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2013session6 4
 

2013session6 4

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  • One can also expose the left renal artery through the base of the mesentery by extra mobilization of the pancreas .
  • One can also expose the left renal artery through the base of the mesentery by extra mobilization of the pancreas .
  • however we had very good success rate for lesions distal to the LCCA with only one patient or 2.6 % failure rate.
  • however we had very good success rate for lesions distal to the LCCA with only one patient or 2.6 % failure rate.
  • however we had very good success rate for lesions distal to the LCCA with only one patient or 2.6 % failure rate.
  • however we had very good success rate for lesions distal to the LCCA with only one patient or 2.6 % failure rate.
  • One can also expose the left renal artery through the base of the mesentery by extra mobilization of the pancreas .
  • One can also expose the left renal artery through the base of the mesentery by extra mobilization of the pancreas .
  • One can also expose the left renal artery through the base of the mesentery by extra mobilization of the pancreas .
  • however we had very good success rate for lesions distal to the LCCA with only one patient or 2.6 % failure rate.
  • however we had very good success rate for lesions distal to the LCCA with only one patient or 2.6 % failure rate.
  • however we had very good success rate for lesions distal to the LCCA with only one patient or 2.6 % failure rate.
  • One can also expose the left renal artery through the base of the mesentery by extra mobilization of the pancreas .
  • One can also expose the left renal artery through the base of the mesentery by extra mobilization of the pancreas .
  • One can also expose the left renal artery through the base of the mesentery by extra mobilization of the pancreas .
  • One can also expose the left renal artery through the base of the mesentery by extra mobilization of the pancreas .
  • One can also expose the left renal artery through the base of the mesentery by extra mobilization of the pancreas .
  • however we had very good success rate for lesions distal to the LCCA with only one patient or 2.6 % failure rate.
  • however we had very good success rate for lesions distal to the LCCA with only one patient or 2.6 % failure rate.

2013session6 4 2013session6 4 Presentation Transcript

  • Endovascular Repair of AcuteAortic DissectionKent MacKenzie, MDDivision of Vascular SurgeryMcGill UniversityMontreal, Quebec
  • Disclosures• Medtronic consultancy agreement• Speaking fees from Cook
  • Acknowledgements• OK Steinmetz, MM Corriveau, CZ Abraham,D Obrand• J Titley MD, Hamilton, Ontario
  • Acute Aortic DissectionWhat is it?
  • Basic Epidemiology of Dissection• 4:1 male to female• 60-75% are Stanford Type A– Peak between 50-60 years• 25% are Stanford Type B– Peak between 60-70 years• Hypertension in >70%
  • Basic Epidemiology of Dissection• Other factors:– Cystic Medial Necrosis (Marfan’s, E-D synd)– Pregnancy– Cocaine– Bicuspid valve– Aortic coarctation– Syndromes - Turner’s, Noonan’s, etc– Chronobiologic patterns• Early am• Winter vs. Summer
  • Clinical Findings in Dissection• Pain• Hypertension• Neurologic– Syncope– Stroke– Spinal cord ischemia• Limb ischemia
  • Complications of Dissection• Type A– Death from coronary malperfusion,tamponade, rupture– Stroke and distal malperfusion• Type B– Rupture– Malperfusion - visceral, spinal, extremity– Aneurysm
  • Intervention• Complicated or Failure of Medical Therapy• What is Complicated? (Failure of Medical)– Rupture– Aneurysmal false lumen or expansion– Malperfusion– Persistent pain– Untreatable hypertension
  • Open Repair
  • Open Repair• Advocated by some for all cases ofcomplicated Type B dissection requiringintervention• Role of open repair in the Endo era isfurther blurred
  • Endovascular Repair• Currently accepted as a viable treatmentoption in selected cases of complicatedType B aortic dissection• What is Complicated? (Failure of Medical)– Rupture– Aneurysmal false lumen or expansion– Malperfusion– Persistent pain– Untreatable hypertension
  • Endovascular Repair• Where did the generalized allure for TEVARfor Aortic Dissection start?
  • Endovascular Repair• Case reports• Case series• Cohort studies• Single-center and multi-center Registries
  • Endovascular Repair
  • Endovascular Repair• At RVH:–Approx 170 TEVAR–23% indication is either:• Acute complicated type B dissection• IMH with ulcer
  • Endovascular Repair• Goals– Cover entry tear of the dissection– Expansion of compressed true lumen– Induce false lumen thrombosis– Allow remodeling of aorta– Potentially prevent aneurysm development– Without the morbidity of open repair
  • Endovascular Repair• Concept of inducing true lumen expansionand false lumen thrombosis is a valid one:– Reduces morbidity/mortality of malperfusion– Lowering the risk of false lumen enlargement• aneurysm
  • Endovascular Repair• In the real world:• True lumen expansion and false lumenthrombosis in complicated Type B dissectioncan be achieved
  • Pain, expansion, HPTN 2008
  • Procedural issues to be considered• Define your indication• Review the CT images• ‘Best guess’ for location of primary tear• Determine appropriate vessel diameters– Guiding graft selection
  • Procedural issues to be considered• Deployment Access Vessel– Best femoral/iliac for delivery– Assure true lumen graft deployment• Femoral access with true lumen imaging• Brachial access• TEE confirmation
  • Procedural issues to be considered• Imaging– Quality– Flush catheter access and position– Contrast delivery– Image Intensifier angulation
  • Imaging - Angulation
  • 45LAOo
  • 45LAOo
  • Imaging Quality C-arm
  • Imaging Quality Angiosuite
  • Imaging Quality Angiosuite
  • What procedural issues should beconsidered?• Blood pressure manipulation duringdeployment– Low - nitro, beta blockers– Very low - adenosine, rapid RV pacing
  • Rapid RV pacingNienaber C et al. J Endovasc Ther 2007.
  • What procedural issues should beconsidered?• Graft oversizing (? less)• ? Limited use of ballooning• Stent graft specific deployment steps–Understand your grafts• Strengths and Weaknesses
  • Graft Selection
  • Graft Selection
  • Have to be familiar with the grafts you will use– What they are capable of doing– How they will perform in routine cases– What they will do when you ask it to do something• Within the IFU• Outside the IFU
  • Endovascular Repair• The technique is useful• The results can be gratifying
  • Endovascular Repair• However:–Caution is required–Recognition of potential problems–There is still a lot we don’t understand
  • Dissection Stent
  • Endovascular Repair• Or:
  • May 2012
  • Ongoing pain, aortic expansion, spikes severe HPTN
  • Endovascular Repair• What are we still unsure about?– The use and utility of uncovered dissection stents– The use of TEVAR for ‘uncomplicated’ dissection• Predictors where treatment is reasonable?– What is the best device?
  • Bare Dissection Stents
  • Bare Dissection Stents
  • Endovascular Repair• What are we still unsure about?– The use and utility of uncovered dissection stents– The use of TEVAR for ‘uncomplicated’ dissection• Predictors where treatment is reasonable?– What is the best device?
  • • Randomized Trial• Acute Dissection <2 weeks• BMT vs. TEVAR• Primary End-Point– False-lumen thrombosis at 1 year– Aortic dilatation at 1 year– Aortic rupture at 1 year• Expect to enroll 250-260 patientsADSORB
  • Endovascular Repair• What are we still unsure about?– The use and utility of uncovered dissection stents– The use of TEVAR for ‘uncomplicated’ dissection• Predictors where treatment is reasonable?– What is the best device?
  • Endovascular Repair• That is for another day
  • Thank You