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“Shaggy aorta” is a highly dangerous sign of TEVAR for aortic arch aneurysm

“Shaggy aorta” is a highly dangerous sign of TEVAR for aortic arch aneurysm. Department of Cardiovascular Surgery Fukushima Medical University, School of Medicine Fukushima, JAPAN. Shinya Takase, Hirono Satokawa, Yoichi Sato, Hiroki Wakamatsu, Yoshiyuki Sato, Hiroyuki Kurosawa,

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“Shaggy aorta” is a highly dangerous sign of TEVAR for aortic arch aneurysm

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  1. “Shaggy aorta” is a highly dangerous sign of TEVAR for aortic arch aneurysm Department of Cardiovascular Surgery Fukushima Medical University, School of Medicine Fukushima, JAPAN Shinya Takase, Hirono Satokawa, Yoichi Sato, Hiroki Wakamatsu, Yoshiyuki Sato, Hiroyuki Kurosawa, Takashi Igarashi, Akihito Kagoshima, Tsuyoshi Yamabe, Hitoshi Yokoyama

  2. Background • Conventional surgery for thoracic aortic aneurysm still has high morbidity and mortality. • In this condition, stentgraft is applied to descending thoracic aortic disease more than graft replacement. • For arch aorta, stentgraft is only deployed to high risk patients in general. However, in TEVAR for this lesion, stroke is concerned because of atheromatousembolization. • Conventional surgery for arch aortic aneurysm even with severe atherom induces catastrophic complication followed by early death.

  3. Purpose This paper is to explore whether TEVAR for aortic arch aneurysm with “shaggy aorta” is acceptable or not.

  4. Severely atheromatous aorta Definition of “Shaggy aorta” Intimal thickness > 2mm No irregularity IT>2mm + Irregularity but not projected Noraml Intimal thickness(IT) < 2mm No irregularity IT>2mm + Irregularity with projection Irregularity (+)

  5. Case 477 y.o. male, True aortic arch aneurysm, Angina

  6. Case 1；82y.o. female Arch Aneurysm with aberrant artery

  7. Treatment Strategy Indication of Conventional Surgery? • Age>75 y.o., • Severity of co-morbidity • Concomittant Procedure (CABG, Valve Surgery)? Possible Impossible Concomittant Proc. Difficult Treans-femoral Access CS Yes No Zone0~1 Zone2 debranched SG SG Fenestrated SG

  8. SGdeployment • Examination • MD-CT＞Angiography • Endoluminal Stentgraft (tailered made) • GiantrucoZstent ;d30-40X l 50-75mm • UBE Ultrathin graft ; d28-40X l 50-150mm • Delivery system (Pull through) • COOKGuiding Sheath (straight / bending) • 0.035”Super stiffness / TERMO J type230cm • Deployment • Hypotension (60-80mmHg) / ATP 0.2-0.4mg/kg / • Rapid pacing 120-140 ppm • Monitoring • INVOS / MEP ( in some cases)

  9. Fenestrated ＳＧ for aortic arch aneurysm Max diameter;42mm Saccular type

  10. (Debranching) + Transaortic SG 8X16mm Y-graft 8mm 3) Reconstruction of cerebral arteries (debraching) 8mm 5F Pigtail 10mm 1) Branched Graft SG (22F Guiding Sheath) over the wire 2) Side clamping and anastomosis 4) Trans-aortic SG

  11. Patients Jan., 2001～May, 2010 SG repair for aortic arch aneurysm (Non-dissecting aneurysm) 23Cases Male:Female = 19：4, Age ; 74±7y.o., Observation ; 30～3219 （848±1058） days

  12. Patients’ Profile with “Shaggy aorta” or not

  13. Postoperative Outcome

  14. Postoperative Outcome *MOF;1, Pneumonia;2, AAA rupture;1,

  15. Actual Survival Non-shaggy 71% 50% Shaggy Log-rankp=0.13

  16. Summary • SG treatment for aortic arch aneurysm is technically successful with debranching and/or fenestrated SG. • There were no differences in preoperative co-morbidities between patients group w/ and w/o “shaggy aorta”. • Embolim was induced around 50% in the group with “shaggy aorta”, whereas it was 0% in that without “shaggy aorta”. • As the result, once one or more organ dysfunctions were occurred in such high risk patients, it led to death. • Once the patients with “shaggy aorta” can tolerate this treatment, they could survive in long time period.

  17. Conclusion “Shaggy aorta“ is a dangerous sign. Special caution of handling in this procedure is required. Adequate informed consent to such patients is also required. Invention of completely preventive measures against embolism is aspired.

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