Treatment of thoracoabdominal aortic aneurysms. surgery alone or hybrid

Lenox Hill Heart and VascularInstitute of New York

Treatment of Thoracoabdominal Aortic Aneurysms. Surgery alone or Hybrid.

Konstadinos A Plestis, MD

Associate Professor

Director of Aortic Surgery

Department of Thoracic and Cardiovascular Surgery

Lenox Hill Hospital, NY


The Risk of ParaplegiaCrawford Classification (n = 1509)

I II III IV

15% 31% 7% 4%

Svensson LG, Crawford ES: J Vasc Surg 1993; 17:357-370


Open Surgical Treatment

Extensive Operations

Need of CPB + DHCA

Risk of Paraplegia

Post-operative Mortality and Morbidity


Endovascular Treatment

Decreases Access Trauma

Decreases Blood Loss

Reduces Morbidity and Mortality?

Improves long term outcomes?


Hybrid repair

Kuratani et al


Debranching + stent

Hughes et al


Debranching + stent

Kabbani et al


Spinal Cord Protection

Cerebral Protection

Visceral Organ Protection

Goals during Open Repair of TA Aneurysms


Current Lenox Hill Technique

Mild systemic hypothermia, 32°C

Distal perfusion

CSF drainage

Monitoring of SSEP and MEP

Spinal cord perfusion pressure (SCPP) monitoring


DHCA: Indications

Proximal clamping is not feasible

Need to clamp above the left subclavian

Type II Aneurysms?


CSF Drainage Technique

CSF catheter : L4-L5 or L3-4

CSF pressure < 10mmHg

CSF drainage: 10 cc/h

CSF drainage for 2-3 days


Current Lenox Hill Technique

Mean BP: 85-95mmHg

CSF drainage for 72-96 hr

CSF drainage at 10 cc/hr

SCPP monitoring

Steroids for 48 hrs

Postoperative Management









Motor-evoked potential (MEP) amplitudes

baseline MEP MEP amplitude disappearance

MEP amplitude recovery


CASE PRESENTATION

42 yo patient

Distal Arch/ Type I TAAA



Visceral Perfusion

Is it necessary?


BUN

23.7

30.4

17.04

20.4

38.1

24.2

19.3

40.5

26.2

Pre OP Highest End

NO DHCA

BUN (all cases)

DHCA

=p<.05


CREATNINE

1.49

2.03

1.431.48

2.92

2.06

1.48

2.83

1.98

Pre OP Highest End

NO DHCA

Creatnine (all cases)

DHCA


AMYLASE

54

428

194

61

175

7962

148

62

Pre Op Highest End

DHCA

Amylase (all cases)

NO DHCA


Total Bilirubin

0.65

2.75

1.23

0.66

2.85

1.170.68

3.46

0.81

Pre OP Highest End

NO DHCA

T. Bilirubin (all cases)

DHCA


SGOT

16

344

3722

137

3323 102

36

Pre OP Highest End

DHCA

SGOT (all cases)

NO DHCA


16

220

54

19

84

362062

33

Pre OP Highest End

DHCA

SGPT (all cases)

NO DHCA

SGPT


Visceral Perfusion

Dilute Blood

Rate at 100-200 cc/min


Case Presentation

67 yr old patient

Type IV TAAA

Previous Descending TA repair

Symptomatic


Celiac axis


R Renal



Iliac Bifurcation



Stroke Prevention

Cannulation TechniquesLeft Axillary CannulationAscending Aorta CannulationArch cannulation

Stage I Elephant Trunk


62 yr old patient

Type I TAAA

Grade V aortic arch

Stenosis of the Celiac, SMA


Grade V Aortic Arch


Descending Thoracic Aorta


Celiac axis


InfrarenalAorta



Stage I ET

Trifurcation graft


Celiac

SMA

Stage I ET



January 2002 – July 2011

Total Cases 219

male 112 51%

female 107 49%

Age 66 + 13


Etiology: N=219

0

10

20

30

40

50

60

70

80

90

Medial

Degen.

Ather. Chr.

Diss.

Acute

Diss.

Other

38%

23%

27%

3%

9%


Presentation: N=219

ElectiveRuptureUrgent

66%

19%

15%


Aneurysm Type:N=219

0

10

20

30

40

50

60

70

80

Type I Type II Type III Type IV

36%

20%

23% 21%


No Distal perfusion 29 13%

Femoral-Femoral 87 40%

Atrial-Femoral 103 47%

DHCA 41 19%


Operative variables

Aortic X time 49 (14-173)

CPB time 87 (17-320)

DHCA time 31 (22-56)


Mortality 13 6%

Paraplegia 4 2%


Post- Op Bleeding 8 4%

Stroke 6 3%

Embolic 3

Hemorrhage 3

Operative Complications


New Onset Renal Complications:Cr>2.5

New onset renal insufficiency 51 24%

New Onset Hemodialysis 8 4%

Ventilation>48h 51 23%


Hospital Stay

Mean 12 d

Range (5-96)


Survival

TAAA

122 105 67 36 21 10


Survival and Dissection

Dissection

Non Dissection

p =0.015

5863 54 32 20 1058 51 33 16 10


Open – Demographics Plestis2011

N=219

Schephens199

N=258

Gambria2002

N=337

Coselli2007N=2286

Conrad-2007N=445

Age 66 65 70 66 71

Extent I + II 56% 58% 44% 64% 42%

Rupture 19% 15% 13% 6% 11%

Hybrid – Demographics Kuratani2009N=86

Choong2009N=70

Donas2009

N=58

Kabbani2010

N=36

Chiesa2009N=31

Age 71 67 64.5 71 70

Extent I + II 27% 56% 14% 31% 45%

Rupture 3% 4% 14% N/A N/A


Open

HybridKuratani2009N=86

Choong2009N=70

Donas2009

N=58

Kabbani2010

N=36

Chiesa2009N=31

Mortality 2.3% 16% 25% 8.3% 19.4%

SCI 1.2% 10% 3.4% 3% 8.6%

Dialysis 2.3% N/A N/A 11% 6.4%

Endoleak 10% N/A 17% 27% N/A

Plestis2011

N=219

Schephens199

N=258

Gambria2002

N=337

Coselli2007N=2286

Conrad-2007N=445

Mortality 6% 10% 8% 7% 8%

SCI 2% 11% 11% 4% 13%

Dialysis 4% 10% 13% 6% 21%


Follow Up Survival -Open

Kuratani2009

Kabbani2010

Chiesa2009

Bockler2008

Survival1 year3 years5 years 70%

80% 60%70%

Follow Up Survival -Endovascular

Plestis2011

Schephens2010

Conrad2007

Kouchoukos2011

Survival1 year5 years10 years

70%51%

83%63%34%

54%29%

55%%23%


Conclusions

Both open and hybrid operations in the thoracoabdominalaorta remain extremelly complex operations

The results of open repair of TAAA have improved significantly over the last decade in centers of excellence

The long term outcomes of hybrid operations have not been determined yet.

Open TAA repair remains the procedure of choice in appropriately selected candidates


Thank you




Extent and Mortality

0

10

20

30

40

50

60

70

80

90

Type I TypeII TypeIII TypeIV Descending

Mortality

6%

0%

13%

6%

6%P>0.05

N


Mortality and Distal Perfusion

0

20

40

60

80

100

120

Atriofemoral Femoral Femoral None

Mortality

No Mortality"

6%

7%

10%

P>0.05


Mortality and Aneurysm Type

0

20

40

60

80

100

120

140

160

1 2

No

5%

6%P>0.05

TAAA DTA


0

20

40

60

80

100

120

140

160

180

1 2

No

Ventilation<48h Ventilation>48h

Mortality and Ventilation>48h

2.5%

13%

P<0.05


0

50

100

150

200

250

1 2

Mortality and HemodialysisNo

4%

19%

P<0.05

No Hemodialysis Hemodialysis


0

50

100

150

200

250

1 2

40%

4%

Stroke and Mortality

StrokeNo Stroke

P<0.05


Survival

TAAA Dissection

DTA Non Dissection

DTA Dissection

TAAA non Dissectionp =0.038


Survival

TAAA

DTA

44 40 29 15 9 5 79 65 50 21 11 7


Questions

Does endovascular surgery treat the same patients as open surgery ?

Does endovascular surgery treat the same extent of aorta?

Does endovascular surgery deliver the same long-term outcomes?


Hybrid Approach

Chieas et al


4 vessel debranching + stent

Biasi et al


Infrarenal replacement + debranching

Bockler et al


MEP and SSEP guided intercostal artery reimplantation

Avoidance of subclavian artery clamping

Operative Management


Is it reasonable to search for a single segmental artery whose preservation will prevent paraplegia? NO

Is it reasonable to monitor spinal cord integrity in the perioperative period and treat cord ischemia when it occurs? YES

Do we yet have a strategy to assure preservation of spinal cord integrity through the perioperative period of thoracic and thoracoabdominal aortic aneurysm resection? NO

Has the neurological outcome of thoracic and thoracoabdominal aortic surgery improved markedly in the past decade? YES

Treatment of thoracoabdominal aortic aneurysms. surgery alone or hybrid

Presentations & Public Speaking

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dayslenox hill heart

new onset hemodialysis84

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cch csf drainage