Post on 13-Jan-2016
ASCVTS 2011 Shaggy aorta & TEVAR
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““Shaggy aorta” is a highly dangerous sign of Shaggy aorta” is a highly dangerous sign of TEVAR for aortic arch aneurysmTEVAR for aortic arch aneurysm
Department of Cardiovascular SurgeryDepartment of Cardiovascular Surgery
Fukushima Medical University, School of MedicineFukushima Medical University, School of Medicine
Fukushima, JAPANFukushima, JAPAN
Shinya Takase, Hirono Satokawa, Yoichi Sato, Shinya Takase, Hirono Satokawa, Yoichi Sato,
Hiroki Wakamatsu, Yoshiyuki Sato, Hiroyuki Kurosawa,Hiroki Wakamatsu, Yoshiyuki Sato, Hiroyuki Kurosawa,
Takashi Igarashi, Akihito Kagoshima, Tsuyoshi Yamabe,Takashi Igarashi, Akihito Kagoshima, Tsuyoshi Yamabe,
Hitoshi YokoyamaHitoshi Yokoyama
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BackgroundBackground
•Conventional surgery for thoracic aortic aneurysm still has high Conventional surgery for thoracic aortic aneurysm still has high
morbidity and mortality.morbidity and mortality.
•In this condition, stentgraft is applied to descending thoracic aortic In this condition, stentgraft is applied to descending thoracic aortic
disease more than graft replacement.disease more than graft replacement.
•For arch aorta, stentgraft is only deployed to high risk patients in For arch aorta, stentgraft is only deployed to high risk patients in
general. However, in TEVAR for this lesion, stroke is concerned general. However, in TEVAR for this lesion, stroke is concerned
because of atheromatous embolization.because of atheromatous embolization.
•Conventional surgery for arch aortic aneurysm even with severe Conventional surgery for arch aortic aneurysm even with severe
atherom induces catastrophic complication followed by early death.atherom induces catastrophic complication followed by early death.
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PurposePurpose
This paper is to explore whether TEVAR This paper is to explore whether TEVAR
for aortic arch aneurysm with “shaggy for aortic arch aneurysm with “shaggy
aorta” is acceptable or not.aorta” is acceptable or not.
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Severely atheromatous aortaSeverely atheromatous aortaDefinition of “Shaggy aorta”
NoramlIntimal thickness(IT) < 2mmNo irregularity
Intimal thickness > 2mmNo irregularity
Irregularity (+)
IT>2mm + Irregularity but not projected
IT>2mm + Irregularity with projection
ASCVTS 2011 Shaggy aorta & TEVAR
Case 4Case 4 77 y.o. male,77 y.o. male,True aortic arch aneurysm, AnginaTrue aortic arch aneurysm, Angina
ASCVTS 2011 Shaggy aorta & TEVAR
Case 1Case 1 ;; 82y.o. female 82y.o. female Arch Aneurysm with aberrant arteryArch Aneurysm with aberrant artery
ASCVTS 2011 Shaggy aorta & TEVAR
Treatment StrategyTreatment Strategy Indication of Conventional Surgery?Indication of Conventional Surgery?
PossiblePossible ImpossibleImpossible
•Age>75 y.o., Age>75 y.o.,
•Severity of co-morbiditySeverity of co-morbidity•Concomittant Procedure (CABG, Valve Surgery)?Concomittant Procedure (CABG, Valve Surgery)?
CSCS
Concomittant Proc.Concomittant Proc.
Difficult Treans-femoral AccessDifficult Treans-femoral Access
YesYes NoNo
debranched SGdebranched SG
Zone0~1Zone0~1 Zone2Zone2
SGSGFenestrated SGFenestrated SG
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SGSG deploymentdeployment•Examination
•MD-CT > Angiography•Endoluminal Stentgraft (tailered made)
•GiantrucoZ stent ; d30-40X l 50-75mm •UBE Ultrathin graft ; d28-40X l 50-150mm
•Delivery system (Pull through)•COOK Guiding Sheath (straight / bending)•0.035” Super stiffness / TERMO J type 230cm
•Deployment•Hypotension (60-80mmHg) / ATP 0.2-0.4mg/kg / •Rapid pacing 120-140 ppm
•Monitoring•INVOS / MEP ( in some cases)
ASCVTS 2011 Shaggy aorta & TEVAR
Fenestrated SG for aortic arch aneurysm
Max diameter;42mmMax diameter;42mm
Saccular typeSaccular type
ASCVTS 2011 Shaggy aorta & TEVAR
(Debranching) + Transaortic SG (Debranching) + Transaortic SG
1) Branched Graft
2) Side clamping and
anastomosis
3) Reconstruction of cerebral arteries
(debraching)
4) Trans-aortic SG
SG (22F Guiding Sheath) over the wire
5F Pigtail
8X16mm Y-graft
8mm
10mm
8mm
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PatientsPatients
Jan., 2001Jan., 2001 ~~ May, 2010May, 2010
SG repair for aortic arch aneurysmSG repair for aortic arch aneurysm
(Non-dissecting aneurysm) (Non-dissecting aneurysm)
2323 CasesCases
Male:Female = 19Male:Female = 19 :: 4,4,
Age ; 74±7Age ; 74±7 y.o.,y.o.,
Observation ; 30Observation ; 30 ~~ 32193219 (( 848±1058848±1058 ) ) daysdays
ASCVTS 2011 Shaggy aorta & TEVAR
Patients’ Profile with “Shaggy aorta” or notPatients’ Profile with “Shaggy aorta” or not
Shaggy aorta, n(%) Non “Shaggy aorta”, n(%)
n=23 n=8 n=15
Male:Female 7:1 12:3 0.65
Age 75±6 73±7 0.59
HT 8(100) 15(100) 1.00
HL 6(75) 10(67) 0.67
DM 1(13) 0(0) 0.35
Cerebrovascular diseases 2(22) 5(33) 0.12
Cardiac disorders 3(38) 3(20) 0.62
Respiratory dysfunction 2(50) 3(53) 1.00
Renal insufficiency 2(25) 3(20) 1.00
PAD 4(50) 1(7) 0.033
Multiple aortic aneurysm 2(25) 2(13) 0.59
Logistic EuroSCORE 30.1±24.6 23.1± 20.1 0.76
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Postoperative OutcomePostoperative OutcomeShaggy aorta, n=8 Non Shaggy aorta, n=15
Approach from aorta 5(63) 4(27) 0.18
CPB use 1(13) 2(13) 1.00
Debranching 5(63) 7(47) 0.67
SG top;Zone0/1/2/3 3(38)/3(38)/0(0)/2(25) 2(13)/3(20)/5(33)/5(33) 0.19
Primary Outcome
Endoleak 2(25) 2(13) 0.59
Surgical conversion 0(0) 1(7) 1.00
Additional SG 1(13) 0(0) 0.35
Access trouble 1(13) 2(13) 1.00
Aorta injury 1(13);dissection 1(7); aorta rupture* 1.00
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Postoperative OutcomePostoperative OutcomeShaggy aorta, n=9 Non Shaggy aorta, n=14
Cerebral infarction 1(13) 0(0) 0.35
Respiratory failure 3(38) 2(13) 0.30
Pneumonia 2(25) 0(0) 0.11
Renal dysfucntion 3(38) 1(7) 0.10
Hemodialysis 3(38) 1(7) 0.10
Bowel ischemia 0(0) 0(0) 1.00
Gastric bleeding 0(0) 1(7) 1.00
Paraparesis 2(25) 0(0) 0.11
Any morbidities 5(63) 2(13) 0.026
MOF 1(13) 0(0) 0.35
Death in 30days 1(13) 1(7) 1.00
Hospital death 4(50) 2(13) 0.13
*MOF;1, Pneumonia;2, AAA rupture;1,
ASCVTS 2011 Shaggy aorta & TEVAR
Actual SurvivalActual Survival
1515
Log-rank p=0.13
50%
71%
Shaggy
Non-shaggy
ASCVTS 2011 Shaggy aorta & TEVAR
SummarySummary
• SG treatment for aortic arch aneurysm is technically SG treatment for aortic arch aneurysm is technically successful with debranching and/or fenestrated SG. successful with debranching and/or fenestrated SG.
• There were no differences in preoperative co-There were no differences in preoperative co-morbidities between patients group w/ and w/o morbidities between patients group w/ and w/o “shaggy aorta”.“shaggy aorta”.
• Embolim was induced around 50% in the group with Embolim was induced around 50% in the group with “shaggy aorta”, whereas it was 0% in that without “shaggy aorta”, whereas it was 0% in that without “shaggy aorta”.“shaggy aorta”.
• As the result, once one or more organ dysfunctions As the result, once one or more organ dysfunctions were occurred in such high risk patients, it led to were occurred in such high risk patients, it led to death.death.
• Once the patients with “shaggy aorta” can tolerate Once the patients with “shaggy aorta” can tolerate this treatment, they could survive in long time period.this treatment, they could survive in long time period.
ASCVTS 2011 Shaggy aorta & TEVAR
ConclusionConclusion
““Shaggy aorta“ is a dangerous sign.Shaggy aorta“ is a dangerous sign.
Special caution of handling in this procedure is Special caution of handling in this procedure is
required.required.
Adequate informed consent to such patients is also Adequate informed consent to such patients is also
required. required.
Invention of completely preventive measures against Invention of completely preventive measures against
embolism is aspired.embolism is aspired.