Who can you really trust??? Vascular Surgery Vascular Surgery 1 - - PowerPoint PPT Presentation

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Jul 01, 2023 15 likes •125 views

3-WAY DEBATE Disclosures: Snorkels and other adjuncts to treat Research and educational grants paid to Stanford from short and difficult necks offer a stable Cook, Medtronic, WL Gore and long term solution No personal financial

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1 3-WAY DEBATE Snorkels and other adjuncts to treat short and difficult necks offer a stable and long term solution

Jason T. Lee, MD UCSF Vascular Symposium 2015

Disclosures:

Research and educational grants paid to Stanford from

Cook, Medtronic, WL Gore

No personal financial disclosures
Off Label use of devices

Vascular Surgery Vascular Surgery

Who can you really trust???

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Vascular Surgery

Who can you really trust???

Vascular Surgery

Who can you really trust???

Vascular Surgery

Who can you really trust???

Vascular Surgery

2008-2015

Referral patterns changed
More devices available and improving
IRB approved protocol for complex EVAR

– 70 juxtarenal snorkel cases (2009-current) – 56 commercial fenestrated (2012-current) – 15 double barrel sandwich (internal iliac) (2009-2011) – 27 iliac branch (10 in trials) (2012-current) – 17 periscope/branch TEVAR (2010-current) – 7 homemade fenestrated/branched (2008-2009)

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Vascular Surgery

Snorkel graft/chimney

Parallel graft alongside

the main aortic endoprosthesis to maintain flow in a covered branch vessel.

Vascular Surgery

Self-expanding bare metal stents Effectively raise renal orifice a few mm Ensure graft material in region of renals without compromising renal flow

Vascular Surgery

6 juxtarenal cases (2 ruptured, 3 urgent) Covered stents Valid alternative to fenestrated during emergency setting or unsuitable for FBE Rescue procedure to salvage side branch

Vascular Surgery

Encroachment vs. snorkel 8 cases of snorkel with neck length 6.9mm All single renal to gain additional 10.4mm 7 out of 8 bare metal stents Emergency setting, no access to FBE

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Vascular Surgery

70 consecutive patients (2009-current) IRB approved protocol 98% technical success 2.9% 30-day mortality 96% primary patency (mean 29 months, 3-62) Survival 89% at one year, 83% at two years

Vascular Surgery

What are the Concerns?

Lack of numbers
Gutters
Renal patency
2nd interventions
Renal function

Vascular Surgery

898 parallel grafts placed into 517 patients

– 692 renal arteries, 156 SMAs, 50 celiacs

94% patency
5.7% type I endoleak
2 year survival 79%

Vascular Surgery

What are the Concerns?

Lack of numbers
Gutters
Renal patency
2nd interventions
Renal function

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Vascular Surgery Vascular Surgery

Imaging Follow-Up

96% overall primary patency at mean 29 months (3-62)

– 6 occluded renals

1 post op (rescued)
1 at 1 month f/u (asymptomatic)
2 at 3 months (1 during abdominal operation, rescued)
1 at 6 month f/u (asymptomatic)
1 at 2 year f/u (rescued)

– 98% secondary patency

2nd interventions (7.1%)

– 1 Type 3 endoleak – 1 Type 1 endoleak – 3 rescued renals

Vascular Surgery

What are the Concerns?

Lack of numbers
Gutters
Renal patency
2nd interventions
Renal function

Vascular Surgery

Long term concerns-Renal Function

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VASCULAR SURGERY VASCULAR SURGERY

Open JAAA

RIFLE: 37.3% overall acute renal dysfunction, 4.1%

dialysis

Of these, 55.6% lowest level (25-50% GFR decline)

VASCULAR SURGERY VASCULAR SURGERY

Open JAAA

RIFLE: 37.3% overall acute renal dysfunction, 4.1%

dialysis

Of these, 55.6% lowest level (25-50% GFR decline)

Sn-EVAR

RIFLE: 32.6% overall acute renal dysfunction, 2.3%

dialysis

Of these, 71.4% lowest level

VASCULAR SURGERY VASCULAR SURGERY

*Defined newly acquired renal insufficiency as increase in serum creatinine >.5 and serum creatinine >1.5 Open JAAA (46 month f/u)

8.5% incidence perioperative, 2% dialysis
19% of patients at latest follow up, 4.8% dialysis

VASCULAR SURGERY VASCULAR SURGERY

*Defined newly acquired renal insufficiency as increase in serum creatinine >.5 and serum creatinine >1.5 Open JAAA (46 month f/u)

8.5% incidence perioperative, 2% dialysis
19% of patients at latest follow up, 4.8% dialysis

Sn-EVAR (21 month f/u)

9.1% incidence perioperative, 2.3% dialysis
23% of patients at latest follow up, 0% dialysis

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VASCULAR SURGERY VASCULAR SURGERY

Open+EVAR Infrarenal AAA repair

VASCULAR SURGERY VASCULAR SURGERY

Sn-EVAR Open+EVAR Infrarenal AAA repair

0.2 0.4 0.6 0.8 1 10 20 30 40 Freedom from Renal Function Decline Time [Months] VASCULAR SURGERY VASCULAR SURGERY

*Defined as transient or permanent increase in creatinine >2 or 30% increase versus baseline FEVAR (15-25 month f/u)

22.2% incidence renal dysfuntion
93.2% branch vessel patency

Sn-EVAR (21 month f/u)

29.7% incidence of renal dysfunction
95% branch vessel patency

Vascular Surgery

How about now that ZFEN is approved?

Approved July 2012 First case September 2012

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Vascular Surgery

10 20 30 40 50 60 70 80 2009 2010 2011 2012 2013 2014 2015 Snorkel ZFEN

24 Snorkel 56 ZFEN

Complex Juxtarenal AAA 2009-current 70 snorkel, 56 ZFEN

Vascular Surgery

81 yo male Prior TEVAR 7.5 cm short neck AAA 32 mm at neck WAIT TIME 3-4 WEEKS

Vascular Surgery

78 yo male 48 hours abd pain Used device planned for someone else

Vascular Surgery

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Vascular Surgery Vascular Surgery

71 yo male 9.3 cm AAA Double angle with downgoing renal SMA at same level as renal

Vascular Surgery Vascular Surgery

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Vascular Surgery Vascular Surgery Vascular Surgery Vascular Surgery

Summary

On-label use of ZFEN if feasible

– Often not feasible….

Low threshold for snorkel/chimney strategy
Neck angulation distorts renal fenestration and SMA scallop

planning

Anatomic limitations of SMA/renal distance
Wait time- need off the shelf strategies
Renal takeoff angulation adds to difficulty
Iliac access

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Vascular Surgery

3-WAY DEBATE Snorkels and other adjuncts to treat short and difficult necks offer a stable and long term solution

VOTE YES

Vascular Surgery