Edward B. Diethrich, MDEdward B. Diethrich, MDPhoenix, ArizonaPhoenix, Arizona

The Future of The Future of Aortic RepairAortic Repair

Malmo, SwedenMalmo, SwedenJune 18, 2010June 18, 2010

What Perspective?What Perspective?

How?How?

Where?Where?Who?Who?

What?What?

How?How?

Where?Where?

Who?Who?• Classical• Endovascular• Robotic• Laparoscopic• Hybrid

• Classical• Endovascular• Robotic• Laparoscopic• Hybrid

• Cathlab• OR• Radiology Suite• Hybrid

• Cathlab• OR• Radiology Suite• Hybrid

• Vascular Surgeon

• Interventional Cardiologist

• Interventional Radiologist

• CT Surgeon• Hybrid

• Vascular Surgeon

• Interventional Cardiologist

• Interventional Radiologist

• CT Surgeon• Hybrid

Infrarenal AAAInfrarenal AAA

• Local anesthesia• Percutaneous• Maybe outpatient• Anyone

• Local anesthesia• Percutaneous• Maybe outpatient• Anyone

What Perspective?What Perspective?

Bown MJ et al.Br J Surg 2002;89:7 14-30.Visser P 2005

Bown MJ et al.Br J Surg 2002;89:7 14-30.Visser P 2005

Perioperative Period:Perioperative Period:Surgical mortality still elevated : Surgical mortality still elevated : 40 – 50% range40 – 50% range

Perioperative Period:Perioperative Period:Surgical mortality still elevated : Surgical mortality still elevated : 40 – 50% range40 – 50% range

Open RepairOpen Repair

Overall mortality of Overall mortality of 75 to 80%75 to 80%Overall mortality of Overall mortality of 75 to 80%75 to 80%

Acute Type B Acute Type B Descending Descending DissectionDissection

AsymptomaticAsymptomatic

What Perspective?What Perspective?

Medical RxMedical Rx EndograftEndograft

ControversyControversy

Waiting for studiesWaiting for studies Our DataOur Data

Symptomatic(malperfusion)Symptomatic(malperfusion)

Endovascular technology with some hybrid

combinations

Endovascular technology with some hybrid

combinations

Acute Type A Acute Type A DissectionDissection

• No AI• Limited to zone 0

[endovascular treatment]• Type I arch/descending• Ascending tube

• No AI• Limited to zone 0

[endovascular treatment]• Type I arch/descending• Ascending tube

What Perspective?What Perspective?

Progressive dissection not inconsequential

Progressive dissection not inconsequential

MortalityMortality

Ruptured CasesRuptured Cases

All PathologiesAll Pathologies TAATAA

Intraop DeathIntraop Death 4 (5.5%)4 (5.5%) 3(12.5%)3(12.5%)

< 30 Days< 30 Days 9 (12.3%)9 (12.3%) 5 (20.8%)5 (20.8%)

ConclusionConclusion

• TEVAR should be the first option of treatment in high risk patients and those with anatomical restraints in order to increase survival.

• Neuro-deficit is decreased when compared to open repair.

• TEVAR should be the first option of treatment in high risk patients and those with anatomical restraints in order to increase survival.

• Neuro-deficit is decreased when compared to open repair.

Natural History

False Lumen at 2 - 5 years

Subject to Aneurismal Dilatation in 20% to 40%

Advance in Vasc Surg. St Louis, Mosby 1998, pp 17-36

SuccessSuccess

SuccessSuccess

Remodeling Changes Continues

Post-op

6 months

P/3 M/3 D/3

Retrograde Flow

ObservationsObservations

a. Retrograde flow at viscerals 17.7% (19pts)

b. Retrograde flow at D/3 18.7% (20pts)

c. Retrograde flow at M/3 1.8% (2pts)d. Retrograde flow at P/3 1.8% (2pts)

flow

FL thrombosis/ patency depend on several factors

Flow

• Complete thrombosis of FL of TA without evidence of antegrade or retrograde flow – 69 pts (65.1%)

Results

Incidence of Aneurismatic Dilatation

Incidence of Aneurismatic Dilatation

• Incidence is 20-40% over 5 year period

• Risk of extending dissection and potential complications including visceral and limb malperfusion 26%

• Incidence is 20-40% over 5 year period

• Risk of extending dissection and potential complications including visceral and limb malperfusion 26%

Observations Pre-Op

Post-Op

1 month

24 months

6 months

Remodeling Changes• True lumen gain volume

• False lumen decrease in diameter

• Whole lumen expand

J Vasc Surg 2009;49:20-8.

Post-Op

6 months

24 months

Case #3P/3 D/3

Type B Dissection, Regardless of Symptoms, Should Be Treated

By Endografting to Prevent Future Complications?

Exceptions ?•Asymptomatic patient without significantly collapsed true lumen, <50%.

Inclined to Treat Non-complicated TBD with ELG

• Endograft is well indicated in aortic dissection type B since the natural history demonstrated high degree of success and positive remodeling changes.

• Endograft is well indicated in aortic dissection type B since the natural history demonstrated high degree of success and positive remodeling changes.

•No commercial products for many of the pathologies encountered

•Frequent customization required

•Complexity of pathology restricts broad training and experience

•No commercial products for many of the pathologies encountered

•Frequent customization required

•Complexity of pathology restricts broad training and experience

Limitations at PresentLimitations at Present

Example?Example?

Our Series: Open vs Endograft

June 1998 and June 2009Retrospective Review

Presented with a rAAA

69 (65.2%) -- Open Repair

36 (33.6%) -- EVAR

30-Day Mortality

• Overall was 29.5% (31)

• 34.8% (24) for Open

• 19.4% (7) for EVAR

(p=0.12) When comparing those EVAR cases with combined use of local anesthesia at initiation of procedure and use of supra-celiac occlusive balloon to those receiving general anesthesia and no balloon, the mortality reduced from 27.8% to 11.1 % (p=0.40)

Conclusions• EVAR in ruptured AAAs has reduced

mortality.

• Supraceliac occlusive balloon, based on CT findings of large retroperitoneal hematoma, initiated under local anesthetic, can prevent circulatory collapse.

Conclusions

• Availability of graft to treat larger caliber necks and low profile devices are some of the technology changes that we need.

Z0Z0

Z1Z1 Z2Z2

Z3Z3

Z4Z4

The Real Challenge:Conquering Zone Zero

The Real Challenge:Conquering Zone Zero

1. Level of the annulus of the aortic valve

2. Sinus of Valsalva3. Sinotubular junction4. Ascending aorta at the

level of pulmonary trunk

1. Level of the annulus of the aortic valve

2. Sinus of Valsalva3. Sinotubular junction4. Ascending aorta at the

level of pulmonary trunk

64 Slice CTOblique Coronal Images Showing the 4 Diameter Measurements of Aortic Root

64 Slice CTOblique Coronal Images Showing the 4 Diameter Measurements of Aortic Root

Acute Dissection Ascending AortaAcute Dissection Ascending Aorta

DissectionDissection HematomaHematoma

High Risk Patient for Open ProcedureHigh Risk Patient for Open Procedure

Balloon Occluding

Device

Balloon Occluding

Device

L. Coronary Artery

L. Coronary Artery

Sheath with Positioning of

ELG

Sheath with Positioning of

ELG

Aortic ValveAortic Valve

Dissection and Hematoma Sealed

Dissection and Hematoma Sealed

24° Post-Op CT24° Post-Op CT

1. Vortex velocity control in aneurysm

2. Laminates the flow in collaterals

3. Accelerates shear stress flow in the vessel

1. Vortex velocity control in aneurysm

2. Laminates the flow in collaterals

3. Accelerates shear stress flow in the vessel

Multi-Layered StentKey Principles

Multi-Layered StentKey Principles

Human Experience(All OUS)

Human Experience(All OUS)

Thoraco Abdominal Aneurysm

Thoraco Abdominal Aneurysm

1 Month Follow-Up

Aneurysm excludedAll visceral arteries openAneurysm excludedAll visceral arteries open

Future Potential for Endovascular ???Future Potential for Endovascular ???

Aortic Stenosis

Aortic Stenosis

Ascending Arch AneurysmAscending Arch Aneurysm

Aortic StenosisAortic Stenosis

Neuro Protection Devices

Neuro Protection Devices

Ascending Endoluminal

Graft

Ascending Endoluminal

Graft

Coronary Inserts

Coronary Inserts

Percutaneous Aortic Valve

Percutaneous Aortic Valve

Special Stent to Correct

Kink

Special Stent to Correct

Kink

Arch/ Descending Endoluminal Graft

with Three Branches

Arch/ Descending Endoluminal Graft

with Three Branches

Horizon Looks Favorable….Horizon Looks Favorable….

TrainingTraining

GovernmentGovernment

FDAFDA

CMSCMS

IndustryIndustry

We are the heritage of our undaunted medical forefathers. Our young physicians

are the genetic products of those great pioneers. Let their fate be the product of

those positive, energetic, inquisitive, creative, and adventurous epigenoms which

have the ability to overcome all adversity and bring ultimate success to all endeavers.

We are the heritage of our undaunted medical forefathers. Our young physicians

are the genetic products of those great pioneers. Let their fate be the product of

those positive, energetic, inquisitive, creative, and adventurous epigenoms which

have the ability to overcome all adversity and bring ultimate success to all endeavers.