Endovascular Repair of Thoracic Arch Aneurysms Postgraduate Course Southern Association for Vascular Surgery H. Edward Garrett, Jr. M.D. Professor of Surgery.

Endovascular Repair of Thoracic Arch Aneurysms

Postgraduate CourseSouthern Association for Vascular Surgery

H. Edward Garrett, Jr. M.D.Professor of Surgery

University of Tennessee Health Sciences CenterMemphis, TN

Financial & Regulatory Disclosure

• Principal investigator for – Gore TAG post-approval study and – Medtronic VALOR Trials (Talent thoracic stent

graft system)

• W.L. Gore sponsors the University of Tennessee Vascular Conference and the Edward Garrett Sr. Midsouth Vascular Society

Surgical results for open repair of aneurysms involving the aortic arch:

• 30 day mortality 15%• Neuro events 10-15%• 5 year survival 75%• Death primarily related to neurological and cardiac

events• Many patients denied open surgical treatment because

of comorbidities Kirklin/Barratt-Boyes Cardiac Surgery, Third Edition , N.T. Kouchoukos et

al

Landing zones in the thoracic aorta

Coverage of the left subclavian artery:Carotid-subclavian bypass or not?

• Gore TAG IFU: “If occlusion of the left subclavian artery ostium is required to obtain adequate neck length for fixation and sealing, transposition of the left subclavian artery should be considered.”

• Vertebral circulation must be evaluated. ?Impact on paraplegia

• Presence of internal mammary artery graft to LAD mandates revascularization

• Debatable whether left subclavian bypass necessary

LIMA bypass graft off the left subclavian artery

pre-implant post-implant

Arizona Heart Institute

• 255 thoracic endograft pts reviewed (2/00-12/05)• LSA covered in 71 pts; partially covered in 47 pts• 15 of 71 pts had pre-stent bypass → 1

CVA (this pt also had car-car bypass)• 3 of 56 pts without pre-stent bypass had

complications: 2 TIA’s, 1 paraparesis (full recovery)• 1 of 56 pts without pre-stent bypass had lt arm

claudication → car-SC bypass• Many other high volume centers are aggressive about

subclavian revascularization -Data used with permission of Grayson Wheatley III, MD

Results of subclavian revascularization

• Prosthetic carotid-subclavian bypass:

– Patency: 85% @ 7 yr– Mortality: 0-2%– Stroke rate: 1-5%

• Carotid-subclavian transposition:

– Patency: 100% @ 7 yr– Mortality: 1-2%– Stroke rate: 0-2%

Rutherford, Vascular Surgery

Coverage of left carotid &/or innominate arteries not included in IFU

but allows expansion of endovascular technique.Debranching the aortic arch mandates some type

of reconstruction:

• Carotid-carotid bypass • Ascending aorta to innominate &

carotid bypass• Proximal carotid stenting• Femoral-axillary bypass• Chuter graft

Ascending aorto – innominate &/or carotid bypass

• Patency 100% at 7 years• Mortality 5%

• Stroke 7%

Crawford et al, Surgery 1983;94:781-791

Ascending aorta to innominate & carotid bypass (Saleh & Inglese, JVS 2006;44:461)

Results of surgical carotid-carotid and aorto-innominate / left carotid

(Y-graft) bypass

Selected case reports

Carotid-

Carotid

30d Mortality /

CVA

Aorto-innominate/

L carotid

30d Mortality /

CVAOther

Kato et al 1 0 / 0 2 1 / 1(same pt)

Bergeron

et al

15 1 / 1 11 1 / 1 1 retro type A dissection

Czerny et al 9 0 / 0 2 0 / 0

Mangialardi et al

1 0 / 0

Zhou et al 16 1 / 0

Saleh & Ingles

15w/ Ao banding

1 / 0

Buth at al 1(Ao-L car-LSC

0 / 0

TOTAL 26 1 / 1 47 4 / 2

Carotid stenting (T. Larzon et al, Eur J Vasc Endovasc Surg 2005;30:148)

Chuter GraftChuter et al, JVS 2003;38:861

Chuter GraftChuter et al, JVS 2003;38:861

Hybrid techniques(Zhou et al, JVS 2006;44:691)

Hybrid techniques(Zhou et al, JVS 2006;44:691)

Hybrid techniques( Diethrich at al, J Endovasc Ther 2005;12:663 )

Case Study: 77 y/o WF with 6.3cm saccular TAA

• Evaluation of left vocal cord paralysis → CT of chest Feb 2006 → large saccular TAA off lateral aspect of distal arch

• History of extensive spinal surgery in 2004 (Harrington rods at lumbar spine); surgical repair of perforated gastric ulcer in May 2005

Baseline CTA – 3D

Baseline CTA

Baseline arch & cerebral arteriogram

Operative procedures

• Right to left carotid-carotid, left carotid-subclavian bypass using 8mm ringed Goretex graft

• Right common iliac artery conduit using 10mm Hemashield graft

• 34 mm x 15 cm Gore TAG deployed just distal to innominate via 22 Fr sheath

• No spinal drain due to previous lumbar surgery and hardware

Intraoperative aortogram

1-month CTA

Open surgical repair still an option

Case study:

• 41 y/o WM s/p patch repair of thoracic aortic coarctation 23 yr ago

• Severe AI and MR; no sig CAD

• CTA of chest 3/06: recurrent coarctation w/ marked aneurysmal dilatation distally

Left carotid-subclavian bypass and attempted endovascular repair

Persistent type I proximal endoleak 4 days post-op → open chest repair

5 days post tube graft repair

Fenestrated Graft: Is This the Future Solution?

Questions?