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Endovascular Repair of Thoracic Arch Aneurysms

Endovascular Repair of Thoracic Arch Aneurysms. Postgraduate Course Southern Association for Vascular Surgery H. Edward Garrett, Jr. M.D. Professor of Surgery University of Tennessee Health Sciences Center Memphis, TN. Financial & Regulatory Disclosure. Principal investigator for

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Endovascular Repair of Thoracic Arch Aneurysms

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  1. Endovascular Repair of Thoracic Arch Aneurysms Postgraduate Course Southern Association for Vascular Surgery H. Edward Garrett, Jr. M.D. Professor of Surgery University of Tennessee Health Sciences Center Memphis, TN

  2. Financial & Regulatory Disclosure • Principal investigator for • Gore TAG post-approval study and • Medtronic VALOR Trials (Talent thoracic stent graft system) • W.L. Gore sponsors the University of Tennessee Vascular Conference and the Edward Garrett Sr. Midsouth Vascular Society

  3. Surgical results for open repair of aneurysms involving the aortic arch: • 30 day mortality 15% • Neuro events 10-15% • 5 year survival 75% • Death primarily related to neurological and cardiac events • Many patients denied open surgical treatment because of comorbidities Kirklin/Barratt-Boyes Cardiac Surgery, Third Edition , N.T. Kouchoukos et al

  4. Landing zones in the thoracic aorta

  5. Coverage of the left subclavian artery:Carotid-subclavian bypass or not? • Gore TAG IFU: “If occlusion of the left subclavian artery ostium is required to obtain adequate neck length for fixation and sealing, transposition of the left subclavian artery should be considered.” • Vertebral circulation must be evaluated. ?Impact on paraplegia • Presence of internal mammary artery graft to LAD mandates revascularization • Debatable whether left subclavian bypass necessary

  6. LIMA bypass graft off the left subclavian arterypre-implantpost-implant

  7. Arizona Heart Institute • 255 thoracic endograft pts reviewed (2/00-12/05) • LSA covered in 71 pts; partially covered in 47 pts • 15 of 71 pts had pre-stent bypass → 1 CVA (this pt also had car-car bypass) • 3 of 56 pts without pre-stent bypass had complications: 2 TIA’s, 1 paraparesis (full recovery) • 1 of 56 pts without pre-stent bypass had lt arm claudication → car-SC bypass • Many other high volume centers are aggressive about subclavian revascularization -Data used with permission of Grayson Wheatley III, MD

  8. Prosthetic carotid-subclavian bypass: Patency: 85% @ 7 yr Mortality: 0-2% Stroke rate: 1-5% Carotid-subclavian transposition: Patency: 100% @ 7 yr Mortality: 1-2% Stroke rate: 0-2% Rutherford, Vascular Surgery Results of subclavian revascularization

  9. Coverage of left carotid &/or innominate arteries not included in IFU but allows expansion of endovascular technique.Debranching the aortic arch mandates some type of reconstruction: • Carotid-carotid bypass • Ascending aorta to innominate & carotid bypass • Proximal carotid stenting • Femoral-axillary bypass • Chuter graft

  10. Ascending aorto – innominate &/or carotid bypass • Patency 100% at 7 years • Mortality 5% • Stroke 7% Crawford et al, Surgery 1983;94:781-791

  11. Ascending aorta to innominate & carotid bypass (Saleh & Inglese, JVS 2006;44:461)

  12. Results of surgical carotid-carotid and aorto-innominate / left carotid (Y-graft) bypass Selected case reports

  13. Carotid stenting(T. Larzon et al, Eur J Vasc Endovasc Surg 2005;30:148)

  14. Chuter GraftChuter et al, JVS 2003;38:861

  15. Chuter GraftChuter et al, JVS 2003;38:861

  16. Hybrid techniques(Zhou et al, JVS 2006;44:691)

  17. Hybrid techniques(Zhou et al, JVS 2006;44:691)

  18. Hybrid techniques( Diethrich at al, J Endovasc Ther 2005;12:663 )

  19. Case Study: 77 y/o WF with 6.3cm saccular TAA • Evaluation of left vocal cord paralysis → CT of chest Feb 2006 → large saccular TAA off lateral aspect of distal arch • History of extensive spinal surgery in 2004 (Harrington rods at lumbar spine); surgical repair of perforated gastric ulcer in May 2005

  20. Baseline CTA – 3D

  21. Baseline CTA

  22. Baseline arch & cerebral arteriogram

  23. Operative procedures • Right to left carotid-carotid, left carotid-subclavian bypass using 8mm ringed Goretex graft • Right common iliac artery conduit using 10mm Hemashield graft • 34 mm x 15 cm Gore TAG deployed just distal to innominate via 22 Fr sheath • No spinal drain due to previous lumbar surgery and hardware

  24. Intraoperative aortogram

  25. 1-month CTA

  26. Open surgical repair still an option Case study: • 41 y/o WM s/p patch repair of thoracic aortic coarctation 23 yr ago • Severe AI and MR; no sig CAD • CTA of chest 3/06: recurrent coarctation w/ marked aneurysmal dilatation distally

  27. Left carotid-subclavian bypass and attempted endovascular repair

  28. Persistent type I proximal endoleak 4 days post-op → open chest repair

  29. 5 days post tube graft repair

  30. Fenestrated Graft: Is This the Future Solution?

  31. Questions?

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