Disclosures A Reasonable Option in Off label use will be presented - - PowerPoint PPT Presentation

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Hybrid Repair for Aortic Pathology: A Reasonable Option in Selected Patients

William J. Quinones-Baldrich MD Professor of Surgery Director UCLA Aortic Center UCLA Medical Center Los Angeles, California

Disclosures

• Off label use will be presented
• Device companies not promote or assure

safety and efficacy of off label use of their products

• Speaker/consultant

W.L. Gore Endologix Medtronic

Hybrid Repair for Aortic Pathology

• Rationale: Reduce magnitude of surgical

intervention

• Thoraco-abdominal aorta
• Aortic Arch
• Use currently available endovascular devices
• Allow treatment of complex pathology in high

risk patients

73y/o with R pelvic kidney s/p repair Type IV TAA, presents with contained visceral patch rupture

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71 y/o with severe COPD, Type II TAA, acute on chronic mesenteric ischemia and severe claudication 71 y/o with severe COPD, Type III TAA, acute on chronic mesenteric ischemia and severe claudication

Stage 1: IR Replacement, Visceral debranching, distal endograft

71 y/o with severe COPD, Type III TAA, acute on chronic mesenteric ischemia and severe claudication: Stage 2 – L CS bypass + TEVAR

45 y/o female with type B aortic dissection and aberrant R subclavian artery (BMI 42)

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Type B aortic dissection and aberrant R subclavian artery: Follow up

68 y/o with enlarging aneurysm with Type B aortic dissection

Stage 1 RCCA to LCCA bypass; LCCA to L SC transposition Stage 2: TEVAR Zone 1

37 y/o s/p Aortic Coarctation repair (age 14) and Apico – DTA bypass (age 27; thrombosed for 14 mo) with severe HTN and claudication

Endovascular Elephant Trunk

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Staged Approach …. Expanded! Staging Decreases Risk

Combined Endovascular and Surgical Approach

• Patient selection

Surgical vs. hybrid vs. endovascular repair

• Individualized plan

Reduce risk of debranching component Must accomplish adequate seal zones

• Staging reduces risk

Single stage: Urgent indications Antegrade deployment zone 0 (arch)

• Interval rupture is a risk

Second stage during same admision Staged retroperitoneal debranching for hybrid repair of type III TAA

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Infrarenal Aortic Replacement as Part of Debranching

Graft size to match available endograft May require distal tapering Pledgeted proximal anastomosis

Aortic Wrap

Circumference = x diameter (endograft)

Combined Endovascular and Surgical Approach to Thoraco-abdominal Pathology: Conduit placement (1rst stage) and thrombectomy (2nd stage)

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North American Complex Abdominal Aortic Debranching (NACAAD) Registry

• High risk patients with complex TAA
• Spinal cord ischemia : 159 patients

Transient 10 / 159; 6.2% Permanent 12 / 159; 7.5% Mortality 16% Risk Type II, coverage, rupture, renal insufficiency

• Ischemic colitis : 208 patients – 6%

Mortality w/o IC – 14% Mortality w IC – 46% Risk Single stage, age, comorbidity score

1998 - 2013 – 51 high risk patients 40 TAA – 8 II, 23 III, 9 IV 5.8 % mortality: 2 interval aneurysm ruptures 1 arch debranching / retrograde dissection Paraplegia – 2/40 at risk (5 %); II,III 1/ (3.2%)

2 year cumulative survival – 78%

2009

CESA (Hybrid) Repair Aortic Arch Pathology

Arch debranching and Endovascular repair 13 reported series > 10 cases reported as of 2011

• Mortality 0 - 20% Avg 7.9% UCLA 5.2%
• Stroke 0 – 19% Avg 5% UCLA No strokes
• All patients “high risk”
• Some series include cases with CPBP/ deep

hypothermia

• CESA for Arch << CESA for TAA

Durable?

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Durable Combined Endovascular and Surgical Approach (CESA or Hybrid Approach)

11 yr

follow up

Durable? Combined Endovascular and Surgical Approach (CESA or Hybrid Approach)

13 yr

follow up

Durable Combined Endovascular and Surgical Approach (CESA or Hybrid Approach)

13 yr

follow up “Hybrid” vs. Total Endovascular Repair

Hybrid More invasive Surgical skill > endovascular skill Less affected by tortuosity and

• r occlusive disease

Great for surgical training Available today Total endovascular repair Less invasive Endovascular skill > surgical skill Significantly affected by tortuosity, occlusive disease Evolving technology; risk EV Cx long term Not available for now; to all

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The hybrid approach has a role today and in the future Vascular surgeons are best (only?) to offer all alternatives