The efficacy of debranching TEVAR for arch aneurysm in high risk patients.

1. The efficacy of debranchingTEVAR for arch aneurysm in high risk patients. Department of Cardiovascular surgery Osaka university graduate school of medicine Y Shirakawa, T Kuratani, K Shimamura, M Takeuchi, K.Kin, T.Yoshida Y Sawa

2. Background The traditional treatment of thoracic aortic aneurysms is open surgical graft replacement. Despite progressive surgical advances, conventional surgical repair is still associated with substantial morbidity and mortality, especially in elderly patients with other major medical conditions. Aortic arch aneurysms present a particular challenge to endovascular repair due to the involvement of supra-aortic vessels and the anatomic curvature of the arch. A variety of maneuvers have been recommended for thoracic endografting to address the landing zone limitations imposed by the arch vessels.

3. Objectives This report presents the results of a review of our 10-year clinical experience with endovascular treatment of aortic arch aneurysms after debranching of arch vessels (debranching TEVAR).

4. Logistic Euroscore : 15.93% +/- 9.77 % (2.76 ~ 43.67) Debranching TEVAR Number of Patients :90 cases(Jan. 1998 ～ Nov. 2009) Sex : Male 65, Female 25 Age : 68.9 ±11.7 （27～95） years old pathology Type B dissection 37 cases（acute case 10） Degenerative 44 cases （rupture case 4） Infective/inflammatory 3 cases Traumatic 4 cases cancer invasion 2 cases co-morbidity High age (over 80 y.o) 17 cases (18.8 %) COPD 30 cases (33.3 %) Concomitant cancer 17 cases (18.8 %) CAD 12 cases (13.3 %) previous cardiac surgery 4 cases (4.4 %)

5. 19 61 10 Debranching TEVAR Proximal landing zone Arch reconstruction procedure Zone 0 Ao-rt.SCA-lt.CCA-lt.SCA bypass 9 bil.FA-rt.SCA-lt.CCA-lt.SCA bypass 1 Zone 1 rt.SCA-lt.CCA-lt.SCA bypass 19 Zone 2 rt.SCA-lt.SCA bypass 32 lt.CCA-lt.SCA bypass 5 Simple sacrifice of lt.SCA 24

6. Ao-rt.SCA-lt.CCA-lt.SCA bypass Approach : Median sternotomy Inflow : Side clamp of Ascending Aorta. Prosthesis : 12mm Hemashield for rt. SCA 8mm Hemashield for lt.CCA & lt.SCA Ao – rt. SCA bypass ~ avoid direct clamp of BCA

7. Debranching TEVAR Early results Primary success 97.8% (88/90) type Ⅰb~ 1, type Ⅱ~ 1 30 days Mortality 1.1 % (1/90) due to iliac rupture Postopeative Complication Stroke 2 (2.2%) (Z2 ~ 2) Respiratory failure 1 (1.1%) Paraplegia 0

8. Debranching TEVAR Late results Freedom from aneurysm related death All cause survival (%) (%) 100 100 80 80 60 60 1 year 96.7 % 3 year 93.6% 5 year 84.2% 10 year 84.2% 1 year 88.1 % 3 year 77.2% 5 year 69.5% 10 year 69.5% 40 40 20 20 0 0 1 3 5 7 10 1 3 5 7 10 (y) (y)

9. Debranching TEVAR Freedom from Aortic event (%) 1 year 96.5 % 3 year 83.1% 5 year 83.1% 10 year 69.3% 100 80 60 Re-TEVAR 3 distal enlargement 1 typeⅠb endoleak 2 in dissection case. Open conversion 1 Graft infection 1 Rupture 1 40 20 0 5 7 10 (y) 1 3

10. Discussion Freedom from Aortic events Operative mortality : 4.3 % In-hospital mortality : 7.2 % Strokes : 5.8 % Paraplegia : 2.9 %

11. First choice Anatomical condition Strategy for Arch Aneurysm Arch and distal arch aneurysm Patients condition First choice High risk patients Open Surgery Debranched TEVAR Anatomical limitations • Proximal neck • diameter 34 ~ 37mm, length 20mm • diameter 23 ~ 33mm, length 15mm • Character of Aortic wall (ascending aorta)

12. Conclusion Debranched TEVAR for aortic arch aneurysms appears to reduce the early mortality and morbidity and long-term durability is very acceptable. Our results suggested that this procedure might be an alternative procedure for low risk patients. In the future, ready made branched endoprostheses will be installed, which may expand the applications of this procedure.