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Department of Cardiothoracic & Vascular Surgery McGovern Medical School / The University of Texas Health Science Center at Houston
Bruce Tjaden MD
Vascular Surgery Fellow
TEVAR (Thoracic Endovascular Aortic Repair)
for Aneurysm and Dissection
Disclosures
I have no relevant financial disclosures.
Definitions
TEVAR
Definitions
TEVAR – Thoracic Endovascular Aortic Repair
Deploying an impermeable graft on a metal
scaffold (stent-graft) inside the thoracic
aorta to exclude a diseased segment of the
aortic wall from arterial pressure and flow
Definitions
Aneurysm
Dilation of an arterial
segment to >150% of its
normal size
Dissection
Tear in the inner-most
layer of the arterial wall
(intima) allowing blood
flow into a false channel (lumen) blood flow
within the arterial wall
TEVAR for
Aneurysm
Thoracic Aortic Aneurysms
(review)
Can be divided anatomically
into aneurysms involving the
ascending aorta, the
transverse arch, or the
descending aorta.
In general, ascending
aneurysms are treated by
Cardiac surgeons
In general, arch and
descending aneurysms may
be treated by either Vascular
or Cardiac surgeons
Natural History
Risk of rupture directly related to size
5cm = 5.5% risk of rupture or
dissection within 1 yr
5.5cm = 7.2% risk of rupture or
dissection within 1 yr
6cm = 9.3% risk of rupture or
dissection within 1 yr
……..
Descending Thoracic Aortic Aneurysms
TEVAR for Descending Thoracic
Aortic Aneurysms Open Surgical Outcomes
Operative mortality 8.5%
Cardiopulmonary complications 44%
Permanent paraplegia 5%
5 year survival 68%
TEVAR Outcomes
Operative mortality 2%
Cardiopulmonary complications 16%
Permanent paraplegia 1.6%
5 year survival 67%
TEVAR for Descending Thoracic
Aortic Aneurysms
1. Who to treat?
Size >6.0-6.5cm
Rapid growth (>1cm/yr)
Symptoms
Chest pain
Back pain
Compression of adjacent structures (airway)
2. When to treat?
Immediately for rupture
Urgently for symptoms or rapid enlargement
Electively for size criteria
TEVAR for Descending Thoracic
Aortic Aneurysms
TEVAR for Descending Thoracic
Aortic Aneurysms
3. Goals of Repair
Exclude the aneurysm
Land in normal-sized aorta
Minimize risk of spinal ischemia
4. Technique
Lumbar drain placed if possible (unless hostile
back anatomy or rupture with major
hemodynamic instability)
Percutaneous approach usually (no incisions)
Oversize device 10-20%
If coverage of the LSA is required, it is usually
performed only after a pre-emptive LSA
revascularization (transposition or bypass)
TEVAR for Descending Thoracic
Aortic Aneurysms
5. Complications
Spinal Cord Ischemia
Branch vessel coverage end-organ
Ischemia
Stroke
Endoleaks
Retrograde Type A dissection
TEVAR for Descending Thoracic
Aortic Aneurysms
TEVAR for
Dissection
Thoracic Aortic Dissections
Thoracic Aortic Dissections
Acute Dissections
< 2 weeks old
Subacute Dissections
2-12 weeks old
Chronic Dissections
>12 weeks old
Uncomplicated Dissections
No evidence of end-
organ ischemia or
rupture
Complicated
Dissections
Evidence of end-
organ ischemia or
rupture
pick one descriptor from each box
TEVAR for Type B Dissections
Difficult to summarize evidence,
significant heterogeneity (acute,
subacute, chronic, complicated,
uncomplicated)
But in summary
TEVAR is associated with better perioperative
outcomes, similar long term survival, but
increased need for reintervention compared
to open surgery.
TEVAR for Type B Dissections
1. Who to treat?
Medical therapy for uncomplicated dissections
TEVAR for complicated dissections
TEVAR for uncomplicated dissections with high-
risk features
Any aortic diameter >44mm
False lumen diameter >22mm
Age >60
Borderline malperfusion (chronic n/v, ileus, fluctuating pulse
exams, refractory pain, refractory HTN)
TEVAR for Type B Dissections
2. When to treat?
Immediately for acute complicated with
malperfusion or rupture
After 2 weeks for acute uncomplicated
dissections with high risk features (allows septum
to thicken, aorta to stabilize)
As needed for chronic dissections that
degenerate into aneurysms, rupture, or develop
late malperfusion
TEVAR for Type B Dissections
3. Goals of Repair
Close proximal entry tear
Land in normal aorta proximally
Improve true lumen flow / decrease false lumen flow
Promote aortic remodeling
Address malperfusion – fasciotomies, ex-lap, etc.
TEVAR for Type B Dissections
4. Technique
Lumbar drain placed if possible (unless hostile back anatomy or
concern about severity of malperfusion makes it too time-
intensive)
Percutaneous approach usually (no incisions)
Intravascular ultrasound to determine location of tear and aid in
sizing
Minimize device oversizing proximally
Don’t hesitate to cover LSA / down to diaphgram / cover celiac if
needed in order to treat the malperfusion in complicated cases
If required in acute dissections, coverage of the LSA is usually
performed without revascularization during that same operation –
patients are followed postop to determine the need for LSA
bypass / transposition
TEVAR for Type B Dissections
5. Complications
Retrograde Type A dissection
More likely in acute dissections, large aortas, larger proximal
landing zones, bare metal stents proximally, ballooning
Stent-graft Induced New Entry (SINE) tears – tear at trailing edge
of stent-graft leading to more false lumen flow at that location –
may require extension or fenestration
Spinal Cord Ischemia
Branch vessel Ischemia
Stroke
Endoleaks
Persistent False Lumen Flow
References Ray HM, Durham CA, Ocazionez D, Charlton-
Ouw KM, Estrera AL, Miller CC, et al.
Predictors of intervention and mortality in
patients with uncomplicated acute type B
aortic dissection. J Vasc Surg.
2016;64(6):1560–8.
Trimarchi S, Eagle KA, Nienaber CA, Pyeritz
RE, Jonker FHW, Suzuki T, et al. Importance of
refractory pain and hypertension in acute
type B aortic dissection: insights from the
International Registry of Acute Aortic
Dissection (IRAD). Circulation. 2010
Sep;122(13):1283–9.
Thompson M. The VIRTUE registry of type B
thoracic dissections - Study design and early
results. Eur J Vasc Endovasc Surg [Internet].
2011;41(2):159–66. Available from:
http://dx.doi.org/10.1016/j.ejvs.2010.08.016
Heijmen R, Fattori R, Thompson M, Dai-Do D,
Eggebrecht H, Degrieck I, et al. Mid-term
outcomes and aortic remodelling after
thoracic endovascular repair for acute,
subacute, and chronic aortic dissection: The
VIRTUE Registry. Eur J Vasc Endovasc Surg
[Internet]. 2014;48(4):363–71. Available from:
http://dx.doi.org/10.1016/j.ejvs.2014.05.007
Canaud L, Ozdemir BA, Patterson BO, Holt
PJE, Loftus IM, Thompson MM. Retrograde
Aortic Dissection After Thoracic Endovascular
Aortic Repair. Ann Surg [Internet].
2014;260(2):389–95. Available from:
http://content.wkhealth.com/linkback/open
url?sid=WKPTLP:landingpage&an=00000658-
201408000-00030
Liu L, Zhang S, Lu Q, Jing Z, Zhang S, Xu B.
Impact of Oversizing on the Risk of
Retrograde Dissection After TEVAR for Acute
and Chronic Type B Dissection. J Endovasc
Ther [Internet]. 2016;23(4):620–5. Available
from: http://journals.sagepub.com/doi/10.1177/152
6602816647939
Chen Y, Zhang S, Liu L, Lu Q, Zhang T, Jing Z.
Retrograde Type A Aortic Dissection After
Thoracic Endovascular Aortic Repair: A
Systematic Review and Meta-Analysis. J Am
Heart Assoc [Internet]. 2017;6(9):e004649.
Available from:
http://jaha.ahajournals.org/lookup/doi/10.11
61/JAHA.116.004649%0Ahttp://www.ncbi.nlm
.nih.gov/pubmed/28939705%0Ahttp://www.p
ubmedcentral.nih.gov/articlerender.fcgi?arti
d=PMC5634245
Furlough CL, Desai SS, Azizzadeh A, Lawrence
PF. Adjunctive technique for the use of
ProGlide Vascular closure device to improve
hemostasis. J Vasc Surg. 2014;60(6):1693–4.
Estrera AL, Sheinbaum R, Miller CC, Azizzadeh
A, Walkes J-C, Lee T-Y, et al. Cerebrospinal
fluid drainage during thoracic aortic repair:
safety and current management. Ann
Thorac Surg. 2009 Jul;88(1):9–15; discussion
15.
https://www.valleyheartandvascular.com/Th
oracic-Aneurysm-Program/Hybrid-
Procedures.aspx
http://www.huntervascular.com/thoracic-
aortic-aneurysm
http://www.surgery.usc.edu/cvti/graphics/a
orticdissection01.jpg
https://www.inkling.com/read/cronenwett-
rutherfords-vascular-surgery-2-volume-set-
8th/chapter-136
http://circ.ahajournals.org/content/132/17/1
620
Davies RR, Goldstein LJ, Coady MA, Tittle SL,
Rizzo JA, Kopf GS, Elefteriades JA. Yearly
rupture or dissection rates for thoracic
aorticaneurysms: simple prediction based on
size. Ann Thorac Surg. 2002;73:17–27.
Coady MA, Rizzo JA, Hammond GL,
Mandapati D, Darr U, Kopf GS, Elefteriades
JA. What is the appropriate size criterion for resection ofthoracic aortic aneurysms? J
Thorac Cardiovasc Surg. 1997;113:476–491.
https://www.inkling.com/read/cronenwett-
rutherfords-vascular-surgery-2-volume-set-
8th/chapter-138/
https://www.ncbi.nlm.nih.gov/pubmed/2881
1003
http://www.internationaljournalofcardiology.
com/article/S0167-5273(17)34002-0/pdf
https://www.sciencedirect.com/science/arti
cle/pii/S1726490115000039
Thank You
Case #1
A 56 year-old man presented with an
acute complicated TBAD with visceral and
left lower extremity malperfusion.
Medical Therapy?
Open Surgery?
TEVAR?
Treated with
TEVAR.
The pre-TEVAR
images
demonstrate poor
filling of the
mesenteric vessels,
while the post-
TEVAR images
show brisk filling
throughout
the reno-visceral segment as well as
through both iliac
arteries.
Mild preop lactic acidosis resolved.
No laparotomy
required.
Case #2
A 55 year-old woman initially presented
with acute uncomplicated TBAD. She was
managed medically, but developed
renal malperfusion during the subacute
phase, mandating repair.
left subvclavian through retrograde
vertebral flow, exclusion of the diseased
aorta, and brisk distal true lumen filling.
She was followed expectantly, and did
not require left subclavian
revascularization.
Case #2
TEVAR
During TEVAR,
angiography
revealed interval
development of
a contained
rupture (left
image). IVUS
confirmed the
dissection
extended into the
distal aortic arch.
Case #2 The operative plan was
modified, and an
endograft was deployed with intentional left
subclavian artery
coverage. Completion
angiogram revealed adequate filling of the
left subvclavian through
retrograde vertebral
flow, exclusion of the
diseased aorta, and brisk
distal true lumen filling
(right image). She was
followed expectantly,
and did not require left subclavian
revascularization.
Case #2 The operative plan was
modified, and an
endograft was deployed with intentional left
subclavian artery
coverage. Completion
angiogram revealed adequate filling of the
left subvclavian through retrograde vertebral flow,
exclusion of the diseased
aorta, and brisk distal
true lumen filling (right
image). She was
followed expectantly,
and did not require left subclavian
revascularization.
Case #3
67M w/ Symptomatic Descending
Thoracic Aortic Aneurysm beginning at
the distal edge of the left subclavian
artery.
Prior EVAR with bilateral internal iliac
artery occlusions.
Medical therapy?
Open surgery?
TEVAR with LSA coverage alone?
TEVAR with LSA coverage and revasc?
Case #3
TEVAR w/ LCCLSA bypass and plug
Case #4
85F w/ descending thoracic aortic
aneurysm - ?world record?
Case #4
TEVAR w/ extensive spinal coverage – no spinal
ischemia – LD removed POD#1 – d/c’d home.
References Ray HM, Durham CA, Ocazionez D, Charlton-
Ouw KM, Estrera AL, Miller CC, et al.
Predictors of intervention and mortality in
patients with uncomplicated acute type B
aortic dissection. J Vasc Surg.
2016;64(6):1560–8.
Trimarchi S, Eagle KA, Nienaber CA, Pyeritz
RE, Jonker FHW, Suzuki T, et al. Importance of
refractory pain and hypertension in acute
type B aortic dissection: insights from the
International Registry of Acute Aortic
Dissection (IRAD). Circulation. 2010
Sep;122(13):1283–9.
Thompson M. The VIRTUE registry of type B
thoracic dissections - Study design and early
results. Eur J Vasc Endovasc Surg [Internet].
2011;41(2):159–66. Available from:
http://dx.doi.org/10.1016/j.ejvs.2010.08.016
Heijmen R, Fattori R, Thompson M, Dai-Do D,
Eggebrecht H, Degrieck I, et al. Mid-term
outcomes and aortic remodelling after
thoracic endovascular repair for acute,
subacute, and chronic aortic dissection: The
VIRTUE Registry. Eur J Vasc Endovasc Surg
[Internet]. 2014;48(4):363–71. Available from:
http://dx.doi.org/10.1016/j.ejvs.2014.05.007
Canaud L, Ozdemir BA, Patterson BO, Holt
PJE, Loftus IM, Thompson MM. Retrograde
Aortic Dissection After Thoracic Endovascular
Aortic Repair. Ann Surg [Internet].
2014;260(2):389–95. Available from:
http://content.wkhealth.com/linkback/open
url?sid=WKPTLP:landingpage&an=00000658-
201408000-00030
Liu L, Zhang S, Lu Q, Jing Z, Zhang S, Xu B.
Impact of Oversizing on the Risk of
Retrograde Dissection After TEVAR for Acute
and Chronic Type B Dissection. J Endovasc
Ther [Internet]. 2016;23(4):620–5. Available
from: http://journals.sagepub.com/doi/10.1177/152
6602816647939
Chen Y, Zhang S, Liu L, Lu Q, Zhang T, Jing Z.
Retrograde Type A Aortic Dissection After
Thoracic Endovascular Aortic Repair: A
Systematic Review and Meta-Analysis. J Am
Heart Assoc [Internet]. 2017;6(9):e004649.
Available from:
http://jaha.ahajournals.org/lookup/doi/10.11
61/JAHA.116.004649%0Ahttp://www.ncbi.nlm
.nih.gov/pubmed/28939705%0Ahttp://www.p
ubmedcentral.nih.gov/articlerender.fcgi?arti
d=PMC5634245
Furlough CL, Desai SS, Azizzadeh A, Lawrence
PF. Adjunctive technique for the use of
ProGlide Vascular closure device to improve
hemostasis. J Vasc Surg. 2014;60(6):1693–4.
Estrera AL, Sheinbaum R, Miller CC, Azizzadeh
A, Walkes J-C, Lee T-Y, et al. Cerebrospinal
fluid drainage during thoracic aortic repair:
safety and current management. Ann
Thorac Surg. 2009 Jul;88(1):9–15; discussion
15.
https://www.valleyheartandvascular.com/Th
oracic-Aneurysm-Program/Hybrid-
Procedures.aspx
http://www.huntervascular.com/thoracic-
aortic-aneurysm
http://www.surgery.usc.edu/cvti/graphics/a
orticdissection01.jpg
https://www.inkling.com/read/cronenwett-
rutherfords-vascular-surgery-2-volume-set-
8th/chapter-136
http://circ.ahajournals.org/content/132/17/1
620
Davies RR, Goldstein LJ, Coady MA, Tittle SL,
Rizzo JA, Kopf GS, Elefteriades JA. Yearly
rupture or dissection rates for thoracic
aorticaneurysms: simple prediction based on
size. Ann Thorac Surg. 2002;73:17–27.
Coady MA, Rizzo JA, Hammond GL,
Mandapati D, Darr U, Kopf GS, Elefteriades
JA. What is the appropriate size criterion for resection ofthoracic aortic aneurysms? J
Thorac Cardiovasc Surg. 1997;113:476–491.
https://www.inkling.com/read/cronenwett-
rutherfords-vascular-surgery-2-volume-set-
8th/chapter-138/
https://www.ncbi.nlm.nih.gov/pubmed/2881
1003
http://www.internationaljournalofcardiology.
com/article/S0167-5273(17)34002-0/pdf
https://www.sciencedirect.com/science/arti
cle/pii/S1726490115000039
Thank You