1. Endovascular techniques are increasingly being used to treat aortic pathologies like aneurysms and dissections as they can reduce mortality and morbidity compared to open surgery. 2. However, many challenging cases involve the ascending aorta and aortic arch, which are still difficult to treat using endovascular methods alone due to anatomical constraints. 3. Hybrid procedures combining endovascular and open surgical techniques show promise for expanding the applications of endovascular therapy in complex cases, with extra-anatomic bypass grafts and branches helping to create adequate landing zones for endografts.

1. Edward B. Diethrich, MD Phoenix, Arizona The Future of Aortic Repair Malmo, Sweden June 18, 2010

2. What Perspective? How? Where? Who? What?

3. How? Where? Who? Classical Endovascular Robotic Laparoscopic Hybrid Cathlab OR Radiology Suite Hybrid Vascular Surgeon Interventional Cardiologist Interventional Radiologist CT Surgeon Hybrid

4. Infrarenal AAA Local anesthesia Percutaneous Maybe outpatient Anyone What Perspective?

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. 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. Acute Type A Dissection No AI Limited to zone 0 [endovascular treatment] Type I arch/descending Ascending tube What Perspective? Progressive dissection not inconsequential

8. Mortality Ruptured Cases All Pathologies TAA Intraop Death 4 (5.5%) 3(12.5%) < 30 Days 9 (12.3%) 5 (20.8%)

9. Conclusion TEVAR should be the first option of treatment in high risk patients and those with anatomical restraints in order to increase survival. Neuro-deficit is decreased when compared to open repair.

10. Natural History False Lumen at 2 - 5 years Subject to Aneurismal Dilatation in 20% to 40% Advance in Vasc Surg. St Louis, Mosby 1998, pp 17-36

11. Success

12. Success

13. Remodeling Changes Continues Post-op 6 months P/3 M/3 D/3 Retrograde Flow

14. Observations Retrograde flow at viscerals 17.7% (19pts) Retrograde flow at D/3 18.7% (20pts) Retrograde flow at M/3 1.8% (2pts) Retrograde flow at P/3 1.8% (2pts) flow FL thrombosis/ patency depend on several factors

15. Complete thrombosis of FL of TA without evidence of antegrade or retrograde flow – 69 pts (65.1%) Results Flow

16. Incidence of Aneurismatic Dilatation Incidence is 20-40% over 5 year period Risk of extending dissection and potential complications including visceral and limb malperfusion  26%

17. Observations Pre-Op Post-Op 1 month 24 months 6 months Remodeling Changes True lumen gain volume False lumen decrease in diameter Whole lumen expand J Vasc Surg 2009;49:20-8.

18. Post-Op 6 months 24 months Case #3 P/3 D/3

19. Type B Dissection, Regardless of Symptoms, Should Be Treated By Endografting to Prevent Future Complications?

20. Exceptions ? Asymptomatic patient without significantly collapsed true lumen, <50%. Inclined to Treat Non-complicated TBD with ELG

21. Endograft is well indicated in aortic dissection type B since the natural history demonstrated high degree of success and positive remodeling changes.

22. No commercial products for many of the pathologies encountered Frequent customization required Complexity of pathology restricts broad training and experience Limitations at Present Example?

23. June 1998 and June 2009 Retrospective Review Presented with a rAAA 69 (65.2%) -- Open Repair 36 (33.6%) -- EVAR Our Series: Open vs Endograft

24. 30-Day Mortality Overall was 29.5% (31) 34.8% (24) for Open 19.4% (7) for EVAR (p=0.12) 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. Conclusions EVAR in ruptured AAAs has reduced mortality. Supraceliac occlusive balloon, based on CT findings of large retroperitoneal hematoma, initiated under local anesthetic, can prevent circulatory collapse.

26. Conclusions Availability of graft to treat larger caliber necks and low profile devices are some of the technology changes that we need.

27. Z0 Z1 Z2 Z3 Z4 The Real Challenge: Conquering Zone Zero

28. Level of the annulus of the aortic valve Sinus of Valsalva Sinotubular junction Ascending aorta at the level of pulmonary trunk 64 Slice CT Oblique Coronal Images Showing the 4 Diameter Measurements of Aortic Root

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. Dissection and Hematoma Sealed

31. 24 ° Post-Op CT

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. Human Experience (All OUS) Thoraco Abdominal Aneurysm

34. 1 Month Follow-Up Aneurysm excluded All visceral arteries open

38. Future Potential for Endovascular ??? Aortic Stenosis Ascending Arch Aneurysm Aortic Stenosis

39. Neuro Protection Devices Ascending Endoluminal Graft Coronary Inserts Percutaneous Aortic Valve Special Stent to Correct Kink Arch/ Descending Endoluminal Graft with Three Branches

40. Horizon Looks Favorable…. Training Government FDA CMS Industry

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.

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

44. Evolution of Endovascular Therapies has Created Expanded Opportunities- Created Uncertainties for the Future

45. Role of the Cardiothoracic Surgeon?

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

47. Often not available to surgeons- High-Quality Imaging is Imperative for High-Quality Results

48. The No Workshop Phenomenon Portable, suboptimum imaging will not be satisfactory for high performance outcomes Catheterization Laboratory

49. Hybrid Operating Rooms Arizona Heart Hospital

50. Integrated Format Medical school-> 6 year thoracic (9 programs) Joint General Surgery/Thoracic Surgery Track 4 year general- 3 year thoracic (10 programs)

51. Many CT surgeons are now seeking education and training in endovascular surgery!

52. Percutaneous Aortic Valve Multi-Disciplinary Team

53. Retroperitoneal Conduit Approach Special Training Required

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

57. Ascending Aorta and Aortic Arch are the Next Generation of Challenges for Endoluminal Grafting

58. Circulatory arrest Profound hypothermia Significant metabolic trauma Bleeding Neurologic insult Prolonged recovery And much more Surgery is Effective- But Significant morbidity and mortality

59. Endovascular Techniques for Ascending & Aortic Arch Will be Coming Branched and Fenestrated Devices Not a Simple Process Other New Concepts

60. J. L. Andersen, Australia Innovative Endovascular Grafting

61. J. L. Andersen, Australia

62. Initial Approach: Concentrate on Distal Arch and Transition into Ascending Aorta

63. Intent of Hybrid Approaches: Expand the Landing Zone for Endoluminal Grafting by Rerouting Arterial Branches Hybrid Procedures- No randomized trials Small case volumes Application of a variety of techniques (no uniformity) No commercial products Requires customization Surgical Endovascular

64. Thoracic Aortic Pathologies Offer Unique Opportunities for Hybrid Procedures Classical Endovascular

65. 57 Year Old Female. Could Not Swallow Without Choking. Esophageal Compression Aberrant RSA

66. Anomalous Origin Right Subclavian Artery Dysphagia Lusoria

68. Depressurization of the Aberrant Right Subclavian Artery Restructured flow to the Right Upper Extremity Therapeutic Plan

69. Cannulation of Aberrant RSA Retrograde Femoral No branches between right vertebral and descending aorta

70. Occluder Placement in RSA

71. Left Radial Subclavian Stump RSA Anastamosis to Right CCA Proximal RSA Ligated

72. No Compression

73. Post-Op

74. Aberrant Rt. subclavian artery Left thoracotomy Interposed graft 37 Years Ago

75. 37 Years Later Pseudoaneurysm Degenerated Graft

76. L. Subclavian A. Bovine Arch Graft to transposed aberrant right subclavian artery (37 yrs ago) Pseudoaneurysm Aberrant right subclavian artery with previous graft

77. L. C-S bypass Right C-S bypass Ligation of degenerated graft ELG deployment

78. Right C-S bypass L. C-S bypass Endoluminal graft Thrombosed pseudoaneurysm

79. Pathologies Encroaching Aortic Arch Options Left C-S Bypass Left SC transposition

80. Areas of Controversy: Covering the Left Subclavian Artery Indications for Left C-S Bypass or Transposition Always Patent IMA or anticipated Left vertebral critical to posterior circulation Previous AAA repair Internal iliac status No Consensus * *

81. Hybrid Example Subclavian aneurysm Previous coarctation repair Large associated aneurysm

82. C-S graft bypass Resection subclavian aneurysm Operative exposure

83. Endoluminal graft deployed at left CCA Simultaneous: Proximal subclavian resection Carotid-subclavian bypass ELG

84. Previous Type A Dissection Aberrant right subclavian artery Left CCA dissection Distal arch dissection False channel expansion Left subclavian dissection Left CCA dissection

85. Hybrid Treatment Plan Rt. subclavian- carotid bypass Vertebral LCCA stent deployed retrograde Rt. aberrant subclavian closed proximally Lt. carotid- subclavian bypass

86. Extra Anatomic Procedures in Preparation for Thoracic Endograft

87. LCCA stent Rt. subclavian- carotid bypass Lt. C-S bypass Rt. aberrant subclavian closed

88. Rollover vehicle accident 15 years ago, multiple injuries Recent TIA, Dx innominate artery aneurysm

89. Bovine arch Initial plan ELG Innominate artery aneurysm (source of emboli) Inadequate landing zone LCCA Compromise LCCA

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

91. Expanding ascending aneurysm Dissection False lumen True lumen Previous ascending graft for type I dissection

92. Requires Partial Cardiopulmonary Support Femoral Artery-Femoral Vein Bypass Insufficient Graft Length

93. Ascending graft Left common carotid bypass Innominate bypass Radiopaque marker for ELG landing zone

94. Ascending graft ELG ascending, arch, descending To left carotid, innominate Bifurcated graft Original ascending graft for type A repair To innominate

95. Ascending Aorta and Contiguous Arch Present Specific Challenges

96. I. Aortic Valve II. Coronary Arteries III. Aortic Root IV. Ascending Aorta and Trunk Vessels

97. Current Potentials for Rx of Ascending Aortic Pathologies I. Degenerative Aneurysms Proximal landing length Distal landing length Proximal-distal discrepancies

98. II. Dissections Current Potentials for Rx of Ascending Aortic Pathologies Initial Tear 1-3cm Type II Extensive Dissection

99. Anatomic Challenge Larger Diameter Ascending Curvature Short Deployment Area Extremely Friable Tissue

100. Overcoming Systemic Pressure

101. Cardiac Pacing Temp. Arrest (Pharmacological) New Concept Overcoming Systemic Pressure

102. Balloon Occlusion of Cardiac Venous Return Right Atrium IVC SVC Reduce Cardiac Output Decreases Systemic Pressure

103. Double Balloon Occluding Catheter

104. 130/80 mmHg Balloon deflates SVC balloon inflates 110/60 IVC balloon inflates 60/20

105. Right Atrium Inflated IVC Inflated SVC BP 130/80 mmHg 60/20 mmHg

107. A Better Answer to Stent Graft Expansion or Remodeling The “UnBalloon”

108. Current Potentials for Rx of Ascending Aortic Pathologies Site of previous vein graft anastomosis Cannulation or de-airing (vent) site Suture line Dissections (limited) Dissections Type A III. Complications of Previous Interventions

109. Investigation of Ascending Endovascular Therapy Bypass Occluded Pseudoaneurysm of Ascending Aorta

110. Coil Embolization

111. Coils failed to close entry point Aneurysm expanded from 6-10cm in 4 months

112. Endoluminal Graft Exclusion of Pseudoaneurysm

113. 1 Year Follow-up

114. 3 Months Post Mitral Valve Replacement 9cm aneurysm 8mm Channel Measured by IVUS Option

115. Amplatz Occluder Retrograde femoral delivery Disc Diameter Ranges Small 12mm-30mm Large 14mm-32mm

116. Aneurysm Excluded

117. 5 Month Follow-Up Preop Small Disc Size 26mm Large Disc Size 30mm

118. Dissection Ascending Aorta Enlarging Dissection Ascending Aorta

119. Dissection JR4 catheter across dissection entry point

120. Occluder

121. Is Endovascular Possible? Aortic Insufficiency Arch Aneurysm

122. Extending Endovascular Even Further with Hybrid Procedures 50 year old male Delta Airline Captain Sudden right leg pain Right groin exploration Case History No thrombus, no antegrade flow, loss of motor and sensory function to entire right lower extremities Result

123. Arch dissection Celiac Left iliac dissection Rt. iliac occlusion CT Examination After Right Groin Exploration Celiac

124. Femoral-femoral bypass graft (Acute ischemia with paralysis) Emergent Fem-Fem Bypass

125. Ascending tube graft Type A Dissection Cardiopulmonary bypass Mild hypothermia Retrograde left femoral cannulation (above fem-fem)

126. Transposition of brachiocephalic and left common carotid arteries Bifurcated graft with conduit Ascending tube graft Off cardiopulmonary bypass

127. 240cm wire to left iliac artery 9 Fr sheath

128. Snare retrieval of conduit wire to left femoral sheath

129. Conduit-Femoral Wire The Banjo Concept

130. Conduit-Femoral Wire Over comes tortuosity Facilitates difficult arch delivery Reduces manipulations across aortic arch Creates control and stability for delivery

131. Completion After 2 nd ELG Deployed Antegrade ELG Delivery Across Aortic Arch

132. Ct 3 Days Post ELG exclusion of arch and descending thoracic dissection Bifurcated graft Stump of conduit

133. 5 Year Follow-Up No Symptoms, Ready to Fly

134. Captain Federal Aviation Administration (FAA) Thank You Edward B. Diethrich