V. Alberti*,M. Orrico§, A. Davì°, S. Ronchey*, S. Fazzini*, N. Mangialardi§

Bologna

23-25 Ottobre 2017

ENDOVASCULAR TREATMENT FOR AORTIC ARCH LESIONS

• LESS INVASIVE

• NO CARDIOPULMONARY BYPASS

• NO AORTIC CROSSCLAMPING

• NO CIRCULATORY ARREST

IN-HOSPITAL 30-DAYS MORTALITY 1,7%-19%

CEREBROVASCULAR EVENTS 5%-15,8%

Shahverdyan, Vascular 2017

Estrera, Ann Thorac Surg 2015

Eur J Cardiothorac Surg 2016

Coselli. J Cardiovasc Surg 2015Haulon S J Thor Cardiov Surg 2014

STILL SUBSTANTIAL

EARLY SECONDARY PROCEDURE 10,5%

FU SECONDARY PROCEDURE 9,1%

TECHNICAL SUCCESS 84,2%

ENDOVASCULAR TREATMENT

• OFF-LABEL GRAFT

• CUSTOME-MADE GRAFT

• HOME-MADE GRAFT

Chuter 2003

Cook Custom

Canaud 2017

Home-made

Haulon 2014

Cook inner branch

Patel 2016

Gore TBE

Huang 2017

Microport castor

Roselli 2015

Medtronic Mona LSA

Inoue 1999

Home-ade

TECHNICAL SUCCESS 89,5%

CEREBROVASCULAR EVENTS 4,2%

TYPE I ENDOLEAKS 10,5

30-DAYS MORTALITY 9,5%

30-DAYS MORTALITY 17%

RETROGRADE DISSECTION 17%

• SPECIFIC GRAFT FOR ASCENDING AORTA

• REDUCE ARCH MANOEUVRES

ENDOSPAN NEXUS

HOW IT WORKSTWO CONFIGURATIONS

ENDOSPAN NEXUS

HOW IT WORKS

TWO CONFIGURATIONS

20F• R/BRACHIO-FEMORAL

THROUGH-AND-THROUGH 400 CM

• LUNDERQUIST

• UNDER RAPID CARDIAC PACING

TRAINING PROCEDURE

• STEPS

• TIP AND TRIKS

• RELEASING VIEWS

KEY POINT

• 2014 >> COUGH >> CTSCAN

72 MM DISCENDENT THORACIC AORTA AN/ INVOLVING SUBCLAVIAN ARTERY

FIRST CASE

RJV 7F INTRODUCERFIAB CATH PACING

RCA 6F INTRODUCERFEN CATH

RBA 8F INTRODUCERTHROUGH/THROUGH

R/DOUBLE PROGLIDEL/ SINGLE PROGLIDE

NEXUS 30-180

NEXUS 40-40

ADVANTA 9-38

• H+12

• PARAPLEGIA

• DISARTHRIA

• R/ARM ATASSIA

• SPINAL FLUID PRESSURE 24MMHG

• CT SCAN LEFT CEREBRAL AND CEREBELAR LESIONS

• MRI: NO LESION – NO EDEMA

• SPINAL DRAINAGE

• O2, HB, PRESSURE SUPPORT

• HEMISFERIC DEFICITS REGRESSION

• SPINAL DEFICIT BECOME BETTER AND BETTER

60 MM

UNEVENTFULL

@2YR

51 MM

N %HTA 1 20CAD 3 60COPD 4 80CRF 2 40ASCAO 2 40CABG 2 40OBESITY 2 40

ASA 2

NYHA 3

FROM 12/2014 TO 03/20175 PZ

POPULATION

EARLY RESULTS

0

50

100

150

200

250

300

350

1 2 3 4 5

OP TIME

XRAY

CONTRASTMEDIUM

1

5

25

125

625

3125

1 2 3 4 5

ICU DD

BLOOD LOSS

BLOOD SUPPLY ML

GG

MEDIA MEDIAN RANGE

OP TIME 193 175 120-330XRAY 80,4 78 55-132

CONTRAST MEDIUM

186 220 90-300

BLOOD LOSS 210 100 50-700

BLOOD SUPPLY 188 0 0-440

ICU 2,8 2

HOSP 10 9

100% TECHN SUCCESS

100% BIL PERC FEM ACC

3/5 TOTALLY P-TEVAR

POSTOPERATIVE COURSE

@FIRST PT WITH FENESTRATION

• MINOR STROKE – QUICKLY SOLVED

• PARAPLEGIA

• CFD – O2 SUPPLY – BLOOD SUPPLY – I.V. CORTICOSTEROIDS

• PERSISTENT TYPE II ENDOLEAK

• X3 EMBOLIZATION SUBCLAVIAN ARTERY

4/5

UNEVENTFULL

FOLLOW-UP

17,6 MM (RANGE 6-33)

0 MORTALITY

0 PARAPLEGIA

0 ICTUS

100% BP PATENCY

100% BRANCH/FEN PATENCY

0 TYPE I ENDOLEAKS

0 AORTIC VALVE DAMAGE

20% TYPE II ENDOLEAK

20% REINTERV

Δ ARCH• -6 MM MED• -9 - +26 MM

CONCLUSION

• MINIINVASIVE EV TREAT IS INTERESTING OPTION

• ESPECIALLY IN DEEMED PATIENTS

• ENDOSPAN NEXUS MAY BE LAND AT THE STJ LEVEL

• TRMT ARCH ANEURYSMS INVOLVING ASCENDING AORTA

• SINGLE BRANCHED DECREASE THE NEED FOR ARCH MANIPULATION

• LESS MICROEMBOLIC RISK

• ENDOSPAN NEXUS HAS PROXIMAL LANDING ZONE IN BCT

• POTENTIALLY HAS LONG TERM MIGRATION RESISTANCE