How I do it: How I do it: Disclosures My Approach to My Approach - - PowerPoint PPT Presentation

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How I do it: My Approach to Chronic Type B Dissections How I do it: My Approach to Chronic Type B Dissections

Professor of Surgery Chief & Program Director

Division of Vascular Surgery Eastern Virginia Medical School Norfolk, VA

Jean M. Panneton, MD, FRCSC, FACS

UCSF Vascular Symposium 2015 San Francisco, CA, April 16-18, 2015

No disclosure

Consultant: Lombard Medical, Medtronic Inc & Volcano

Disclosures

Aortic rupture, shock Cardiac Tamponade Aortic valve incompetence Myocardial ischemia Stroke, Limb ischemia Visceral ischemia, renal failure Accelerated Hypertension Paraplegia, Paraparesis Back, chest or abdominal pain

“The great masquerader”

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” Sir William Osler, 1849-1919

Aortic Dissection

Clinical manifestations

Chronic Dissection

Background

Chronic aortic dissection remains one of the most challenging pathologies for aortic surgeons TEVAR is frequently only the initial procedure and further interventions are often required Patience and persistence are

• f the utmost importance

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Chronic Dissection

Objectives

• Understand the complexity of treating patients with

chronic aortic dissection

• Explore the surgical options to treat chronic aortic

dissection

Aneurysm rupture Aneurysm expansion

> 5.5 - 6 cm growth rate > 5mm/yr Arch aneurysm DTA TAAA AAA

Chronic malperfusion

Mesenteric angina Renovascular HTN Claudication Chronic Dissection

Indications

Rupture with hemothorax TEVAR with delayed VAT

Not as common as Acute dissection with malperfusion Different pathophysiology than Acute Dissection Less Dynamic Obstruction of true lumen More Static Obstruction of the Branch vessel Some organ / limb perfusion may be false lumen dependent Nearly always associated with Aneurysm

How different from Acute Malperfusion ?

Chronic Dissection

Chronic Malperfusion

Open repair:

thoracoabdominal aortic replacement aortic fenestration

Endovascular repair:

TEVAR Percutaneous aortic fenestration Fenestrated or Branched EVAR

Hybrid Repairs:

proximal TEVAR with Open distal aortic replacement Visceral debranching followed by TEVAR

Tailored therapy to minimize the physiologic impact on the patient Chronic Dissection

Surgical options

3 Patient related Aortic related

• Age
• Comorbidities
• Prior sternotomy / thoracotomy
• Cardiac / Coronary status
• Pulmonary function
• Renal function
• Type A vs B
• Arch involvement
• Visceral involvement
• Marfan or CTD
• Fixation zones
• Prior TEVAR

Preoperative considerations Preoperative considerations

Chronic Dissection

Surgical options

Young patients and those with CTD are best treated by

• pen repair whereas older patients or those with

comorbidities are selected for endovascular repair Chest / Abdomen & Pelvis CTA Head CT with Circle of Willis Carotid & Visceral Duplex TEE, MRA

Imaging Patient Preparation

Hold anticoagulation & Plavix Preoperative hydration Respiratory therapy Optimize myocardium

Preoperative Planning Preoperative Planning

Chronic Dissection

Surgical options

Posterolateral Thoracotomy Medial visceral rotation Diaphragm sparing Creech technique Visceral patch reimplantation Motor evoked potentials Intercostal revascularization CSF drainage Distal aortic perfusion Partial left heart bypass

Open Thoracoabdominal Aortic Replacement Open Thoracoabdominal Aortic Replacement

Chronic Dissection

Surgical options

Chronic Dissection

Open aortic fenestration

Panneton JM et al, J Vasc Surg 2000;32:711-21

Paravisceral aortic septum resection w or w/o infrarenal aortic replacement

4.4% of 321 procedures for aortic dissection 0 % operative mortality for elective fenestration procedure combined with infrarenal aortic grafting

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58 y o male patient with Chronic type B, max diam DTA at 3.2cm; with 6cm AAA Chronic mesenteric ischemia R leg claudication SMA & RRA true lumen Right iliac occlusion

Paravisceral aortic fenestration with Aorto-bi-iliac replacement for chronic malperfusion Paravisceral aortic fenestration with Aorto-bi-iliac replacement for chronic malperfusion

Chronic Dissection

Surgical options

Chronic Dissection

Surgical options

Chronic TBAD with expanding symptomatic TAAA Aberrant RSA Entry tear SMA & RRA w TL LRA w FL

Chronic Dissection

Surgical options

• 1. Create a proximal landing zone with

bilateral subclavian to carotid transpositions

• 2. Zone 1 TEVAR deployment
• 3. Retrograde embolization of LSA
• 4. Distal TEVAR with a tapered graft
• 5. Percutaneous fenestration to reconnect

the LRA with the true lumen

• 6. Kissing iliac stenting to restore left iliac

perfusion

Chronic Dissection

Surgical options

Pre TEVAR deployment angiogram Post TEVAR deployment angiogram

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Chronic Dissection

Surgical options

Completion arch angiogram Retrograde angiogram type II endoleak from LSA Resolution after Amplatzer plug embolization

Chronic Dissection

Surgical options

Percutaneous fenestration Left renal malperfusion induced by TEVAR

Chronic Dissection

Surgical options

Aims of TEVAR for Chronic Dissection Aims of TEVAR for Chronic Dissection

• 1. Cover the entry tear
• 2. Treat or Prevent Rupture
• 3. Reestablish organ / limb

perfusion

• 4. Cover the distal reentry tears
• 5. Induce false lumen thrombosis
• 6. Promote aortic remodeling

Chronic Dissection

TEVAR

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2 yr post TEVAR 2 yr post TEVAR 4 cm 4 yr post TEVAR 6.5 cm

Chronic Dissection

Post TEVAR Surveillance TEVAR for chronic dissection

• Proximal landing zone is more likely to require arch vessels procedures
• Graft sizing is similar with < 10% oversizing
• The septum is thicker, percutaneous fenestration may be harder
• The true lumen may remain compressed
• The false lumen is more likely to remain patent because of reentries
• Graft tapering is more likely to be needed
• Extensive aortic coverage is required
• Distal malperfusion may be induced by the TEVAR

Chronic Dissection

Learning points

Chronic Dissection

Surgical options False Lumen interventions after TEVAR

Direct FL embolization with plugs or coils

Hofferberth SC et al, J Endovasc Ther 2012;19:538-45

Covered stent placement in branches “Knickerbocker” technique

Kitagawa A et al, J Vasc Surg 2013;58:625-34

In 30 patients with TAAA from chronic type B dissection, FEVAR was feasible without technical problems from narrow true lumen and with low postoperative mortality / morbidity and favorable aortic remodeling but required multiple reinterventions in extensive dissection with visceral involvement

Endovascular option: Fenestrated or Branched EVAR

Chronic Dissection

Surgical options

Narrow true lumen: fenestration are preferred over branches and staging TEVAR first may help Branch vessels originating from false lumen and there’s a thicker septum separating them from TL Landing zones are inexistent and may need to be created

Technical Challenges

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Johnston WF et al, J Vasc Surg 2012;56:1495-1502

Staged Hybrid Repair:

Proximal TEVAR from LSA to celiac followed by distal open repair of type IV TAAA with visceral patch reimplantation or multibranch graft

Chronic Dissection

Surgical options

Staged Hybrid repair with Visceral Debranching followed by TEVAR

Chronic Dissection

Surgical Options

Indications for CSF Drainage

Excessive aortic coverage ( > 20 cm ) Critical aortic coverage ( T8-T12 ) History of AAA repair ( open / EVAR ) Associated severe PAD, HA occlusion Concomitant TEVAR and EVAR Coverage of LSA w/o revascularization

Chronic Dissection

Additional considerations

Spinal Cord Ischemia

TEVAR for chronic aortic dissection is feasible, relatively safe and offers reduced morbidity and mortality After TEVAR for chronic dissection, imaging surveillance is essential because of lesser paravisceral aortic remodeling and higher need for reintervention than for acute dissection Chronic Dissection

Summary