate direct suturing. Typically, the more proximal aorta is replaced with an interposition graft because patients with arch aneurysms usually have some underlying ascending aortopathy as well.
- (&lt; 3%) have required conversion to open repair. Although hospital survival has been good in our experience with open conversion after TEVAR, late survival was less than favorable, and 42% of patients required additional operations. Conversion may be indicated for type I endoleak, retrograde dissection, chronic aortic dissection with persistent false lumen perfusion and growth, Graft infection the need for secondary surgical intervention after TEVAR is low but carries risk. By analyzing mechanisms of failure, the majority of these events could have been avoided by a more strict indication. Thereby, further critical evaluation and respecting limitations of TEVAR will help to reduce the need for these operations.
- The first important mechanism being easily prevented is the length of the proximal and distal landing zone. It has been the subject of previous work and is now proven, that there is a direct correlation between length of land- ing zone and early and long-term success [1, 5, 11]. We have been following an aggressive approach regarding this issue for years and do request a landing zone, proximally and distally of at least 3cm, the longer the better. It was interesting to observe that proximal or distal endoleak formation was ā if more than one stent- graft was used- always accompanied by type III endoleak formation, which becomes clear when reflecting that lateral instability of the most proximal or distal grafts directly affects longitudinal stability of connecting stent- grafts. As such it also remains important that overlapping zones are extensive and have ā in our setting- to be at least 5cm. In addition, respecting anatomy is a crucial issue. Despite potential sufficient landing zones, disrespecting angulations may lead to failure. A classical example is depicted in Figures 6Aā6C showing a suitable distal landing zone regarding length but an unsuitable landing zone regarding angulation as by oblique configuration of the stent-graft and by unphysiologic wall stress, local aortic wall fatigue has been induced resulting in aneu- rismal formation in a primarily normally dimensioned segment. In our setting steep angulation is defined as 90Ā°.
- A dangerous ā because unpredictable issue ā remains retrograde type A dissection. Recently, factors leading to this catastrophic event have been identified [12]. It seems that stent-grafts with proximal bare springs are more prone to cause this event than non-bare spring stent- grafts. However, other factors such as a steep angulated aortic arches causing shear stress and wall tension may also be causative [13]. Finally, intrinsic disease of a morphologically normal proximal aorta as well as com- pliance mismatch between the stent-graft and the native aortic wall may contribute to retrograde type A dissection [14]. In this series, all patients had the underlying diag- nosis of acute complicated type B aortic dissection. How- ever, it should not be forgotten, that the potential for this complication is present in each and every indication for TEVAR. Interestingly, this event may happen even years after TEVAR. Distal aneurysm formation is a chronic process occur- ring predominantly after TEVAR for acute type B dissec- tion. It may be difficult to detain this process as several factors may be responsible. The length of the covered segment seems to play a major role. However, due to justified fear of impaired spinal cord perfusion - espe- cially in the emergency situation-, the level of the distal end of the stent-graft usually is mostly set at the level of the pulmonary artery [15]. Multisegmental downstream apposition of the dissecting membrane to the adventitia may turn out as a decisive factor for prevention of late aneurysmal formation [16]. However, other factors may contribute such as the number of communications be- tween both lumina as the domino effect of membrane apposition is less the more communications do exist.
- Finally, an underlying diagnosis of a mycotic aneurysm may well predispose to the need of secondary surgical conversion [17]. However, initial stabilization in such a situation by TEVAR may be a most valuable bridge to definitive therapy. Aorto-esophageal or aorto-bronchial fistulation may also occur secondary to ā contained- rup- ture into the posterior mediastinum as resorption hema- toma may cause wall fatigue and thereby fistulation [18]. As a consequence, we now do perform a left sided thoracotomy 2 days after TEVAR in such situations and do widely open the mediastinal pleura in order to de- compress the structures of the posterior mediastinum In this series, 62% of patients would have been deemed suitable for conventional surgery. As such, the question is justified why these patients have been treated by TEVAR. The answer is simple as most likely each patient with an acute type B dissection- due to the predomi- nantly young age- may be suitable for conventional surgery. However, as evidence as well as clinical consent exist that TEVAR is the therapy of first choice in this situation, this strategy was chosen. This fact explains the high percentage of suitability for conventional surgery in this series. We do use EuroSCORE stratification in these patients as we do not have a better stratification tool at the moment. We do well know that this score was not designed for these patients. However, in our hands it serves as the best approximation available. It will be task of upcoming studies from our group to provide an appropriate risk stratification tool for these patients. Mortality in this series was substantial. As in each and every clinical situation in cardiovascular surgery, there was a striking difference between elective and emergent operations [19]. Some details may be interesting. In non-infective thoracic or thoracoabdominal replacement- according to the individual situation and the clinical need- stent-grafts may be left in place or may be merely partially resected. This may easen surgery. Furthermore, clamping of the stent-graft can be done easily as nitinol returns into its natural position after declamping. In infective situations, surgery may be more demanding as conventional alloplastic vascular material may not be used without a certain risk of recurrence of infection. As such, one of the authors (JS) developed an alternative approach by creating a neo-vessel by wrapping a bovine pericardial patch. By this approach, no reinfection, de- spite discontinuation of antibiotic therapy after months could be observed. Finally, outcome after secondary surgical interventions after TEVAR was excellent as could be expected due to the fact that material fatigue of the prosthesis or the sutures is ā fortunately- an ex- tremely rare event.
- Strengths, limitations and outlook of this study. With- out doubt this is retrospectively gained knowledge. How- ever, due to our current state of knowledge, we will not- except in emergency situations as a bailout- electively perform TEVAR without a landing zone of at least 3cm measured on the inner curvature of the respective seg- ment involved. Furthermore, in patients with an angula- tion of more than 90%, we will make a careful risk-benefit ratio and apply TEVAR only if the angulation may be anatomically used as a hypomochlion and not as poten- tial fixation segment. The issue of retrograde type A dissection remains unpredictable, the association of bare metal stents in the arch with this adverse event may be not causal as retrograde type A dissections may also happen with non-bare stent devices (personal experi- ence) and in many centers, merely stent-grafts with bare stents (due to manufacturersā standards) are available. Without doubt there is potential for further patients to present with late failure. However, this may be strongly dependent onto the primary indication for TEVAR. In monosegmental descending aortic disease the probabil- ity of late failure after a stable course for several years is most unlikely. However, in patients after TEVAR for acute type B dissection, little is known onto the develop- ment of downstream segments were a complete domino effect of apposition is not reached. As such, continuing surveillance remains mandatory.