Branched Arch TEVAR :The March to Zone 0

January 26th, 2014STS TechCon

Orlando, Florida

Jehangir AppooDivision of Cardiac Surgery

Libin Cardiovascular InstituteUniversity of Calgary

Disclosures

Consultant Gore Medical

Investigational devices

Futuristic license

Outline

Why is Arch TEVAR important?

Options for Arch TEVAR

Demonstrate a case

Descending thoracic aortic surgery has transitioned to endovascular treatment

Why is Arch TEVAR important?

Technically some isolated ascending aortic surgery can be done endovascularly

Why is Arch TEVAR important?

So… what’s left to solve….?

Image courtesy of Dr. C. Abraham – Montreal, Canada

If arch can be solved …

…Implications?

Why is Arch TEVAR important?

Classification of Zone 0 endovascular options

Open Chest – Hybrid Operations

Closed Chest - Endo Total Arch

Sternotomy

Arch Debranching

Antegrade Deployment

Single Stage Repair

Hybrid Arch proposed as lower risk alternative for diffuse thoracic aortic pathology

Avoidance of prolonged circ arrest

Mild hypothermia

Challenging distal operation converted to proximal anastomosis

122 pts with acute Type A dissection

Open placement of triple branched stent graft into descending aorta and arch vessels

4.9% operative mortality

Closed Chest Options as Futuristic Treatment Modality

Multi-layer aortic repair systems

Fenestrated graftsinsitu fenestration

Chimney technique

Branched arch graftsmulti branch graftssingle branch grafts

Multi-Layer Aortic Repair Systems

383 patients @ 35 sites in Japan1.6% Mortality1.8% Stroke

Customized fenestrated device

19 types precurved stent body8 types fenestrations for arch vessels

Chimney Technique

Using standard devices

Multibranch arch Single branch arch

Carotid-subclavian bypass preop

Main body deployed transfemorally

Head vessels cannulated from above

Cook Multibranch Arch Graft is custom made for alignment of patient’s arch vessels

Narrower body in arch

40-50 selected cases worldwide

1st 38 cases – stroke and mortality rates < 10% (unreported)

64 y.o maleType A repair 2009

Complicated course

Aorta growing at rate of 1cm/year

Arch dissectedLarge residual primary

intimal tear in archTrue lumen effaced

2013

Total endo arch Custom built branched arch graft

Complexity

VR images 3 months post op

Single Branch Arch Devices

Gore FDA study6 sites enrolling in US1st patient-Jan 2014

Medtronic FDA study7 pts at 2 US Sites

Off the shelf devicesDesigned for LSADual wire lumens

Single Branch Arch Grafts potentially could be combined with extra-anatomic carotid carotid bypass for full arch reconstruction

ConclusionsDynamic Evolution in treatment of thoracic aortic disease

Summary:

Hybrid open chest operations

vs.

Closed chest aortic arch

Branched arch graftssingle vs. multi branchoff the shelf vs. custom

Fenestrated arch graftsChimney graftsMultilayer aortic stent grafts

ConclusionsDynamic Evolution in treatment of thoracic aortic disease

Future is likely to be less invasive

Investigational process to determine pros/cons of each of the closed chest arch operation

Different therapies applicable for different anatomy

Exciting opportunity to be involved with ongoing evolution

ConclusionsDynamic Evolution in treatment of thoracic aortic disease

Once algorithm for endovascular approach to arch is defined…could ”routine” ascending aortic replacement potentially be envisioned as part of the armamentarium of endovascular surgeons?

Paradigm shift: Are CT surgeons ready to be endovascular specialists?

Thank You

Surgeon Year ET1 Mortality

ET2 Mortality

Interval Mortality

Rx Mortality

Svensson 2004 2% 8.5% 14% 18%

Safi 2007 6.3% 9.6% 10% 13.3%

Lemaire/Coselli 2006 12% 4% 25% 36%

Kouchoukos 2007 7.2% -- -- 7.2%

Grieppe 2008 6% 7% 12% 24.5%

Etz, Grieppe et al. – Eur J. CT Surg 2008

Even in centres of experience, operative mortality with 2 stage elephant trunk technique is high