Roberto Chiesa Vascular Surgery, Università Vita-Salute

Scientific Institute San Raffaele – Milan, Italy

THORACOABDOMINAL AORTIC ANEURYSMS HYBRID REPAIR

Update on Open and Endovascular Therapeutic Option for Aortic Repair

CENTRE CARDIO-TORACIQUE DE MONACO

Friday November 7th, 2014

- PI / Co-PI for several thoracic and abdominal aortic stent graft

trials (Cook, Inc, Cordis® Corporation, Bolton Medical)

- Proctor and lecturer at symposia hosted by Cook, Inc., Bolton,

W.L. Gore and Associates, Jotec and Medtronic, Inc.

- Educational grants from Cook, Inc.

Conflict of interest

Open TAAA repair

Safi et al., Ann Surg 2014

“Extensive aortic aneurysm

is a complex problem,

but it can be managed safely”

Alternative strategies?

Total endovascular repair

Branched stent-graft (Zenith® t-BranchTM)

Chimney-graft (Gore c-TAG + Viabahn & Fluency)

• No thoracotomy • No laparotomy • No aortic cross-clamping • No LHBP / ECC

Total endovascular repair Selected cases

• Anatomic suitability

• Material availability

• Costs

• X-rays exposure

• Follow up? Eagleton, Greenberg, Sem Vasc Surg 2009

Late rupture

Third option?

Hybrid surgery

Open Surgery +

Endovascular Repair

“The way to a wider application of endovascular technology for management of complex

aortic disease”

Hollier LH. J Endovasc Surg 1998

Operative technique

Visceral arteries

rerouting

Stage 1

Operative technique

TAAA

stent-graft repair

Stage 2

Selection criteria OSR experience

Systemic conditions • Advanced age • Severe COPD • ↓Ejection fraction • CAD • Valvulopathy

Local conditions • Frozen chest • Redo TAAA

Redo thoracotomy

Oxygen therapy / Dilated ventricle

No BEVAR / FEVAR

Case reports

• Female, 22

• Marfan syndrome • Previous multiple thoracic aortic interventions

• Thoracic wall infection • Collapsed true lumen

#1 Dissecting type II TAAA

Infrarenal aortic grafting with custom made graft

Trans-peritoneal vessels exposure

Celiac trunk

Pancreas

#1 Dissecting type II TAAA

Post-op (Stent-graft in FL) Pre-op

Patent debranching grafts

#1 Dissecting type II TAAA

“In-graft” landing zones (Cook TX2)

#2 Visceral aortic patch aneurysm

Tshomba, Chiesa et al., J Vasc Surg 2008

• Male, 68

• Severe COPD, left nephrectomy

• Previous TAAA III open repair

• Previous aorto-bifemoral bypass

RRA

SMA

CT

• Inflow:

iliac prosthetic

branch

• Sequential bypass

SMA CT

Medtronic Valiant

#2 Visceral aortic patch aneurysm

Tshomba, Chiesa et al., J Vasc Surg 2008

• Male, 59

• Previous left lung resection (“frozen chest”)

• Retroperitoneal fibrosis

• Previous TAAA IV open repair

• Hypotrophic left kidney

Chiesa et al., Eur J Surg Endovasc Surg 2009

#3. Type II TAAA (Alternative in-flow)

CT

SMA RRA

Ascending ao

Diaphragm

Chiesa et al., Eur J Surg Endovasc Surg 2009

#3. Type II TAAA (Alternative in-flow)

Cook TX2

#3. Type III TAAA (Alternative in-flow)

Chiesa et al., Eur J Surg Endovasc Surg 2009

Sutureless distal anastomosis

Gore Hybrid Vascular Graft (GHVG)

#3. Type II TAAA (Gore Hybrid Vascular Graft)

#3. Type II TAAA (Gore Hybrid Vascular Graft)

Open 81 384 522

TEVAR 203 261 65

Tot: 1516 pts 284 645 587

(’93-’14)

(’98-’14)

(987 pts – 65.1%)

(529 pts – 34.9%)

Arch DTA TAAA

OSR series 1993-2014 Thoracic aorta – 1516 patients

65

56 Hybrid

9 FEVAR/BEVAR

TAAA hybrid repair: 56 patients 30-day results

N° patients (%)

Mortality 7 (12.5) Multiorgan failure 2 (3.6)

Myocardial infaction 2 (3.6)

Coagulopathy 1 (1.8)

Bowel infarction 1 (1.8)

Pancreatitis 1 (1.8)

TAAA hybrid repair: 56 patients 30-day results

N° patients (%)

Complications 15 (28.8) Renal failure 5 (8.9) Pancreatitis 3 (5.8) Respiratory failure 3 (5.3) Transient paraparesis 2 (3.6) Paraplegia 1 (1.7) Dysphagia 1 (1.7)

TAAA hybrid repair: 56 patients Mid-term results (mean follow-up 36.3±19 mts)

N° patients (%)

Related mortality 4 (7.1) Aortic rupture 2 (3.6) Visceral graft occlusion 2 (3.6)

Non-related mortality 9 (16.0) Complications 9 (16.0) Endoleak/migration 5 (8.9) Visceral bypass stenosis/kinking 2 (3.6) Renal failure 1 (1.7) Pancreatitis 1 (1.7)

Graft occlusion 9.8% (16/163) Assisted patency 15.6% (23/147 grafts)

6-months FU: SMA anastomosis angulation

12-months FU: SMA stenting, graft to CT occlusion

Visceral bypass long-term patency

Chiesa et al., J Cardiovasc Surg 2010

Discussion

Chiesa et al., Eur J Vasc Endovasc Surg 2009

Technical issues

1. CT revascularization

2. Renal protection

3. Intraoperative angiography

4. Timing

1. CT revascularization Associated CT and SMA revascularization

Always when possible!

CT SMA

20 days later… Retro-pancreatic routing

1. CT revascularization

Graft to CT Acute pancreatitis

Ante-pancreatic routing

CT

1. CT revascularization

2. Renal protection

Tshomba, […], & Chiesa. J Vasc Surg 2013

Custodiol®

(Histidine-Tryptophan-Ketoglutarate)

• Significantly reduced acute kydney injury compare to Ringered Lactated solution during TAAA repair

Intraoperative quality check

3. Intraoperative angiography

LRA

RRA

SMA CT

4. Timing

Strategy to be chosen patient by patient

SIMULTANEOUS

• Single anesthesia

• ↑ Bleeding

• ↑ Coagulopathy

• ↑ Risk of paraplegia

STAGED

• ↓ Operative time/bleeding

• ↓ Invasiveness

• Spinal cord conditioning

• Intersurgical rupture

%

30-day mortality 12.8

Irreversible paraplegia 4.5

Renal failure 8.8

Visceral graft patency 96.5

19 publications - 507 cases

Moulakakis, Liapis et al., Circulation 2011

TAAA hybrid repair Metanalysis 2000-2011

%

30-day mortality 26.7

Irreversible paraplegia 10

Chronic hemodialysis 6.7

One-year graft patency 97.3

30 patients

Gkremoutis A, et al., Eur J Vac Endovasc Surg 2014

TAAA hybrid repair Emergency TAAA treatment (2007-2013)

TAAA hybrid repair Conclusions

• Current highly selective indications

• Technical challenge

• Good long-term grafts patency

• Careful follow-up

Milano, December 11th - 13th, 2014

Waiting for you…