Diethrich Sweden


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  • Running, H
  • Elwell, Anne
  • Hathaway Line 1- 2001 Line 2- 2003 Line 3- 2004
  • Diethrich Sweden

    1. 1. Edward B. Diethrich, MD Phoenix, Arizona The Future of Aortic Repair Malmo, Sweden June 18, 2010
    2. 2. What Perspective? How? Where? Who? What?
    3. 3. How? Where? Who? <ul><li>Classical </li></ul><ul><li>Endovascular </li></ul><ul><li>Robotic </li></ul><ul><li>Laparoscopic </li></ul><ul><li>Hybrid </li></ul><ul><li>Cathlab </li></ul><ul><li>OR </li></ul><ul><li>Radiology Suite </li></ul><ul><li>Hybrid </li></ul><ul><li>Vascular Surgeon </li></ul><ul><li>Interventional Cardiologist </li></ul><ul><li>Interventional Radiologist </li></ul><ul><li>CT Surgeon </li></ul><ul><li>Hybrid </li></ul>
    4. 4. Infrarenal AAA <ul><li>Local anesthesia </li></ul><ul><li>Percutaneous </li></ul><ul><li>Maybe outpatient </li></ul><ul><li>Anyone </li></ul>What Perspective?
    5. 5. Bown MJ et al.Br J Surg 2002;89:7 14-30. Visser P 2005 Perioperative Period: Surgical mortality still elevated : 40 – 50% range Open Repair Overall mortality of 75 to 80%
    6. 6. Acute Type B Descending Dissection Asymptomatic What Perspective? Medical Rx Endograft Controversy Waiting for studies Our Data Symptomatic (malperfusion) Endovascular technology with some hybrid combinations
    7. 7. Acute Type A Dissection <ul><li>No AI </li></ul><ul><li>Limited to zone 0 [endovascular treatment] </li></ul><ul><li>Type I arch/descending </li></ul><ul><li>Ascending tube </li></ul>What Perspective? Progressive dissection not inconsequential
    8. 8. Mortality Ruptured Cases All Pathologies TAA Intraop Death 4 (5.5%) 3(12.5%) < 30 Days 9 (12.3%) 5 (20.8%)
    9. 9. Conclusion <ul><li>TEVAR should be the first option of treatment in high risk patients and those with anatomical restraints in order to increase survival. </li></ul><ul><li>Neuro-deficit is decreased when compared to open repair. </li></ul>
    10. 10. Natural History <ul><li>False Lumen at 2 - 5 years </li></ul><ul><li>Subject to Aneurismal Dilatation in 20% to 40% </li></ul>Advance in Vasc Surg. St Louis, Mosby 1998, pp 17-36
    11. 11. Success
    12. 12. Success
    13. 13. Remodeling Changes Continues Post-op 6 months P/3 M/3 D/3 Retrograde Flow
    14. 14. Observations <ul><ul><li>Retrograde flow at viscerals 17.7% (19pts) </li></ul></ul><ul><ul><li>Retrograde flow at D/3 18.7% (20pts) </li></ul></ul><ul><ul><li>Retrograde flow at M/3 1.8% (2pts) </li></ul></ul><ul><ul><li>Retrograde flow at P/3 1.8% (2pts) </li></ul></ul>flow FL thrombosis/ patency depend on several factors
    15. 15. <ul><li>Complete thrombosis of FL of TA without evidence of antegrade or retrograde flow – 69 pts (65.1%) </li></ul>Results Flow
    16. 16. Incidence of Aneurismatic Dilatation <ul><li>Incidence is 20-40% over 5 year period </li></ul><ul><li>Risk of extending dissection and potential complications including visceral and limb malperfusion  26% </li></ul>
    17. 17. Observations Pre-Op Post-Op 1 month 24 months 6 months <ul><li>Remodeling Changes </li></ul><ul><li>True lumen gain volume </li></ul><ul><li>False lumen decrease in diameter </li></ul><ul><li>Whole lumen expand </li></ul>J Vasc Surg 2009;49:20-8.
    18. 18. Post-Op 6 months 24 months Case #3 P/3 D/3
    19. 19. Type B Dissection, Regardless of Symptoms, Should Be Treated By Endografting to Prevent Future Complications?
    20. 20. <ul><li>Exceptions ? </li></ul><ul><ul><li>Asymptomatic patient without significantly collapsed true lumen, <50%. </li></ul></ul>Inclined to Treat Non-complicated TBD with ELG
    21. 21. <ul><li>Endograft is well indicated in aortic dissection type B since the natural history demonstrated high degree of success and positive remodeling changes. </li></ul>
    22. 22. <ul><li>No commercial products for many of the pathologies encountered </li></ul><ul><li>Frequent customization required </li></ul><ul><li>Complexity of pathology restricts broad training and experience </li></ul>Limitations at Present Example?
    23. 23. <ul><li>June 1998 and June 2009 Retrospective Review </li></ul><ul><ul><li>Presented with a rAAA </li></ul></ul><ul><ul><li>69 (65.2%) -- Open Repair </li></ul></ul><ul><ul><li>36 (33.6%) -- EVAR </li></ul></ul>Our Series: Open vs Endograft
    24. 24. 30-Day Mortality <ul><li>Overall was 29.5% (31) </li></ul><ul><li>34.8% (24) for Open </li></ul><ul><li>19.4% (7) for EVAR </li></ul><ul><li>(p=0.12) </li></ul>When comparing those EVAR cases with combined use of local anesthesia at initiation of procedure and use of supra-celiac occlusive balloon to those receiving general anesthesia and no balloon , the mortality reduced from 27.8% to 11.1 % (p=0.40)
    25. 25. Conclusions <ul><li>EVAR in ruptured AAAs has reduced mortality. </li></ul><ul><li>Supraceliac occlusive balloon, based on CT findings of large retroperitoneal hematoma, initiated under local anesthetic, can prevent circulatory collapse. </li></ul>
    26. 26. Conclusions <ul><li>Availability of graft to treat larger caliber necks and low profile devices are some of the technology changes that we need. </li></ul>
    27. 27. Z0 Z1 Z2 Z3 Z4 The Real Challenge: Conquering Zone Zero
    28. 28. <ul><li>Level of the annulus of the aortic valve </li></ul><ul><li>Sinus of Valsalva </li></ul><ul><li>Sinotubular junction </li></ul><ul><li>Ascending aorta at the level of pulmonary trunk </li></ul>64 Slice CT Oblique Coronal Images Showing the 4 Diameter Measurements of Aortic Root
    29. 29. Acute Dissection Ascending Aorta Hematoma High Risk Patient for Open Procedure Balloon Occluding Device L. Coronary Artery Sheath with Positioning of ELG Aortic Valve Dissection
    30. 30. Dissection and Hematoma Sealed
    31. 31. 24 ° Post-Op CT
    32. 32. 1. Vortex velocity control in aneurysm 2. Laminates the flow in collaterals 3. Accelerates shear stress flow in the vessel Multi-Layered Stent Key Principles
    33. 33. Human Experience (All OUS) Thoraco Abdominal Aneurysm
    34. 34. 1 Month Follow-Up Aneurysm excluded All visceral arteries open
    35. 38. Future Potential for Endovascular ??? Aortic Stenosis Ascending Arch Aneurysm Aortic Stenosis
    36. 39. Neuro Protection Devices Ascending Endoluminal Graft Coronary Inserts Percutaneous Aortic Valve Special Stent to Correct Kink Arch/ Descending Endoluminal Graft with Three Branches
    37. 40. Horizon Looks Favorable…. Training Government FDA CMS Industry
    38. 41. We are the heritage of our undaunted medical forefathers. Our young physicians are the genetic products of those great pioneers. Let their fate be the product of those positive, energetic, inquisitive, creative, and adventurous epigenoms which have the ability to overcome all adversity and bring ultimate success to all endeavers.
    39. 43. In All Aspects of Cardiovascular Therapy, the Pendulum is Swinging to Less Invasive Endovascular Approaches CABG Angioplasty Arrhythmia EP Aneurysm Endograft PVD Balloon & Stent ??? Carotid
    40. 44. Evolution of Endovascular Therapies has Created Expanded Opportunities- Created Uncertainties for the Future
    41. 45. Role of the Cardiothoracic Surgeon?
    42. 46. Cardiovascular care is rapidly moving toward catheter-based technologies Surgeons lack skill set Obstacles Even more importantly they often do not recognize the complexity of endovascular
    43. 47. Often not available to surgeons- High-Quality Imaging is Imperative for High-Quality Results
    44. 48. The No Workshop Phenomenon Portable, suboptimum imaging will not be satisfactory for high performance outcomes Catheterization Laboratory
    45. 49. Hybrid Operating Rooms Arizona Heart Hospital
    46. 50. <ul><li>Integrated Format Medical school-> 6 year thoracic (9 programs) </li></ul><ul><li>Joint General Surgery/Thoracic Surgery Track 4 year general- 3 year thoracic (10 programs) </li></ul>
    47. 51. Many CT surgeons are now seeking education and training in endovascular surgery!
    48. 52. Percutaneous Aortic Valve Multi-Disciplinary Team
    49. 53. Retroperitoneal Conduit Approach Special Training Required
    50. 54. Hybrid Operating Rooms Hybrid Training Programs Hybrid Procedures A hybrid is a combination of two or more different things, aimed at achieving a particular objective or goal
    51. 57. Ascending Aorta and Aortic Arch are the Next Generation of Challenges for Endoluminal Grafting
    52. 58. <ul><li>Circulatory arrest </li></ul><ul><li>Profound hypothermia </li></ul><ul><li>Significant metabolic trauma </li></ul><ul><li>Bleeding </li></ul><ul><li>Neurologic insult </li></ul><ul><li>Prolonged recovery </li></ul><ul><li>And much more </li></ul>Surgery is Effective- But Significant morbidity and mortality
    53. 59. Endovascular Techniques for Ascending & Aortic Arch Will be Coming Branched and Fenestrated Devices Not a Simple Process Other New Concepts
    54. 60. J. L. Andersen, Australia Innovative Endovascular Grafting
    55. 61. J. L. Andersen, Australia
    56. 62. Initial Approach: Concentrate on Distal Arch and Transition into Ascending Aorta
    57. 63. Intent of Hybrid Approaches: Expand the Landing Zone for Endoluminal Grafting by Rerouting Arterial Branches <ul><li>Hybrid Procedures- </li></ul><ul><li>No randomized trials </li></ul><ul><li>Small case volumes </li></ul><ul><li>Application of a variety of techniques (no uniformity) </li></ul><ul><li>No commercial products </li></ul><ul><li>Requires customization </li></ul>Surgical Endovascular
    58. 64. Thoracic Aortic Pathologies Offer Unique Opportunities for Hybrid Procedures Classical Endovascular
    59. 65. 57 Year Old Female. Could Not Swallow Without Choking. Esophageal Compression Aberrant RSA
    60. 66. Anomalous Origin Right Subclavian Artery Dysphagia Lusoria
    61. 68. <ul><li>Depressurization of the Aberrant Right Subclavian Artery </li></ul><ul><li>Restructured flow to the Right Upper Extremity </li></ul>Therapeutic Plan
    62. 69. Cannulation of Aberrant RSA Retrograde Femoral No branches between right vertebral and descending aorta
    63. 70. Occluder Placement in RSA
    64. 71. Left Radial Subclavian Stump RSA Anastamosis to Right CCA Proximal RSA Ligated
    65. 72. No Compression
    66. 73. Post-Op
    67. 74. <ul><li>Aberrant Rt. subclavian artery </li></ul><ul><li>Left thoracotomy </li></ul><ul><li>Interposed graft </li></ul>37 Years Ago
    68. 75. 37 Years Later Pseudoaneurysm Degenerated Graft
    69. 76. L. Subclavian A. Bovine Arch Graft to transposed aberrant right subclavian artery (37 yrs ago) Pseudoaneurysm Aberrant right subclavian artery with previous graft
    70. 77. L. C-S bypass Right C-S bypass Ligation of degenerated graft ELG deployment
    71. 78. Right C-S bypass L. C-S bypass Endoluminal graft Thrombosed pseudoaneurysm
    72. 79. Pathologies Encroaching Aortic Arch Options Left C-S Bypass Left SC transposition
    73. 80. Areas of Controversy: Covering the Left Subclavian Artery Indications for Left C-S Bypass or Transposition <ul><li>Always </li></ul><ul><li>Patent IMA or anticipated </li></ul><ul><li>Left vertebral critical to posterior circulation </li></ul><ul><li>Previous AAA repair </li></ul><ul><li>Internal iliac status </li></ul>No Consensus * *
    74. 81. Hybrid Example Subclavian aneurysm Previous coarctation repair Large associated aneurysm
    75. 82. C-S graft bypass Resection subclavian aneurysm Operative exposure
    76. 83. Endoluminal graft deployed at left CCA Simultaneous: <ul><li>Proximal subclavian resection </li></ul><ul><li>Carotid-subclavian bypass </li></ul><ul><li>ELG </li></ul>
    77. 84. Previous Type A Dissection Aberrant right subclavian artery Left CCA dissection Distal arch dissection False channel expansion Left subclavian dissection Left CCA dissection
    78. 85. Hybrid Treatment Plan Rt. subclavian- carotid bypass Vertebral LCCA stent deployed retrograde Rt. aberrant subclavian closed proximally Lt. carotid- subclavian bypass
    79. 86. Extra Anatomic Procedures in Preparation for Thoracic Endograft
    80. 87. LCCA stent Rt. subclavian- carotid bypass Lt. C-S bypass Rt. aberrant subclavian closed
    81. 88. Rollover vehicle accident 15 years ago, multiple injuries Recent TIA, Dx innominate artery aneurysm
    82. 89. Bovine arch Initial plan ELG Innominate artery aneurysm (source of emboli) Inadequate landing zone LCCA Compromise LCCA
    83. 90. Coiled aneurysm Transposition of Rt. subclavian artery Carotid-carotid bypass Coiled aneurysm Transposition of Rt. subclavian artery Carotid-carotid bypass Ligation distal innominate Retrograde femoral approach
    84. 91. Expanding ascending aneurysm Dissection False lumen True lumen Previous ascending graft for type I dissection
    85. 92. Requires Partial Cardiopulmonary Support Femoral Artery-Femoral Vein Bypass Insufficient Graft Length
    86. 93. Ascending graft Left common carotid bypass Innominate bypass Radiopaque marker for ELG landing zone
    87. 94. Ascending graft ELG ascending, arch, descending To left carotid, innominate Bifurcated graft Original ascending graft for type A repair To innominate
    88. 95. Ascending Aorta and Contiguous Arch Present Specific Challenges
    89. 96. I. Aortic Valve II. Coronary Arteries III. Aortic Root IV. Ascending Aorta and Trunk Vessels
    90. 97. Current Potentials for Rx of Ascending Aortic Pathologies I. Degenerative Aneurysms Proximal landing length Distal landing length Proximal-distal discrepancies
    91. 98. II. Dissections Current Potentials for Rx of Ascending Aortic Pathologies Initial Tear 1-3cm Type II Extensive Dissection
    92. 99. Anatomic Challenge Larger Diameter Ascending Curvature Short Deployment Area Extremely Friable Tissue
    93. 100. Overcoming Systemic Pressure
    94. 101. <ul><li>Cardiac Pacing </li></ul><ul><li>Temp. Arrest (Pharmacological) </li></ul><ul><li>New Concept </li></ul>Overcoming Systemic Pressure
    95. 102. Balloon Occlusion of Cardiac Venous Return Right Atrium IVC SVC <ul><li>Reduce Cardiac Output </li></ul><ul><li>Decreases Systemic Pressure </li></ul>
    96. 103. Double Balloon Occluding Catheter
    97. 104. 130/80 mmHg Balloon deflates SVC balloon inflates 110/60 IVC balloon inflates 60/20
    98. 105. Right Atrium Inflated IVC Inflated SVC BP 130/80 mmHg 60/20 mmHg
    99. 107. A Better Answer to Stent Graft Expansion or Remodeling The “UnBalloon”
    100. 108. Current Potentials for Rx of Ascending Aortic Pathologies <ul><li>Site of previous vein graft anastomosis </li></ul><ul><li>Cannulation or de-airing (vent) site </li></ul><ul><li>Suture line </li></ul><ul><li>Dissections (limited) </li></ul><ul><li>Dissections Type A </li></ul>III. Complications of Previous Interventions
    101. 109. Investigation of Ascending Endovascular Therapy Bypass Occluded Pseudoaneurysm of Ascending Aorta
    102. 110. Coil Embolization
    103. 111. Coils failed to close entry point Aneurysm expanded from 6-10cm in 4 months
    104. 112. Endoluminal Graft Exclusion of Pseudoaneurysm
    105. 113. 1 Year Follow-up
    106. 114. 3 Months Post Mitral Valve Replacement 9cm aneurysm 8mm Channel Measured by IVUS Option
    107. 115. Amplatz Occluder Retrograde femoral delivery Disc Diameter Ranges Small 12mm-30mm Large 14mm-32mm
    108. 116. Aneurysm Excluded
    109. 117. 5 Month Follow-Up Preop Small Disc Size 26mm Large Disc Size 30mm
    110. 118. Dissection Ascending Aorta Enlarging Dissection Ascending Aorta
    111. 119. Dissection JR4 catheter across dissection entry point
    112. 120. Occluder
    113. 121. Is Endovascular Possible? Aortic Insufficiency Arch Aneurysm
    114. 122. Extending Endovascular Even Further with Hybrid Procedures <ul><li>50 year old male Delta Airline Captain </li></ul><ul><li>Sudden right leg pain </li></ul><ul><li>Right groin exploration </li></ul>Case History No thrombus, no antegrade flow, loss of motor and sensory function to entire right lower extremities Result
    115. 123. Arch dissection Celiac Left iliac dissection Rt. iliac occlusion CT Examination After Right Groin Exploration Celiac
    116. 124. Femoral-femoral bypass graft (Acute ischemia with paralysis) Emergent Fem-Fem Bypass
    117. 125. Ascending tube graft Type A Dissection Cardiopulmonary bypass Mild hypothermia Retrograde left femoral cannulation (above fem-fem)
    118. 126. Transposition of brachiocephalic and left common carotid arteries Bifurcated graft with conduit Ascending tube graft Off cardiopulmonary bypass
    119. 127. 240cm wire to left iliac artery 9 Fr sheath
    120. 128. Snare retrieval of conduit wire to left femoral sheath
    121. 129. Conduit-Femoral Wire The Banjo Concept
    122. 130. Conduit-Femoral Wire <ul><li>Over comes tortuosity </li></ul><ul><li>Facilitates difficult arch delivery </li></ul><ul><li>Reduces manipulations across aortic arch </li></ul><ul><li>Creates control and stability for delivery </li></ul>
    123. 131. Completion After 2 nd ELG Deployed Antegrade ELG Delivery Across Aortic Arch
    124. 132. Ct 3 Days Post ELG exclusion of arch and descending thoracic dissection Bifurcated graft Stump of conduit
    125. 133. 5 Year Follow-Up No Symptoms, Ready to Fly
    126. 134. Captain Federal Aviation Administration (FAA) Thank You Edward B. Diethrich