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Tilo Kölbel, MD, PhD University Heart Center Hamburg University Hospital Eppendorf TEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes
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TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Mar 18, 2018

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Page 1: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Tilo Kölbel, MD, PhD

University Heart Center Hamburg

University Hospital Eppendorf

TEVAR and the Aortic Arch :

Challenges, Planning and Techniques for Good Outcomes

Page 2: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Gold Standard for Descending Aorta

Page 3: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Cheng et al 2010, JACC 55:986-1001

Descending Aorta

TEVAR vs. Open

TEVAR better:

– 30d mortaliy

– Paraplegia rate

– Transfusion

– Cardiac compl.

– Renal function

– Pneumonia

– Reoperation

– ICU and Hospital LOS

Metaanalysis of comparative studies

TAA and Type B Dissection (n = 5888)

Page 4: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Gold Standard for the Arch

Surgery for the aortic arch:

Open repair

Elephant trunk

Mortality rates 5-15%

Stroke: 4-12%

Sundt et al. 2008; Ann Thorac Surg 86:787-96

Minakawa et al. 2010; Ann Thorac Surg 90:72-7

Page 5: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Endovascular Challengers

Tsagakis et al. 2013 Ann Cardiothorac Surg 2:612-20

Frozen Elephant Trunk

Chiesa et al. 2010 J Endovasc Ther

17:1-11

Hybrid Repair Branched/Fenestrated Repair

Haulon et al. 2014 J Thorac Cardiovasc Surg,

Page 6: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Aortic Arch Zones

Ishimaru-classification

Page 7: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Aortic Arch Zones

Ishimaru-classification

Page 8: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Challenges of the Aortic

Arch

Branch vessels

Patency / endoleak

Pulsatility

Oversizing / migration

Curvature

Conformity / infolding

Access

Distance / profile / kinking

Page 9: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Outline

Planning

Challenges

Techniques

Page 10: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Most technical Errors

follow

insufficient planning !

Planning

Page 11: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Planning

Perpendicular measurement

Multiplanar-reconstruction (MPR)

Pulsatility

Graft-properties

Proximal Landing

Page 12: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Workstation

Page 13: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Perpendicular Diameter in

MPR

Page 14: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Perpendicular Diameter

Page 15: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Pulsatility

Page 16: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Pulsatility

Page 17: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Jonker et al 2010; EJVES; 40:564-71

Hypovolemia and Aortic

Diameter

Page 18: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Proximal Landing

Preferred landing site:

Length

Diameter

Shape

Thrombus

Non-dissected healthy

aortic wall

Page 19: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Proximal Landing

Page 20: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

52 patients, FU 31m

47 stentgrafts distal to LSA

9 patients proximal erosion and aneurysm

3 patients with rupture, 2 fatal

Manning et al, JEVT, 2009

Proximal Landing

Page 21: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Techniques

Access-techniques

Endovascular Techniques

Arch-conformance

Fenestrated / branched Devices

In-situ Fenestration

Page 22: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Access Techniques

Iliac-conduit

Paving and Cracking

Through & Through-Wire

Transcardiac Access

Page 23: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Access Techniques

Page 24: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Access Techniques

Page 25: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Access Techniques

Page 26: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Iliac Conduit

Page 27: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Paving and Cracking

Page 28: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Through&Through-Wire

Stiff Guidewire Soft transbrachial Throughwire

Page 29: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Transseptal Through-Wire

Page 30: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Insufficient SG-conformity

to the anatomy of the arch

→ Aortic wall erosion

→ Type 1 endoleak

→ Stent-graft collapse

Arch-Conformance

Page 31: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

• Angulation of arch

• Small aortic diameter

• Stent-graft oversizing

• Transsection

• Stent-graft rigidity

Potential Factors

Page 32: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

• Angulation of arch

• Small aortic diameter

• Stent-graft oversizing

• Transsection

• Stent-graft rigidity

Potential Factors

Page 33: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Controlled Deployment by ProForm

Zenith® TX2 ProForm®

Page 34: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zenith® TX2 ProForm®

Controlled Deployment by ProForm

Page 35: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Aortic Arch Techniques for

Zone 0

Page 36: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 –Debranching

Page 37: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 –Debranching

Page 38: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 – Chimney Graft

Page 39: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 – Chimney Graft

Page 40: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 – Chimney Graft

Page 41: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 – Chimney Graft

Page 42: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Chinmey Graft

ENDOLEAKS !

Hogendoorn et al. 2013; JVS

Page 43: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 – In-Situ Fenestration

Page 44: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 – In-Situ Fenestration

Page 45: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 – In-Situ Fenestration

Page 46: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

J Vasc Surg 2013;58:1171-7

In-Situ Laser Fenestration

Page 47: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

In-Situ Laser Fenestration

Page 48: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 – Fenestrated Stent-Graft

Page 49: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Branched Arch Repair

1995-1998

N=15

14 single branch,

1 triple branch

Outer branches

Traction wire

Inoue et al. 1999; Circulation 100:316-21

Page 50: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Branched Arch Repair

Chuter et al. 2007; Perspect Vasc Surg Endovasc Ther19(2):188-92

Courtesy Krassi Ivancev

2003 – 2010(?)

N=10-20(?)

Outer branch

Transcervical

access

Page 51: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Branched Arch Repair

Outer Branches Inner Branches

Page 52: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 – Branched Stent-Graft

A-Branch:

• Arch aneurysms

• Internal side-branches

• Nitinol & stainless steel Z-stents

• Low-profile high

density dacron fabric

• Self orienting delivery system

• Controlled deployment

Page 53: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 – Branched Stent-Graft

Page 54: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Zone 0 – Branched Stent-Graft

Page 55: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Branched Arch Endograft

Multicenter Study

n = 38

Technichal success 32/38

Mortality 5/38 (13%)

Stroke/TIA 6/38

Haulon et al. 2013; J Thor Cardiovasc Surg 148:1709-16

Page 56: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Learning Curve

Haulon et al. 2014; J Thorac Cardiovasc Surg Epub

Page 57: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Cook Branched Arch Endograft

Subsequent experience:

n = 27; Hamburg, Tokio, Lille

4/2013- 11/2014

Technical success 27/27

30d Mortality 0/27

1y mortality 1/27

Stroke/TIA 3/27

Spear et al 2016; Eur J Vasc Endovasc Surg 51: 380-5

Page 58: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Branched Arch Endograft

Hamburg Experience 2012-2014:

Cases: 32

Aneuysm: 13

Residual dissection: 15

Acute Type A: 2

PAU: 2

30d-Mortality: 1

Stroke:2

Page 59: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Anatomical Suitability

Diameter ≤ 38mm

Length ≥ 40mm

Proximal landing zone ≥ 20mm

Innominate diameter ≤ 20mm

Appropriate access vessels

No significant aortic regurge

No mechanical aortic valve

No dissection of branch-vessels

Page 60: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Technique

Two stage repair:

1. LCCA-LSA bypass

2. Branched repair:

Transfemoral access for

the main-graft

RCCA-cutdown for IA-

branch

Left brachial puncture

for LCCA-branch and

LSA-plug

Page 61: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Technique

Precurved self-orienting device

LV-wire position

Cardiac output-reduction:

IVC balloon-occlusion

Rapid ventricular pacing

Zenith-limb for IA

Fluency for the LCCA

Plug-occlusion for LSA

Page 62: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Lesion-Type

Aneurysm and PAU of the arch

Chronic dissection

Acute Type A dissection

Page 63: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Residual Dissection

Potential challenges:

Kinking of ascending stentgraft

Dissection of targetvessels with

multiple entries

Distal false-lumen perfusion

Page 64: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Residual Dissection

Page 65: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Residual Dissection

Bilateral carotid-subclavian bypass Axillo-axillary bypass

Page 66: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Residual Dissection

True lumen catheterization Creation of landing zone

Page 67: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Residual Dissection

Landing in dissected LCCA

Page 68: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Residual Dissection

Page 69: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Acute Type A Dissection

Branched Arch Endograft

Page 70: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Comparing…

Page 71: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Indications

71

Fenestrated Device

(n=6)

Branched Device

(n=9)

PAU 1 (inner curvature) 1 (outer curvature)

Post-traumatic

aneurysm at the

subclavian artery

1 0

Type B Dissection with

Arch involvment

2 (dissection

proximal of the

subclavian)

2 (aneurysm of the

arch)

Arch Aneurysm or TAAA 2 3

Residual Arch

Dissection 0 2

Type A Dissection 0 1

Page 72: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Target Vessels

72

Fenestrated Device

(n=6)

Branched Device

(n=9)

Target Vessels 7 18

Median of Target Vessels 1 2

Vessel Distribution Fenestrated Device

(n=6)

Branched Device

(n=9)

Bovine Innominate Artery 2 0

Innominate Artery 1 9

LCA 2 9

LSA 2 0

Page 73: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Fenestrated Arch Graft

Comparing…

Branched Arch Graft

Page 74: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Potential CONs for

Fenestrated Arch Grafts

Alignement of fenestrations

difficult

No strutfree fenestrations

larger than 12mm restricts use

for innominate artery

Preloaded wire may entangle

in struts of scallop

74

Page 75: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Potential CONs for

Branched Arch Grafts

Higher risk for trapped air

and embolism

Maximum ascending

diameter 38mm and

minimum length of 70mm

limits use.

Required left-ventricle

wire position limits use in

mechanical aortic valves

Page 76: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Conclusion

Page 77: TEVAR and the Aortic Arch - divine [id] Lille... · Metaanalysis of comparative studies ... to the anatomy of the arch → Aortic wall erosion ... system • Controlled deployment

Conclusions

Arch-vessels, curvature and access are main challenges.

Perpendicular measurement, multiplanar reconstruction,

centerline reconstruction required.

Rapid development depending on local infrastructure

Feasible and lifesaving option in patients unfit for surgery

Role of stent-grafts in the aortic arch not yet defined.