thoracic aortic pathology challenges and solutions thomas c. naslund, m.d. vanderbilt university...
TRANSCRIPT
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THORACIC AORTIC PATHOLOGY
CHALLENGES AND SOLUTIONS
Thomas C. Naslund, M.D.Vanderbilt University Medical Center
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CONFLICT OF INTEREST
WL Gore Investigator, Speaker, Consultant
Boston Scientific Consultant
LeMaitre VascularScientific Advisory Board
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OFF LABEL USE
• WL Gore TAG
• Cook Zenith
• WL Gore Excluder
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FREQUENTLY SEEN PATHOLOGY
• Aneurysm
-fusiform *
-saccular (concern for infection)
• Aortic Dissection – Type A* and B
• Traumatic transection
• Penetrating ulcer
• Intramural hematoma
*labeled use for TAG
*surgical management
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PENETRATING ULCER
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INTRAMURAL HEMATOMA
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THORACIC AORTIC ANEURYSM
• Atherosclerosis of iliacs– 8-9 mm EI make most TEVAR easy
– 7-8 mm EI make some TEVAR difficult
– <6 mm EI is a clear danger zone (alternate access)• Dilation with serial dilators if EI normal
• KY jelly helps
• Extreme caution with dilators and atherosclerosis
• Tortuosity of iliacs and TA (arch)• Neck
– <2cm in straight distal attachment can work
– 2cm with angle in arch will not work
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ACCESS FOR THE DISEASED ILIAC
• Conduit– Sutured to the CI artery end to side– Complete TEVAR via conduit– Consider anastomosis to CFA after completion
• May need secondary intervention• CFA may already be exposed/opened/damaged
• Direct CI/Abdominal Aorta Access– Transverse incision over rectus sheath– Retract rectus laterally/RP dissection– CI/terminal aorta easily exposed – Counter puncture in lower quadrant– Direct arterial closure
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GOALS OF ENDOVASCULAR MANAGEMENT
Acute Type B Aortic Dissection
• Redirect flow into true lumen
• Cover entire descending thoracic aorta
• Provide satisfactory visceral flow
• Facilitate aortic healing
• Avoid surgical repair
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DISSECTION TREATMENT ALGORITHM
• Type A- Medical Therapy &Emergency Cardiac Surgery Evaluation
• Type B- Medical therapy» Stent graft for complications in acute phase» Stent graft for aneurysm formation in late follow up» Long term follow up for all Type B to assess aneurysm
formation/stent graft
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NECK PROBLEMS/SOLUTIONS
• Big (>36mm) – 45mm TAG in EU
• Small (<23mm)– 18-23mm diameter graft
• Short (< 2cm)– Debranching/fenestration
• Angled (>?)– Specific design/fenestration
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LENGTHENING THE NECKCovering Branch Vessels
• Left Subclavian– Consider vertebrobasilar circulation
• Contralateral vertebral/carotid disease
• Celiac– Consider pancreaticoduodenal and gastroduodenal
• SMA disease
• Coiling typically not needed– Subclavian for Type II leak
• Transbrachial– Celiac
• Flow robust– Catheterize, cover celiac/trap catheter, coil
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SURGICAL DEBRANCHING
• Viscerals– Celiotomy
• Midline gets all 4
• Left flank gets 3,maybe 4
• Arch– Left subclavian to carotid transposition– Carotid-carotid bypass (retroesophageal)– Aortoinnominant & carotid bypass
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ARCH REPAIR
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TRAUMATIC TRANSECTION
• Deceleration injury–MVA
–falls
• Sudden movement of aortic arch
• Circumferential tear of arterial intima and media
• Survivors have intact adventitia and possibly some media
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TRAUMATIC TRANSECTION
• Innominate artery second most common site
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VANDERBILT SERIESOpen Repair 1987
• 41 Patients
• 5 Died without repair– 3 preoperatively
– 2 en route with emergency thoracotomy
• 5/36 Repaired died during operation– 3/5 associated with aortic clamping
• 2/36 Paraparesis
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TRANSECTION PRE OP MEDICAL MANAGEMENT
• Beta Blockade
• BP/HR control
• Discontinue after repair
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STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION
n = 20
• Since 2005
• Age 35 (15 – 72)
• Mortality 1/20 (5%) – 72 yo MSOF
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STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION
n = 20• Mean procedure time 103min
• Mean blood loss 390ml
• Mean intraoperative transfusion 1 unit
• Grafts utilized– TAG - 9
– Cook Iliac extenders- 9
– Excluder aortic cuffs - 2
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STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION
n = 20
• Technical success 100%– graft exclusion of injured
segment
– No deaths pre operatively
• Operative complications– groin access site – 2
– TAG graft collapse – 2
– spinal cord injury – 0
– dialysis – 0
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LATE FOLLOW UP
• Erosions – 0
• Endoleaks/aneurysm – 0
• Access site false aneurysm – 0
• Paraplegia – 0
• Secondary interventions – 0
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USE OF COOK ILIAC LIMB EXTENDER
• Aorta diameter too small for TAG prosthesis (<23mm)
• 55 mm length (satisfactorily covers entire area of injury)
• Z stent design (no collapse)
• Requires manual loading into long sheath to reach aortic arch
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ZENITH Delivery and Deployment
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USE OF ABDOMINAL AORTIC CUFF EXTENDERS
• 33 – 36 mm length
• Reported in several series with success
• Requires 3 or more individual cuffs to bridge injured region
• Requires inventory of substantial numbers of aortic cuffs
• Cook, Medtronic, and Gore
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TIGHT ARCH
• Typical of adolescence and young adults
• Implant can either poorly oppose the inner arch and collapse
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FOLLOW UP
• Interval CT in 1 – 3 days (renal function considerations)
• Follow up CT 1 -3 months after discharge
• Annual CT • Eventually CT each 3-5
years • Emphasis on permanent
life-long follow up
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LATE CONCERNS
• Erosion
• False aneurysm formation
• Infections
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MINIMAL AORTIC INJURY
• Focal-non-circumferential intimal disruption
• No false aneurysm
• No periaortic hematoma
• Suitable for medical therapy and CT follow up rather than intervention– Healing typical in 3-6 months– Persistent fixed lesions identified after 1 year
followup