Single-Stage Management of Dynamic Malperfusion Utilizing a Novel - - PowerPoint PPT Presentation

▶
single stage management
SMART_READER_LITE
LIVE PREVIEW

Single-Stage Management of Dynamic Malperfusion Utilizing a Novel - - PowerPoint PPT Presentation

Feb 16, 2024 282 likes •527 views

Single-Stage Management of Dynamic Malperfusion Utilizing a Novel Arch Remodeling Hybrid Graft S. Bozso, J. Nagendran, M.W.A. Chu, B. Kiaii, I. El-Hamamsy, M. Ouzounian, J. Kempfert, C. Starck A. Shahriari, M.C. Moon Background Acute

slide-1
SLIDE 1

Single-Stage Management

  • f Dynamic Malperfusion

Utilizing a Novel Arch Remodeling Hybrid Graft

  • S. Bozso, J. Nagendran, M.W.A.

Chu, B. Kiaii, I. El-Hamamsy, M. Ouzounian, J. Kempfert, C. Starck

  • A. Shahriari, M.C. Moon
slide-2
SLIDE 2

Background

  • Acute DeBakey I aortic dissection is a life threatening condition that

requires emergent surgery to save the patient’s life

  • Emergent hemiarch repair is the standard-of-care and it successfully

addresses the primary entry tear by resection, however, with several limitations:

  • Residual false lumen (FL) remains in the distal aorta
  • Threat of visceral and peripheral malperfusion
  • Creation of an anastomotic entry tear, allowing for antegrade

pulsatile flow and pressurization of FL

slide-3
SLIDE 3

Anastomotic Entry Tear causing Antegrade Pulsatile Flow (APF) Malperfusion Surgically created Anastomotic Entry Tear Negative Remodeling *

slide-4
SLIDE 4

AMDS Mode of Action

Close anastomotic entry tear Expand and stabilize TL Malperfusion mgmt. and distal remodeling Arch & arch vessel remodeling and healing

slide-5
SLIDE 5
slide-6
SLIDE 6
slide-7
SLIDE 7

Objective

  • To investigate outcomes in patients presenting with acute DeBakey I aortic

dissection complicated by malperfusion treated with surgical repair and implantation of the AMDS

slide-8
SLIDE 8

Enrollment

  • Inclusion Criteria
  • Patients 18-80 years
  • Acute DeBakey I aortic dissection within 14-days
  • Exclusion Criteria
  • Extreme hemodynamic compromise requiring CPR
  • Marfan, Loeys-Dietz, or Ehlers-Danlos syndrome
  • Proximal descending thoracic aortic aneurysm >45mm
slide-9
SLIDE 9

End-Points and Definitions

  • CT scans were performed at 1, 3, 6 and 12-months post-operatively
  • Primary End-Point
  • Status of malperfusion after AMDS implantation
  • Malperfusion
  • Loss of blood supply to a vital organ caused by branch arterial
  • bstruction secondary to the dissection
  • Supra-aortic vessel malperfusion: high-grade stenosis (>75%) or
  • cclusion of the vessel due to compression by the non-perfused FL

leading to interruption of flow

slide-10
SLIDE 10

Demographics

  • From March 2017 to January 2019, a total of 47 patients underwent

emergent surgical repair with AMDS implantation

  • Malperfusion was detected pre-operatively in 55.3% (n=26/47)
  • The following outcomes focus specifically on the cohort of patients

presenting with malperfusion Age (y) 63.5 (55.3, 71.0) Male Gender 65.4% (n=17) Reoperation 3.8% (n=1) Hypertension 53.8% (n=14) Prior Stroke 26.9% (n=7) COPD 11.5% (n=3) Chronic Renal Failure 15.4% (n=4)

slide-11
SLIDE 11

Procedure and Hospital Course

Successful Device Deployment 100% (n=26) Axillary Artery Arterial Cannulation 92.3% (n=24) Femoral Artery Arterial Cannulation 7.7% (n=2) Median DHCA Duration (min) 34.0 (26.5, 42.5) Median Cerebral Perfusion Duration (min) 32.0 (21.5, 40.5) Median AMDS Implantation Time (min) 3.0 (2.0, 5.5) Median ICU length-of-stay (days) 9.0 (5.8, 13.3) Median hospital length-of-stay (days) 14.0 (9.0, 19.5)

slide-12
SLIDE 12

Mortality and Serious Adverse Events

30-day mortality 7.7% (n=2) New neurologic deficit identified post-operatively 7.7% (n=2) Aortic injury associated with device implantation 0% (n=0) New aortic arch branch vessel compromise 0% (n=0) Acute renal failure 19.2% (n=5) Dialysis 19.2% (n=5)

slide-13
SLIDE 13

Malperfusion Management

  • In the 24 patients included in efficacy analysis, 66 vessel malperfusions

identified

  • Two patients were excluded from efficacy analysis due to early death,

without a post-operative CT

  • Hypoxic encephalopathy secondary to bilateral common carotid artery
  • cclusions pre-operatively
  • Multi-system organ failure
slide-14
SLIDE 14

Malperfusion Patient Coronar y Innom RCCA LCCA LSCA RSCA Spinal cord Celiac art SMA R Renal L Renal LLE RLE Total 1 90% 1 2 Occ 1 3 80% 90% 2 4 Occ Occ Occ Occ Occ 5 5 70% 90% 2 6 Occ 90% Occ 3 7 90% Occ Occ 3 8 Occ Occ Occ 3 9 99% x Occ Occ Occ Occ 6 10 x Occ 2 11 Occ Occ Occ Occ 4 12 x 90% 2 13 Occ 90% 90% 3 14 Occ 99% 2 15 Occ Occ 2 16 Occ 99% 2 17 Occ Occ 2 18 Occ Occ 2 19 90% 1 20 Occ Occ 2 21 Occ Occ 2 22 STE Occ Occ Occ Occ Occ Occ Occ 8 23 Occ Occ 2 24 Occ Occ Occ Occ 4 Total 1 6 6 7 2 1 3 6 8 6 10 7 3 66 % of Tot 1.5% 9.1% 9.1% 10.6% 3.0% 1.5% 4.5% 9.1% 12.1% 9.1% 15.2% 10.6% 4.5% 100%

slide-15
SLIDE 15

Malperfusion Management

  • 95.5% (n=63) of vessel malperfusions resolved after AMDS implantation,

without a secondary procedure

  • Supra-aortic: 95.5% (n=21/22)
  • Visceral: 92.9% (n=13/14)
  • Renal: 93.8% (n=15/16)
  • Lower Extremity: 100% (n=10/10)
  • Paralysis: 100% (n=3/3)
slide-16
SLIDE 16

Cerebral Malperfusion

  • Of the 66 vessel malperfusions, 22 (33.3%) involved supra-aortic vessels
  • Of the 26 patients presenting with ATAAD complicated by malperfusion, 6

(23.1%) were diagnosed with a neurologic injury post-operatively

  • Four patients had clinical evidence of cerebral malperfusion in the

emergency department pre-operatively

  • Two patients had a new neurologic deficit identified post-operatively

without neurologic symptoms pre-operatively

  • All post-operatively identified neurologic deficits occurred with

dissection or malperfusion of a cerebral vessel

  • None occurred in patients with anatomically normal cerebral vessels.
slide-17
SLIDE 17

Courtesy University

  • f Alberta
slide-18
SLIDE 18

Occluded SMA Occluded Renal Arteries Bilaterally Patent SMA Patent Renal Arteries Bilaterally

F G

Nearly Occluded Common Carotid Arteries Patent Common Carotid Arteries

D E

Courtesy Montreal Heart Institute

slide-19
SLIDE 19
  • LCC and

L CFA malperfusion

Courtesy University Hospital Network, Toronto

slide-20
SLIDE 20

Courtesy University Hospital Network, Toronto

slide-21
SLIDE 21

Secondary Procedures

  • Three patients required disease-related secondary procedures
  • Left renal artery stenting for static malperfusion
  • Superior mesenteric artery stenting for static malperfusion
  • Bilateral femoral artery patch angioplasty and left lower extremity

fasciotomy secondary to delayed presentation

slide-22
SLIDE 22

Key Points

  • The AMDS is a safe and reproducible adjunct to the current standard-of-

care repair in ATAAD without adding significant time or complexity

  • When faced with malperfusion, the AMDS is capable of effectively treating

malperfusion in over 95% of cases

  • Static malperfusions can be addressed effectively after life-saving

surgery on a semi-elective basis

  • A unique characteristic in this cohort was healing of malperfusions

involving cerebral vessels and reversal of dissection-induced paralysis

  • Based on the data presented we advocate for single-stage management of

malperfusion during the index operation without delaying life-saving surgery

slide-23
SLIDE 23

Questions?