Current role of tever in acute and chronic dissection results in china

1. Current Role of TEVER in Acute and
Chronic Dissection: Results in China
Chang Shu M.D., PhD.
Department of Vascular Surgery,
The 2nd Xiang-Ya Hospital, Central-South University, China
Email：changshu01@yahoo.com

2. Incidence
In China, more than 15,000 cases of acute and Chronic type
B aortic dissection cases happen per year.
Most of the cases, about 70%, receive TEVAR, especially
the cases with huge hemothorax, intractable
hypertension, acute paralysis, and acute ischemia of
visceral arteries.
In 2010, the number of TEVAR cases was about 6000, and
has increased about 30% each year.
The dates coming from the commercial market, CNKI database and the article “Vascular Surgery
in China” (James S.T. Yao. Ann Vasc Surg, 2012;26: 889-894)

3. How about the current rule
• There is no standard rule of TRVAR in treating
acute, chronic aortic dissection in China;
• To Acute aortic dissection, most of the centers
will obey the rule of the AHA etc.
• To Chronic aortic dissection, the opinion of
TRVAR is controlversy

4. Prof. Zhong Gao Wang
Before 1998, Wang treated severalTBAD
cases with TEVAR via homemade stent-
grafts in China.
 Academician of the Chinese Academy of
Science
 The founder and 1st President of the
Chinese Society of Vascular Surgery
 The founder of the Asian Society of
Vascular Surgery
 Corresponding member of the Society for
Vascular Surgery
The history of TEVAR in China

5. Volume of TBAD Treated in China
0
2000
4000
6000
8000
10000
12000
14000
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
1999: The first case of aortic
dissection treated by TEVAR
2002: less than 100 cases
2004: less than 500
2006: less than 2000
2008: less than 5000
2010: about 6000
2011: about 9000
2012: about 12000
The dates coming from the commercial market, CNKI database and the article “Vascular Surgery
in China” (James S.T. Yao. Ann Vasc Surg, 2012;26: 889-894)

6. Development of Management strategy
Before 2003: Single cases, the indication is very strict:
• First entry should below the left subclavian A 2cm
• The visceral arteries are coming from true lumen
2004~2005: Some ischemia of the visceral arteries can be treated;
Partial of the cases left subclavian A can be covered;
Extra-anatomic bypass had been applied in the TEVAR.
2006~2007：Most of the acute TBAD cases can be treated, no matter
have some complications.
2007~2010: Aortic arch invaded can be treated, many new technique
including Chimney etc had been applied to focus on the
proximal and distal side
2011~2013: Complications after TRVAR had been pointed out and new
methods had been applied.

7. Acute TBAD with Huge Hemothorax, in 2004
Shu C, et al. Endovascular repair of complicated acute type-B aortic dissection with stentgraft: early and mid-
term results. Eur J Vasc Endovasc Surg. 2011

8. TEVAR with extra-anatomic bypass, in 2004
Chang Shu, et al. Endovascular repair combined with associated techniques for the treatment of
TBAD involving aortic arch. Chin J Gen Surg, 2011

9. TBAD invaded celiac artery and caused ischemia,
in 2006
Li M, Shu C, et al. Midterm results of intentional celiac artery coverage during TEVAR for type B aortic
dissection.J Endovasc Ther. 2013

10. Acute renal failure caused by acute TBAD,
treated with TEVAR, in 2006

11. Nowadays,
most of the
centers
focus on
~ ~
~ ~
Appropriated
peri-operative
medical treatment
For
complications
pre-operation
For complicated
anatomic
situations
For
complications
post-operation
Management strategy for TBAD

12. ~ huge hemothorax
~ ischemia of lower extremities
~ Acute paraplegia (before/after TEVAR)
~ celiac artery involved
~ ascending aorta invaded
For complications
pre-operation
~ acute renal failure
~ supra-aortic branches invaded

13. for complicated
anatomic situations
~ Chimney technique
~ Double chimney technique
~ Sacrifice LSA
~ Extra-anatomic bypass
~ Debranch and hybrid reconstruction technique
~ Fenestrated technique
~ Bare stent technique

14. ~ Type I endoleak
~ Type II endoleak
~ Paraplegia post-TEVAR
~ Huge hemothorax post-TEVAR
~ Left subclavian artery steal syndrome
~ Distal new entry tear
~ Left subclavian artery dissection
For complications
post-operation

15. TBAD with mal-perfusion syndrome
It’s the most common severe complication of acute
type B aortic dissection, including renal failure,
paraplegia et al. Some cases can’t be treated
previously. Weiguo, Changshu et al explored the
treatment from 2004, and received excellent results.
Now, the severe cases can be treated in some main
vascular centers in China.

16. Mal-perfusion of distal aorta
There is no contrast in
the distal abdominal aorta.
The patient had typical
symptoms of acute lower
extremities ischemia.
Pre-operation

17. Post-operation
Emergent TEVAR should be
performed to release mal-
perfusion syndrome.
After operation, the
compressed true lumen re-
opened. Blood supply and all
symptoms recover immediately.
Mal-perfusion of distal aorta
Chang Shu, et al. Early results of left carotid
chimney technique in endovascular repair of
acute non-a-non-B aortic dissections. J
Endovasc Ther，2011

18. Mal-perfusion caused acute paraplegia
The patients with abrupt paraplegia
was caused by ischemia of arteriae
lumbales and intercostal arteries.
In out department, 7 patients
suffered from paraplegia：
• 3 cases pre-TEVAR
• 4 cases post-TEVAR

19. This patient suffered from
acute severe paraplegia 10
hours after TEVAR.
Emergent CTA indicated
satisfying remodeling of
descending aorta with
completed thrombosis in the
false lumen, coverage of the
original of the LSA.

20. Anaesthesia
record indicated
hypotension
during TEVAR.

21. Emergent management:
• Drainage of CSF
• Stosstherapy with adrenal cortex hormone
• Dehydration
• Maintain the blood pressure at about
140/90mmHg
• Medical treatment to dilate collateral artery
• Neurotrophy
• Functional exercise

22. TEVAR for Retrograde type A AD
Retrograde type A aortic dissection is associated with the risk of severe aortic
regurgitation, cardiac tamponade, coronary arteries involved, brain ischemia, especially
the cases with patent false lumen in ascending aorta.

23. TEVAR for Retrograde type A AD
2 weeks after TEVAR
Shu C, et al. Thoracic endovascular aortic repair for retrograde type A aortic dissection with an
entry tear in the descending aorta. J Vasc Interv Radiol. 2012

24. Secondary TEVAR for distal
new entry tear
With the usage of TEVAR for TBAD, Since the stent-
graft are straight and not tapped one, more and more
post-TEVAR complications happen, such as the distal
new entry tear. Secondary operation is a necessity.

25. Secondary TEVAR for distal new entry tear
3months after TEVAR, a new ruptured entry tear happened near the distal ending of
the stent-graft. Secondary TEVAR with a stent-graft overlapped with the previous one
was performed.

26. Complicated type I
endoleak post-operation

27. A patient with aortic dissection
received TEVAR 3 years ago.
An endoleak and a new distal entry
tear were found during follow-up.

29. It seems like
the endoleak is
coming from the
new distal entry
tear. So, an
extending stent-
graft in the
descending
aorta was used,
overlapped with
the previous
one.

30. However,
after the distal
extending stent-
graft deployed,
an typical type I
endoleak
happened.
Why?

31. An cuff was
used in the
proximal to seal
type I endoleak.

32. After all the
procedures, the
patient recovered
well.

33. Chimney technique
Has been applied in China from 2007, First aortic
arch case treated by Chimney technique reported
by Changshu et al in 2008. It is commonly used to
treat the aortic arch diseases in some of the big
vascular centers in China

34. TEVAR with chimney technique for
TBAD involved aortic arch

35. Chimney technique
+ PDA occlude for LSA
If chimney technique is used in the common carotid
artery, the covered LSA has the risk of type II endoleak.
PDA occlude technique is a ideal management

36. • TBAD related LSA
• Chimney technique
should be used
Chimney technique+ PDA occlude

38. • Chimney stent-graft
reconstructed left
common carotid
artery.
• Typical type II
endoleak from LSA

39. • PDA occlude was
used to seal type II
endoleak.

40. 2 weeks after TEVAR, no type II endoleak lasted.

41. Double-chimney technique
The 1st aortic arch dissection case treated by
double-chimney technique reported by Zhaipinjing et
al in 2009. It can replace the conventional open
surgery, and be used to reconstruct all supra-aortic
branches. Some big vascular centers in China
master the technique.

42. The patient suffer from an acute aortic
dissection, which the left common carotid
artery was invaded and leaded to severe
carotid artery stenosis.

44. The patient recovered well, without any serious complications

45. Bi-chimney technique was
used.
Two Fluency stent-grafts were
used to reconstruct IA and
LCCA. The LSA was covered.
The patient recovered well,
without any complications.
Until now, several cases have
received bi-chimney technique in
our hospital, short-term result
is acceptable, no technique-
related complications happen,
but long-term result is
unclear.

46. fenestrated SG
It has been used in China beginning from 2005, Some of
the stenting-grafts has been modified to fit the aortic
arch area by some experienced vascular surgeons

47. Fenestration—treatment
• Step 1:
CT and DSA for
accurate
measurement were
performed pre-
operation.

48. Fenestration—treatment
• Step 2:
deploy partial of the
proximal stent graft in
vitro, and eliminate
part of the lateral fabric.

49. Fenestration—treatment
Step 3

50. Fenestration—follow up
The fenestrated stent graft
covered the aortic arch
dissection completely
With patent supra-aortic
branches

51. TBAD with Marfan syndrome
The first case is reported by Changshu et al in 2008,
some of the big vascular centers has done it now in
China

52. MFS associated with TBAD
Bentall technique was performed previously

53. Replacement of
aortic root and
valves was
performed 3 years
ago.
Abrupt severe back
pain was
encountered caused
by TBAD.
MFS received Bentall previously

54. Two weeks after TEVAR
The aortic
dissection in the
descending aorta
was occluded with
remodeling of
related distal aorta.

55. TBAD
+ Marfan syndrome
+ pregnancy
The first case reported by Changshu et al in 2009.
Until now, Three cases have been treated by
TEVAR. All the patients and their infants recovered
uneventfully.

56. A 23-year-old female, gestated for 36
months.
Widen mediastinum was found by chest
X-ray. And CT angiography confirmed
chronic type B aortic dissection.
No signs of threatened labor.
MFS associated with pregnancy
Shu C, et al. J Cardiovasc Surg. 2013. accepted

57. Caesarean section was
performed followed on
emergent TEVAR.
The patient recovered well,
and the infant was healthy.
No complication happened !
MFS associated with pregnancy
Shu C, et al. J Cardiovasc Surg. 2013. accepted

58. MFS associated with pregnancy
Shu C, et al. J Cardiovasc Surg. 2013. accepted

59. In the future, some new techniques will be used
in ascending and distal descending aorta
• Branched Stent-Graft
• Single-banched
• Double-branched
• Tri-branched
• Split-Type Branched Stent-Grafts
• Bare stent used in distal descending aorta

60. New types of branched stent-graft for aortic
arch lesions
Some vascular centers invented the branched stent-graft
for aortic arch lesions and had been applied in animal or
clinical study, not available commercially in China

61. Single/double branched stent-graft used in acute
aortic arch dissection
By Z-P Jing. Am Surg. 2010; Eur J CardiothoracSurg.2011.

62. The special
branched stent-
graft is invented
to treat aortic
disease involving
aortic arch and
ascending aorta,
such as type A
AD !
Split-Type Branched Stent-Grafts
Invented by
Changshu et
al.

63. Bare stent used TBAD
Bare stent technique is applied in China from 2009, in
order to open the true lumen of the dissection area and
restrict the stenting-graft in the distal side to get a
reasonable profile of the aorta

65. A typical type B aortic dissection

66. The bare stent restrict the distal diameter of the Valiant
stent-graft.

67. RESULTS

68. RESULTS

69. RESULTS

70. RESULTS

71. RESULTS of A Single Center
1 Technically success: 99.9%
2 Recovered uneventfully: 90.4%
3 Peri-TEVAR complications: 29 (3.1%)
4 Late complications: 36 (3.9%)
5 Fatal cases: 11 (1.2%)

72. RESULTS
• In China, because of the diet improvement and the bad
control of the hypertention, the incidence of acute type
B aortic dissection increase rapidly, the age of the
patients is relatively younger, the role of treatment
should be TEVAR
• Chronic AD, with complications, TEVAR should be
performed. But to some young patients, although with no
severe complications, TEVAR can be done for decreasing
the larger of the false lumen.
• Therapy with traditional medicines is the basic management
for type B aortic dissection, endovascular stent graft
placement is the first option.

73. • Today, in China, with the development of endovascular
technique, such as fenestrated technique, branched stent-
grafts, debranch technique, and so on, most type B aortic
dissection cases can be treated endoluminally, even some
type A aortic dissection cases can be treated by endo.
• Current Role of TEVAR in Acute and Chronic Dissection are
focus on with or without complications, many chinese doctors
pay much attention to get a better anatomy profile of the
aorta by TEVAR, so as to get a much better follow up. But
we have to emphasize: evidence is the most important thing!
RESULTS