Tilo Kölbel, MD, PhD

University Heart Center Hamburg

University Hospital Eppendorf

TEVAR and the Aortic Arch :

Challenges, Planning and Techniques for Good Outcomes

Gold Standard for Descending Aorta

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)

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

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,

Aortic Arch Zones

Ishimaru-classification

Aortic Arch Zones

Ishimaru-classification

Challenges of the Aortic

Arch

Branch vessels

Patency / endoleak

Pulsatility

Oversizing / migration

Curvature

Conformity / infolding

Access

Distance / profile / kinking

Outline

Planning

Challenges

Techniques

Most technical Errors

follow

insufficient planning !

Planning

Planning

Perpendicular measurement

Multiplanar-reconstruction (MPR)

Pulsatility

Graft-properties

Proximal Landing

Workstation

Perpendicular Diameter in

MPR

Perpendicular Diameter

Pulsatility

Pulsatility

Jonker et al 2010; EJVES; 40:564-71

Hypovolemia and Aortic

Diameter

Proximal Landing

Preferred landing site:

Length

Diameter

Shape

Thrombus

Non-dissected healthy

aortic wall

Proximal Landing

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

Techniques

Access-techniques

Endovascular Techniques

Arch-conformance

Fenestrated / branched Devices

In-situ Fenestration

Access Techniques

Iliac-conduit

Paving and Cracking

Through & Through-Wire

Transcardiac Access

Access Techniques

Access Techniques

Access Techniques

Iliac Conduit

Paving and Cracking

Through&Through-Wire

Stiff Guidewire Soft transbrachial Throughwire

Transseptal Through-Wire

Insufficient SG-conformity

to the anatomy of the arch

→ Aortic wall erosion

→ Type 1 endoleak

→ Stent-graft collapse

Arch-Conformance

• Angulation of arch

• Small aortic diameter

• Stent-graft oversizing

• Transsection

• Stent-graft rigidity

Potential Factors

• Angulation of arch

• Small aortic diameter

• Stent-graft oversizing

• Transsection

• Stent-graft rigidity

Potential Factors

Controlled Deployment by ProForm

Zenith® TX2 ProForm®

Zenith® TX2 ProForm®

Controlled Deployment by ProForm

Aortic Arch Techniques for

Zone 0

Zone 0 –Debranching

Zone 0 –Debranching

Zone 0 – Chimney Graft

Zone 0 – Chimney Graft

Zone 0 – Chimney Graft

Zone 0 – Chimney Graft

Chinmey Graft

ENDOLEAKS !

Hogendoorn et al. 2013; JVS

Zone 0 – In-Situ Fenestration

Zone 0 – In-Situ Fenestration

Zone 0 – In-Situ Fenestration

J Vasc Surg 2013;58:1171-7

In-Situ Laser Fenestration

In-Situ Laser Fenestration

Zone 0 – Fenestrated Stent-Graft

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

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

Branched Arch Repair

Outer Branches Inner Branches

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

Zone 0 – Branched Stent-Graft

Zone 0 – Branched Stent-Graft

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

Learning Curve

Haulon et al. 2014; J Thorac Cardiovasc Surg Epub

Cook Branched Arch Endograft

Subsequent experience:

n = 27; Hamburg, Tokio, Lille

4/2013- 11/2014

Technical success 27/27

30d Mortality 0/27

1y mortality 1/27

Stroke/TIA 3/27

Spear et al 2016; Eur J Vasc Endovasc Surg 51: 380-5

Branched Arch Endograft

Hamburg Experience 2012-2014:

Cases: 32

Aneuysm: 13

Residual dissection: 15

Acute Type A: 2

PAU: 2

30d-Mortality: 1

Stroke:2

Anatomical Suitability

Diameter ≤ 38mm

Length ≥ 40mm

Proximal landing zone ≥ 20mm

Innominate diameter ≤ 20mm

Appropriate access vessels

No significant aortic regurge

No mechanical aortic valve

No dissection of branch-vessels

Technique

Two stage repair:

1. LCCA-LSA bypass

2. Branched repair:

Transfemoral access for

the main-graft

RCCA-cutdown for IA-

branch

Left brachial puncture

for LCCA-branch and

LSA-plug

Technique

Precurved self-orienting device

LV-wire position

Cardiac output-reduction:

IVC balloon-occlusion

Rapid ventricular pacing

Zenith-limb for IA

Fluency for the LCCA

Plug-occlusion for LSA

Lesion-Type

Aneurysm and PAU of the arch

Chronic dissection

Acute Type A dissection

Residual Dissection

Potential challenges:

Kinking of ascending stentgraft

Dissection of targetvessels with

multiple entries

Distal false-lumen perfusion

Residual Dissection

Residual Dissection

Bilateral carotid-subclavian bypass Axillo-axillary bypass

Residual Dissection

True lumen catheterization Creation of landing zone

Residual Dissection

Landing in dissected LCCA

Residual Dissection

Acute Type A Dissection

Branched Arch Endograft

Comparing…

Indications

71

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

Target Vessels

72

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

Fenestrated Arch Graft

Comparing…

Branched Arch Graft

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

74

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

Conclusion

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.