UC UC SF SF Disclosures The Endovascular Management Research - - PowerPoint PPT Presentation

▶
uc uc sf sf disclosures
SMART_READER_LITE
LIVE PREVIEW

UC UC SF SF Disclosures The Endovascular Management Research - - PowerPoint PPT Presentation

Aug 21, 2023 294 likes •372 views

UC UC SF SF Disclosures The Endovascular Management Research support and royalties of Acute Type B Dissection from Cook, Inc. Jade S. Hiramoto, MD, MAS April 14, 2016 VASCULAR SURGERY UC SAN FRANCISCO VASCULAR SURGERY UC

slide-1
SLIDE 1

1

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

The Endovascular Management

  • f Acute Type B Dissection

Jade S. Hiramoto, MD, MAS April 14, 2016

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Disclosures

  • Research support and royalties

from Cook, Inc.

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Endovascular Treatment of Acute Type B Dissection

  • Rupture
  • Stent-graft
  • Unremitting pain, refractory hypertension,

early expansion

  • Stent-graft
  • Induce favorable aortic remodeling
  • Stent-graft +/- distal bare stent +/- covered branch

vessel stents

  • Malperfusion
  • Stent-graft +/- distal bare stent +/- branch vessel

stents

  • Fenestration +/- stent

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Malperfusion Syndrome

  • Associated with early mortality
  • End organ ischemia secondary to aortic branch

compromise from dissection

  • Can involve one or more vascular beds

simultaneously

  • Early symptoms can be subtle
  • Dynamic vs static obstruction
slide-2
SLIDE 2

2

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Malperfusion Syndrome: Dynamic Obstruction

  • Compressed true lumen unable to provide

adequate volume flow

  • Motion of intimal flap within aortic lumen
  • bstructs orifice of branch vessel
  • Responsible for ~80% of malperfusion
  • May vary depending on blood pressure
  • Would be expected to respond to exclusion
  • f entry tear or aortic fenestration

Uchida et al; ICTVS 2009;8:75-78

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Malperfusion Syndrome: Static Obstruction

  • Dissecting process extends into branch

vessel, causing narrowing

  • Unlikely to resolve with restoration of

aortic true lumen flow alone

  • Re-assess after stent graft/fenestration
  • May require branch vessel stenting

Uchida et al; ICTVS 2009;8:75-78

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Goals of Treatment

  • Focus on most minimal/expedient intervention

to restore perfusion as soon as possible

  • Primary goal: Expansion of true lumen with

restoration of flow to visceral vessels/lower extremity

  • Stent-graft repair with coverage of proximal entry tear
  • Fenestration (convert complicated into uncomplicated

dissection)

  • Secondary goal: obliteration of false lumen flow

with subsequent complete thrombosis

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Treatment Strategies

  • Stent-graft repair
  • Advantages: restore true lumen flow; prevent late

aneurysm formation; favorable aortic remodeling with lower risk of aortic rupture

  • Disadvantages: paraplegia; retrograde dissection
  • Fenestration
  • Advantages: restore true lumen flow; minimal risk of

paraplegia

  • Disadvantages: promotes blood flow through false

lumen, potentially leading to progressive dilation/aneurysmal degeneration

slide-3
SLIDE 3

3

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

  • Pre-operative imaging
  • CT angiography
  • Assess vertebral circulation
  • IVUS and angiography
  • Verify preoperative anatomy
  • Verify true lumen passage of guidewire
  • Avoid inadvertent deployment in false lumen
  • Consider transesophageal echo

Endovascular Treatment of Acute Type B Dissection

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Intravascular Ultrasound

Sfyroeras et al; JEVT 2011;18:78-86

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Angiography

  • Long sheath inserted into aortic arch
  • Angiography at different levels to

verify true lumen position

  • “Viscera on a stick”

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Treatment: Stent-graft Repair

  • Avoid aggressive oversizing
  • Avoid ballooning of seal zones
  • Minimize aortic coverage (<20cm) to reduce risk
  • f spinal ischemia
  • Coverage of left subclavian artery (~50%)
  • Re-assess distal perfusion after stent-graft

deployment

  • May still have inadequate true lumen flow
  • Consider placement of uncovered distal stent: support

true lumen and stabilize dissection flap

  • Additional stent placement for visceral branch vessel
  • bstruction
slide-4
SLIDE 4

4

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

  • Subsequent angiography at different levels

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

The Petticoat Concept

  • Provisional extension to induce complete

attachment

  • Placement of scaffolding distal stent after

sealing proximal tear with stent-graft

  • Why do this?
  • Even after successful thoracic stent-graft

placement, fate of distal abdominal segment unresolved

  • With large distal reentry points, abdominal

segment of false lumen tends not to thrombose and remodel completely

  • Try to diminish late complications

Nienaber et al; JEVT 2006;13:738-746

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

The Petticoat Concept

  • Placement of bare stent scaffold

extension into implanted stent-graft

  • Abolish distal true lumen collapse
  • Enhance remodeling process of entire

dissected aorta by fixation of distal lamella

  • STABLE trial (complicated dissections):
  • Favorable early clinical outcomes
  • Favorable aortic remodeling

Nienaber et al; JEVT 2006;13:738-746 Lombardi et al; J Vasc Surg 2014;59:1544-1554

slide-5
SLIDE 5

5

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Modified Petticoat Technique

  • Concern regarding original Petticoat

concept:

  • Further aortic dissection/damage from initial

TEVAR deployment into distal diseased aorta

  • Pre-placement of distal bare stent as

adjunct to proximal TEVAR

  • Prevent excessive force of the distal end of the

stent graft on the aorta

  • Prevent early aortic wall damage, distal re-

dissection

  • Restricts effect of oversizing of distal

stent-graft

  • Reduces potential for distal true lumen

collapse and visceral malperfusion

He et al; Eur J Vasc Endovasc Surg 2015;50:450-459

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

He et al; Eur J Vasc Endovasc Surg 2015;50:450-459

Modified Petticoat Technique

Initial release of distal bare stent at distal landing zone Subsequent deployment of proximal stent-graft

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Modified Petticoat Technique

  • Diameter of adjunctive bare stent:
  • Select using greatest diameter of TL at

intended distal edge of stent-graft

  • Bare stent not oversized compared to aorta
  • Anticipate 3-4 cm of overlap with distal

end of proximal covered stent-graft

  • Sinus XL-stent (OptiMed, Ettlingen,

Germany):

  • Diameter: 18-26 mm
  • Length: 60-80 mm
  • Available in diameters 16-36 mm in varying

lengths

  • Largest wallstent: 24 mm

He et al; Eur J Vasc Endovasc Surg 2015;50:450-459

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Treatment: Fenestration

  • Relieve dynamic obstruction by creating flap

fenestration to generate large reentry tear

  • Potential use in patients who cannot be treated

with a thoracic stent-graft because of anatomic constraints

  • Flow ensured within false lumen, precluding

thrombosis

  • Branch vessel compromise (malperfusion) is

treated, but not the aorta

  • If static obstruction exists, perform branch

vessel stent placement

slide-6
SLIDE 6

6

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Fenestration: Technique

  • Smaller (true) to larger (false) lumen
  • Rosch-Uchida needle, Colopinto needle, or

back end of 0.014 wire to create fenestration close to compromised aortic branch

  • After needle and stiff wire advanced from true

to false lumen, catheter advanced and confirmation by angiography

  • Large angioplasty balloon used to create

fenestration tear

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

  • May require membrane puncture with re-

entry catheter

  • Guidewire passed through re-entry

catheter and across membrane

  • Guidewire snared through contralateral

transfemoral access (through and through wire access)

  • Cheese-wire maneuver
  • Portions of fenestrated membrane can
  • cclude iliac artery – be prepared to stent

Fenestration: Technique

Kos et al; Cardiovasc Intervent Radiol 2011;34:1296-1302

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Fenestration with Bare Metal Stent Placement

Vendrell et al; J Thorac Cardiovasc Surg 2015;150:108-115

  • “Funnel technique”
  • Uncovered stent
  • True lumen to false lumen
  • Above level of visceral vessels
  • May require additional

fenestration/stent placement below visceral vessels

  • For persistent malperfusion of

lower extremities

Miyachi et al; J Nippon Med Sch 2014;81:340-345

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Stent-graft or Fenestration?

  • Endograft therapy first line of treatment
  • Aims to restore native aortic anatomy by closure of

primary tear

  • Percutaneous fenestration
  • Aims to increase true lumen perfusion by equalizing

pressures in true/false lumens

  • Does not address underlying abnormality of

dissection itself

  • Limit to patients who lack suitable proximal landing

zone or complex multilumen dissections not easily corrected by closure of primary tear

slide-7
SLIDE 7

7

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

How Much to Stent?

  • Coverage of primary entry tear only
  • May have continued false lumen perfusion
  • Lower risk of paraplegia
  • Coverage of entire thoracic aorta
  • Treats primary entry tear as well as distal reentry sites
  • Reduced potential for continued false lumen perfusion
  • Higher risk of paraplegia
  • Need carotid subclavian bypass, spinal drain
  • Coverage of primary entry tear and distal bare

metal stent

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Spinal Drain?

  • Extensive aortic coverage with coverage of left

subclavian

  • >15-20 cm thoracic aortic coverage
  • Coverage of last 5 cm of distal thoracic aorta
  • Paraplegia not as well correlated with length of

prosthesis as in aneurysm repair

  • Persistent false lumen perfusion
  • If choose not to place pre-operatively, be ready

for prompt placement of spinal drain

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Carotid Subclavian Bypass?

  • Dominant left vertebral artery
  • Left internal mammary to LAD bypass graft
  • Extensive aortic coverage
  • Snorkel graft into left subclavian artery