TEVAR for the Ruptured TEVAR for the Ruptured Aneurysms Aneurysms

Jamal J. Hoballah MD, MBA, FACSJamal J. Hoballah MD, MBA, FACSProfessor and ChairmanProfessor and ChairmanDepartment of SurgeryDepartment of Surgery

American University of BeirutAmerican University of Beirut

14th Congress of Asian Society for Vascular Surgery & 8th Asian Venous Forum14th Congress of Asian Society for Vascular Surgery & 8th Asian Venous Forum16thCongress of Turkish Society for Vascular and Endovascular Surgery16thCongress of Turkish Society for Vascular and Endovascular Surgery

ObjectivesObjectives

• Review available data on TEVAR Review available data on TEVAR for Ruptured Thoracic Aneurysmsfor Ruptured Thoracic Aneurysms

• Recommendations for successful Recommendations for successful Emergency TEVAR programEmergency TEVAR program

Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsScope of the problem Scope of the problem

Incidence:Incidence: 5/100,0005/100,000

Ascending & ArchAscending & Arch 70%70%Descending Aorta Descending Aorta 30%30%

Johansson et al JVS 1995Johansson et al JVS 1995

Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsICD 9 cm Cases/ year

2011

Thoracic Aneurysm 7601

Ruptured Thoracic Aneurysm

798

Abdominal Aortic Aneurysm

43466

Ruptured AAA 5023

2011 Nationwide In Patient Sample Data US Department of Health & Human Services

TAA : 7 times less than AAATAA Rupture: 7 times less than Ruptured AAA

Ruptured Thoracic Aortic Ruptured Thoracic Aortic AneurysmsAneurysms

ICD 9 cm Mortality Routine Discharge

Home health care

Short term hospital/Rehab center/nursing home

Ruptured Thoracic Aneurysm

37% 15% 12% 36%

2011 Nationwide In Patient Sample DataUS Department of Health & Human Services

Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsHeterogeneous PathologyHeterogeneous Pathology

LocationLocation

• Ascending AortaAscending Aorta• Aortic ArchAortic Arch• Descending AortaDescending Aorta• Thoraco-Abdominal AortaThoraco-Abdominal Aorta

Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsHeterogeneous PathologyHeterogeneous Pathology

EtiologyEtiology

• Degenerative Thoracic AneurysmDegenerative Thoracic Aneurysm• Traumatic blunt injury PseudoaneurysmTraumatic blunt injury Pseudoaneurysm• Complicated Dissection ( Acute or Chronic)Complicated Dissection ( Acute or Chronic)• Miscellaneous ( Mycotic)Miscellaneous ( Mycotic)

Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic Aneurysms Heterogeneous Pathology Heterogeneous Pathology

PresentationPresentation

UnstableUnstableStable/ Contained ruptureStable/ Contained rupture

Ruptured Thoracic Aortic Aneurysms: Ruptured Thoracic Aortic Aneurysms: ManagementManagement

• Open Surgical InterventionOpen Surgical Intervention

• TEVARTEVAR

– Chimney/ SnorkelChimney/ Snorkel– Hybrid Approach (Debranching)Hybrid Approach (Debranching)

Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsOpen Surgical InterventionOpen Surgical Intervention

• Traditional approachTraditional approach• Requires thoracic surgical expertiseRequires thoracic surgical expertise• Limited Thoracic CentersLimited Thoracic Centers• Techniques:Techniques:

– Clamp and sewClamp and sew– Heart lung Machine; Left Heart BypassHeart lung Machine; Left Heart Bypass– Deep hypothermic circulatory arrestDeep hypothermic circulatory arrest

Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsOpen Surgical InterventionOpen Surgical Intervention

Contemporary ResultsContemporary Results

Mortality rate: 18- 27%Mortality rate: 18- 27%

Girardi et al Ann Thorac Surg 2002Girardi et al Ann Thorac Surg 2002Barbato et al JVS 2007Barbato et al JVS 2007

Population-based outcomes of Population-based outcomes of open descending thoracic aortic open descending thoracic aortic

aneurysm repairaneurysm repair

Schermerhorn ML et al J Vasc Surg 2008 Oct.

2549 patients Mortality rateEntire group

Age>75

Intact 10% 17.6%

Ruptured 45% 52%

TEVAR for Ruptured Thoracic TEVAR for Ruptured Thoracic Aortic AneurysmsAortic Aneurysms

• First EVAR for ruptured AAA reported in 1994First EVAR for ruptured AAA reported in 1994– Yusuf SW, Whitaker SC, Chuter TA, et al. Yusuf SW, Whitaker SC, Chuter TA, et al. Emergency endovascular repair Emergency endovascular repair

of leaking aortic aneurysms. Lancet 1994; 344:of leaking aortic aneurysms. Lancet 1994; 344:1645.1645.

• First TEVAR for ruptured TAA reported in 1997First TEVAR for ruptured TAA reported in 1997– Semba CP, et al. Acute rupture of the descending thoracic aorta: repair Semba CP, et al. Acute rupture of the descending thoracic aorta: repair

with use of endovascular stent-grafts. J Vasc Interv Radiol 1997;8:337-42with use of endovascular stent-grafts. J Vasc Interv Radiol 1997;8:337-42

TEVAR Advantages TEVAR Advantages

• Can be provided by experienced Vascular or Cardio Can be provided by experienced Vascular or Cardio Thoracic SurgeonsThoracic Surgeons

• Can be provided at non cardiac surgery centersCan be provided at non cardiac surgery centers• Increase availability of expertise capable of dealing with Increase availability of expertise capable of dealing with

the problemthe problem• Still needs Cardio Thoracic Surgery back up Still needs Cardio Thoracic Surgery back up

TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic AneurysmsAvailable DataAvailable Data

• Case reportsCase reports• Single Institution ExperienceSingle Institution Experience• Multi Institution ExperienceMulti Institution Experience• Meta analysis studiesMeta analysis studies• Nationwide Data baseNationwide Data base

Endovascular stent-graft placement for acute Endovascular stent-graft placement for acute and contained rupture of the descending and contained rupture of the descending

thoracic aorta.thoracic aorta.

• 17 patients; July 1999 - November 2004,17 patients; July 1999 - November 2004,• Rupture due to: Rupture due to: • Thoracic Aortic Aneurysm TAA n=6 Thoracic Aortic Aneurysm TAA n=6 • Acute aortic dissection AAD, n=6 Acute aortic dissection AAD, n=6

Penetrating aortic ulcer PAU, n=3 Penetrating aortic ulcer PAU, n=3 • Blunt chest trauma n=2Blunt chest trauma n=2

– Eggebrecht at al Eggebrecht at al Catheter Cardiovasc Interv. 2005 Dec 2005 Dec

Endovascular stent-graft placement for acute Endovascular stent-graft placement for acute and contained rupture of the descending and contained rupture of the descending

thoracic aorta.thoracic aorta.

• Technical feasibility 100%Technical feasibility 100%• Complete exclusion 65%Complete exclusion 65%• 30 day mortality 24%30 day mortality 24%• 1 yr survival 52%1 yr survival 52%• 3 yr survival 52%3 yr survival 52%

– Eggebrecht at al Eggebrecht at al Catheter Cardiovasc Interv. 2005 Dec 2005 Dec

Endovascular stent-graft placement for Endovascular stent-graft placement for acute and contained rupture of the acute and contained rupture of the

descending thoracic aortadescending thoracic aorta

Pre-procedural determinants of mortalityPre-procedural determinants of mortality• Etiology of rupture TAA or AAD (P=0.024)Etiology of rupture TAA or AAD (P=0.024)• Maximum aortic diameter>5 cm (P=0.024)Maximum aortic diameter>5 cm (P=0.024)• Presence of mediastinal hematoma (P=0.056)Presence of mediastinal hematoma (P=0.056)• Estimated lesion length requiring >1 stent-graft Estimated lesion length requiring >1 stent-graft

to be covered (P=0.009to be covered (P=0.009

– Eggebrecht at al Eggebrecht at al Catheter Cardiovasc Interv. 2005 Dec 2005 Dec

Endovascular stent-graft placement for acute Endovascular stent-graft placement for acute and contained rupture of the descending and contained rupture of the descending

thoracic aorta.thoracic aorta.

Post-procedural determinants of mortalityPost-procedural determinants of mortality• residual leakage at the conclusion (P=0.009), residual leakage at the conclusion (P=0.009), • postprocedural need for dialysis (P=0.004), postprocedural need for dialysis (P=0.004), • prolonged ventilation (P=0.043) prolonged ventilation (P=0.043)

– Eggebrecht at al Eggebrecht at al Catheter Cardiovasc Interv.Catheter Cardiovasc Interv. 2005 Dec 2005 Dec

A comparative analysis of open and A comparative analysis of open and endovascular repair for the ruptured descending endovascular repair for the ruptured descending

thoracic aorta.thoracic aorta.Single Institution ( University of Michigan)Single Institution ( University of Michigan)

• TEVAR: Older patientsTEVAR: Older patients• Independent predictors of early mortality, stroke, permanent Independent predictors of early mortality, stroke, permanent

spinal cord ischemiaspinal cord ischemia– Hemodynamic instability Hemodynamic instability – Open repairOpen repair

Patel et al J Vasc Surg. 2009 DePatel et al J Vasc Surg. 2009 Decc

TEVAR OPEN

Patients: 69 35 34

Mortality % 11 26

Open surgery versus endovascular repair of Open surgery versus endovascular repair of ruptured thoracic aortic aneurysms.ruptured thoracic aortic aneurysms.

..• 161 patients at 7 Institutions161 patients at 7 Institutions

• Risk factor for composite event : Risk factor for composite event : – Increasing ageIncreasing age– Hypotension Hypotension

Jonker et al Jonker et al J Vasc Surg.J Vasc Surg. 2011 May 2011 May

TEVAR OPEN

Patients 92 69

Mortality 30 day% 17 24

Composite mortality , stroke paraplegia%

21 36

4 yr survival % 75 64

Endovascular repair of ruptured thoracic aortic Endovascular repair of ruptured thoracic aortic aneurysms.aneurysms.

..• 92 TEVAR patients at 7 Institutions92 TEVAR patients at 7 Institutions

• Jonker et al Eur Jonker et al Eur J EndoVasc Surg.J EndoVasc Surg. 2011 2011

<75yrs >75yrs

Patients 67 25

Mortality 30 day% 13.4 32

Postoperative stroke% 1.5 24

2 yr survival % 84 52

Meta-analysis of open versus endovascular Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic repair for ruptured descending thoracic aortic

aneurysmaneurysm

• 28 studies; 224 patients;28 studies; 224 patients;

– Jonker FH et al, J Vasc Surg.Jonker FH et al, J Vasc Surg. 2010 Apr 2010 Apr

TEVAR Open Repair

Patients 143 (63.2%) 81 (36.2%)

30 d Mortality 18.9% 33.3%

Myocardial Infarction 3.5% 11.1%

Stroke 4.1% 10%

Paraplegia 3.1% 5.5%

Additional Vascular Intervention 9.1% 2.3%

3 yr Aneurysm related survival 70.6% unavailable

Endovascular versus open repair of ruptured Endovascular versus open repair of ruptured descending thoracic aortic aneurysms: a descending thoracic aortic aneurysms: a

nationwide risk-adjusted study of 923 patients.nationwide risk-adjusted study of 923 patients.

• 923 between 2006-2008923 between 2006-2008• TEVAR 39% OTR 60%TEVAR 39% OTR 60%• Mortality Rate; TEVAR :23% Open: 28%Mortality Rate; TEVAR :23% Open: 28%• Odds of mortality , complications and failure to Odds of mortality , complications and failure to

rescue:rescue: comparablecomparable• TEVAR 3X higher odds of routine dischargeTEVAR 3X higher odds of routine discharge

– Gopaldas RR et al J Thorac Cardiovasc Surg.Gopaldas RR et al J Thorac Cardiovasc Surg. 2011 2011

Endovascular versus open repair of ruptured Endovascular versus open repair of ruptured descending thoracic aortic aneurysms: a descending thoracic aortic aneurysms: a

nationwide risk-adjusted study of 923 patients.nationwide risk-adjusted study of 923 patients.

Smaller hospitals: Smaller hospitals:

• Lower mortality rate for TEVAR vs Open repairLower mortality rate for TEVAR vs Open repair

Smaller hospital vs Larger HospitalSmaller hospital vs Larger Hospital

• Mortality, complication , failure to rescueMortality, complication , failure to rescue– TEVAR : comparableTEVAR : comparable– Open repair : higher Open repair : higher

• Gopaldas RR et al J Thorac Cardiovasc Surg.Gopaldas RR et al J Thorac Cardiovasc Surg. 2011 2011

Endovascular versus open repair of ruptured Endovascular versus open repair of ruptured descending thoracic aortic aneurysms: a descending thoracic aortic aneurysms: a

nationwide risk-adjusted study of 923 patients.nationwide risk-adjusted study of 923 patients.

TEVARTEVAR

• May be an ideal alternative to OAR for ruptured descending May be an ideal alternative to OAR for ruptured descending thoracic aortic aneurysmthoracic aortic aneurysm

• Particularly in small hospitals where expertise in OAR may Particularly in small hospitals where expertise in OAR may be lacking be lacking

– Gopaldas RR et al J Thorac Cardiovasc Surg.Gopaldas RR et al J Thorac Cardiovasc Surg. 2011 2011

Meta-analysis of endovascular vs open repair for Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture.traumatic descending thoracic aortic rupture.

• 17 studies17 studies• 589 patients; 369 Open 220 TEVAR589 patients; 369 Open 220 TEVAR

• TEVAR Lower 30 day mortality ODD ratio 0.44TEVAR Lower 30 day mortality ODD ratio 0.44• TEVAR Lower Procedure related mortality ODD Ratio TEVAR Lower Procedure related mortality ODD Ratio

0.310.31

– Xenos ES et al, J Vasc Surg 2008 NovXenos ES et al, J Vasc Surg 2008 Nov

Tends and Outcomes of endovascular and open Tends and Outcomes of endovascular and open treatment for traumatic thoracic aortic injurytreatment for traumatic thoracic aortic injury

New York State SPARCS data base 2000-20007New York State SPARCS data base 2000-20007328 patients; Open 80% TEVAR 20%328 patients; Open 80% TEVAR 20%

• TEVAR rates exceeded Open as of 2006TEVAR rates exceeded Open as of 2006• TEVAR lower mortality rate and post operative TEVAR lower mortality rate and post operative

pulmonary complicationspulmonary complications• No difference in cardiac complication, renal failure, No difference in cardiac complication, renal failure,

stroke or paraplegiastroke or paraplegia• TEVAR device related complications 9%TEVAR device related complications 9%

– Jonker et al, J Vasc Surg 2010 MarchJonker et al, J Vasc Surg 2010 March

Update on blunt thoracic aortic injury: fifteen-year Update on blunt thoracic aortic injury: fifteen-year single-institution experiencesingle-institution experience

• Level I Trauma Center 1997-2012Level I Trauma Center 1997-2012

– Estrera et alEstrera et al J Thorac Cardiovasc Surg 2013 March.J Thorac Cardiovasc Surg 2013 March.

TEVAR Open repair distal perfusion

Open repair Cross clamp

patients 69 77 29

Early Mortality 4% 14% 31%

I yr survival 92% 76% 76%

5 yr survival 87% 75% 75%

Expanding TEVAR into Ascending and Arch Expanding TEVAR into Ascending and Arch Aortic RupturesAortic Ruptures

• TTotal endovascular repair of acute ascending otal endovascular repair of acute ascending aortic rupture: a case report and review of the aortic rupture: a case report and review of the literatureliterature– McCallum JCMcCallum JC Vasc Endovascular Surg.Vasc Endovascular Surg. 2013 Jul 2013 Jul

• Emergency One-Stage Hybrid Surgery for Emergency One-Stage Hybrid Surgery for Ruptured Aneurysm of the Distal Aortic ArchRuptured Aneurysm of the Distal Aortic Arch– Kim et al Tex Heart Inst J. 2013Kim et al Tex Heart Inst J. 2013

TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic AneurysmsSummarySummary

• Successful Delivery: >95% Successful Delivery: >95% • Very Low rate of conversion to openVery Low rate of conversion to open• Mortality rate 30 days : 12-15%Mortality rate 30 days : 12-15%

– Traumatic: Traumatic: 5%5%– Degenerative >75 yr:Degenerative >75 yr:32% 32%

• Morbidity rate lower than openMorbidity rate lower than open• Reintervention may be neededReintervention may be needed• Acceptable 1-4 yr follow upAcceptable 1-4 yr follow up

• Can be Safely done at smaller hospitals Can be Safely done at smaller hospitals

TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic AneurysmsRecommendations for Success Recommendations for Success

• Establish a team ( Vascular / Thoracic /Interventional)Establish a team ( Vascular / Thoracic /Interventional)• Develop Your protocolDevelop Your protocol• Plan a Hybrid OR suitePlan a Hybrid OR suite• Graft InventoryGraft Inventory• Preoperative CT 1mm imaging to include pelvisPreoperative CT 1mm imaging to include pelvis• Large Sheaths/ Possible need for iliac conduitsLarge Sheaths/ Possible need for iliac conduits• Coverage of subclavian or celiac/ debranchingCoverage of subclavian or celiac/ debranching• CSF DrainageCSF Drainage• Case selectionCase selection

TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic AneurysmsInto the Future Into the Future

• Here to stayHere to stay• Hybrid Approach to include Ascending and Hybrid Approach to include Ascending and

Arch aneurysms rupturesArch aneurysms ruptures• Newer Off the Shelf GraftsNewer Off the Shelf Grafts

A multicenter clinical trial of endovascular A multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the stent graft repair of acute catastrophes of the

descending thoracic aorta.descending thoracic aorta.

59 patients; 59 patients; Dissection: cTBD Dissection: cTBD n = 19n = 19Degenerative: RDADegenerative: RDA n = 20n = 20 Traumatic TT:Traumatic TT: n = 20 n = 20

– Cambria et al Cambria et al J Vasc Surg.J Vasc Surg. 2009 Dec 2009 Dec

TEVAR Open

30 day Mortality 12% 24%Mortality or Paraplegia 13.6% 30%

A multicenter clinical trial of endovascular A multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the stent graft repair of acute catastrophes of the

descending thoracic aorta.descending thoracic aorta.

– Cambria et al Cambria et al J Vasc Surg.J Vasc Surg. 2009 Dec 2009 Dec

At I yr TEVAR

Actuarial survival 66 %

Dissection 79 %

Traumatic 79%

Degenerative 37 %

Conversion 1 patient

Major device related events 2 patients

A multicenter clinical trial of endovascular A multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the stent graft repair of acute catastrophes of the

descending thoracic aorta.descending thoracic aorta.

• TEVAR for thoracic aortic catastrophes has TEVAR for thoracic aortic catastrophes has advantages when compared with literature-advantages when compared with literature-based results of open repair. based results of open repair.

• One-year treatment results indicate a low One-year treatment results indicate a low incidence of graft-related complications. incidence of graft-related complications.

• TEVAR is the preferred initial treatment for the TEVAR is the preferred initial treatment for the DTA catastrophes.DTA catastrophes.

– Cambria et al Cambria et al J Vasc Surg.J Vasc Surg. 2009 Dec 2009 Dec