TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges,...
Transcript of TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges,...
![Page 1: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/1.jpg)
Tilo Kölbel, MD, PhD
University Heart Center Hamburg
University Hospital Eppendorf
TEVAR and the Aortic Arch :
Challenges, Planning and Techniques for Good Outcomes
![Page 2: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/2.jpg)
Gold Standard for Descending Aorta
![Page 3: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/3.jpg)
Cheng et al 2010, JACC 55:986-1001
Descending Aorta
TEVAR vs. Open
TEVAR better:
– 30d mortaliy
– Paraplegia rate
– Transfusion
– Cardiac compl.
– Renal function
– Pneumonia
– Reoperation
– ICU and Hospital LOS
Metaanalysis of comparative studies
TAA and Type B Dissection (n = 5888)
![Page 4: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/4.jpg)
Gold Standard for the Arch
Surgery for the aortic arch:
Open repair
Elephant trunk
Mortality rates 5-15%
Stroke: 4-12%
Sundt et al. 2008; Ann Thorac Surg 86:787-96
Minakawa et al. 2010; Ann Thorac Surg 90:72-7
![Page 5: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/5.jpg)
Endovascular Challengers
Tsagakis et al. 2013 Ann Cardiothorac Surg 2:612-20
Frozen Elephant Trunk
Chiesa et al. 2010 J Endovasc Ther
17:1-11
Hybrid Repair Branched/Fenestrated Repair
Haulon et al. 2014 J Thorac Cardiovasc Surg,
![Page 6: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/6.jpg)
Aortic Arch Zones
Ishimaru-classification
![Page 7: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/7.jpg)
Aortic Arch Zones
Ishimaru-classification
![Page 8: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/8.jpg)
Challenges of the Aortic
Arch
Branch vessels
Patency / endoleak
Pulsatility
Oversizing / migration
Curvature
Conformity / infolding
Access
Distance / profile / kinking
![Page 9: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/9.jpg)
Outline
Planning
Challenges
Techniques
![Page 10: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/10.jpg)
Most technical Errors
follow
insufficient planning !
Planning
![Page 11: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/11.jpg)
Planning
Perpendicular measurement
Multiplanar-reconstruction (MPR)
Pulsatility
Graft-properties
Proximal Landing
![Page 12: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/12.jpg)
Workstation
![Page 13: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/13.jpg)
Perpendicular Diameter in
MPR
![Page 14: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/14.jpg)
Perpendicular Diameter
![Page 15: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/15.jpg)
Pulsatility
![Page 16: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/16.jpg)
Pulsatility
![Page 17: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/17.jpg)
Jonker et al 2010; EJVES; 40:564-71
Hypovolemia and Aortic
Diameter
![Page 18: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/18.jpg)
Proximal Landing
Preferred landing site:
Length
Diameter
Shape
Thrombus
Non-dissected healthy
aortic wall
![Page 19: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/19.jpg)
Proximal Landing
![Page 20: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/20.jpg)
52 patients, FU 31m
47 stentgrafts distal to LSA
9 patients proximal erosion and aneurysm
3 patients with rupture, 2 fatal
Manning et al, JEVT, 2009
Proximal Landing
![Page 21: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/21.jpg)
Techniques
Access-techniques
Endovascular Techniques
Arch-conformance
Fenestrated / branched Devices
In-situ Fenestration
![Page 22: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/22.jpg)
Access Techniques
Iliac-conduit
Paving and Cracking
Through & Through-Wire
Transcardiac Access
![Page 23: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/23.jpg)
Access Techniques
![Page 24: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/24.jpg)
Access Techniques
![Page 25: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/25.jpg)
Access Techniques
![Page 26: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/26.jpg)
Iliac Conduit
![Page 27: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/27.jpg)
Paving and Cracking
![Page 28: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/28.jpg)
Through&Through-Wire
Stiff Guidewire Soft transbrachial Throughwire
![Page 29: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/29.jpg)
Transseptal Through-Wire
![Page 30: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/30.jpg)
Transseptal Through-Wire
![Page 31: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/31.jpg)
Transseptal Through-Wire
![Page 32: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/32.jpg)
Transapical Through-Wire
![Page 33: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/33.jpg)
![Page 34: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/34.jpg)
Cardiac Output reduction:
Adenosine
Rapid Pacing
IVC balloon occlusion
Cook TX2 Kasirajan et al; J Vasc Surg 2010
Windsocket Effect –
Retroflexion
![Page 35: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/35.jpg)
Case: Retroflection
![Page 36: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/36.jpg)
Case: Retroflection
![Page 37: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/37.jpg)
Case: Retroflection
![Page 38: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/38.jpg)
½ x MAP wihin 1 minute
IVC Balloon Occlusion
![Page 39: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/39.jpg)
Insufficient SG-conformity
to the anatomy of the arch
→ Aortic wall erosion
→ Type 1 endoleak
→ Stent-graft collapse
Arch-Conformance
![Page 40: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/40.jpg)
• Angulation of arch
• Small aortic diameter
• Stent-graft oversizing
• Transsection
• Stent-graft rigidity
Potential Factors
![Page 41: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/41.jpg)
• Angulation of arch
• Small aortic diameter
• Stent-graft oversizing
• Transsection
• Stent-graft rigidity
Potential Factors
![Page 42: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/42.jpg)
Controlled Deployment by ProForm
Zenith® TX2 ProForm®
![Page 43: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/43.jpg)
Zenith® TX2 ProForm®
Controlled Deployment by ProForm
![Page 44: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/44.jpg)
Aortic Arch Techniques for
Zone 0
![Page 45: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/45.jpg)
Zone 0 –Debranching
![Page 46: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/46.jpg)
Zone 0 –Debranching
![Page 47: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/47.jpg)
Zone 0 – Chimney Graft
![Page 48: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/48.jpg)
Zone 0 – Chimney Graft
![Page 49: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/49.jpg)
Zone 0 – Chimney Graft
![Page 50: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/50.jpg)
Zone 0 – Chimney Graft
![Page 51: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/51.jpg)
Zone 0 – In-Situ Fenestration
![Page 52: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/52.jpg)
Zone 0 – In-Situ Fenestration
![Page 53: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/53.jpg)
Zone 0 – In-Situ Fenestration
![Page 54: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/54.jpg)
J Vasc Surg 2013;58:1171-7
In-Situ Laser Fenestration
![Page 55: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/55.jpg)
In-Situ Laser Fenestration
![Page 56: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/56.jpg)
Zone 0 – Fenestrated Stent-Graft
![Page 57: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/57.jpg)
Branched Arch Repair
1995-1998
N=15
14 single branch,
1 triple branch
Outer branches
Traction wire
Inoue et al. 1999; Circulation 100:316-21
![Page 58: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/58.jpg)
Branched Arch Repair
Chuter et al. 2007; Perspect Vasc Surg Endovasc Ther19(2):188-92
Courtesy Krassi Ivancev
2003 – 2010(?)
N=10-20(?)
Outer branch
Transcervical
access
![Page 59: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/59.jpg)
Branched Arch Repair
Outer Branches Inner Branches
![Page 60: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/60.jpg)
Zone 0 – Branched Stent-Graft
A-Branch:
• Arch aneurysms
• Internal side-branches
• Nitinol & stainless steel Z-stents
• Low-profile high
density dacron fabric
• Self orienting delivery system
• Controlled deployment
![Page 61: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/61.jpg)
Zone 0 – Branched Stent-Graft
![Page 62: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/62.jpg)
Zone 0 – Branched Stent-Graft
![Page 63: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/63.jpg)
Branched Arch Endograft
Multicenter Study
n = 38
Technichal success 32/38
Mortality 5/38 (13%)
Stroke/TIA 6/38
Haulon et al. 2013; J Thor Cardiovasc Surg 148:1709-16
![Page 64: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/64.jpg)
Learning Curve
Haulon et al. 2014; J Thorac Cardiovasc Surg Epub
![Page 65: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/65.jpg)
Comparing…
![Page 66: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/66.jpg)
Indications
66
Fenestrated Device
(n=6)
Branched Device
(n=9)
PAU 1 (inner curvature) 1 (outer curvature)
Post-traumatic
aneurysm at the
subclavian artery
1 0
Type B Dissection with
Arch involvment
2 (dissection
proximal of the
subclavian)
2 (aneurysm of the
arch)
Arch Aneurysm or TAAA 2 3
Residual Arch
Dissection 0 2
Type A Dissection 0 1
![Page 67: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/67.jpg)
Target Vessels
67
Fenestrated Device
(n=6)
Branched Device
(n=9)
Target Vessels 7 18
Median of Target Vessels 1 2
Vessel Distribution Fenestrated Device
(n=6)
Branched Device
(n=9)
Bovine Innominate Artery 2 0
Innominate Artery 1 9
LCA 2 9
LSA 2 0
![Page 68: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/68.jpg)
Fenestrated Arch Graft
Comparing…
Branched Arch Graft
![Page 69: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/69.jpg)
Potential CONs for
Fenestrated Arch Grafts
Alignement of fenestrations
difficult
No strutfree fenestrations
larger than 12mm restricts use
for innominate artery
Preloaded wire may entangle
in struts of scallop
69
![Page 70: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/70.jpg)
Potential CONs for
Branched Arch Grafts
Higher risk for trapped air
and embolism
Maximum ascending
diameter 38mm and
minimum length of 70mm
limits use.
Required left-ventricle
wire position limits use in
mechanical aortic valves
![Page 71: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/71.jpg)
Conclusion
![Page 72: TEVAR and the Aortic Arch - divine [id] · PDF fileTEVAR and the Aortic Arch : Challenges, Planning and Techniques for Good Outcomes. Gold Standard for Descending Aorta . Cheng et](https://reader035.fdocuments.in/reader035/viewer/2022070607/5aadf63a7f8b9a07498b7419/html5/thumbnails/72.jpg)
Conclusions
Arch-vessels, curvature and access are main challenges.
Perpendicular measurement, multiplanar reconstruction,
centerline reconstruction required.
Rapid development depending on local infrastructure
Feasible and lifesaving option in patients unfit for surgery
Role of stent-grafts in the aortic arch not yet defined.