Unresolved Problems of Cerebral Events during TEVAR Richard Gibbs - - PowerPoint PPT Presentation

Unresolved Problems of Cerebral Events during TEVAR

Richard Gibbs Vascular Unit Imperial College NHS Trust London

Disclosures

• Research support from GORE Medical

Brain Injury in TEVAR

Stroke 8% ‘Silent’ stroke 70% Motor deficits Delirium Cognitive changes

Procedural Stroke:

• 1. Overt CNS Injury
• 2. Covert CNS Injury
• 3. Neurological dysfunction without CNS injury

Neurologic Academic Research Consortium 2017

‘Universal and unambiguous definitions of stroke and neurovascular events become of paramount importance to understanding the etiology of stroke in TEVAR procedures’

What has the data told us so far?

• 1. TEVAR is associated with cerebral infarction

TEVAR

N=52 Median age 69

TCD

N=42

DW-MRI

N=31 Neurocognitive assessment N=17

100% HITS 13% Stroke 68% SCI 88%

Decline 6/7 domains age>69

Maximum HITS Stent deployment 62 (IQR 35-192) Contrast injection 62 (IQR 22-163)

Median infarct volume

164mm3 IQR (108.64-1328.30mm3)

• REY auditory verbal test, verbal

learning and memory

• Trail A – visual search and motor
• Trail B – mental flexibility &

switching

• Grooved pegboard – fine motor

skills

• COWA (FAS) – executive function

Observational study: 77 patients DW-MRI St Thomas’ Hospital and St Mary’s Hospital

Zone 0 100% (6/6) (50% 3/3 stroke) Zone 1 77% (7/9) (22% 2/9 stroke) Zone 2 79% (22/28) (6/28 stroke 22%) Zone 3 62% (13/21) (2/21 stroke 10%) Zone 4 39%(5 /13) (0/13 strokes 0%)

VASCULAR BRAIN INFARCTS (VBI)

Single unilateral large lesions Multiple unilateral lesions Bilateral small lesions

Stent graft deployment Wire/catheter exchange Pre-operative

• 2. TCD provides a procedural time stamp for embolization

TCD provides a procedural time stamp for embolization

• 3. TCD HITS Relate To Cerebral Outcomes

• 4. Particulate cerebral embolization can be reduced…..

CEPD reduced both number and size of new infarcts Median no particles in filters: 937 (146-1687)

…but all 3 supra-aortic trunks need protection

Protected 7/9 (78%) 23 new lesions Total SA=379mm2 Median SA= 6mm2 (3-16) Unprotected 9/12 (75%) 55 new lesions Total SA=1534mm2 Median SA=16mm2 (3-103)

Maximum proportion of SOLID HITS – Wire& pigtail 13% , Stent deployment 11%

• 5. TCD embolic differentiation software shows the

major component of embolization is gaseous

• 6. Gaseous embolization is associated with DWI- MRI

infarcts

Number of new MRI lesions vs gaseous HITS

• 1. Insert Ctag into

Dryseal

• 2. 1cm of Ctag

exposed

• 3. Inflate dryseal

VALVE port with 5ml saline

• 4. Connect dryseal FLUSH

port to CO2 tubing

• 5. Saline flush into dryseal

port and guidewire lumen port

• 6. Remove CTAG from

dryseal and leave submerged under saline in tray

Observational TEVAR-De-airing C02 Study

Pre-operative investigations:

• CT aortogram (standard work-up)
• 3T Brain MRI
• Neurocognitive testing & Neurology
• MMSE ( + depression HADS score)

TEVAR With CO2 flushing 2L/min 2.8bar

• Transcranial doppler (TCD) solid/ gas

differentiation

• Zone 2-4 TEVAR

Post-operative investigations:

• 3T Brain MRI
• Neurocognitive testing MMSE(HADs)

Outpatient investigations:

• Neurocognitive testing MMSE (HADs)
• Neurological exam

Saline (n= 77) CO2 (n=28) P value Urgency

Elective Emergency 65% (50/77) 35% (27/77) 89% (25/28) 11% (3/28) 0.015

Pathology

TAA TAAA DTA TBD CTBD Coarctation pseudoaneurysm PAU Mycotic Trauma 23% (18/77) 20% (15/77) 13% (10/77) 14% (11/77) 8% (6/77) 7% (5/77) 12% (9/77) 10% (8/77) 4% (3/77) 11% (3/28) 50% (14/28) 0% (0/28) 4% (1/28) 18% (5/28) 4% (1/28) 11% (3/28) 4% (1/28) 0% (0/28) 0.151 0.002 0.059 0.175 0.158 1.000 1.000 0.439 0.563

Operation

TEVAR TEVAR+ scallop/fenestration TEVAR+ LSA TEVAR+ arch hybrid TEVAR+ F/BEVAR TEVAR+visceral hybrid 51% (39/76) 8% (6/76) 21% (16/76) 15% (11/76) 1% (1/76) 1% (1/76) 64% (18/28) 14% (4/28) 4% (1/28) 14% (4/28) 4% (1/28) 0% (0/28) 0.238 0.453 0.037 1.000 0.468 1.000

Zone

1 2 3 4 8% (6/77) 12% (9/77) 36% (28/77) 27% (21/77) 17% (13/77) 11% (3/28) 4% (1/28) 14%(4/28) (13/28) 25% (7/28) 0.698 0.283 0.030 0.064 0.349

Saline (n= 77) CO2 (n=28) P value Cerebral infarction

• n MRI

69% (53/77) 38% (9/24) 0.006 ‘Silent’ stroke 52% (40/77) 25% (6/24) 0.021 Stroke 17% (13/77) 13% (3/24) 0.756 Neurocognitive assessment Ongoing follow-up Ongoing follow-up

INTERCePT GP: INTERvention with Cerebral Embolic Protection in TEVAR: Gaseous Protection

ClinicalTrials.gov Identifier: NCT03886675 l.hanna@ic.ac.uk

• RCT TEVAR-CO2
• Multi-center
• Multi-graft
• Standardized Saline and CO2 de-airing techniques