Jean M. Panneton, MD, FRCSC, FACS ... Jean M. Panneton, MD, FRCSC, FACS Professor of Surgery, Chief...

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Transcript of Jean M. Panneton, MD, FRCSC, FACS ... Jean M. Panneton, MD, FRCSC, FACS Professor of Surgery, Chief...

  • Jean M. Panneton, MD, FRCSC, FACS

    Professor of Surgery,

    Chief & Program Director

    Division of Vascular Surgery Eastern Virginia Medical SchoolEastern Virginia Medical School

    Norfolk, VA

    The Houston Aortic Symposium Houston TX, February 23-25th 2017

  • Disclosures

    EndoAnchors & TEVAR

    Disclosures

    Consultant: Cook Medical, Bolton Medical, Medtronic Inc, Volcano, WL Gore Speakers’ Bureau: Bolton Medical, Medtronic Inc., WL Gore Advisory Board: Medtronic Inc., Mellon Medical, VolcanoAdvisory Board: Medtronic Inc., Mellon Medical, Volcano

    Eastern Virginia Medical Center

  • For prophylaxis or therapy

    EndoAnchors & TEVAR

    Indications:

    Migration/ Type 1 LeakSevere

    For prophylaxis or therapy

    Type 1 LeakSevere Angulation

    TherapyTherapyProphylaxisProphylaxis Difficult landing

    Birdbeaking

    Difficult landing

    Component separation

    revision

    3

  • A S G S

    EndoAnchors & TEVAR

    Can we predict TEVAR failures ?

    ANATOMIC SEVERITY GRADING SCORE

    ASG score= 24

    ASG score= 43

    • Anatomic criteria assessed for 4 distinct segments of DTA

    • Each characteristic graded from 0-3

    • Anatomic criteria assessed for 4 distinct segments of DTA

    • Each characteristic graded from 0-3

    score= 43

    • All categories added to obtain a composite ASG score ( range 2 to 57 )

    • All categories added to obtain a composite ASG score ( range 2 to 57 )

    J Vasc Surg 2016;64:912-20.

  • Freedom from postoperative endoleakFreedom from postoperative endoleak

    EndoAnchors & TEVAR

    Can we predict TEVAR failures ?

    ***

    Freedom from postoperative endoleak requiring reintervention at 2 years Freedom from postoperative endoleak requiring reintervention at 2 years

    Sensitivity=92%Sensitivity=92%Sensitivity=92%

    100% **

    **

    *

    *

    Sensitivity=92% Specificity=50% Sensitivity=92% Specificity=50% Sensitivity=92% Specificity=50%

    69%

    ***

    *P=0.002*P=0.002*P=0.002 *For an ASG score ≥24

    *For an ASG score ≥24

    *For an ASG score ≥24

    *For an ASG score ≥24

    score ≥24score ≥24score ≥24

    This novel anatomic severity grading system can successfully identifyThis novel anatomic severity grading system can successfully identify patients at increased risk for postoperative endoleak formation and endoleak requiring reintervention following TEVAR for primary DTA

  • Prophylactic indication: challenging anatomy EndoAnchors & TEVAR

    Pre TEVAR hemiarch

    debranchingdebranching

  • Prophylactic indication: challenging anatomy EndoAnchors & TEVAR

    No endoleak after 23 months

    Placement of EndoAnchors at the

    inner curvature

    Completion Aortogram after prophylactic

    EndoAnchorsinner curvature EndoAnchors

    @ 3 years follow [email protected] 3 years follow up no migration no endoleaks

  • Prophylactic indication: preventing upward migration

    EndoAnchors & TEVAR

    preventing upward migration

    Distal TEVAR with celiac catheterization

    Circumferential placement of EndoAnchors at distal end

    Completion Aortogram after prophylactic

    EndoAnchorsceliac catheterization EndoAnchors at distal end

    EndoAnchors

    @ 2 yrs follow up No migration No endoleaks

  • EndoAnchors & TEVAR

    Therapeutic indication: revision

    Type Ia endoleak 2 years after 4 vessels FEVAR with PMEG treated with proximal EndoAnchors and Onyx

    CTA 3 years after EndoAnchor rescue with no endoleakCTA 3 years after EndoAnchor rescue with no endoleak

  • EndoAnchors & TEVAR

    Therapeutic indication: revision

    Treating failed EVAR (migration & type I endoleak) with 3 vessels FEVAR w/ ZFEN & AUI conversion & EndoAnchors

  • EndoAnchors & TEVAR

    Therapeutic indication

    Proximal type I endoleak 1 yr Redo TEVAR with Left CCAProximal type I endoleak 1 yr after TEVAR & 4 vessels FEVAR for Type I TAAA

    Redo TEVAR with Left CCA Laser Fenestration

    with residual type I endoleak

  • EndoAnchors & TEVAR

    Therapeutic indication

    Completion Aortogram after EndoAnchors rescue

    Placement of EndoAnchors at the inner curvature

    CTA at 12 months: no endoleaks

  • Procedural Technique: Guide selection & deployment EndoAnchors & TEVAR

    Recommended Heli-FX Guide Selection

    Aortic Inner

    18-28 mm

    28-38 mm

    38-42 mmInner

    Diameter mm mm mm

    Guide Tip Reach

    22 mm 32 mm 42 mm

    Controlled, Tactile, Intuitive, Safe

    2 steps process: Recapture & Release

    18Fr OD, 90cm working

    lengthlength

    22 mm 32 mm

    42 mm

  • Procedural Technique: advanced deployment EndoAnchors & TEVAR

    Ascending aorta deployment in RAO view

    Side arch deployment in barrel view

  • Procedural Technique: outer arch deployment

    EndoAnchors & TEVAR

    Easy Zone 1 Tricky Zone 1

    Undersize the guide for the outer curvature

    Easy Zone 1 Tricky Zone 1

  • Procedural Technique: antegrade deployment

    EndoAnchors & TEVAR

    Arch aneurysm requiring sternotomy and total arch debranching with antegrade TEVARwith antegrade TEVAR

  • EndoAnchors & TEVAR

    Procedural Technique: antegrade deployment

    Antegrade deployment of posterior EndoAnchors zone 0

    3D CTA @ 6 months

  • EndoAnchors & TEVAR

    Indications

    N =N = 101101 proceduresprocedures

    Experience in TEVAR & CEVAR

    N =N = 101101 proceduresprocedures TEVAR, FEVAR, ChEVARTEVAR, FEVAR, ChEVAR

    N =N = 4747 FEVAR or ChEVARFEVAR or ChEVAR

    N =N =5454 TEVARTEVAR FEVAR or ChEVARFEVAR or ChEVARTEVARTEVAR

    Study Population Treated for:

    Mean age = 73 years Male gender = 72 ( 71.3% )

    Dec 2012 - June 2016

    Arch / DTA 22

    TAAA 35

    Dec 2012 - June 2016 Mean Follow up = 14.3 months

    Range = 1 to 42 months

    Pararenal AAA 22

    Juxtarenal + failed EVAR 22

  • EndoAnchors & TEVAR

    Procedural Indications

    N =N = 101101 proceduresprocedures

    TEVAR, FEVAR, ChEVARTEVAR, FEVAR, ChEVAR

    N =N = 4545 Index procedureIndex procedure

    N =N = 5656 Redo procedureRedo procedure

    N =N = 3939 N =N = 3636 N =N = 2020N =N = 66N =N = 3939 ProphylacticProphylactic

    N =N = 3636 TherapeuticTherapeutic

    N =N = 2020 ProphylacticProphylactic

    N =N = 66 TherapeuticTherapeutic

  • Procedural Success Total of 930 Endo Anchors were deployed ( 9.8 / pt )

    EndoAnchors & TEVAR

    Total of 930 Endo Anchors were deployed ( 9.8 / pt )

    Technical success rate = 99.6%

    Endoanchors retrieval

    0.39% ( N=3 )

    Aortic Deployment Zones

    Zone of No. of 2 by snare technique

    1 retrieval with Aptus system

    Zone of

    EndoAnchor

    No. of

    EndoAnchors

    Zone 0 12

    Zone 1 75Zone 1 75

    Zone 2 61

    Zone 3 39

    Zone 4 8Zone 4 8

    Zone 5 169

    Zone 6 86

    Zone 7 84Zone 7 84

    Zone 8 132

    Zone 9 98

  • EndoAnchors & TEVAR

    Procedural challengesProcedural challenges

    Index Redo Total

    Proximal Landing ZonesProximal Landing Zones

    Operations

    N=27

    Operations

    N=27 N=54

    Zone 0 2 5 7

    Zone 1 9 6 15

    Zone 2 7 1 8Zone 2 7 1 8

    Zone 3 4 2 6

    Zone 4 0 2 2Zone 4 0 2 2

    Zone 5 5 11 16

    56 % landed in the arch & 41 % Zones 0-156 % landed in the arch & 41 % Zones 0-1

  • Procedural OutcomeProcedural Outcome EndoAnchors & TEVAR

    N =N = 5454 TEVARTEVAR

    N = 37N = 37 ProphylacticProphylactic

    N = 17N = 17 TherapeuticTherapeutic

    NONO Endoanchor relatedEndoanchor related

    5.9%5.9% Endoanchor relatedEndoanchor relatedEndoanchor relatedEndoanchor related

    reinterventionsreinterventions Endoanchor relatedEndoanchor related

    reinterventionreintervention

    1 type Ia / Ib endoleaks1 type Ia / Ib endoleaks

    No migrationNo migration

    No type I or III endoleakNo type I or III endoleak

    No migrationNo migration

  • Procedural Outcome EndoAnchors & TEVAR & CEVAR

    Freedom from Type I endoleak

    by Anatomy by Indicationby Anatomy by Indication

    100 % @ 1 & 2 yrs 96.7 % @ 1 & 2 yrs

    94 % @ 1 & 2 yrs

    94 % @ 1 & 2 yrs

    93.7 % @ 1 & 2 yrs

    94 % @ 1 & 2 yrs

  • Summary EndoAnchors & TEVAR

    EndoAnchors can be used prophylactically during TEVAR for complex aneurysms and appear to prevent migration and late endoleak formation,aneurysms and appear to prevent migration and late endoleak formation,

    however longer follow up is needed

    EndoAnchors can be used therapeutically for type I & III endoleaks in indexEndoAnchors can be used therapeutically for type I & III endoleaks in index or redo TEVAR and can effectively eliminate endoleaks and reduce

    recurrences

    Type I endoleak Type I endo