Current role of tever in acute and chronic dissection results in china

Current Role of TEVER in Acute and

Chronic Dissection: Results in China

Chang Shu M.D., PhD.

Department of Vascular Surgery,

The 2nd Xiang-Ya Hospital, Central-South University, China

Email：changshu01@yahoo.com

Incidence

In China, more than 15,000 cases of acute and Chronic type

B aortic dissection cases happen per year.

Most of the cases, about 70%, receive TEVAR, especially

the cases with huge hemothorax, intractable

hypertension, acute paralysis, and acute ischemia of

visceral arteries.

In 2010, the number of TEVAR cases was about 6000, and

has increased about 30% each year.

The dates coming from the commercial market, CNKI database and the article “Vascular Surgery

in China” (James S.T. Yao. Ann Vasc Surg, 2012;26: 889-894)

How about the current rule

• There is no standard rule of TRVAR in treating

acute, chronic aortic dissection in China;

• To Acute aortic dissection, most of the centers

will obey the rule of the AHA etc.

• To Chronic aortic dissection, the opinion of

TRVAR is controlversy

Prof. Zhong Gao Wang

Before 1998, Wang treated several TBAD

cases with TEVAR via homemade stent-

grafts in China.

Academician of the Chinese Academy of

Science

The founder and 1st President of the

Chinese Society of Vascular Surgery

The founder of the Asian Society of

Vascular Surgery

Corresponding member of the Society for

Vascular Surgery

The history of TEVAR in China

Volume of TBAD Treated in China

0

2000

4000

6000

8000

10000

12000

14000

19

99

2000

2001

2002

2003

2004

2005

2006

20

07

2008

2009

2010

2011

2012

1999: The first case of aortic

dissection treated by TEVAR

2002: less than 100 cases

2004: less than 500

2006: less than 2000

2008: less than 5000

2010: about 6000

2011: about 9000

2012: about 12000

The dates coming from the commercial market, CNKI database and the article “Vascular Surgery

in China” (James S.T. Yao. Ann Vasc Surg, 2012;26: 889-894)

Development of Management strategy

Before 2003: Single cases, the indication is very strict: • First entry should below the left subclavian A 2cm

• The visceral arteries are coming from true lumen

2004~2005: Some ischemia of the visceral arteries can be treated;

Partial of the cases left subclavian A can be covered;

Extra-anatomic bypass had been applied in the TEVAR.

2006~2007：Most of the acute TBAD cases can be treated, no matter

have some complications.

2007~2010: Aortic arch invaded can be treated, many new technique

including Chimney etc had been applied to focus on the

proximal and distal side

2011~2013: Complications after TRVAR had been pointed out and new

methods had been applied.

Acute TBAD with Huge Hemothorax, in 2004

Shu C, et al. Endovascular repair of complicated acute type-B aortic dissection with stentgraft: early and mid-

term results. Eur J Vasc Endovasc Surg. 2011

TEVAR with extra-anatomic bypass, in 2004

Chang Shu, et al. Endovascular repair combined with associated techniques for the treatment of

TBAD involving aortic arch. Chin J Gen Surg, 2011

TBAD invaded celiac artery and caused ischemia,

in 2006

Li M, Shu C, et al. Midterm results of intentional celiac artery coverage during TEVAR for type B aortic

dissection.J Endovasc Ther. 2013

Acute renal failure caused by acute TBAD,

treated with TEVAR, in 2006

Nowadays,

most of the

centers

focus on~ ~

~ ~

Appropriated

peri-operative

medical treatment

For

complications

pre-operation

For complicated

anatomic

situations

For

complications

post-operation

Management strategy for TBAD

~ huge hemothorax

~ ischemia of lower extremities

~ Acute paraplegia (before/after TEVAR)

~ celiac artery involved

~ ascending aorta invaded

For complications

pre-operation

~ acute renal failure

~ supra-aortic branches invaded

for complicated

anatomic situations

~ Chimney technique

~ Double chimney technique

~ Sacrifice LSA

~ Extra-anatomic bypass

~ Debranch and hybrid reconstruction technique

~ Fenestrated technique

~ Bare stent technique

~ Type I endoleak

~ Type II endoleak

~ Paraplegia post-TEVAR

~ Huge hemothorax post-TEVAR

~ Left subclavian artery steal syndrome

~ Distal new entry tear

~ Left subclavian artery dissection

For complications

post-operation

TBAD with mal-perfusion syndrome

It’s the most common severe complication of acute

type B aortic dissection, including renal failure,

paraplegia et al. Some cases can’t be treated

previously. Weiguo, Changshu et al explored the

treatment from 2004, and received excellent results.

Now, the severe cases can be treated in some main

vascular centers in China.

Mal-perfusion of distal aorta

There is no contrast in

the distal abdominal aorta.

The patient had typical

symptoms of acute lower

extremities ischemia.

Pre-operation

Post-operation

Emergent TEVAR should be

performed to release mal-

perfusion syndrome.

After operation, the

compressed true lumen re-

opened. Blood supply and all

symptoms recover immediately.

Mal-perfusion of distal aorta

Chang Shu, et al. Early results of left carotid

chimney technique in endovascular repair of

acute non-a-non-B aortic dissections. J

Endovasc Ther，2011

Mal-perfusion caused acute paraplegia

The patients with abrupt paraplegia

was caused by ischemia of arteriae

lumbales and intercostal arteries.

In out department, 7 patients

suffered from paraplegia：• 3 cases pre-TEVAR

• 4 cases post-TEVAR

This patient suffered from

acute severe paraplegia 10

hours after TEVAR.

Emergent CTA indicated

satisfying remodeling of

descending aorta with

completed thrombosis in the

false lumen, coverage of the

original of the LSA.

Anaesthesia

record indicated

hypotension

during TEVAR.

Emergent management:

• Drainage of CSF

• Stosstherapy with adrenal cortex hormone

• Dehydration

• Maintain the blood pressure at about

140/90mmHg

• Medical treatment to dilate collateral artery

• Neurotrophy

• Functional exercise

TEVAR for Retrograde type A AD

Retrograde type A aortic dissection is associated with the risk of severe aortic

regurgitation, cardiac tamponade, coronary arteries involved, brain ischemia, especially

the cases with patent false lumen in ascending aorta.

TEVAR for Retrograde type A AD

2 weeks after TEVAR

Shu C, et al. Thoracic endovascular aortic repair for retrograde type A aortic dissection with an

entry tear in the descending aorta. J Vasc Interv Radiol. 2012

Secondary TEVAR for distal

new entry tear

With the usage of TEVAR for TBAD, Since the stent-

graft are straight and not tapped one, more and more

post-TEVAR complications happen, such as the distal

new entry tear. Secondary operation is a necessity.

Secondary TEVAR for distal new entry tear

3months after TEVAR, a new ruptured entry tear happened near the distal ending of

the stent-graft. Secondary TEVAR with a stent-graft overlapped with the previous one

was performed.

Complicated type I

endoleak post-operation

A patient with aortic dissection

received TEVAR 3 years ago.

An endoleak and a new distal entry

tear were found during follow-up.

It seems like

the endoleak is

coming from the

new distal entry

tear. So, an

extending stent-

graft in the

descending

aorta was used,

overlapped with

the previous

one.

However,

after the distal

extending stent-

graft deployed,

an typical type I

endoleak

happened.

Why?

An cuff was

used in the

proximal to seal

type I endoleak.

After all the

procedures, the

patient recovered

well.

Chimney technique

Has been applied in China from 2007, First aortic

arch case treated by Chimney technique reported

by Changshu et al in 2008. It is commonly used to

treat the aortic arch diseases in some of the big

vascular centers in China

TEVAR with chimney technique for

TBAD involved aortic arch

Chimney technique

+ PDA occlude for LSA

If chimney technique is used in the common carotid

artery, the covered LSA has the risk of type II endoleak.

PDA occlude technique is a ideal management

• TBAD related LSA

• Chimney technique

should be used

Chimney technique+ PDA occlude

• Chimney stent-graft

reconstructed left

common carotid

artery.

• Typical type II

endoleak from LSA

• PDA occlude was

used to seal type II

endoleak.

2 weeks after TEVAR, no type II endoleak lasted.

Double-chimney technique

The 1st aortic arch dissection case treated by

double-chimney technique reported by Zhaipinjing et

al in 2009. It can replace the conventional open

surgery, and be used to reconstruct all supra-aortic

branches. Some big vascular centers in China

master the technique.

The patient suffer from an acute aortic

dissection, which the left common carotid

artery was invaded and leaded to severe

carotid artery stenosis.

The patient recovered well, without any serious complications

Bi-chimney technique was

used.

Two Fluency stent-grafts were

used to reconstruct IA and

LCCA. The LSA was covered.

The patient recovered well,

without any complications.

Until now, several cases have

received bi-chimney technique in

our hospital, short-term result

is acceptable, no technique-

related complications happen,

but long-term result is

unclear.

fenestrated SG

It has been used in China beginning from 2005, Some of

the stenting-grafts has been modified to fit the aortic

arch area by some experienced vascular surgeons

Fenestration—treatment

• Step 1:

CT and DSA for

accurate

measurement were

performed pre-

operation.

Fenestration—treatment

• Step 2:

deploy partial of the

proximal stent graft in

vitro, and eliminate

part of the lateral fabric.

Fenestration—treatment

Step 3

Fenestration—follow up

The fenestrated stent graft

covered the aortic arch

dissection completely

With patent supra-aortic

branches

TBAD with Marfan syndrome

The first case is reported by Changshu et al in 2008,

some of the big vascular centers has done it now in

China

MFS associated with TBAD

Bentall technique was performed previously

Replacement of

aortic root and

valves was

performed 3 years

ago.

Abrupt severe back

pain was

encountered caused

by TBAD.

MFS received Bentall previously

Two weeks after TEVAR

The aortic

dissection in the

descending aorta

was occluded with

remodeling of

related distal aorta.

TBAD

+ Marfan syndrome

+ pregnancy

The first case reported by Changshu et al in 2009.

Until now, Three cases have been treated by

TEVAR. All the patients and their infants recovered

uneventfully.

A 23-year-old female, gestated for 36

months.

Widen mediastinum was found by chest

X-ray. And CT angiography confirmed

chronic type B aortic dissection.

No signs of threatened labor.

MFS associated with pregnancy

Shu C, et al. J Cardiovasc Surg. 2013. accepted

Caesarean section was

performed followed on

emergent TEVAR.

The patient recovered well,

and the infant was healthy.

No complication happened !

MFS associated with pregnancy

Shu C, et al. J Cardiovasc Surg. 2013. accepted

MFS associated with pregnancy

Shu C, et al. J Cardiovasc Surg. 2013. accepted

In the future, some new techniques will be used

in ascending and distal descending aorta

• Branched Stent-Graft• Single-banched

• Double-branched

• Tri-branched

• Split-Type Branched Stent-Grafts

• Bare stent used in distal descending aorta

New types of branched stent-graft for aortic

arch lesions

Some vascular centers invented the branched stent-graft

for aortic arch lesions and had been applied in animal or

clinical study, not available commercially in China

Single/double branched stent-graft used in acute

aortic arch dissection

By Z-P Jing. Am Surg. 2010; Eur J CardiothoracSurg.2011.

The special

branched stent-

graft is invented

to treat aortic

disease involving

aortic arch and

ascending aorta,

such as type A

AD !

Split-Type Branched Stent-Grafts

Invented by

Changshu et

al.

Bare stent used TBAD

Bare stent technique is applied in China from 2009, in

order to open the true lumen of the dissection area and

restrict the stenting-graft in the distal side to get a

reasonable profile of the aorta

A typical type B aortic dissection

The bare stent restrict the distal diameter of the Valiant

stent-graft.

RESULTS

RESULTS

RESULTS

RESULTS

RESULTS of A Single Center

1 Technically success: 99.9%

2 Recovered uneventfully: 90.4%

3 Peri-TEVAR complications: 29 (3.1%)

4 Late complications: 36 (3.9%)

5 Fatal cases: 11 (1.2%)

RESULTS

• In China, because of the diet improvement and the bad

control of the hypertention, the incidence of acute type

B aortic dissection increase rapidly, the age of the

patients is relatively younger, the role of treatment

should be TEVAR

• Chronic AD, with complications, TEVAR should be

performed. But to some young patients, although with no

severe complications, TEVAR can be done for decreasing

the larger of the false lumen.

• Therapy with traditional medicines is the basic management

for type B aortic dissection, endovascular stent graft

placement is the first option.

• Today, in China, with the development of endovascular

technique, such as fenestrated technique, branched stent-

grafts, debranch technique, and so on, most type B aortic

dissection cases can be treated endoluminally, even some

type A aortic dissection cases can be treated by endo.

• Current Role of TEVAR in Acute and Chronic Dissection are

focus on with or without complications, many chinese doctors

pay much attention to get a better anatomy profile of the

aorta by TEVAR, so as to get a much better follow up. But

we have to emphasize: evidence is the most important thing!

RESULTS