4th Aortic Live Symposium

TEVAR FOR ASCENDING AORTIC PATHOLOGIES:TIPS AND TRICKS

TengC.Lee,M.D.,F.A.C.S.AssociateProfessorofSurgery

UniversityofCalifornia,SanFrancisco

Disclosure

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Speaker name: Teng C Lee, M.D., F.A.C.S...........................................................................................I have the following potential conflicts of interest to report:

ConsultingEmployment in industryStockholder of a healthcare companyOwner of a healthcare companyOther(s)

I do not have any potential conflict of interest

Theangio videosandphotosshownherearecourtesyofDr.Kölbel.

Disclosure

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• TEVARinthe ascending aorta has been performed since2000and data about 119patients worldwide had beenpublished based onrecent meta-analyses.

• Mortality (2.8-5.9%)and morbidity (stroke=1.8-3.3%)seemsto be acceptable with type1endoleak rateof 16.7-18.6%.

TEVAR for Ascending Aortic Pathologies

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• 87yearoldwheelchair-boundmalewithalonghistoryofsmokingonhomeoxygen

• Presentedwithchestpainfromanursinghome• Chronicrenalinsufficiency• CTscanshowedalargesaccular aneurysmintheascendingaorta.

• High-riskforopensurgery

Case presentation

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Case presentation

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Case presentation

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• Aorticdiameterbetween16mmand44mm

• DistancebetweenSTJandinnominate(brachiocephalic)artery

6-10cm.

• Landingzones>1cmintheascendingaorta

• Entrytearmorethan1cmaboveSTJand0.5cmproximaltoinnominateartery

General Guidelines

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NBaikoussis etal.JVasc Surg 2017;AKhoynezhad etal.JVasc Surg 2016;63:1483-95

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Tips and Tricks

• Goodimagingiscriticaltosuccess• OnlyEKG-gatedCT(1mmorlesscuts)

formeasurementanddeterminationofentrytear.

• RepeatCTifoutsideCTnotgated.• 3Dreconstruction

• TeraRecon orothersoftware• Notonlycenterlinemeasurement

butgreatercurveandlessercurve

Tip #1 Planning

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• Transfemoral• Ifdevicetooshort,canuseiliacconduit.

• TRANSAPICAL• Trans-subclavian/axillary• Trans-carotid

Tip #2 Approach

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• Shortdistancetolandingzones,betteraccuracy• Usefulforhorizontalaorta,easiertobeco-axial• Noneedtoworryaboutnose-conescausingventricularrupture

• Niceforstent-graftsthathavebare-stents• Immediatetruelumenaccessindissectioncases• Abletodrainpericardialblood• AbletodecompressheartforpatientswithsevereAI

Why TRANSAPICAL?

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• Location:5th or6th intercostalspacebutuseimagingtohelp• CT• Fluoro• TEE• VisualizeLAD

• LargeTeflonpledgets• 2-0or3-0suturesfor2horizontalmattresssuturesorpursestring• Largeneedle(MHorSH)• UseRummels• Tyingunderventricularpacing• Heparinization aftersuturesplaced• Haveanassistantholdontosheathatalltimesanddonottorquesheath

Tip #3 Transapical Approach

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• IVUS- especiallyimportantfordissectiontoconfirmtruelumenaccessandalsolocationoftears.

• TEE- Againtoconfirmtruelumenaccessandalsotocheckforvalvefunctionandpericardialeffusionaftertheprocedure.

Tip #4 Visualization

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• Forstability,thewiremustcrossthevalve.• Usepigtailtocrossthevalveorfloppytypewire(ifcomingfromfemoral).

• Iftransfemoral,usedouble-curvedLunderquist orextendedcurvedLunderquist.

• Iftransapical,woulduseregularcurvedLunderquist orAmplatzSuperstiff.NODOUBLECURVEDLUNDERQUIST.

• Atendofprocedure,makesuretoremovewireacrossvalveviaexchangecathetertopreventdamagingthevalve.

Tip #5 Must cross the aortic valve

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• Over-sizing• <10%fordissection• 20-30%forotherpathologies

Tip #6 Fixation

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• Formoreaccuratepositioning,mustachieveminimalcardiacoutput• Rapidpacing• Inflowocclusion• Pharmacologic(adenosine)

Tip #7 Positioning

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• Rate160-180• Viafemoralvein• Musthavedefibrillationpadsattachedandconnected

• VenoussheathcanalsoberapidlychangedoutforCPBcannula

Tip #8 Rapid pacing

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• EspeciallyinpatientwithsevereAI,poorventricularfunction

• Pumpneedstobeprimedor“wet”• Appropriatesizecannulae intheroomoronthetable.

Tip #9 Cardiopulmonary pump standby

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1. Planning- gatedCT/3Dreconstruction2. Approach3. Transapical4. Visualization-IVUS/TEE5. Crossingaorticvalve6. Fixation7. Positioning8. Rapidpacing9. Cardiopulmonarybypassstand-by

Summary

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QUESTIONS?

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• ItisimportanttonotethattherearenoFDAapprovedascendingdevicesintheUS.

• AliKhoynezhad andRodneyWhiteinLAhaveaPS-IDEwithamedtronic Valiantdevice.

• GoreisconductingatypeAdissectiontrialusinganascendingdevice(aorticextensionsfromtheirTBEtrial).

• CookAscenddevicewhichisavailableinEurope.

• Mostofthedevicesusedinthecaseserieswerephysicianmodifiedorusingcurrentlyavailabledescendingdevicesifthelengthsareappropriate.

TEVAR for Ascending Aortic Pathologies

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TEVAR for Ascending Aortic Pathologies

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Brand Diameter(mm)

Length(mm)

System-Length(mm)

Sheath-DiameterID(F)

CookZenith TX2ProForm 22-42 77-216 75 20-22

MedtronicValiantCaptivia

22-46 110-226 88 22-25

GoreCTAG 21-45 100-200 115 18-24

BoltonRelay 22-46 100-250 90+x 22-24

Jotec Evita3G 24-44 130-230 95 20-24