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Tilo Kölbel, MD, PhD
University Heart Center Hamburg
University Hospital Eppendorf
TEVAR and the Aortic Arch :
Challenges, Planning and Techniques for Good Outcomes
Cheng et al 2010, JACC 55:986-1001
Descending Aorta
TEVAR vs. Open
TEVAR better:
– 30d mortaliy
– Paraplegia rate
– Transfusion
– Cardiac compl.
– Renal function
– Pneumonia
– Reoperation
– ICU and Hospital LOS
Metaanalysis of comparative studies
TAA and Type B Dissection (n = 5888)
Gold Standard for the Arch
Surgery for the aortic arch:
Open repair
Elephant trunk
Mortality rates 5-15%
Stroke: 4-12%
Sundt et al. 2008; Ann Thorac Surg 86:787-96
Minakawa et al. 2010; Ann Thorac Surg 90:72-7
Endovascular Challengers
Tsagakis et al. 2013 Ann Cardiothorac Surg 2:612-20
Frozen Elephant Trunk
Chiesa et al. 2010 J Endovasc Ther
17:1-11
Hybrid Repair Branched/Fenestrated Repair
Haulon et al. 2014 J Thorac Cardiovasc Surg,
Challenges of the Aortic
Arch
Branch vessels
Patency / endoleak
Pulsatility
Oversizing / migration
Curvature
Conformity / infolding
Access
Distance / profile / kinking
Planning
Perpendicular measurement
Multiplanar-reconstruction (MPR)
Pulsatility
Graft-properties
Proximal Landing
Proximal Landing
Preferred landing site:
Length
Diameter
Shape
Thrombus
Non-dissected healthy
aortic wall
52 patients, FU 31m
47 stentgrafts distal to LSA
9 patients proximal erosion and aneurysm
3 patients with rupture, 2 fatal
Manning et al, JEVT, 2009
Proximal Landing
Techniques
Access-techniques
Endovascular Techniques
Arch-conformance
Fenestrated / branched Devices
In-situ Fenestration
Insufficient SG-conformity
to the anatomy of the arch
→ Aortic wall erosion
→ Type 1 endoleak
→ Stent-graft collapse
Arch-Conformance
• Angulation of arch
• Small aortic diameter
• Stent-graft oversizing
• Transsection
• Stent-graft rigidity
Potential Factors
• Angulation of arch
• Small aortic diameter
• Stent-graft oversizing
• Transsection
• Stent-graft rigidity
Potential Factors
Branched Arch Repair
1995-1998
N=15
14 single branch,
1 triple branch
Outer branches
Traction wire
Inoue et al. 1999; Circulation 100:316-21
Branched Arch Repair
Chuter et al. 2007; Perspect Vasc Surg Endovasc Ther19(2):188-92
Courtesy Krassi Ivancev
2003 – 2010(?)
N=10-20(?)
Outer branch
Transcervical
access
Zone 0 – Branched Stent-Graft
A-Branch:
• Arch aneurysms
• Internal side-branches
• Nitinol & stainless steel Z-stents
• Low-profile high
density dacron fabric
• Self orienting delivery system
• Controlled deployment
Branched Arch Endograft
Multicenter Study
n = 38
Technichal success 32/38
Mortality 5/38 (13%)
Stroke/TIA 6/38
Haulon et al. 2013; J Thor Cardiovasc Surg 148:1709-16
Cook Branched Arch Endograft
Subsequent experience:
n = 27; Hamburg, Tokio, Lille
4/2013- 11/2014
Technical success 27/27
30d Mortality 0/27
1y mortality 1/27
Stroke/TIA 3/27
Spear et al 2016; Eur J Vasc Endovasc Surg 51: 380-5
Branched Arch Endograft
Hamburg Experience 2012-2014:
Cases: 32
Aneuysm: 13
Residual dissection: 15
Acute Type A: 2
PAU: 2
30d-Mortality: 1
Stroke:2
Anatomical Suitability
Diameter ≤ 38mm
Length ≥ 40mm
Proximal landing zone ≥ 20mm
Innominate diameter ≤ 20mm
Appropriate access vessels
No significant aortic regurge
No mechanical aortic valve
No dissection of branch-vessels
Technique
Two stage repair:
1. LCCA-LSA bypass
2. Branched repair:
Transfemoral access for
the main-graft
RCCA-cutdown for IA-
branch
Left brachial puncture
for LCCA-branch and
LSA-plug
Technique
Precurved self-orienting device
LV-wire position
Cardiac output-reduction:
IVC balloon-occlusion
Rapid ventricular pacing
Zenith-limb for IA
Fluency for the LCCA
Plug-occlusion for LSA
Residual Dissection
Potential challenges:
Kinking of ascending stentgraft
Dissection of targetvessels with
multiple entries
Distal false-lumen perfusion
Indications
71
Fenestrated Device
(n=6)
Branched Device
(n=9)
PAU 1 (inner curvature) 1 (outer curvature)
Post-traumatic
aneurysm at the
subclavian artery
1 0
Type B Dissection with
Arch involvment
2 (dissection
proximal of the
subclavian)
2 (aneurysm of the
arch)
Arch Aneurysm or TAAA 2 3
Residual Arch
Dissection 0 2
Type A Dissection 0 1
Target Vessels
72
Fenestrated Device
(n=6)
Branched Device
(n=9)
Target Vessels 7 18
Median of Target Vessels 1 2
Vessel Distribution Fenestrated Device
(n=6)
Branched Device
(n=9)
Bovine Innominate Artery 2 0
Innominate Artery 1 9
LCA 2 9
LSA 2 0
Potential CONs for
Fenestrated Arch Grafts
Alignement of fenestrations
difficult
No strutfree fenestrations
larger than 12mm restricts use
for innominate artery
Preloaded wire may entangle
in struts of scallop
74
Potential CONs for
Branched Arch Grafts
Higher risk for trapped air
and embolism
Maximum ascending
diameter 38mm and
minimum length of 70mm
limits use.
Required left-ventricle
wire position limits use in
mechanical aortic valves
Conclusions
Arch-vessels, curvature and access are main challenges.
Perpendicular measurement, multiplanar reconstruction,
centerline reconstruction required.
Rapid development depending on local infrastructure
Feasible and lifesaving option in patients unfit for surgery
Role of stent-grafts in the aortic arch not yet defined.