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Treatment of thoracoabdominal aortic aneurysms. surgery alone or hybrid
- 1. Lenox Hill Heart and Vascular Institute of New York Treatment of Thoracoabdominal Aortic Aneurysms. Surgery alone or Hybrid. Konstadinos A Plestis, MD Associate Professor Director of Aortic Surgery Department of Thoracic and Cardiovascular Surgery Lenox Hill Hospital, NY
- 2. Lenox Hill Heart and Vascular Institute of New York The Risk of Paraplegia Crawford Classification (n = 1509) I II III IV 15% 31% 7% 4% Svensson LG, Crawford ES: J Vasc Surg 1993; 17:357-370
- 3. Lenox Hill Heart and Vascular Institute of New York Open Surgical Treatment Extensive Operations Need of CPB + DHCA Risk of Paraplegia Post-operative Mortality and Morbidity
- 4. Lenox Hill Heart and Vascular Institute of New York Endovascular Treatment Decreases Access Trauma Decreases Blood Loss Reduces Morbidity and Mortality? Improves long term outcomes?
- 5. Lenox Hill Heart and Vascular Institute of New York Hybrid repair Kuratani et al
- 6. Lenox Hill Heart and Vascular Institute of New York Debranching + stent Hughes et al
- 7. Lenox Hill Heart and Vascular Institute of New York Debranching + stent Kabbani et al
- 8. Lenox Hill Heart and Vascular Institute of New York Spinal Cord Protection Cerebral Protection Visceral Organ Protection Goals during Open Repair of TA Aneurysms
- 9. Lenox Hill Heart and Vascular Institute of New York Current Lenox Hill Technique Mild systemic hypothermia, 32°C Distal perfusion CSF drainage Monitoring of SSEP and MEP Spinal cord perfusion pressure (SCPP) monitoring
- 10. Lenox Hill Heart and Vascular Institute of New York DHCA: Indications Proximal clamping is not feasible Need to clamp above the left subclavian Type II Aneurysms?
- 11. Lenox Hill Heart and Vascular Institute of New York CSF Drainage Technique CSF catheter : L4-L5 or L3-4 CSF pressure < 10mmHg CSF drainage: 10 cc/h CSF drainage for 2-3 days
- 12. Lenox Hill Heart and Vascular Institute of New York Current Lenox Hill Technique Mean BP: 85-95mmHg CSF drainage for 72-96 hr CSF drainage at 10 cc/hr SCPP monitoring Steroids for 48 hrs Postoperative Management
- 13. Lenox Hill Heart and Vascular Institute of New York
- 14. Lenox Hill Heart and Vascular Institute of New York
- 15. Lenox Hill Heart and Vascular Institute of New York
- 16. Lenox Hill Heart and Vascular Institute of New York
- 17. Lenox Hill Heart and Vascular Institute of New York
- 18. Lenox Hill Heart and Vascular Institute of New York
- 19. Lenox Hill Heart and Vascular Institute of New York
- 20. Lenox Hill Heart and Vascular Institute of New York Motor-evoked potential (MEP) amplitudes baseline MEP MEP amplitude disappearance MEP amplitude recovery
- 21. Lenox Hill Heart and Vascular Institute of New York CASE PRESENTATION 42 yo patient Distal Arch/ Type I TAAA
- 22. Lenox Hill Heart and Vascular Institute of New York
- 23. Lenox Hill Heart and Vascular Institute of New York Visceral Perfusion Is it necessary?
- 24. Lenox Hill Heart and Vascular Institute of New York BUN 23.7 30.4 17.04 20.4 38.1 24.2 19.3 40.5 26.2 Pre OP Highest End NO DHCA BUN (all cases) DHCA =p<.05
- 25. Lenox Hill Heart and Vascular Institute of New York CREATNINE 1.49 2.03 1.43 1.48 2.92 2.06 1.48 2.83 1.98 Pre OP Highest End NO DHCA Creatnine(allcases) DHCA
- 26. Lenox Hill Heart and Vascular Institute of New York AMYLASE 54 428 194 61 175 7962 148 62 Pre Op Highest End DHCA Amylase(all cases) NO DHCA
- 27. Lenox Hill Heart and Vascular Institute of New York Total Bilirubin 0.65 2.75 1.23 0.66 2.85 1.170.68 3.46 0.81 Pre OP Highest End NO DHCA T. Bilirubin (all cases) DHCA
- 28. Lenox Hill Heart and Vascular Institute of New York SGOT 16 344 37 22 137 33 23 102 36 Pre OP Highest End DHCA SGOT (all cases) NO DHCA
- 29. Lenox Hill Heart and Vascular Institute of New York 16 220 54 19 84 3620 62 33 Pre OP Highest End DHCA SGPT (all cases) NO DHCA SGPT
- 30. Lenox Hill Heart and Vascular Institute of New York Visceral Perfusion Dilute Blood Rate at 100-200 cc/min
- 31. Lenox Hill Heart and Vascular Institute of New York Case Presentation 67 yr old patient Type IV TAAA Previous Descending TA repair Symptomatic
- 32. Lenox Hill Heart and Vascular Institute of New York Celiac axis
- 33. Lenox Hill Heart and Vascular Institute of New York R Renal
- 34. Lenox Hill Heart and Vascular Institute of New York
- 35. Lenox Hill Heart and Vascular Institute of New York Iliac Bifurcation
- 36. Lenox Hill Heart and Vascular Institute of New York
- 37. Lenox Hill Heart and Vascular Institute of New York Stroke Prevention Cannulation Techniques Left Axillary Cannulation Ascending Aorta Cannulation Arch cannulation Stage I Elephant Trunk
- 38. Lenox Hill Heart and Vascular Institute of New York 62 yr old patient Type I TAAA Grade V aortic arch Stenosis of the Celiac, SMA
- 39. Lenox Hill Heart and Vascular Institute of New York Grade V Aortic Arch
- 40. Lenox Hill Heart and Vascular Institute of New York Descending Thoracic Aorta
- 41. Lenox Hill Heart and Vascular Institute of New York Celiac axis
- 42. Lenox Hill Heart and Vascular Institute of New York Infrarenal Aorta
- 43. Lenox Hill Heart and Vascular Institute of New York
- 44. Lenox Hill Heart and Vascular Institute of New York Stage I ET Trifurcation graft
- 45. Lenox Hill Heart and Vascular Institute of New York Celiac SMA Stage I ET
- 46. Lenox Hill Heart and Vascular Institute of New York
- 47. Lenox Hill Heart and Vascular Institute of New York January 2002 – July 2011 Total Cases 219 male 112 51% female 107 49% Age 66 + 13
- 48. Lenox Hill Heart and Vascular Institute of New York Etiology: N=219 0 10 20 30 40 50 60 70 80 90 Medial Degen. Ather. Chr. Diss. Acute Diss. Other 38% 23% 27% 3% 9%
- 49. Lenox Hill Heart and Vascular Institute of New York Presentation: N=219 Elective Rupture Urgent 66% 19% 15%
- 50. Lenox Hill Heart and Vascular Institute of New York Aneurysm Type:N=219 0 10 20 30 40 50 60 70 80 Type I Type II Type III Type IV 36% 20% 23% 21%
- 51. Lenox Hill Heart and Vascular Institute of New York No Distal perfusion 29 13% Femoral-Femoral 87 40% Atrial-Femoral 103 47% DHCA 41 19%
- 52. Lenox Hill Heart and Vascular Institute of New York Operative variables Aortic X time 49 (14-173) CPB time 87 (17-320) DHCA time 31 (22-56)
- 53. Lenox Hill Heart and Vascular Institute of New York Mortality 13 6% Paraplegia 4 2%
- 54. Lenox Hill Heart and Vascular Institute of New York Post- Op Bleeding 8 4% Stroke 6 3% Embolic 3 Hemorrhage 3 Operative Complications
- 55. Lenox Hill Heart and Vascular Institute of New York New Onset Renal Complications:Cr>2.5 New onset renal insufficiency 51 24% New Onset Hemodialysis 8 4% Ventilation>48h 51 23%
- 56. Lenox Hill Heart and Vascular Institute of New York Hospital Stay Mean 12 d Range (5-96)
- 57. Lenox Hill Heart and Vascular Institute of New York Survival TAAA 122 105 67 36 21 10
- 58. Lenox Hill Heart and Vascular Institute of New York Survival and Dissection Dissection Non Dissection p =0.015 58 63 54 32 20 10 58 51 33 16 10
- 59. Lenox Hill Heart and Vascular Institute of New York Open – Demographics Plestis 2011 N=219 Schephens 199 N=258 Gambria 2002 N=337 Coselli 2007 N=2286 Conrad- 2007 N=445 Age 66 65 70 66 71 Extent I + II 56% 58% 44% 64% 42% Rupture 19% 15% 13% 6% 11% Hybrid – Demographics Kuratani 2009 N=86 Choong 2009 N=70 Donas 2009 N=58 Kabbani 2010 N=36 Chiesa 2009 N=31 Age 71 67 64.5 71 70 Extent I + II 27% 56% 14% 31% 45% Rupture 3% 4% 14% N/A N/A
- 60. Lenox Hill Heart and Vascular Institute of New York Open Hybrid Kuratani 2009 N=86 Choong 2009 N=70 Donas 2009 N=58 Kabbani 2010 N=36 Chiesa 2009 N=31 Mortality 2.3% 16% 25% 8.3% 19.4% SCI 1.2% 10% 3.4% 3% 8.6% Dialysis 2.3% N/A N/A 11% 6.4% Endoleak 10% N/A 17% 27% N/A Plestis 2011 N=219 Schephens 199 N=258 Gambria 2002 N=337 Coselli 2007 N=2286 Conrad- 2007 N=445 Mortality 6% 10% 8% 7% 8% SCI 2% 11% 11% 4% 13% Dialysis 4% 10% 13% 6% 21%
- 61. Lenox Hill Heart and Vascular Institute of New York Follow Up Survival -Open Kuratani 2009 Kabbani 2010 Chiesa 2009 Bockler 2008 Survival 1 year 3 years 5 years 70% 80% 60% 70% Follow Up Survival -Endovascular Plestis 2011 Schephens 2010 Conrad 2007 Kouchoukos 2011 Survival 1 year 5 years 10 years 70% 51% 83% 63% 34% 54% 29% 55%% 23%
- 62. Lenox Hill Heart and Vascular Institute of New York Conclusions Both open and hybrid operations in the thoracoabdominal aorta remain extremelly complex operations The results of open repair of TAAA have improved significantly over the last decade in centers of excellence The long term outcomes of hybrid operations have not been determined yet. Open TAA repair remains the procedure of choice in appropriately selected candidates
- 63. Lenox Hill Heart and Vascular Institute of New York Thank you
- 64. Lenox Hill Heart and Vascular Institute of New York
- 65. Lenox Hill Heart and Vascular Institute of New York
- 66. Lenox Hill Heart and Vascular Institute of New York Extent and Mortality 0 10 20 30 40 50 60 70 80 90 Type I TypeII TypeIII TypeIV Descending Mortality 6% 0% 13% 6% 6% P>0.05 N
- 67. Lenox Hill Heart and Vascular Institute of New York Mortality and Distal Perfusion 0 20 40 60 80 100 120 Atriofemoral Femoral Femoral None Mortality No Mortality" 6% 7% 10% P>0.05
- 68. Lenox Hill Heart and Vascular Institute of New York Mortality and Aneurysm Type 0 20 40 60 80 100 120 140 160 1 2 No 5% 6% P>0.05 TAAA DTA
- 69. Lenox Hill Heart and Vascular Institute of New York 0 20 40 60 80 100 120 140 160 180 1 2 No Ventilation<48h Ventilation>48h Mortality and Ventilation>48h 2.5% 13% P<0.05
- 70. Lenox Hill Heart and Vascular Institute of New York 0 50 100 150 200 250 1 2 Mortality and Hemodialysis No 4% 19% P<0.05 No Hemodialysis Hemodialysis
- 71. Lenox Hill Heart and Vascular Institute of New York 0 50 100 150 200 250 1 2 40% 4% Stroke and Mortality StrokeNo Stroke P<0.05
- 72. Lenox Hill Heart and Vascular Institute of New York Survival TAAA Dissection DTA Non Dissection DTA Dissection TAAA non Dissection p =0.038
- 73. Lenox Hill Heart and Vascular Institute of New York Survival TAAA DTA 44 40 29 15 9 5 79 65 50 21 11 7
- 74. Lenox Hill Heart and Vascular Institute of New York Questions Does endovascular surgery treat the same patients as open surgery ? Does endovascular surgery treat the same extent of aorta? Does endovascular surgery deliver the same long- term outcomes?
- 75. Lenox Hill Heart and Vascular Institute of New York Hybrid Approach Chieas et al
- 76. Lenox Hill Heart and Vascular Institute of New York 4 vessel debranching + stent Biasi et al
- 77. Lenox Hill Heart and Vascular Institute of New York Infrarenal replacement + debranching Bockler et al
- 78. Lenox Hill Heart and Vascular Institute of New York MEP and SSEP guided intercostal artery reimplantation Avoidance of subclavian artery clamping Operative Management
- 79. Lenox Hill Heart and Vascular Institute of New York Is it reasonable to search for a single segmental artery whose preservation will prevent paraplegia? NO Is it reasonable to monitor spinal cord integrity in the perioperative period and treat cord ischemia when it occurs? YES Do we yet have a strategy to assure preservation of spinal cord integrity through the perioperative period of thoracic and thoracoabdominal aortic aneurysm resection? NO Has the neurological outcome of thoracic and thoracoabdominal aortic surgery improved markedly in the past decade? YES