George Trellopoulos MD Papanikolaou Hospital Thessaloniki ‘Advances in the Endovascular Management of the Descending Thoracic Aorta Pathologies’
George Trellopoulos MDPapanikolaou Hospital
Thessaloniki
‘Advances in the Endovascular Management of the
Descending Thoracic Aorta Pathologies’
• Thoracic aneurysm - descending thoracic aneurysm - thoracic arch aneurysm - thoracoabdominal • Type B dissection - acute (complicated and uncomplicated) - chronic (complicated and uncomplicated)• Trauma disruption
– acute– remote (chronic)
• Other – penetrating aortic ulcers – pseudoaneurysm – IMH – aortobronchial fistula – aortoesophageal fistula – coarctation – anastomotic pseudoaneurysm – Shaggy aorta
Reported Applications for Reported Applications for Thoracic Stent Grafts Thoracic Stent Grafts
TransectionTransection
Dissecting AneurysmDissecting Aneurysm
AneurysmAneurysm
PseudoaneurysmPseudoaneurysm
Thoracic Aneurysms Results
• Eurostar 2006Eurostar 2006• TAG Phase IITAG Phase II• TTRTTR• VALOR TRIALVALOR TRIAL
• No randomized trials (Level 1 or 2)• Few case-control series• Numerous case series and registries
n 30d Mortality
Paraplegia
Verdant Montreal 1995 351 35(10%) 0
Galloway NYU 1996 62 4(6.5%) 0
Ehrlich Vienna 1998 58 18(31%) 6(10%)
Biglioli Milan 1999 143 8(5.5%) 7(5%)
Cooley THI 2000 132 17(13%) 11(8%)
Coselli Baylor 2004 387 17(4.3%) 10(2.6%)
Estrera/Safi UT 2005 300 24(8%) 7(2.3%)
Glade Nether 2005 53 6(11%) 4(8%)
Makaroun TAG 2006 94 11(11.7%) 13(13.8%)
Stone MGH 2006 93 14(15.1%) 8(8.6%)
1673 154(9.2%) 66(3.9%)
Results:Open Thoracic Aneurysm Repair
30 day mortality: 4.3-31%Paraplegia: 0-13.8%
Endovascular repair of the descending thoracic aorta: evidence for the change in clinical practice.
Sayed & Thomson, Vascular. 2005 May-Jun;13(3):148-57
• 1,518 patients underwent endovascular repair for thoracic aortic disease;• 810 thoracic aortic aneurysms • 500 type B thoracic aortic dissections• 106 traumatic ruptures• The 30-day mortality rate was 5.5% and 6% for late postoperative deaths • Primary technical success rate was 97% (only 15 patients requiring open conversion)• 118 endoleaks were reported; (29 were restented, and the remainder required surgical intervention). • Graft infection occurred in 6 cases• Migrations were detected in 10
n=656 n=457 n=142EurostarEurostar TTRTTR TAGTAG
Results of Endovascular Registries and Trials
VALOR PIVOTAL TRIAL: High Risk Arm
Multicenter (18 sites), prospective
study of Talent Thoracic patients with descending aneurysms
– 137 high risk patients
– 1 year follow-up
– 75% aneurysm, 7% pseudoaneurysm, 6% traumatic injury
Successful use of thoracic stent graft in high risk patients at 1 year
– 1 year mortality 24.1% (33/137)
– Paraplegia 0.8% (1/137)
– Stroke (13/137) 9.5% (8 in zone 1 or 2)
– Migration (>5mm) 1.5% (2/137)
– Endoleaks 7.5%(10 pts) (Type I 4 pts, Type II 5 pts, 1 unknown)
Data presented at VEITH 2006:
OPEN SURGER ARM: Data to be presented at SVS, June 2007
Results of Thoracic Endovascular Grafting in Different Aortic Segments
Melissano et al., J Endovasc Ther 2007;14;150-157
• 30 day Mortality 6.3% 2% 28.6%
• Technical Success 85.9% 98% 100%
• Spinal Cord Injury 3.1% 4% 7.1%
• Stroke 3.1% 1% 0%
• Endoleak 12.5% 2% 0%
Arch n=64 DTA (n=100) TaA n=14
• 30 day Mortality 11.8% 1.8%30 day Mortality 11.8% 1.8%
• Technical Success 88.2% 97.3%Technical Success 88.2% 97.3%
• 30 day clinical success 75% 96.4%30 day clinical success 75% 96.4%
Comparison of outcomes in the Hybrid and Non- Hybrid Comparison of outcomes in the Hybrid and Non- Hybrid Procedure Groups:Procedure Groups:
Hybrid n=68 Non-Hybrid n=110
Debranching Supraaortic Vessels and Visceral Vessels
““TEVAR is more challenging in the aortic arch due to its curvature movement and high flow”
“The evolution of fenestrated devices and further developments of totally endovascular techniques may represent an alternative to hybrid procedures”
Management of Type B Dissection
Complications to Acute Dissection•Mortality 10-20% / 30 day•Rupture 10%•Organ Ischemia 5-10%•Dilatation/Aneurysm 30-40%/ 4 years•Refractory Hypertension 5-10%
Uncomplicated Type B DissectionMedical Treatment
Uncomplicated Type B DissectionStent Grafting (Chronic)
Data presented at Veith 2006Data presented at Veith 2006
(1) 12 month all cause mortality Best medical management – 3% Endograft – 10% (NS)(2) Over 95% False Lumen Thrombosis with stent graft vs. over 50% with medical management(3) 7 patients (10,6%) of patients in medical management crossed over to stent graft in 1 year
«« For uncomplicated type B dissection a primary strategy of tailored anti-hypertensive medical
treatment and serial imaging is justified, with deferred stent-graft implantation as an option for patients
failing to respond to medical management. ». »
Uncomplicated Type B DissectionStent Grafting (Acute)
(IRAD 2006) Long-term survival in patients presenting with type B acute aortic
dissection: Insights from the International Registry of
Acute Aortic Dissection.Natural History of Acute Type B Dissection:
Tsai et al., Circulation 114:2226, 2006
N=317N=317
Medical RXMedical RX78%78%
EndograftEndograft11%11%
SurgerySurgery11%11%
In-hospital mortalityIn-hospital mortality10%10%
In-hospital mortalityIn-hospital mortality11%11%
In-hospital mortalityIn-hospital mortality29%29%
Complicated Type B Dissections
• Feasibility established by Nienaber classic 2003 report
• n = 11 patients with no in-hospital mortality
Open Surgery• 30 day mortality 30-60%• Paraplegia 20-30%
Complicated Type B DissectionsCombined experience from the EUROSTAR and United Kingdom Thoracic Endograft
RegistriesLeurs et al., J Vasc Surg 40: 670-80, 2004
• Technical Success 88,6% • Paraplegia or Paresis 0,8%• Stroke 1,5%• Endoleak 6,0%• 30 day Mortality 8,4 % (Elective 6.5%, Emergency 12%)
Aortic Dissection (elective n=62, Emergency 60%)
Concept of Endovascular Repair in Aortic Dissection
Complicated Type B DissectionDissected Aneurysm
Localization and IncidenceTransection
• Traumatic rupture of the aorta is usually fatal; only 10%-20% reach the hospital alive
• Of those reaching the hospital alive, an additional 5-10% die within a few hours due to massive, multi-system injury
• The appropriate treatment of the remaining 5- 10% remains controversial
Transection Open Surgery• Mortality 5-25%• Paraplegia 9-19%
Transection
• 39 published case series (2001-2006)• 352 patients
– 30 d mortality = 11.2% (0-23.1)– Paraplegia = None
Endovascular Repair
AVAILABLE DEVICESAVAILABLE DEVICES
Commercially Available Grafts
• GORE TAG• MEDRONIC TALENT (Valiant)• BOLTON RELAY • ZENITH XT2• ENDOMED ENDOFIT
• Variety of different technical properties and deployment techniques.
• Up to 10% oversizing and long overlapping (4-5 cm)
GORE Tag
After 2001:• the 2 longitudinal nitinol
spines were removed. (due to fractures)
• The middle layers of the PTFE were reworked to add rigitidity and assist with tracking and delivery of device
Video GORE
Medtronic Talent Thoracic / Valiant
Valiant Talent Valiant
Video MEDTRONIC
Critical Issue (1) • Paraplegia after endovascular stent grafting
Factors: Prevention and Treatment:
• Number of devices• Length of coverage >205 mm• Prior AAA• Hypotension (MAP <90)
• Preoperative imaging and identification of critical vessels• Cerebrospinal fluid drainage• Avoid perioperative hypotension
Retrograde Type A Dissection after EVAR
Critical Issue (2) Critical Issue (2)
Critical Issue (2a) Critical Issue (2a)
How to prevent
1. Careful aortic arch evaluation (no IMH, tortuocity, atheroma)
2. Limited Oversizing (10%)
3. Avoid postoperative hypertension
4. Avoid balloon moulding
Retrograde Type A Dissection after EVAR
Critical Issue (3)Endograft Collapse
• Out of 68 device compression reported to GORE, 72% occurred in patients with trauma related injuries
• 51/68 patients successful re- intervention confirmed
How to prevent
• Less oversizing in transection (2mm)• Overstendting of LSA• Stent graft with better apposition in the inner curve• Stent graft with more radial force
Critical Issue (3a)Endograft Collapse
Critical Issue (4) How to canalize the True Lumen
• Careful Pre-TEVAR imaging assessment (CTA, MRA, DSA for proximal entry , distal entry, extension of dissection
• Preparation of both Femoral and Brachial Arteries
• Canalise the true Lumen from Brachial to Femoral artery
• Angiography step by step
Critical Issue (5) How to advance the stent graft in severe tortuosity and
carvature arch
1. Brachial - femoral guidewire stretch technique
2. Use of 2 stiff guidewires from the femoral artery
3. Using a large dilatators from one femoral artery and 2 stiff guidewires from the other femoral artery
Summary Summary
Summary: Thoracic Endograft
• No randomized trials• Technical success in more than 98%• Type I endoleak is more common than Type II• Endograft associated with improved short-term outcomes (mortality, paraplegia)• 15-20% require iliac/aortic conduit• Coverage of LSCA is relatively benign and most avoid
prophylactic bypass except– Dominant L vertebral artery– Incomplete Circle of Willis– Patent LIMA
• SCI after endograft is less frequent than after open repair
Summary: Thoracic Endograft
• Endograft treatment of complicated type B dissections is SUPERIOR to open surgery
• Endograft treatment of uncomplicated type B dissections is INFERIOR to best medical management
• Role of endograft in treatment of traumatic aortic injury is feasible but of unproven benefit – No FDA-approved device
• SCI very rare in traumatic aortic injury