Hybrid Aortic Arch Stenting 2008

8/14/2019 Hybrid Aortic Arch Stenting 2008

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Hybrid Procedures for Congenital Heart Repair:Hybrid Procedures for Congenital Heart Repair:

Aortic Arch StentingAortic Arch Stenting

Redmond P. Burke MD, FACS

Chief, Division of Cardiovascular Surgery

The Congenital Heart Institute

Miami Childrens Hospital and Arnold Palmer HospitalMiami Childrens Hospital and Arnold Palmer Hospitalwww.pediatricheartsurgery.comwww.pediatricheartsurgery.com


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PredicatesPredicates

To perform hybridTo perform hybrid

procedures successfully,procedures successfully,

there must be a strongthere must be a strong

relationship between surgicalrelationship between surgical

and medical subspecialties.and medical subspecialties.Program members mustProgram members must

adopt and share a commonadopt and share a common

philosophy to use theirphilosophy to use their

combined skills to reduce thecombined skills to reduce the

trauma of care for eachtrauma of care for each

patient.patient.


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Common Pre-operative Considerations forCommon Pre-operative Considerations for

Aortic Hybrid ProceduresAortic Hybrid Procedures

At our conferences, each patient presented forAt our conferences, each patient presented fortherapy is discussed. We ask ourselves: Will atherapy is discussed. We ask ourselves: Will ahybrid approach decrease cumulative trauma?hybrid approach decrease cumulative trauma?

We then identify the optimal setting (OperatingWe then identify the optimal setting (Operating

Room (OR) or Cath Lab or both)Room (OR) or Cath Lab or both)to use the cath lab, you need mobile cardiopulmonaryto use the cath lab, you need mobile cardiopulmonary

bypass capabilitybypass capability

We design an approachWe design an approach For patients with open chests, we can put sheaths directly intoFor patients with open chests, we can put sheaths directly into

the heart.the heart. For some patients, a carotid artery approach is optimalFor some patients, a carotid artery approach is optimal For complex patients requiring other cardiac surgical repairs, aFor complex patients requiring other cardiac surgical repairs, a

Trans-aortic sheath is used.Trans-aortic sheath is used.

Is the procedure ethical? consent, IRBIs the procedure ethical? consent, IRB


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Ethical standard: Would you use this approach forEthical standard: Would you use this approach for

your own child? I ask this of myself frequently.your own child? I ask this of myself frequently.


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TeamworkTeamwork

Synchronize the scheduling of the procedure soSynchronize the scheduling of the procedure so

that each team is available and on sitethat each team is available and on site Minimize total bypass and ischemic arrest timesMinimize total bypass and ischemic arrest times

Set each other up with optimal visualization andSet each other up with optimal visualization andaccess. We adopt the surgical assistant principleaccess. We adopt the surgical assistant principle

and try to make each other look good.and try to make each other look good.

Operating room and Cath lab staff willOperating room and Cath lab staff willenthusiastically participate in operations that areenthusiastically participate in operations that are

efficient and effective.efficient and effective.


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Hybrid Aortic Arch Stent InsertionHybrid Aortic Arch Stent Insertion

Our Justification for this approach:Our Justification for this approach: We see 15-30% arch obstruction after Stage I palliationWe see 15-30% arch obstruction after Stage I palliation

for HLHS: the natural consequence of large patchesfor HLHS: the natural consequence of large patches

placed on small native aortas.placed on small native aortas.

Surgical repairs of recurrent arch obstruction wasSurgical repairs of recurrent arch obstruction was

traumatic, particularly to the left phrenic nerve, resultingtraumatic, particularly to the left phrenic nerve, resulting

in occasional diaphragm paralysis.in occasional diaphragm paralysis.

Balloon angioplasty produced mixed resultsBalloon angioplasty produced mixed results

Transcatheter implantation of adult sized stents inTranscatheter implantation of adult sized stents in

infants created significant vascular injury.infants created significant vascular injury.


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Anatomic ConsiderationsAnatomic Considerations

Arch obstructionArch obstructionafter Stage I isafter Stage I isusually distal,usually distal,circumferentialcircumferentialductal tissue,ductal tissue,

kinking, proximitykinking, proximityof left PA andof left PA andnerves.nerves.

You can see theYou can see theductal tissue inductal tissue in

this arch by thethis arch by theforceps, thisforceps, thistissue contractstissue contractsover time.over time.


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Case Report 1. Hybrid Arch StentCase Report 1. Hybrid Arch Stent

CLINICAL HISTORY: At the time of catheterization, Baby A was aCLINICAL HISTORY: At the time of catheterization, Baby A was a4-month-old born with initial diagnosis of hypoplastic left heart4-month-old born with initial diagnosis of hypoplastic left heartsyndrome. As a newborn, he underwent stage I Norwood palliation.syndrome. As a newborn, he underwent stage I Norwood palliation.However, subsequently, he developed aortic arch obstruction. ForHowever, subsequently, he developed aortic arch obstruction. Forthis, he underwent balloon angioplasty with a moderatethis, he underwent balloon angioplasty with a moderateimprovement.improvement.

He was scheduled for bidirectional cavopulmonary anastomosis andHe was scheduled for bidirectional cavopulmonary anastomosis andwas noted to have persistent aortic archwas noted to have persistent aortic arch

obstruction.obstruction.

We therefore planned hybrid implantation of anWe therefore planned hybrid implantation of anadult-sized aortic stent.adult-sized aortic stent.


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HLHS: Initial Operative ImageHLHS: Initial Operative Image


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Completed Stage 1 ReconstructionCompleted Stage 1 Reconstruction


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Technique: Hybrid Arch Stent InsertionTechnique: Hybrid Arch Stent Insertion

At time of cavopulmonary anastomosisAt time of cavopulmonary anastomosis

Can be done On/off by-passCan be done On/off by-pass

Sheath in ascending aortaSheath in ascending aorta

Fluoroscopic guidanceFluoroscopic guidance

Wire to descending aortaWire to descending aorta

Angiography via sheathAngiography via sheath

Stent deliveryStent delivery

Follow-up angiographyFollow-up angiography

Remove sheath repair aortaRemove sheath repair aorta


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SURGEON

CPB

CANULATION

VASCULAR ACCESS

INTERVENTIONAL

CARDIOLOGIST

STENT PLACEMENT

ANGIOPLASTY


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Hospital Course: These are the daily pictureHospital Course: These are the daily picture

of this patients postoperative recovery.of this patients postoperative recovery.


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Reoperations after arch stents: What doesReoperations after arch stents: What does

the surgeon need to know?the surgeon need to know?

OPERATIVE REPORTOPERATIVE REPORT

DATE OF PROCEDURE: 05/19/2006DATE OF PROCEDURE: 05/19/2006

PREOPERATIVE DIAGNOSIS:PREOPERATIVE DIAGNOSIS:1. Hypoplastic left heart syndrome.1. Hypoplastic left heart syndrome.2. Aortic arch obstruction status post stent insertion.2. Aortic arch obstruction status post stent insertion.

POSTOPERATIVE DIAGNOSIS:POSTOPERATIVE DIAGNOSIS:1. Hypoplastic left heart syndrome.1. Hypoplastic left heart syndrome.2. Aortic arch obstruction status post stent insertion.2. Aortic arch obstruction status post stent insertion.

PROCEDURE:PROCEDURE:1. Fontan, extracardiac, fenestrated 19-mm Impra tube graft.1. Fontan, extracardiac, fenestrated 19-mm Impra tube graft.2. Aortic arch reconstruction with pericardial patch and opening of2. Aortic arch reconstruction with pericardial patch and opening ofstent.stent.

SURGEON: Redmond P Burke, M.D.SURGEON: Redmond P Burke, M.D.

ASSISTANT: Michael O'Brien, P.A.ASSISTANT: Michael O'Brien, P.A.

ANESTHESIA: General endotracheal.ANESTHESIA: General endotracheal.

INDICATIONS FOR OPERATION: The patient is a 5-year-old boy withINDICATIONS FOR OPERATION: The patient is a 5-year-old boy withhypoplastic left heart syndrome who underwent an Norwood procedure as ahypoplastic left heart syndrome who underwent an Norwood procedure as anewborn followed by a bidirectional cavopulmonary anastomosis. He hasnewborn followed by a bidirectional cavopulmonary anastomosis. He hasbeen treated with stents in his aortic arch and his left pulmonarybeen treated with stents in his aortic arch and his left pulmonaryartery. The left pulmonary artery stent has the capacity to reach adultartery. The left pulmonary artery stent has the capacity to reach adultsize. However, the aortic arch stent does not. The child thereforesize. However, the aortic arch stent does not. The child thereforewill require opening of the stent at this operation. The child iswill require opening of the stent at this operation. The child isstable with no evidence of active infection at the time of surgery.stable with no evidence of active infection at the time of surgery.

Surgeons must

know which stents

have the potential

to reach adultsize. We have to

communicate this

well between the

members of thecardiac team, and

record the

information in our

notes.


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Observations on Surgical StentObservations on Surgical Stent

ReoperationsReoperationsIt can be difficult to get distal control, low flowIt can be difficult to get distal control, low flowbypass and intralumenal suction are necessary.bypass and intralumenal suction are necessary.

Within months stents will become embedded inWithin months stents will become embedded inthe aortic wall, they cannot be removed, but canthe aortic wall, they cannot be removed, but can

be split open with scissors and bent open withbe split open with scissors and bent open withsome distal extension.some distal extension.

An onlay patch will work, but stent spikes mayAn onlay patch will work, but stent spikes maycut suture. They can be trimmed with scissors.cut suture. They can be trimmed with scissors.

No fresh aortic suture lines have ruptured orNo fresh aortic suture lines have ruptured orbled acutely, or formed aneurysms, as a result ofbled acutely, or formed aneurysms, as a result ofhybrid stentinghybrid stenting


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Operative images: Arch Dissection after prior stentOperative images: Arch Dissection after prior stent

placementplacement


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Ive cut through the stent, and must make sure toIve cut through the stent, and must make sure to

cut the final link, or the obstruction will persistcut the final link, or the obstruction will persist..


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The childs postoperative courseThe childs postoperative course

was uncomplicated.was uncomplicated.


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Clinical Review of Hybrid intra-Clinical Review of Hybrid intra-

operative arch stentoperative arch stent

PreliminaryPreliminaryexperience in 3experience in 3patients (n = 74patients (n = 74patients having Stagepatients having Stage1 palliation )1 palliation )

Procedural SuccessProcedural Success100%100%

Adult sized stentsAdult sized stentsplaced withoutplaced withoutresidual gradients orresidual gradients orbleedingbleeding


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Disadvantages of Hybrid StentDisadvantages of Hybrid Stent

Implantation in the ORImplantation in the OR

Sub-optimal angiographic imagingSub-optimal angiographic imaging

Lack of biplane angiographyLack of biplane angiography

Limited C-arm angulation and qualityLimited C-arm angulation and quality

Direct surgical visualization limitedDirect surgical visualization limited

We use intraoperative endoscopy to look inside theWe use intraoperative endoscopy to look inside the

repairs and ensure correct stent placementrepairs and ensure correct stent placement

Cardioscopy, TEE,Direct Pressure Measuremen


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ConclusionsConclusions

Intra-operative Hybrid stent implantationsIntra-operative Hybrid stent implantationsin the aorta can be performed safely, within the aorta can be performed safely, withhigh precision, and high proceduralhigh precision, and high procedural

success rates.success rates.Reoperations on arch stents are veryReoperations on arch stents are verymanageablemanageable

Redilations have been successfulRedilations have been successfulSuccess with a hybrid approach dependsSuccess with a hybrid approach dependson a unified congenital heart team.on a unified congenital heart team.


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Thank you.Thank you.

Hybrid Aortic Arch Stenting 2008

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