jean m. panneton, md, frcsc, facs...jean m. panneton, md, frcsc, facs professor of surgery, chief...

Jean M. Panneton, MD, FRCSC, FACS

Professor of Surgery,

Chief & Program Director

Division of Vascular SurgeryEastern Virginia Medical SchoolEastern Virginia Medical School

Norfolk, VA

The Houston Aortic SymposiumHouston TX, February 23-25th 2017

Disclosures

EndoAnchors & TEVAR

Disclosures

Consultant: Cook Medical, Bolton Medical, Medtronic Inc, Volcano, WL GoreSpeakers’ Bureau: Bolton Medical, Medtronic Inc., WL GoreAdvisory Board: Medtronic Inc., Mellon Medical, VolcanoAdvisory Board: Medtronic Inc., Mellon Medical, Volcano

Eastern Virginia Medical Center

For prophylaxis or therapy

EndoAnchors & TEVAR

Indications:

Migration/Type 1 LeakSevere

For prophylaxis or therapy

Type 1 LeakSevereAngulation

TherapyTherapyProphylaxisProphylaxis Difficultlanding

Birdbeaking

Difficultlanding

Componentseparation

revision

3

A S G S

EndoAnchors & TEVAR

Can we predict TEVAR failures ?

ANATOMIC SEVERITY GRADING SCORE

ASGscore= 24

ASGscore= 43

• Anatomic criteria assessed for 4 distinctsegments of DTA

• Each characteristic graded from 0-3

• Anatomic criteria assessed for 4 distinctsegments of DTA

• Each characteristic graded from 0-3

score= 43

• All categories added to obtain acomposite ASG score ( range 2 to 57 )

• All categories added to obtain acomposite ASG score ( range 2 to 57 )

J Vasc Surg 2016;64:912-20.

Freedom from postoperative endoleakFreedom from postoperative endoleak

EndoAnchors & TEVAR

Can we predict TEVAR failures ?

***

Freedom from postoperative endoleakrequiring reintervention at 2 yearsFreedom from postoperative endoleakrequiring reintervention at 2 years

Sensitivity=92%Sensitivity=92%Sensitivity=92%

100%**

**

*

*

Sensitivity=92%Specificity=50%Sensitivity=92%Specificity=50%Sensitivity=92%Specificity=50%

69%

***

*P=0.002*P=0.002*P=0.002 *For an ASGscore ≥24

*For an ASGscore ≥24

*For an ASGscore ≥24

*For an ASG score ≥24

score ≥24score ≥24score ≥24

This novel anatomic severity grading system can successfully identifyThis novel anatomic severity grading system can successfully identifypatients at increased risk for postoperative endoleak formation andendoleak requiring reintervention following TEVAR for primary DTA

Prophylactic indication: challenging anatomyEndoAnchors & TEVAR

Pre TEVARhemiarch

debranchingdebranching

Prophylactic indication: challenging anatomyEndoAnchors & TEVAR

No endoleak after 23months

Placement ofEndoAnchors at the

inner curvature

Completion Aortogramafter prophylactic

EndoAnchorsinner curvature EndoAnchors

@ 3 years follow up@ 3 years follow upno migrationno endoleaks

Prophylactic indication:preventing upward migration

EndoAnchors & TEVAR

preventing upward migration

Distal TEVAR withceliac catheterization

Circumferential placement ofEndoAnchors at distal end

Completion Aortogramafter prophylactic

EndoAnchorsceliac catheterization EndoAnchors at distal endEndoAnchors

@ 2 yrs follow upNo migrationNo endoleaks

EndoAnchors & TEVAR

Therapeutic indication: revision

Type Ia endoleak 2 years after 4 vessels FEVAR with PMEGtreated with proximal EndoAnchors and Onyx

CTA 3 years after EndoAnchor rescue with no endoleakCTA 3 years after EndoAnchor rescue with no endoleak

EndoAnchors & TEVAR

Therapeutic indication: revision

Treating failed EVAR (migration & type I endoleak) with3 vessels FEVAR w/ ZFEN & AUI conversion & EndoAnchors

EndoAnchors & TEVAR

Therapeutic indication

Proximal type I endoleak 1 yr Redo TEVAR with Left CCAProximal type I endoleak 1 yrafter TEVAR & 4 vesselsFEVAR for Type I TAAA

Redo TEVAR with Left CCALaser Fenestration

with residual type I endoleak

EndoAnchors & TEVAR

Therapeutic indication

Completion Aortogramafter EndoAnchors rescue

Placement of EndoAnchors atthe inner curvature

CTA at 12 months:no endoleaks

Procedural Technique: Guide selection & deploymentEndoAnchors & TEVAR

Recommended Heli-FX Guide Selection

AorticInner

18-28mm

28-38mm

38-42mmInner

Diametermm mm mm

Guide TipReach

22 mm 32 mm 42 mm

Controlled, Tactile, Intuitive, Safe

2 steps process: Recapture & Release

18Fr OD,90cm working

lengthlength

22 mm32 mm

42 mm

Procedural Technique: advanced deploymentEndoAnchors & TEVAR

Ascending aortadeployment in RAO view

Side arch deployment inbarrel view

Procedural Technique: outer arch deployment

EndoAnchors & TEVAR

Easy Zone 1 Tricky Zone 1

Undersize the guide for the outer curvature

Easy Zone 1 Tricky Zone 1

Procedural Technique: antegrade deployment

EndoAnchors & TEVAR

Arch aneurysm requiring sternotomy and total arch debranchingwith antegrade TEVARwith antegrade TEVAR

EndoAnchors & TEVAR

Procedural Technique: antegrade deployment

Antegrade deployment of posterior EndoAnchors zone 0

3D CTA @ 6 months

EndoAnchors & TEVAR

Indications

N =N = 101101 proceduresprocedures

Experience in TEVAR & CEVAR

N =N = 101101 proceduresproceduresTEVAR, FEVAR, ChEVARTEVAR, FEVAR, ChEVAR

N =N = 4747FEVAR or ChEVARFEVAR or ChEVAR

N =N =5454TEVARTEVAR FEVAR or ChEVARFEVAR or ChEVARTEVARTEVAR

Study Population Treated for:

Mean age = 73 yearsMale gender = 72 ( 71.3% )

Dec 2012 - June 2016

Arch / DTA 22

TAAA 35

Dec 2012 - June 2016Mean Follow up = 14.3 months

Range = 1 to 42 months

Pararenal AAA 22

Juxtarenal + failed EVAR 22

EndoAnchors & TEVAR

Procedural Indications

N =N = 101101 proceduresprocedures

TEVAR, FEVAR, ChEVARTEVAR, FEVAR, ChEVAR

N =N = 4545Index procedureIndex procedure

N =N = 5656Redo procedureRedo procedure

N =N = 3939 N =N = 3636 N =N = 2020N =N = 66N =N = 3939ProphylacticProphylactic

N =N = 3636TherapeuticTherapeutic

N =N = 2020ProphylacticProphylactic

N =N = 66TherapeuticTherapeutic

Procedural SuccessTotal of 930 Endo Anchors were deployed ( 9.8 / pt )

EndoAnchors & TEVAR

Total of 930 Endo Anchors were deployed ( 9.8 / pt )

Technical success rate = 99.6%

Endoanchors retrieval

0.39% ( N=3 )

Aortic Deployment Zones

Zone of No. of2 by snare technique

1 retrieval with Aptus system

Zone of

EndoAnchor

No. of

EndoAnchors

Zone 0 12

Zone 1 75Zone 1 75

Zone 2 61

Zone 3 39

Zone 4 8Zone 4 8

Zone 5 169

Zone 6 86

Zone 7 84Zone 7 84

Zone 8 132

Zone 9 98

EndoAnchors & TEVAR

Procedural challengesProcedural challenges

Index Redo Total

Proximal Landing ZonesProximal Landing Zones

Operations

N=27

Operations

N=27N=54

Zone 0 2 5 7

Zone 1 9 6 15

Zone 2 7 1 8Zone 2 7 1 8

Zone 3 4 2 6

Zone 4 0 2 2Zone 4 0 2 2

Zone 5 5 11 16

56 % landed in the arch & 41 % Zones 0-156 % landed in the arch & 41 % Zones 0-1

Procedural OutcomeProcedural OutcomeEndoAnchors & TEVAR

N =N = 5454TEVARTEVAR

N = 37N = 37ProphylacticProphylactic

N = 17N = 17TherapeuticTherapeutic

NONOEndoanchor relatedEndoanchor related

5.9%5.9%Endoanchor relatedEndoanchor relatedEndoanchor relatedEndoanchor related

reinterventionsreinterventionsEndoanchor relatedEndoanchor related

reinterventionreintervention

1 type Ia / Ib endoleaks1 type Ia / Ib endoleaks

No migrationNo migration

No type I or III endoleakNo type I or III endoleak

No migrationNo migration

Procedural OutcomeEndoAnchors & TEVAR & CEVAR

Freedom from Type I endoleak

by Anatomy by Indicationby Anatomy by Indication

100 % @ 1 & 2 yrs 96.7 % @ 1 & 2 yrs

94 % @ 1 & 2 yrs

94 % @ 1 & 2 yrs

93.7 % @ 1 & 2 yrs

94 % @ 1 & 2 yrs

SummaryEndoAnchors & TEVAR

EndoAnchors can be used prophylactically during TEVAR for complexaneurysms and appear to prevent migration and late endoleak formation,aneurysms and appear to prevent migration and late endoleak formation,

however longer follow up is needed

EndoAnchors can be used therapeutically for type I & III endoleaks in indexEndoAnchors can be used therapeutically for type I & III endoleaks in indexor redo TEVAR and can effectively eliminate endoleaks and reduce

recurrences

Type I endoleakType I endoleakafter total archType I endoleak

after total archdebranching and

redo TEVAR

after total archdebranching and

redo TEVARresolved afterredo TEVAR resolved after

zone 0EndoAnchors

EndoAnchors & TEVAR