February 23, 24 & 25, 2017February 23, 24 & 25, 2017

The HoustonAortic SymposiumAortic SymposiumFrontiers in Cardiovascular Diseases

ROBERTO DI BARTOLOMEO

CARDIAC SURG. DEPT.ST. ORSOLA – HOSPITAL

UNIVERSITY OF BOLOGNA

ROBERTO DI BARTOLOMEO

UNIVERSITY OF BOLOGNA

FINANCIAL DISCLOSURE: NONE

HOUSTON, TEXASHOUSTON, TEXAS

Complex lesions of the thoracic aorta

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Complex lesions of the thoracic aorta

““Pa tholog yofthe a orta sta rting from the a sc e nd ing a orta orPa tholog yofthe a orta sta rting from the a sc e nd ing a orta ora ortic a rc h a nd e xte nd ing d ownwa rd intothe d e sc e nd ing thora c ica ortic a rc h a nd e xte nd ing d ownwa rd intothe d e sc e nd ing thora c ica ortic a rc h a nd e xte nd ing d ownwa rd intothe d e sc e nd ing thora c ica ortic a rc h a nd e xte nd ing d ownwa rd intothe d e sc e nd ing thora c ic

orthora c oa b d om ina la ortaorthora c oa b d om ina la orta ””

ACU TE

Type A a ortic d isse c tion

CHRO N IC

Chronic a ne urysm sType A a ortic d isse c tion

Type B a ortic d isse c tion

Chronic a ne urysm s

Type A a ortic d isse c tion

PAU – AoHa e m a tom a Type B a ortic d isse c tion

PAU – AoHa e m a tom aPAU – AoHa e m a tom a

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

1982 –THE BIRTH OF THE ELEPHANT TRUNK

The problem: 2 patients with mega-aorta

Re fle ctionsof Borst

The problem: 2 patients with mega-aortasyndrome

Idea: “Decided to replace the aortic arch with aH. BORSTH. BORST

Idea: “Decided to replace the aortic arch with along graft, whose free ‘‘elephant trunk’’ extensionwas to be suspended freely in the distal aorta”

1 st stage1 st stage1 st stage1 st stage 2 nd stage2 nd stageCardiac Surgery Dept. – University of Bologna

roberto.dibartolomeo@ unibo.it

TheThe mostmost recentrecent developmentdevelopment ofof thethe classicclassic elephantelephant trunktrunk

techniquetechnique isis thethe combinationcombination ofof anan endovascularendovascular stentstent graftgraft

withwith aa conventionalconventional surgicalsurgical graftgraft forfor hybridhybrid proceduresprocedures ofof

thethe entireentire thoracicthoracic aortaaorta..

ThisThis newnew optionoption waswas termedtermed::ThisThis newnew optionoption waswas termedtermed::

FROZEN ELEPHANTFROZEN ELEPHANTFROZEN ELEPHANTFROZEN ELEPHANTTRUNKTRUNK

Kark M,Haverich A, et al.Kark M,Haverich A, et al. The froze ne le pha nttrunk te c hnique :a ne wThe froze ne le pha nttrunk te c hnique :a ne wtre a tm e ntforthora c ic a ortic a ne urysm stre a tm e ntforthora c ic a ortic a ne urysm s. J Thorac Cardiovasc Surg 2003;. J Thorac Cardiovasc Surg 2003;125:1550125:1550--33

THE TRUNK EVOLUTION

1982

TodayBirth of ET

1992ET modified

Today

ET modifieddistal suture

Crawford-Svensson

2004Branched ET

NeriSvensson

2007FET Hybrid graft 2012

2003Birth of FET

Chavan-HaverichFET Hybrid graft 2012

Branched FET

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Chavan-Haverich

SURGICAL INDICATIONS OF FET

1. Asce nding, arch and de sce ndingaortic ane ury smaortic ane ury sm

2. Distalaortic arch andde sce nding aorta ane ury smde sce nding aorta ane ury sm

3. Acute and ch ronic aorticdisse ction

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

disse ction

Rationale for FET in typeA and B acute dissection

• Type A acute aortic dissections Intimal tear in the arch

Young patients

Malperfusion syndrome

Retrograde dissection

• Type B acute aortic dissection• Type B acute aortic dissection

Impending rupture when TEVAR isnot feasiblenot feasible

Associated with ascending and archaneurysm

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

aneurysm

COMMERCIALLY AVAILABLE STENTED GRAFTSIN EUROPEIN EUROPE

E-vita Open plus - JotecE-vita Open plus - Jotec

Thoraflex - Vascutek

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Currently under investigation

Stanford University, California

Emory Saint Joseph's Hospital, Georgia

Northwestern Memorial Hospital, IllinoisNorthwestern Memorial Hospital, Illinois

Ann Arbor, Michigan

The Mount Sinai Hospital, NewYork

Columbia University Medical Center, NewYork

NewYork-Presbyterian Weill Cornell Medical Center, NewYork

Duke University Medical Center, North Carolina

Cleveland Clinic, Ohio

University of Pennsylvania, Philadelphia University of Pennsylvania, Philadelphia

University of Pittsburgh Medical Center (UPMC), Pittsburgh

Baylor St. Luke’s, Texas

University of Texas-Memorial Hermann Medical Center, Texas University of Texas-Memorial Hermann Medical Center, Texas

The Heart Hospital Baylor Plano, Texas

Aortic anatomy assessmentAortic anatomy assessment

• Myocardial

Organ protection

• Myocardial

• Cerebral

• Visceral

Surgical technique/strategy

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Aortic Disse ction

AORTIC ANATOMY ASSESSMENT

• Intim alflap e ste ntion

•Entry site

Aortic Disse ction

TL

FL

•Re lation true /false lum e n

•Visce ralve sse lsorigin

•Re e ntry

TL

FL

TL

FLFL

•Re e ntry

•• NoNo ove rsizingove rsizing

FL

FL

TL FL

EntryEntryEntry siteEntry site

ReentryReentry ReentriesReentries

EntryEntry

AORTIC ANATOMY ASSESSMENT

CHRONIC

Evaluation of

CHRONICANEURY SMS

Evaluation ofaortic diam e te rs

OVERSIZING: 10OVERSIZING: 10--20%20%

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

OVERSIZING: 10OVERSIZING: 10--20%20%

ORGAN PROTECTION - MYOCARDIAL

C u stodiol®® ModifiedModified BretschneiderBretschneider solutionsolution(Koe hle rChe m ie ,Alsb a c h-Ha e nle in,G e rm a ny)

• H ypothermia(8 -10°C )• 20-25cc/Kgsingle dose

18 0 min (3h)ischemia

S elective infu sion+/-retrograde perfu sion

RCL C

L owL owpressu repressu repressu repressu reP erfu sionP erfu sion(5(5--8 min)8 min) Cardiac Surgery Dept. – University of Bologna

roberto.dibartolomeo@ unibo.it

Antegrade Selective Cerebral Perfusion

ORGAN PROTECTION – CEREBRAL PROTECTION

Antegrade Selective Cerebral PerfusionAxilla ry,b ra c hioc e pha lic a nd c a rotid a rte rie s

400 ml/min(5ml/Kg/min)

1 lt/min

8 0 KgptP max:8 0 mmH g M oderate systemic hypothermia:

26 °C of nasoph.T

Ox

1 lt/minKeepgoodpressu re in the

O xigenator

flowmeter

P artialclamp

A dvantages:

RA

B IOP UM P

>1,5lt/min! :spin/min

flowmeter

• A ntegrade flow• L eftcarotid and leftsu bclavian art.selective cannu lation

RA

D rawbacks:• Two system cerebralperfu sion• N o rightradialarterypressu re• N o rightradialarterypressu re

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

ORGAN PROTECTION – VISCERAL AND SPINALCORD PROTECTION

P max:8 0 mmH g

After Distal Anastomosis

CORD PROTECTION

400 ml/min(5ml/Kg/min)

1 lt/min

8 0 mmH g

KeepgoodP artialclamp

RA

Ox

B IO

Keepgoodpressu re in the

O xigenator

flowmeter

clamp

RAB IOP UM P

>1,5lt/min! :spin/min

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Thoraflex hybrid implantation in …

……

Step-1 FET – Spinal fluid drainage

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Step-2 Guidewire positioning

True Lumen Confirmation by TEE

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Central arterial cannulationStep-3

Ax illary arte ry Carotid arte ry

Brach ioce p h alic trunk

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Step-4

Arterial cannulaArterial cannula

ASCPASCP cannulacannula

ASCP cannulaASCP cannula

Cannulation of epiaorticvessels for antegrade

Di bartolomeo-ASCP Cannulavessels for antegrade

cerebral perfusionDi bartolomeo-ASCP Cannula

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Step-5 Preparation of the distal aorta

False lumenFalse lumen

• Acute /Ch ronic Ao disse ction:re ap p rox im ation of th e TL and FL

• Ch ronic ane ury sm

GuidewireGuidewire

True lumenTrue lumenTrue lumenTrue lumen

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Endoscopy inside the Thoracic AortaStep-6

Before and after stent graft release

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Antegrade introduction of the stent graftStep-7

Th orafle x Hy b rid

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Distal anastomosisStep-8

• Just beyond left subclavian artery• Between left subclavian and left carotid arteryBetween left subclavian and left carotid artery• Between left carotid and brachiocephalic artery• Before brachiocephalic artery

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Restore visceral perfusionStep-9

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Epiaortic vessels reimplantationStep-10

Separated -Thoraflex

AA

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

B

Left subclavian artery reimplantationStep-11

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Proximal anastomosisStep-12

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Epiaortic vessels reimplantationStep-13

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

FET - Features of the 4-branched hybrid graft

Arch BranchesFROM 2007

CollarTO 2012

EndograftSide branch forart. cannulation Endograft

• Reduction of myocardial and lower body ischemia• Pathological regions of the aortic arch can be totally

art. cannulation

• Pathological regions of the aortic arch can be totallyresected (individual arch vessel reimplantation)

• Distal anastomosis can be achieved more proximally in

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

• Distal anastomosis can be achieved more proximally inthe arch

BOLOGNA FET - EXPERIENCE

January 2007 –April 2016

Jotek EVITA: 161 pts Vascutek Thoraflex: 64 pts

Cardiac Surgery Dept. – University of Bolognaroberto.dibartolomeo@ unibo.it

Frozen versus conventional elephant trunk technique:application in clinical practice

Roberto Di Bartolomeo†, Giacomo Murana*,†, Luca Di Marco,

IN SUMMARY

Roberto Di Bartolomeo†, Giacomo Murana*,†, Luca Di Marco,Antonio Pantaleo, Jacopo Alfonsi, Alessandro Leone and Davide Pacini

Eur J Cardiothorac Surg 2017

Useful tips to facilitate FET implantation are:

IN SUMMARY

Useful tips to facilitate FET implantation are:

•Search for re-entry tears in the downstream aorta on•Search for re-entry tears in the downstream aorta onthe pre-operative CT-angiograms in aortic dissection

•Use TEE during guide-wire introduction•Use TEE during guide-wire introduction•Prepare the aorta for distal anastomosis using teflon

feltsfelts•Drain the cerebrospinal fluid to keep the P <12mmHg

Frozen versus conventional elephant trunk technique:application in clinical practice

Roberto Di Bartolomeo†, Giacomo Murana*,†, Luca Di Marco,

IN SUMMARY

Roberto Di Bartolomeo†, Giacomo Murana*,†, Luca Di Marco,Antonio Pantaleo, Jacopo Alfonsi, Alessandro Leone and Davide Pacini

Eur J Cardiothorac Surg 2017

Useful tips to facilitate FET implantation are:

IN SUMMARY

•Look inside the descending thoracic aortaendoscopically before/after release of the stent graft

Useful tips to facilitate FET implantation are:

endoscopically before/after release of the stent graft•Restart systemic perfusion and ‘rewarming’

immediately after completing the distal anastomosisimmediately after completing the distal anastomosis•Avoid stent oversize in aortic dissection•Keep mean systemic pressure >80 mmHg after device•Keep mean systemic pressure >80 mmHg after device

implantation to better perfuse the spinal cord

13-14 November 201713-14 November 2017

…SAVE THE DATE!…SAVE THE DATE!