Pro- and cons of staging complex EVAR Is there more to staging than lower paraplegia? Barend Mees, Michiel de Haan, Geert Willem Schurink
Waar gaan we naar toe? Disclosures Consulting: Cook, Bentley, Abbott, Getinge
Complex EVAR = endo TAAA repair
Types of staging • Historical staging • Arch/TEVAR first with/without debranching/access conduit • Temporary sac perfusion • Minimal Invasive Segmental Artery Coil Embolisation (MISACE)
Historical staging • 20-47% of patients with TAAA have had previous aortic repair • Previous aortic repair is protective for mortality and development of SCI.
Previous Aortic Repair Gustavo Oderich; Endovascular Aortic Repair
Iliofemoral conduit staging Gustavo Oderich; Endovascular Aortic Repair
Gustavo Oderich; Endovascular Aortic Repair
Ascending, Arch, FET first Gustavo Oderich; Endovascular Aortic Repair
TEVAR first In Type I and II TAAAs TEVAR first is common staging strategy, especially in combination with carotid-LSA bypass Gustavo Oderich; Endovascular Aortic Repair
Historical and TEVAR staging • Reduce operative time • Reduce limb ischemia • Reduce complications • Reduce mortality and morbidity • Reduce paraplegia
Temporary Aneurysm Sac Perfusion • Perfusion branches • Open branch • Stent between stent graft components • Unconnected iliac limb
Perfusion branches
Open branch strategy Sac perfusion No Sac Perfusion (n=40) (n=43) Paraplegia 5% 21%
MISACE
MISACE
What are the cons of staging? • Rupture • Occlusion of target vessel • Disturbed flow in sac causing emboli • General anesthesia 2x • Complication of coiling segmental arteries • Patient satisfaction
Rupture/Mortality before completion 2 nd stage • Cleveland 2/27 • Birmingham 1/92 • Regensburg 1/40 • Maastricht 0
Target vessel occlusion
Target vessel occlusion
What are the cons of staging? • Rupture • Occlusion of target vessel • Disturbed flow in sac causing emboli • General anesthesia 2x • Complication of coiling segmental arteries • Patient satisfaction
General anesthesia • Maastricht axillary access and MEPS • Regensburg 23% local anesthesia
What are the cons of staging? • Rupture • Occlusion of target vessel • Disturbed flow in sac causing emboli • General anesthesia 2x • Complication of coiling segmental arteries • Patient satisfaction
What are the cons of staging? • Rupture • Occlusion of target vessel • Disturbed flow in sac causing emboli • General anesthesia 2x • Complication of coiling segmental arteries • Patient satisfaction
There is no doubt that Waar gaan we naar toe? staging endo TAAA repair is beneficial • Staging has reduced paraplegia rates dramatically • It also reduces mortality and morbidity • Only retrospective evidence • Low or very low GRADE
Department of General, 542 Vascular and Transplant Surgery, Poland endovascular thoracoabdominal / juxtarenal procedures 161 patients (from 2018) mortality 10/161 (6,2%) Number of patients paraplegia 2/151 (1,3%) good clinical outcome 92,5% 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Year, month
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