Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD,...

44
Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS

Transcript of Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD,...

Page 1: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

Hybrid Surgery for Aortic Diseases

George Economopoulos,MD,FACS

Page 2: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

DISCLOSURES

NONE

Page 3: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

WHAT is a “HYBRID” PROCEDURE ?

A combination of endoluminal and open surgical techniques at the sametime aiming to reduce the morbidity associated with a completely “open”surgical procedure

Page 4: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 5: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

What was the standard for extensive aneurysmal aortic disease till recently?

Standard technique included:- DHCA- Elaborate methods to protect vital organs

( brain, heart, kidneys, spinal cord etc)- Bleeding problems, from hard to reach sites

And was associated with

High CVA risk (up to 20%)Reccurent nerve and Respiratory riskBleeding and CoagulopathyKidney and spinal cord injury riskMortality up to 15%Long hospital stay($$$$$)

Page 6: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

Everything started with an elephant !

Page 7: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

What was the ultimate strategy of the procedure?

1. Treat the proximal aortic pathology first (Ao Root, Asc Aorta , Arch)and introduce a piece of tubular graft in the beginning of the DAduring the procedure

2. At a second stage anastomose a graft in the trunk (elephant trunk)hanging inside the DA with another graft

L Swenson

Page 8: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

Did the “Elephant trunk” procedure achieved the sought afterimprovements in mortality,morbidity , and associatedcomplications ?

Page 9: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

“To a man with a hammer everything lookslike a nail”Mark Twain

Page 10: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

Since the high interval mortality , the combined overall mortality and problemswith ET deployment the concept of “Frozen ET “ (FET) was introduced in 1990(Kato)

A procedure combining the concept of a prosthesis in the DA from the“traditional” ET procedure and the concept of fixing it from the TEVARtechnology in one stage ,with the stented prosthesis increasing the “sealing”effect, acting as a distal anastomosis

Page 11: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 12: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

AORTIC ARCH DEBRANCHING PROCEDURES

AIM: To apply aortic arch procedures to patients not previously deemedcandidates due to serious comorbidities

HOW: Avoid CPB, Hypothermia, aortic clamping

Endovascular prosthesis in the Aortic arch requires an adequate “landing” zonein the aortic arch and have to take account a) the supraaortic vessels and b) theanatomic and hemodynamic properties of that part of the aorta ( curvature, highflow velosity and the significant movement of that part of the aorta with eachheart beat)

Page 13: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

Proposal Aortic De-branching plus Arch stents

Rerouting blood flow to the supra-aortic vessels prior to stent graftdeployment by transposition or bypass techniques

Page 14: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 15: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

16% Endoleaks !

Page 16: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

SOME USEFUL AND IMPORTANT FACTS

1. NO Randomized controlled trial has been performed comparing thesetechniques2. The FET technique cannot be considered a single stage technique sincesubsequent interventions are required in the majority of patients ( endoleaks,other stents)3. FET has a higher incidence of SCI vs the traditional ET4. Major concern with Aortic De-branching are the endo-leaks (16%) and longterm durability and survival results are lacking

SO

ENDOVASCULAR TREATMENT OF COMPLEX AORTIC DISEASE REQUIRESSTRICT FOLLOW UP AND UNTIL ITS LONG TERM DURABILITY ISCONFIRMED,EXTENSION OF ITS APPLICATION TO GOOD SURGICALCANDIDATES MAY EVEN SEEM HAZARDOUS

Page 17: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

THANK YOU!

Page 18: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 19: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 20: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 21: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal

Why do we want to do ARCH Hybrid procedures instead of classic open procedures?

1 Classic open Txs has serious disadvantages

a High CVA risk (20%)b Recurrent Nerve and Respiratory riskc Bleeding at posterior suture lines(difficult to control)d Eliminates DHCA and often CPB completelye Eliminates second stage mortality and Interval death rate

2Not because of the proximal Ascending / Arch component

3Hybrid procedures provide us the ability to offer a tailoredrepair to patients with complex aortic pathology

Page 22: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 23: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 24: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 25: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 26: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 27: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 28: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 29: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 30: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 31: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 32: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 33: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 34: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 35: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 36: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 37: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 38: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 39: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 40: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 41: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 42: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 43: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal
Page 44: Hybrid Surgery for Aortic Diseases · Hybrid Surgery for Aortic Diseases George Economopoulos,MD, FACS. DISCLOSURES NONE. WHAT is a “HYBRID” PROCEDURE ? A combination of endoluminal