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Jean M. Panneton, MD, FRCSC, FACS
Professor of Surgery,
Chief & Program Director
Division of Vascular SurgeryEastern Virginia Medical SchoolEastern Virginia Medical School
Norfolk, VA
The Houston Aortic SymposiumHouston TX, February 23-25th 2017
Disclosures
EndoAnchors & TEVAR
Disclosures
Consultant: Cook Medical, Bolton Medical, Medtronic Inc, Volcano, WL GoreSpeakers’ Bureau: Bolton Medical, Medtronic Inc., WL GoreAdvisory Board: Medtronic Inc., Mellon Medical, VolcanoAdvisory Board: Medtronic Inc., Mellon Medical, Volcano
Eastern Virginia Medical Center
For prophylaxis or therapy
EndoAnchors & TEVAR
Indications:
Migration/Type 1 LeakSevere
For prophylaxis or therapy
Type 1 LeakSevereAngulation
TherapyTherapyProphylaxisProphylaxis Difficultlanding
Birdbeaking
Difficultlanding
Componentseparation
revision
3
A S G S
EndoAnchors & TEVAR
Can we predict TEVAR failures ?
ANATOMIC SEVERITY GRADING SCORE
ASGscore= 24
ASGscore= 43
• Anatomic criteria assessed for 4 distinctsegments of DTA
• Each characteristic graded from 0-3
• Anatomic criteria assessed for 4 distinctsegments of DTA
• Each characteristic graded from 0-3
score= 43
• All categories added to obtain acomposite ASG score ( range 2 to 57 )
• All categories added to obtain acomposite ASG score ( range 2 to 57 )
J Vasc Surg 2016;64:912-20.
Freedom from postoperative endoleakFreedom from postoperative endoleak
EndoAnchors & TEVAR
Can we predict TEVAR failures ?
***
Freedom from postoperative endoleakrequiring reintervention at 2 yearsFreedom from postoperative endoleakrequiring reintervention at 2 years
Sensitivity=92%Sensitivity=92%Sensitivity=92%
100%**
**
*
*
Sensitivity=92%Specificity=50%Sensitivity=92%Specificity=50%Sensitivity=92%Specificity=50%
69%
***
*P=0.002*P=0.002*P=0.002 *For an ASGscore ≥24
*For an ASGscore ≥24
*For an ASGscore ≥24
*For an ASG score ≥24
score ≥24score ≥24score ≥24
This novel anatomic severity grading system can successfully identifyThis novel anatomic severity grading system can successfully identifypatients at increased risk for postoperative endoleak formation andendoleak requiring reintervention following TEVAR for primary DTA
Prophylactic indication: challenging anatomyEndoAnchors & TEVAR
Pre TEVARhemiarch
debranchingdebranching
Prophylactic indication: challenging anatomyEndoAnchors & TEVAR
No endoleak after 23months
Placement ofEndoAnchors at the
inner curvature
Completion Aortogramafter prophylactic
EndoAnchorsinner curvature EndoAnchors
@ 3 years follow up@ 3 years follow upno migrationno endoleaks
Prophylactic indication:preventing upward migration
EndoAnchors & TEVAR
preventing upward migration
Distal TEVAR withceliac catheterization
Circumferential placement ofEndoAnchors at distal end
Completion Aortogramafter prophylactic
EndoAnchorsceliac catheterization EndoAnchors at distal endEndoAnchors
@ 2 yrs follow upNo migrationNo endoleaks
EndoAnchors & TEVAR
Therapeutic indication: revision
Type Ia endoleak 2 years after 4 vessels FEVAR with PMEGtreated with proximal EndoAnchors and Onyx
CTA 3 years after EndoAnchor rescue with no endoleakCTA 3 years after EndoAnchor rescue with no endoleak
EndoAnchors & TEVAR
Therapeutic indication: revision
Treating failed EVAR (migration & type I endoleak) with3 vessels FEVAR w/ ZFEN & AUI conversion & EndoAnchors
EndoAnchors & TEVAR
Therapeutic indication
Proximal type I endoleak 1 yr Redo TEVAR with Left CCAProximal type I endoleak 1 yrafter TEVAR & 4 vesselsFEVAR for Type I TAAA
Redo TEVAR with Left CCALaser Fenestration
with residual type I endoleak
EndoAnchors & TEVAR
Therapeutic indication
Completion Aortogramafter EndoAnchors rescue
Placement of EndoAnchors atthe inner curvature
CTA at 12 months:no endoleaks
Procedural Technique: Guide selection & deploymentEndoAnchors & TEVAR
Recommended Heli-FX Guide Selection
AorticInner
18-28mm
28-38mm
38-42mmInner
Diametermm mm mm
Guide TipReach
22 mm 32 mm 42 mm
Controlled, Tactile, Intuitive, Safe
2 steps process: Recapture & Release
18Fr OD,90cm working
lengthlength
22 mm32 mm
42 mm
Procedural Technique: advanced deploymentEndoAnchors & TEVAR
Ascending aortadeployment in RAO view
Side arch deployment inbarrel view
Procedural Technique: outer arch deployment
EndoAnchors & TEVAR
Easy Zone 1 Tricky Zone 1
Undersize the guide for the outer curvature
Easy Zone 1 Tricky Zone 1
Procedural Technique: antegrade deployment
EndoAnchors & TEVAR
Arch aneurysm requiring sternotomy and total arch debranchingwith antegrade TEVARwith antegrade TEVAR
EndoAnchors & TEVAR
Procedural Technique: antegrade deployment
Antegrade deployment of posterior EndoAnchors zone 0
3D CTA @ 6 months
EndoAnchors & TEVAR
Indications
N =N = 101101 proceduresprocedures
Experience in TEVAR & CEVAR
N =N = 101101 proceduresproceduresTEVAR, FEVAR, ChEVARTEVAR, FEVAR, ChEVAR
N =N = 4747FEVAR or ChEVARFEVAR or ChEVAR
N =N =5454TEVARTEVAR FEVAR or ChEVARFEVAR or ChEVARTEVARTEVAR
Study Population Treated for:
Mean age = 73 yearsMale gender = 72 ( 71.3% )
Dec 2012 - June 2016
Arch / DTA 22
TAAA 35
Dec 2012 - June 2016Mean Follow up = 14.3 months
Range = 1 to 42 months
Pararenal AAA 22
Juxtarenal + failed EVAR 22
EndoAnchors & TEVAR
Procedural Indications
N =N = 101101 proceduresprocedures
TEVAR, FEVAR, ChEVARTEVAR, FEVAR, ChEVAR
N =N = 4545Index procedureIndex procedure
N =N = 5656Redo procedureRedo procedure
N =N = 3939 N =N = 3636 N =N = 2020N =N = 66N =N = 3939ProphylacticProphylactic
N =N = 3636TherapeuticTherapeutic
N =N = 2020ProphylacticProphylactic
N =N = 66TherapeuticTherapeutic
Procedural SuccessTotal of 930 Endo Anchors were deployed ( 9.8 / pt )
EndoAnchors & TEVAR
Total of 930 Endo Anchors were deployed ( 9.8 / pt )
Technical success rate = 99.6%
Endoanchors retrieval
0.39% ( N=3 )
Aortic Deployment Zones
Zone of No. of2 by snare technique
1 retrieval with Aptus system
Zone of
EndoAnchor
No. of
EndoAnchors
Zone 0 12
Zone 1 75Zone 1 75
Zone 2 61
Zone 3 39
Zone 4 8Zone 4 8
Zone 5 169
Zone 6 86
Zone 7 84Zone 7 84
Zone 8 132
Zone 9 98
EndoAnchors & TEVAR
Procedural challengesProcedural challenges
Index Redo Total
Proximal Landing ZonesProximal Landing Zones
Operations
N=27
Operations
N=27N=54
Zone 0 2 5 7
Zone 1 9 6 15
Zone 2 7 1 8Zone 2 7 1 8
Zone 3 4 2 6
Zone 4 0 2 2Zone 4 0 2 2
Zone 5 5 11 16
56 % landed in the arch & 41 % Zones 0-156 % landed in the arch & 41 % Zones 0-1
Procedural OutcomeProcedural OutcomeEndoAnchors & TEVAR
N =N = 5454TEVARTEVAR
N = 37N = 37ProphylacticProphylactic
N = 17N = 17TherapeuticTherapeutic
NONOEndoanchor relatedEndoanchor related
5.9%5.9%Endoanchor relatedEndoanchor relatedEndoanchor relatedEndoanchor related
reinterventionsreinterventionsEndoanchor relatedEndoanchor related
reinterventionreintervention
1 type Ia / Ib endoleaks1 type Ia / Ib endoleaks
No migrationNo migration
No type I or III endoleakNo type I or III endoleak
No migrationNo migration
Procedural OutcomeEndoAnchors & TEVAR & CEVAR
Freedom from Type I endoleak
by Anatomy by Indicationby Anatomy by Indication
100 % @ 1 & 2 yrs 96.7 % @ 1 & 2 yrs
94 % @ 1 & 2 yrs
94 % @ 1 & 2 yrs
93.7 % @ 1 & 2 yrs
94 % @ 1 & 2 yrs
SummaryEndoAnchors & TEVAR
EndoAnchors can be used prophylactically during TEVAR for complexaneurysms and appear to prevent migration and late endoleak formation,aneurysms and appear to prevent migration and late endoleak formation,
however longer follow up is needed
EndoAnchors can be used therapeutically for type I & III endoleaks in indexEndoAnchors can be used therapeutically for type I & III endoleaks in indexor redo TEVAR and can effectively eliminate endoleaks and reduce
recurrences
Type I endoleakType I endoleakafter total archType I endoleak
after total archdebranching and
redo TEVAR
after total archdebranching and
redo TEVARresolved afterredo TEVAR resolved after
zone 0EndoAnchors
EndoAnchors & TEVAR