a

Vascular Surgery Center

National Center for Cardiovascular Diseases.

Fuwai Hospital, CAMS & PUMC Beijing, China

Aortic Arch pathology options: Open,Hybrid，fenestration, Chimney or branched stent-graft?

Chang Shu, M.D., Ph.D

Email: Changshu01@fuwaihospital.org

changshu01@yahoo.com

Disclosure of Conflicts

None.

Total Volume of Aortic Surgery in

Fuwai Hospital（1997-2016）

1143 aortic operations in 2016:

1.9% of mortality.

573 open repair, 93 hybrid procedure, 477 endo-repair

1143 cases

Current Approaches for Arch

Open Repair

Total arch replacement

Hybrid TechniquesHybrid arch replacement

Debranching + TEVAR

Extra-anatomic bypass + TEVAR

Total Endo Techniques

Fenestrated stent-graft

Branched stent-graft

Chimney technique

OPEN REPAIR:

Total arch replacement

Suitable for arch anatomy, with or without elephant trunk implantation and ascending replacement.

Standard approach with credible long-term durability.

Standard option（2014 ESC, 2010 ACC/AHA/ACCF）

Circulatory arrest is mandatory

Peri-operative complications(cerebral, renal, spinal)

Risk arises in aged patient and co-morbidities

IRAD:Mortality 24.7%（ Circulation 2004）

IRAD:Mortality 17%-26% (2016)

OPEN REPAIR:

Total arch replacement

Age Distribution in Treated Patients

in Fuwai Hospital

Percentage of aged patients increased every year, age is the first

risk factor of mortality and it limits open repair utilization.

Categories of Hybrid Procedure

RCCA – LCCA – LSARSA– LCCA RSA– LSA

De-branching:

Arch branch

transposition

Hybrid arch

replacement

Extra-anatomic bypass + TEVAR

Aortic arch pseudoaneurysm

Hybrid technique was adopted.

Ascending aorta – innominate artery – left carotid artery –

LSA bypass was achieved first.

Then TEVAR was used.

The patient recovered unevertfully.

Debranching ProcedureAscending - Supra Aortic Branches transposition

Avoided DHCA, regular CPB

Extended landing zone in prosthetic graft, reduce retrograde TAAD

Antegrade and retrograde delivery could be selected

Reduced complication compare with total arch replacement

Hybrid Arch Replacement

Hybrid procedure

Mata Analysis Results（2010）Overall 30-day mortality:8.3%

EL:9.2%

stroke:4.4%

paraplegia:3.9%

No affect between On or off-pump.

Elephant Trunk Arch Debranching:

30-day Mortality: 9.5% 11.9%

Cerebrovascular events 7.6% 3.6%

Spinal cord Injury 6.2% 5.0%

Hybrid procedure

For aortic arch pathology, minimal invasive

option is preferred in decision-making.

Adopted from Ivan Casserly MB

Massive

InvasiveLess

Invasive

Minimal

Invasive

Non-

invasiv

eOpen repair:

Better exposureHybrid:

InterimTotal-Endo

101 of 477 patients received total endovascular arch branch

revascularization plus TEVAR/EVAR in 2016

Endovascular aortic repair in Fuwai

Hospital

Endovascular aortic repair in Fuwai Hospital &

Second Xiangya Hospital（Nov2015-Nov2017）

Total TEVAR 1593

Arch branch

revascularization

354

Single Chimney 168

Double Chimney 16

Triple Chimney 2

Fenestration 92

Double Fenestration 8

Triple Fenestration 6

Snorkel 8

168

162

92

8 6 8

Single Chimney Double Chimney Triple Chimney

Fenestration Double Fenestration Triple Fenestration

Snorkel

Single

ChimneyFenestration

Fenestrated

Technique Branched

Stent-graftChimney Technique

Double Chimney

Technique

Total Endovascular Repair of

Supra-arch Branch

Nov, 2007

The 1st case of CSG

2008

CSG + PDA occluder

2009

Double CSG

2016

Triple CSG

Chimney Stent-graft (CSG)

During 1.5 years

follow up, no

complication

happened.

As a result, double

chimney technique

can be used for

retrograde type A

aortic dissection

with caution.

Double Chimney Technique

The patient, 84 years old, male,

received TEVAR for aortic aneurysm

in 2005, and suffered from chest pain

for 1 month.

With the development of

popularization of endovascular

technique and increasing of average

life span, more and more post-TEVAR

complications will happen and need

secondary intervention in the future.

Double Chimney Technique

Double chimney technique is a efficient and safe technique to

extend the proximal landing zone of aortic arch, especially for

aged patient.

• 3 months after TEVAR plus triple chimney procedure

• Double chimney with LSA snorkel stent

Triple Chimney Technique

Institutional outcomes in Fuwai TeamChimney Cohort

122 cases report from our center

Overall results:

Technical Success Rate:98.6%

84.2% free from any EL

80.6% free from any adverse events

Report of our center shows well

results using double chimney .

87.0% free from any Endoleaks

73.8% free from any adverse

evenets

Institutional outcomes in Fuwai Team

Chimney Stent-graft (CSG)

2017 Meta-analysis report

373 patients and 387 CGs

Overall technical success :91.3%

Pooled 30-day mortality:7.9%

Overall early type Ia EL:9.4%

Early patency,:97.9%

Late patency:92.9%

Retrograde type A dissection:1.8%

Stroke, 2.6%

Fenestration Technique

Fenestration

In Vitro

Fenestration

In Situ

Fenestration

Off-the-shelf

Fenestration

Physician-modified

Fenestration

In Situ Needle

Fenestration

In Situ Laser

Fenestration

In Vitro Fenestration:

Physician-modified fenestration

Fenestration:Branch stent insertion

Pre-dilation and modelling of fenestration

Antegrade fashion:

Via femoral access

Retrograde fashion:

Via branchial access

On-the-table manner of In vitro fenestrationplus LSA branchstenting

LCCA + LSA: in vitro fenestration with Viabahn insertion

Inominate artery: Chimney with Fluency insertion

Double Fenestration plus chimney

Ballooned fenestration needle in facilitating in situs Fenestration

Fenestrated Graft:

In situs fenestration

In situ fenestration

In situ fenestration

Ann Thorac Surg 2016

In situs fenestration:

from single to multiple branch

• Total 3-Arch Repair Using In Situ Fenestration for Arch

Aneurysm, reported by Katada in 2016

• Success rate: 6/7 ------Ann Thorac Surg 2016

Physician-modified vs Off-the-shelf Fenestration

Overall clinical treatment success :

Physician-modified fenestration 91.4%

Off-the-shelf fenestration 95.0%

Branched stent-graft

Branched stent-graft

Branched Stent-graft under Trials

Gore TAG thoracic branch

endoprosthesis

• Currently being studied

in the United States for

a zone 0–2 deployment

Cook arch-branch

• Available in the EU,

Canada, and South

America

• Over 100 patients have

been treated with this

system

• Ascending aortic

diameters must be ≤ 38

mm to ensure good

proximal fixation and seal

The Valiant Mona LSA stent

-graft system

• “Volcano” type cuff

• Allowing for 20° to

30° of mal-alignment

between the cuff and

the SCA

Adapted from Endovascular Today

Castor Micro-port

First single-arm

branched stent-graft

available in ChinaRelay NBS Plus

47 patients have been treated with

these custom devices in Europe

Open portion procedure remains standard approach for aortic arch

pathology with long-term durability yet higher mortalities.

Hybrid and total endovascular procedure may substitute open repair

for patients with significant comorbidities.

Endo-techniques and devices, including fenestrated stent-graft/

branched stent-graft/ chimney technique are expected and should be

done individually according to the aortic arch pathology.

For total endo-technique(Fenestration and chimney approach, etc.),

long-term durability, efficacy and safety remains to be investigated in

larger patient cohorts before being widely adopted.

Conclusion and Prospective

Thank You!

2018 China Vascular Congress (CVC)

&

Annual Meeting of National Society of

Vascular Surgery, China (NSVS)

Welcome You!

August 2018, Beijing, China