The document discusses endovascular treatment of aortic dissection. It begins with an introduction to aortic dissection, including definitions, classifications, epidemiology, clinical presentation, and natural history. It then discusses the diagnosis and imaging of aortic dissection. Medical and surgical management strategies are reviewed. Endovascular techniques for treating various types of aortic dissection are summarized. Key considerations for endovascular stent grafting as an alternative to open surgery are outlined.
Intracoronary Imaging – when to use, how to use and how to interpret the imagesEuro CTO Club
Intracoronary Imaging – when to use, how to use and how to
interpret the images
Javier Escaned, Spain
The Experts “Live” Workshop 2017
Saturday, September 16th, 2017
A detailed description of ct coronary angiography and calcium scoring with various aspects regarding the preparation, procedure, limitations and a short review regarding post CABG imaging.
Intracoronary Imaging – when to use, how to use and how to interpret the imagesEuro CTO Club
Intracoronary Imaging – when to use, how to use and how to
interpret the images
Javier Escaned, Spain
The Experts “Live” Workshop 2017
Saturday, September 16th, 2017
A detailed description of ct coronary angiography and calcium scoring with various aspects regarding the preparation, procedure, limitations and a short review regarding post CABG imaging.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
Diagnostic catheters for coronary angiography Aswin Rm
Overview of diagnostic catheters used in coronary angiography
Guide catheters not included
History of coronary catheters
Radial techniques and catheters
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
Diagnostic catheters for coronary angiography Aswin Rm
Overview of diagnostic catheters used in coronary angiography
Guide catheters not included
History of coronary catheters
Radial techniques and catheters
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
Another Critical Care Collaborative Deep Dive into the assessment and management of shock. Covers classification of shock, diagnosis, serial assessment methods and management.
Stanford Type A Aortic Dissection: a Complex Disease for Patients and Cardiot...Crimsonpublisherssmoaj
Acute type A aortic dissection is a catastrophic event in which blood exits the vascular lumen and dissects the media, creating a false lumen. Surgery is the best possible treatment but it is complex. The surgical team needs to understand the anatomy and physiopathology before dealing with the repair. While there are just a few surgical solutions for the repair of the dissected ascending aorta, debate is still ongoing about the best surgical option for the disease involving the arch and the descending aorta. Late reoperations are relatively common on the aortic valve and/or the distal aorta after primary repair. Results are excellent in specialized centers with high volume and complexity. Lifelong follow-up is required in survivors.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
3. AORTIC DISSECTION (AD)
Disruption of the medial layer provoked by intramural bleeding.
Results in separation of the aortic wall layers and subsequent formation of a True Lumen
(TL) and a False lumen (FL) with or without communication.
An intimal tear is the initiating condition, resulting in tracking of the blood in a dissection
plane within the media – Identified on noninvasive imaging in 90%, on autopsy in 95%.
Followed either by an aortic rupture in the case of adventitial disruption or by a re-entering
into the aortic lumen through a second intimal tear.
Can be antegrade or retrograde.
15% have Intramural hematoma.
5. EPIDEMIOLOGY
Underestimated incidence. 1-4 cases per 100000 per year. Highest in Italy.
0.5% of patients presenting with chest pain to ED.
Circulation 2013;127:2031–2037
Incidence increases with age. Mean age 63 years.
Males (65%) > Females
Risk factors - Hypertension (70%)- uncontrolled commonly
- Pre-existing aortic diseases or aortic valve disease,
- History of cardiac surgery
- Cigarette smoking
- Direct blunt chest trauma
- IV drug abuse (e.g. cocaine and amphetamines)
Risk factors in age < 40 yr - Marfan S. and other CTDs
IRAD registry. JAMA 2000;283:897–903
6. ACUTE DISSECTION
ACUTE - diagnosed within 2 weeks of symptom onset. Highest mortality.
SUBACUTE - survived first 2 weeks
CHRONIC - survived first 8 weeks - Behave more like aneurysm
- Rupture is the risk
- Malperfusion is uncommon
ACC/AHA guideline. Circulation 2010;121:e266
8. ANATOMICAL
CLASSIFICATIO
N
DeBakey
Stanford : MC used
Presentation and natural
history depends on type
Therefore management and
prognosis is decided by type
ACC/AHA guideline. Circulation 2010;121:e266
10. NATURAL HISTORY
TYPE A
Mortality (untreated)
1st 24 hrs – 1-2% per hour
1st 48 hrs – 36-72%
1st week – 60-90%
Mortality (on Medical Mx only)
1st 24 hrs – 24%
1st 48 hrs – 29%
1st week – 44%
1st 2 weeks – 50%
1st year – 90% - Most die in 3 mos.
TYPE B
Mortality (Untreated)
1st month – 10%
1st year – 15%
5 years – 20%
‘Complicated’ Type B (on Medical Mx only)
1st 48 hrs – 20%
1st month – 25%
ESC task force. Eur heart J. 2001;22:1642-81
IRAD registry. JAMA 2000;283:897–903
11. NATURAL HISTORY
PREDICTORS OF MORTALITY
Age > 70 yr
Hypotension
Pericardial tamponade
Myocardial infarct/ischemia
Stroke/Coma
Intestinal ischemia
Renal failure
Pulse differences
‘COMPLICATED’ TYPE B – 30-42% of
TBAAD
Persistent or recurrent pain
Uncontrolled HTN despite full medication
Early aortic expansion
Malperfusion
Signs of rupture (haemothorax, increasing
periaortic/mediastinal haematoma)
Retrograde dissection into the aortic arch
ESC task force. Eur heart J. 2001;22:1642-81
IRAD registry. JAMA 2000;283:897–903
13. Grossly underdiagnosed!
Most common , most lethal aortic emergency
Among life-threatening causes of chest pain, AD has the highest mortality — an estimated 1-2% per hour for the
first 48 hours.
Still a formidable diagnostic challenge in ED - As many as 65% AD missed in initial exam.
Freedman DL. Aortic dissection: Be suspicious or the autopsy will make diagnosis.
ED Legal Letter 2000; 11:105-116.
Diagnostic delays of >24 hrs in 39 % patients. (31 % proximal AD, 53 % distal AD )
Viljanen T. Diagnostic difficulties in aortic dissection.
Ann Chir Gynaecol 1986;75:328–32
14. PRETEST
PROBABILITY
LOW PROBABILITY
0-1 risk group features
present
HIGH PROBABILITY
2-3 risk group features
OR
Typical chest pain
ACC/AHA guideline. Circulation 2010;121:e266
15. CLASS I
CLASS I
CLASS I
CLASS IIa
CLASS I
CLASS I
CLASS IIa
ACC/AHA guideline. Circulation 2010;121:e266
16. IMAGING IN AORTIC DISSECTION
REQUIRED DETAILS
MDCT – MC used – speed, availability and accuracy (>95% in diagnosis
and identification of side branch involvement)
ESC guideline. Eur heart J. 2014;35:2873-2926
18. MEDICAL MANAGEMENT
ANTI IMPULSE THERAPY
Reduces propagation tendency
BP lowering: SBP 100-120
Rule out significant AR
Watch for oliguria
HR lowering: ≤ 60 bpm
Decreasing LV contraction velocity
Decreasing Aortic wall shear stress
19. MEDICAL MANAGEMENT
ANTI IMPULSE THERAPY
Beta blockers DOC – but cautious of significant
AR
IV Labetalol
IV Esmolol
Additional drugs +/-
IV Verapamil/Diltiazem
IV Enalapril
IV Nitroprusside
Vasodilators always with background rate control
Avoid Hydralazine – increase shear stress
PAIN CONTROL
Opioids: Morphine DOC
23. SURGICAL MANAGEMENT OUTCOME
TYPE A
In hospital mortality - 27%
- 10% by 24 hours
- 16% by 7 days
- 20% by 14 days
(Still 30% mortality benefit at 2 weeks vs. Medical
Rx alone – so, clear TOC!)
Survival post discharge - 96% at 1 year
- 91% at 3 years
TYPE B ‘COMPLICATED’
In hospital mortality - 31%
Paraplegia - varies 2-19%
Survival post discharge - 83% at 3 year
(Poorer prognosis than Type A!)
24. 30 day mortality of types
of dissection with medical
/ surgical management
27. ENDOVASCULAR THERAPY vs. OPEN
SURGERY
Advantages
Less Invasive – No thoracotomy/No CPB
Less painful
Less morbidity – No aortic clamp – Less stroke
– Less intercostal artery coverage –
Less paraplegia
Shorter hospitalization
Feasible in high surgical risk pts
Feasible in hemodynamically unstable pts – less blood
loss
Disadvantages
Suitable anatomy is pre-requisite
Contrast related toxicity
Higher cost
More secondary interventions
Lifelong follow-up required
28. ENDOVASCULAR THERAPY vs. OPEN
SURGERY
Advantages
Less Invasive – No thoracotomy/No CPB
Less painful
Less morbidity – No aortic clamp – Less stroke
– Less intercostal artery coverage –
Less paraplegia
Shorter hospitalization
Feasible in high surgical risk pts
Feasible in hemodynamically unstable pts – less blood
loss
Disadvantages
Suitable anatomy is pre-requisite
Contrast related toxicity
Higher cost
More secondary interventions
Lifelong follow-up required
TBAAD TEVAR
• In hospital mortality rates - 5-9%
• Stroke - 2-6%
• Paraplegia - 1-3%
30. Principles of Endovascular Stent graft
Rationale of stent-graft Rx is 2-fold:
~ in the acute phase: prevents imminent aortic rupture & relieve dynamic branch-vessel
occlusion
~ in the chronic phase: promote thrombosis of the false lumen & decrease morbidity
associated with patency of the false lumen: aneurysmal dilation, late aortic rupture & late
mortality
Ability to cover the primary intimal tear & create a seal to stop the flow of blood entering the
false lumen & prevent the transmission of systemic pressure across the major intimal defect
33. ‘COMPLICATED’ TYPE B AD
If anatomy suitable – Endovascular preferred over surgery
No randomized trial – but long term registries show lower mortality than surgical
series
34.
35.
36.
37.
38. UNCOMPLICATED TYPE B AD
Apart from best medical Mx – endovascular Mx has been tried
Rationale – To promote Aortic positive remodeling – thinking it would improve
survival
Compared in 3 randomised trials
Remains a controversy!
47. Suitable anatomy is pre-requisite
Adequate access - Iliofemoral anatomy
CFA MC access - MC right CFA for device delivery (Right EIA bifurcates at less acute angle from CIA)
- left CFA for diagnostic angiography guide catheters to guide deployment
- But not universal, needs individual assessment by imaging
- 20-24 Fr system MC
Ideal access - lumen 8 mm or more - females have lower caliber arteries
- lowest diameter at proximal EIA
- no heavy calcified plaque – hinders device delivery
- no substantial tortuosity
- atleast one side iliofemoral artery non-dissected
If EIA/femoral anatomy inadequate - CIA access by ileal conduit
- rarely, Distal aortic access – entire ilial system is hostile
Rutherford’s vascular surgery. 8th Ed. 2014
48. Suitable anatomy is pre-requisite
Adequate aortic channel
Abdominal aorta less often a problem
Proximal descending thoracic aorta may have tortuous angle specially when aneurysmal – excessive sheath bending
Severe arch angulation (>60 degrees)
Rutherford’s vascular surgery. 8th Ed. 2014
49. Suitable anatomy is pre-requisite
Aortic sealing zones
Adequate proximal and distal landing zones
Adequate lengths vary from 15-30 mm for various devices
Longer sealing zones preferable - esp. in angulated areas
- decrease late endoleaks
- decrease late aneurysmal degeneration
But, this urge to cover more aorta - increased risk of spinal cord ischemia/paraplegia
Landing zone in curved parts – inner curve susceptible to leaks, as graft stiffness straightens it
Free of significant disease
“correct” device dimension: diameter based on non-diseased aorta immediately proximal to the entry tear: the segment between Left CC & Left
SCA is used: oversized by 10% to ensure secure anchoring & a tight circumferential seal
If possible, ideal landing zone in TBAAD – Zone 3/4 proximally (after LSCA) and Zone 5 distally (before celiac trunk)
Rutherford’s vascular surgery. 8th Ed. 2014
50. 11 Landing zones
for aortic
interventions
Rutherford’s vascular surgery. 8th Ed. 2014
51. Suitable anatomy is pre-requisite
Adequate device dimension
Diameter based on non-diseased aorta immediately proximal to the entry tear:
MC segment between Left CC & Left SCA is used
Oversized by 10% to ensure secure anchoring & a tight circumferential seal
Rutherford’s vascular surgery. 8th Ed. 2014
52. STENT GRAFT SYSTEMS
All thoracic stent-grafts have a metallic
skeleton with a covering membrane (either
PTFE or polyester).
Most have either proximal or distal
uncovered stents for better stent-graft
anchoring to the aortic wall, and some also
have metallic barbs for the same purpose.
are all self-expanding and constrained by a
sleeve or sheath.
53. STENT GRAFT SYSTEMS
Zenith TX2 by Cook Medical (A)
TAG by GORE (B)
Valiant by Medtronic AVE (C)
Relay Thoracic Stent-Graft by Bolton Medical
(D)
EndoFit by LeMaitre Vascular (E)
54. PROCEDURE
Vascular access is preferably gained through surgical exposure of the right
common femoral artery. If the femoral arteries are too small or diseased, the
common iliac artery or abdominal aorta via a retroperitoneal approach can be
used
Whenever those vascular accesses are considered inappropriate, anterograde
access through the ascending aorta by direct exposure via median
sternotomy can be achieved.
55. PROCEDURE
Vascular access is preferably gained through surgical exposure of the right common
femoral artery. If the femoral arteries are too small or diseased, the common iliac artery
or abdominal aorta via a retroperitoneal approach can be used
Whenever those vascular accesses are considered inappropriate, anterograde access
through the ascending aorta by direct exposure via median sternotomy can be
achieved.
56. PROCEDURE
Initial Preparation - An angiography catheter is inserted through the right
brachial artery
When the lesion is too close to the LSA, an additional catheter is advanced in the
ascending aorta via a percutaneous left brachial approach and is used as an adequate
landmark for the LSA origin for delivery.
57. PROCEDURE
Delivery of the Stent-Graft
A hydrophilic guidewire is placed in the aortic arch under fluoroscopic guidance.
exchanged for a stiff guidewire.
intravenous administration of 5000 IU of heparin sodium
the delivery system is passed over the stiff guidewire and positioned at the proximal end of the aortic
abnormality.
The exact placement site is selected on the basis of angiographic and transesophageal echocardiography
information, considering aortic wall status and diameter at the neck sites.
58. PROCEDURE
Delivery of the Stent-Graft
A hydrophilic guidewire is placed in the aortic arch under fluoroscopic guidance.
exchanged for a stiff guidewire.
intravenous administration of 5000 IU of heparin sodium
the delivery system is passed over the stiff guidewire and positioned at the proximal end of the aortic
abnormality.
The exact placement site is selected on the basis of angiographic and transesophageal echocardiography
information, considering aortic wall status and diameter at the neck sites.
59. PROCEDURE
Deployment of the Stent-Graft
For optimal fixation, all stent-grafts are oversized in diameter compared with the diameter of the
proximal and distal necks of the lesion, by 10%–15%
delivered either by holding the stent-graft stationary with a pusher rod while withdrawing the delivery
sheath or by pulling a string that releases the stent-graft– covering sleeve.
demonstrate no significant shortening during or after deployment.
60. PROCEDURE
Once the desired location is reached, the outer sheath is withdrawn to completely deploy the stent-graft.
During release of the device, the systolic arterial blood pressure is lowered to 70 mm Hg. If
needed, a balloon catheter can then be inflated to achieve full expansion and to anchor the stent to the
aortic wall. Additional segments may be deployed distally as necessary to ensure disease exclusion.
Completion angiography is performed to confirm proper stent-graft placement and complete disease
exclusion and to verify the presence of correct perfusion through the graft without perigraft leakage.
No further anticoagulation is administered.
61. Complications
Early adverse events
Paraplegia (1-5%)
Stroke
Retrograde dissection into the
ascending aorta (2%)
Stent-graft collapse (3%)
Periprocedural endoleaks
(<10%): mostly type I
Late adverse events
Endoleaks (<5%): mostly type II
Retrograde dissection into the
ascending aorta (2%)
Stent-graft migration/torsion
Strut fracture or erosion
Aortic aneurysm formation &
rupture
Aorto-oesophageal fistula
Mobile thrombus within the stent-
graft lumen
62. Endoleaks
Coined by White, et al, 1996
Leak around proximal or distal attachment sites
Persistent flow in aneurysm sac
Incomplete exclusion
Rates
0 to 44%
Risks
Aneurysm Expansion
Rupture
64. Endoleak management
Type I and Type III endoleaks - regarded as treatment failures
o Warrant further treatment to prevent the continuing risk of rupture – Class I indication
o MC endovascular stenting – MC covered graft
Type II endoleaks – usually conservative Management
o ‘wait-and-watch’ strategy to detect aneurysmal expansion, except for supra-aortic arteries
Types IV and V endoleaks – usually benign course
o Treatment is required in cases of aneurysm expansion.
65. Outcome
The IRAD registry provides an analysis of the different management options for type B aortic
dissection, with data comparing the impact on survival of different treatment strategies in 571
patients with acute type B aortic dissection
390 patients (68.3%) with uncomplicated aortic dissection were treated medically, whereas among
complicated cases, 59 (10.3%) underwent standard open surgery and 66 (11.6%) underwent
endovascular repair.
TEVAR provided better outcomes, with 9.3% mortality in patients treated with a stent graft and
33.9% mortality in patients who underwent open surgery.
In patients discharged to home, longterm results seem to confirm the benefit of stent graft repair
with respect to medical therapy alone.
66. Outcome
Procedural success: 89%
Periprocedural endoleak: 6.7%
Neurologic complications: 2.3%
30-day mortality rate: 8.4%
One year data was available for 67 pts
Late intervention :1.5%
Late endoleak: 1.5%
Late death: 1.5%
1-year cumulative survival rate:90%
67.
68. PETTICOAT
concept!
Entry point is sealed with
endograft
Remaining thoracic and
potentially abdominal
aorta is stented open
Decrease chance of true
lumen collapse, enhance
aortic remodeling, and
promote false lumen
thrombosis