Prof Dr Hakan PosacıoğluEge Üniversitesi Kalp ve Damar Cerrahisi

Prof Dr Hakan PosacıoğluEge Üniversitesi Kalp ve Damar Cerrahisi

VISCERAL DEBRANCHING FOR THE TREATMENT OF TAAAVISCERAL DEBRANCHING FOR THE TREATMENT OF TAAA

MANAGEMENT OF THE TAAA MANAGEMENT OF THE TAAA

- OPEN SURGERY- OPEN SURGERY

Mortality rates 2-20%(rates are higher for type II)

Complications of repair include -renal failure (2-12%) -cardiopulmonary (4-33%) -neurologic deficit (1-15%)

20-30% patients being dischargedto another instution rather than home

Mortality rates 2-20%(rates are higher for type II)

Complications of repair include -renal failure (2-12%) -cardiopulmonary (4-33%) -neurologic deficit (1-15%)

20-30% patients being dischargedto another instution rather than home

-ENDOVASCULAR-ENDOVASCULAR

-FENESTRATED OR BRANCHED STENT GRAFTS

-CHIMNEY OR SNORKEL TECHNIQES COMBINED WITH STENT GRAFT

-FENESTRATED OR BRANCHED STENT GRAFTS

-CHIMNEY OR SNORKEL TECHNIQES COMBINED WITH STENT GRAFT

-MULTI LAYERED FLOW MODULATER STENTS

-MULTI LAYERED FLOW MODULATER STENTS

-VISCERAL DEBRANCHING WITH STENT GRAFTS-VISCERAL DEBRANCHING WITH STENT GRAFTS

HYBRIDTAAA REPAIR

HYBRIDTAAA REPAIR

DEFINITION OF VISCERAL DEBRANCHING DEFINITION OF VISCERAL DEBRANCHING

EXTRA-ANATOMIC REVASCULARIZATION OF 1- CELIAC 2- SMA 3- RENAL ARTERIES

EXTRA-ANATOMIC REVASCULARIZATION OF 1- CELIAC 2- SMA 3- RENAL ARTERIES

THE KEY PRINCIPLES OF THIS HYBRID TAAA REPAIR

THE KEY PRINCIPLES OF THIS HYBRID TAAA REPAIR

-RETROGRADE FASHION REVASCULARIZATION

-COMPLETE EXCLUSION OF TAAA WITH STANDARD ENDOVASCULAR STENT GRAFTS

-RETROGRADE FASHION REVASCULARIZATION

-COMPLETE EXCLUSION OF TAAA WITH STANDARD ENDOVASCULAR STENT GRAFTS

VISCERAL HYBRID TAAA REPAIRVISCERAL HYBRID TAAA REPAIR

ADVANTAGES;

-REDUCED VISCERAL ISCHEMIC TIME AND SPINAL CORD ISCHEMIA

-NO AORTIC CROSS CLAMP

-AVOIDANCE OF THORACOTOMY, LESS PULMONARY COMPLICATIONS

-LESS HEMODYNAMIC INSTABILITY

-REDUCED HOSPITAL STAY

-LESS BLOOD LOSS/REDUCED TRANSFUSION REQUIREMENT

ADVANTAGES;

-REDUCED VISCERAL ISCHEMIC TIME AND SPINAL CORD ISCHEMIA

-NO AORTIC CROSS CLAMP

-AVOIDANCE OF THORACOTOMY, LESS PULMONARY COMPLICATIONS

-LESS HEMODYNAMIC INSTABILITY

-REDUCED HOSPITAL STAY

-LESS BLOOD LOSS/REDUCED TRANSFUSION REQUIREMENT

IN EMERGENCY CASES, THESE STENT GRAFTS ARE READILY AVAILABLE,UNLIKE FENESTRATED OR BRANCHED STENT-GRAFTS

IN EMERGENCY CASES, THESE STENT GRAFTS ARE READILY AVAILABLE,UNLIKE FENESTRATED OR BRANCHED STENT-GRAFTS

DETERMINATION OF INFLOW SITEDETERMINATION OF INFLOW SITE

1-EXTEND OF ANEURYSMAL DISEASE (IF RENAL ARTERIES ARE NOT INVOLVED ABDOMINAL AORTA CAN BE USED)

1-EXTEND OF ANEURYSMAL DISEASE (IF RENAL ARTERIES ARE NOT INVOLVED ABDOMINAL AORTA CAN BE USED)

2-PREVIOUS EVAR OR INFRA RENAL SURGERY FOR AAA REPAIR( affect the determination of inflowsite)

2-PREVIOUS EVAR OR INFRA RENAL SURGERY FOR AAA REPAIR( affect the determination of inflowsite)

3-COMMON AND EXTERNAL ILIAC ARTERY DIAMETER,PRE- EXISTENCE OF STENOSIS,TORTUOSITY AND KINKING ARE ALSO IMPORTANT FACTORS IN CHOOSING INFLOW SITE

3-COMMON AND EXTERNAL ILIAC ARTERY DIAMETER,PRE- EXISTENCE OF STENOSIS,TORTUOSITY AND KINKING ARE ALSO IMPORTANT FACTORS IN CHOOSING INFLOW SITE

**WE NEVER USE INFLOW ILIAC ARTERY AS A SITE FOR STENT GRAFT INSERTION

**WE NEVER USE INFLOW ILIAC ARTERY AS A SITE FOR STENT GRAFT INSERTION

GRAFT CHOICE GRAFT CHOICE

- HEPARIN BOUNDED PTFE GRAFT

- SMA OR CELIAC GRAFTS CONSTITUTE MAIN TRUNK THE OTHERS WERE ANASTOMOSED TO MAIN TRUNK END TO SIDE FASHION

- HEPARIN BOUNDED PTFE GRAFT

- SMA OR CELIAC GRAFTS CONSTITUTE MAIN TRUNK THE OTHERS WERE ANASTOMOSED TO MAIN TRUNK END TO SIDE FASHION

IF DOPPLER SIGNALS ARE SATISFACTORYIN THE BYPASS GRAFTS, NATIVE ARTERIES ARE LIGATEDTO PREVENT TYPE II ENDOLEAK .

IF DOPPLER SIGNALS ARE SATISFACTORYIN THE BYPASS GRAFTS, NATIVE ARTERIES ARE LIGATEDTO PREVENT TYPE II ENDOLEAK .

**THERE IS ONE EXCEPTION (CELIAC TRUNK). VERY DENSE VENOUS COLLATERALS AND LYMPHATICS MAKE THE DISSECTION AND LIGATION VERY DIFFICULT.CT LEFT UNLIGATED AND CLOSED WITH COILS OR VASCULAR PLUG 2-4 WEEKS AFTER OP.

**THERE IS ONE EXCEPTION (CELIAC TRUNK). VERY DENSE VENOUS COLLATERALS AND LYMPHATICS MAKE THE DISSECTION AND LIGATION VERY DIFFICULT.CT LEFT UNLIGATED AND CLOSED WITH COILS OR VASCULAR PLUG 2-4 WEEKS AFTER OP.

Coils and glue

HYBRID REPAIR OF TYPE II TAAA

HYBRID REPAIR OF TYPE II TAAA

OPERATIVE TECHNIQUEOPERATIVE TECHNIQUE

MIDLINE LAPAROTOMYMIDLINE LAPAROTOMY

1- CELIAC TRUNK EXPOSURE1- CELIAC TRUNK EXPOSURE

COMMON HEPATIC ARTERY(OUT FLOW FOR CELIAC REVASCULARIZATION)

COMMON HEPATIC ARTERY(OUT FLOW FOR CELIAC REVASCULARIZATION)

GASTRODUODENAL ARTERYGASTRODUODENAL ARTERY

WE PERFORM OUTFLOW ANASTOMOSIS FIRSTWE PERFORM OUTFLOW ANASTOMOSIS FIRST

ACCESS IS OBTAINED IN THE LESSER SAC, LEFT LOBE OF THE LIVER SLIGHTLY RETRACTED TO THE RIGHT, STOMACH AND PANCREAS HELD CAUDALLY

ACCESS IS OBTAINED IN THE LESSER SAC, LEFT LOBE OF THE LIVER SLIGHTLY RETRACTED TO THE RIGHT, STOMACH AND PANCREAS HELD CAUDALLY

PTFE GRAFT (USUALLY 6 MM) ANASTOMOSED COMMON HEPATIC ARTERY. PTFE GRAFT (USUALLY 6 MM) ANASTOMOSED COMMON HEPATIC ARTERY.

THE GRAFT IS TUNNELLED BETWEEN THE PANCREAS AND STOMACH TO THE RETROPERITONEUM

THE GRAFT IS TUNNELLED BETWEEN THE PANCREAS AND STOMACH TO THE RETROPERITONEUM

PANCREASPANCREAS

STOMACH STOMACH

COMMON HEPATICARTERY

COMMON HEPATICARTERY

2- SMA EXPOSURE2- SMA EXPOSURE

IT STARTS LIKE STANDARD INFRENAL ABDOMINAL AORTIC EXPOSURE

IT STARTS LIKE STANDARD INFRENAL ABDOMINAL AORTIC EXPOSURE

DUODENUM AND TREIZ LIGAMENT MOBILIZED. SMA TRUNK CAN BE FOUND 1 OR 1.5 CM ABOVE THE RENAL ARTERY ORIFICES

DUODENUM AND TREIZ LIGAMENT MOBILIZED. SMA TRUNK CAN BE FOUND 1 OR 1.5 CM ABOVE THE RENAL ARTERY ORIFICES

8MM PTFE GRAFT IS ANASTOMOSED TO SMA END TO SIDE FASHION 8MM PTFE GRAFT IS ANASTOMOSED TO SMA END TO SIDE FASHION

SMASMA

“LAZY C” GRAFT “LAZY C” GRAFT

COMMON HEPATIC GRAFT

COMMON HEPATIC GRAFT

3-LEFT AND RIGHT RENAL ARTERY EXPOSURE3-LEFT AND RIGHT RENAL ARTERY EXPOSURE

DURING LRA EXPOSURE ; WE PERFORM ANTERIOR APPROACH SIMILAR TO THAT USED FOR CONVENTIONAL AAA REPAIR. LEFT RENAL VEIN FREED AND SOME BRANCHES LIGATURED.

DURING LRA EXPOSURE ; WE PERFORM ANTERIOR APPROACH SIMILAR TO THAT USED FOR CONVENTIONAL AAA REPAIR. LEFT RENAL VEIN FREED AND SOME BRANCHES LIGATURED.

RIGHT RENAL EXPOSURE; IT REQUIRES LIMITED TAKE DOWN OF THE HEPATIC FLEXURE OF THE COLON .

RIGHT RENAL EXPOSURE; IT REQUIRES LIMITED TAKE DOWN OF THE HEPATIC FLEXURE OF THE COLON .

MOST DIFFICULT EXPOSURE AND ANASTOMOSIS IS THE RIGHT RENAL ARTERY;

1- EXTENSIVE DISSECTION

2-VERY DISTAL ANASTOMOSIS DUE TO VCI (4-5 MM RENAL ARTERY)

3-TUNNELING OF THE GRAFT TO THE INFLOW SITE IS DIFFICULT

4-SURGEON SOULD BE AWARE OF EARLY BRANCHING OR MULTIPLE RENAL ARTERIES

MOST DIFFICULT EXPOSURE AND ANASTOMOSIS IS THE RIGHT RENAL ARTERY;

1- EXTENSIVE DISSECTION

2-VERY DISTAL ANASTOMOSIS DUE TO VCI (4-5 MM RENAL ARTERY)

3-TUNNELING OF THE GRAFT TO THE INFLOW SITE IS DIFFICULT

4-SURGEON SOULD BE AWARE OF EARLY BRANCHING OR MULTIPLE RENAL ARTERIES

1-CEREBRO SPINAL FLUID DRAINAGE -POSTOP DAY 1 AND 2 ACTIVE DRAINAGE

- POSTOP DAY 3 JUST PRESSURE MONITORING

- POSTOP DAY 4 NO MONITORING BUT IT STAYS

1-CEREBRO SPINAL FLUID DRAINAGE -POSTOP DAY 1 AND 2 ACTIVE DRAINAGE

- POSTOP DAY 3 JUST PRESSURE MONITORING

- POSTOP DAY 4 NO MONITORING BUT IT STAYS

SPINAL CORD PROTECTION STRATEGYSPINAL CORD PROTECTION STRATEGY

2-MEAN ARTERIAL PRESSURE SHOULD BE ≥ 90-100mmHG

2-MEAN ARTERIAL PRESSURE SHOULD BE ≥ 90-100mmHG

3- HYPOXIA AND ACIDOSIS SHOULD BE AVOIDED

3- HYPOXIA AND ACIDOSIS SHOULD BE AVOIDED

4- HEMOGLOBIN SHOULD BE ≥ 10-12 mg/dl 4- HEMOGLOBIN SHOULD BE ≥ 10-12 mg/dl

EGE UNIVERSITY CARDIOVASCULAR SURGERY EXPERIENCEEGE UNIVERSITY CARDIOVASCULAR SURGERY EXPERIENCE

88 11 4422 33

PATIENTS : 18 (16 MALE)

CONTAINED RUPTURE: 4

MEDIAN AGE: 72±

CSF DRAINAGE: 16

INFLOW SITE: -INFRARENAL AA :2 -COMMON ILIAC: 16

FOLLOW UP:40±6 MONTHS

PATIENTS : 18 (16 MALE)

CONTAINED RUPTURE: 4

MEDIAN AGE: 72±

CSF DRAINAGE: 16

INFLOW SITE: -INFRARENAL AA :2 -COMMON ILIAC: 16

FOLLOW UP:40±6 MONTHS

NO MORTALITYNO MORTALITY

WHAT ABOUT GRAFT DURABILITY?WHAT ABOUT GRAFT DURABILITY?

WE ARE SURPRISED THAT EARLY AND MIDTERM GRAFTTHROMBOSIS RATE REMAINS VERY LOW

WE ARE SURPRISED THAT EARLY AND MIDTERM GRAFTTHROMBOSIS RATE REMAINS VERY LOW

RIGHTRENAL8/8(4 chimney)

RIGHTRENAL8/8(4 chimney)

SMA14/14

SMA14/14 LEFT

RENAL7/5

LEFTRENAL7/5

COMMANHEPATIC16/16(1 snorkel)

COMMANHEPATIC16/16(1 snorkel)

LEFT İLİACARTERY

LEFT İLİACARTERY

COMMON TRUNK2/2

COMMON TRUNK2/2

SMA

HEPATİC

SPLENIC

RESULTS: GRAFTS PATENCY: 95%RESULTS: GRAFTS PATENCY: 95%

TOTAL 42 GRAFTS 2 OCCLUSION

TOTAL 42 GRAFTS 2 OCCLUSION

PATIENT 1: 78 YEARS OLD MEN.TYPE 4 TAAA AND RENAL FUNCTIONS MODERATLY ELEVATED. ONE STAGE OPERATION CSF DRAINAGE +

PATIENT 1: 78 YEARS OLD MEN.TYPE 4 TAAA AND RENAL FUNCTIONS MODERATLY ELEVATED. ONE STAGE OPERATION CSF DRAINAGE +

PREOP CTPREOP CT

SMA

COMMONHEPATİC

LEFT RENAL

DEBRANCHING GRAFTSDEBRANCHING GRAFTS

POSTOP CT (1 YEAR)POSTOP CT (1 YEAR)

PATIENT 2: 75 YEARS OLD MALE PATIENT. TYPE 1 TAAA. PREVIOUS MULTIPLE PCI AND LOW EF. TWO-STAGE OPERATION CSF DRAINAGE +

PATIENT 2: 75 YEARS OLD MALE PATIENT. TYPE 1 TAAA. PREVIOUS MULTIPLE PCI AND LOW EF. TWO-STAGE OPERATION CSF DRAINAGE +

PREOP CTPREOP CT

DEBRANCHING GRAFTSDEBRANCHING GRAFTS

SMA

COMMANHEPATIC

LEFT RENAL

RIGHTRENAL

POSTOP CT (5 YEAR)ENLARGEMENT OF DISTAL LANDING ZONE

POSTOP CT (5 YEAR)ENLARGEMENT OF DISTAL LANDING ZONE

EXTENSION OF CHIMNEY

EXTENSION OF CHIMNEY

EXTENSION OF STENT GRAFTAND RIGHT RENAL ARTERY CHIMNEY

EXTENSION OF STENT GRAFTAND RIGHT RENAL ARTERY CHIMNEY

EXTENDEDVIABANH

EXTENDEDVIABANH

LAST CTLAST CT

PATIENT 3: 65 YEARS OLD WOMEN. BEHÇET’S DISEASE WITH VASCULAR INVOLVEMENT. TYPE 3 TAAA 3 MONTHS AGO BENTALL OPERATION TWO STAGE OPERATION - CSF DRAINAGE +

PATIENT 3: 65 YEARS OLD WOMEN. BEHÇET’S DISEASE WITH VASCULAR INVOLVEMENT. TYPE 3 TAAA 3 MONTHS AGO BENTALL OPERATION TWO STAGE OPERATION - CSF DRAINAGE +

PREOP CTPREOP CT

COMPLETE VISCERAL AND RENAL ARTERY DEBRANCHING** right renal artery very small

COMPLETE VISCERAL AND RENAL ARTERY DEBRANCHING** right renal artery very small

POSTOP CT (3 YEAR)POSTOP CT (3 YEAR)

COMPLICATIONS:COMPLICATIONS:

GRAFT OCCLUSION: 2 (RENAL ARTERY)

DELAYED PARESTHESIA: 1(COMPLETE RECOVERY )

PROLONGED VENTIALATION: 1 (1 WEEK)

SMA DISSECTION AND TYPE II ENDOLEAK: 1

GRAFT OCCLUSION: 2 (RENAL ARTERY)

DELAYED PARESTHESIA: 1(COMPLETE RECOVERY )

PROLONGED VENTIALATION: 1 (1 WEEK)

SMA DISSECTION AND TYPE II ENDOLEAK: 1

GRAFT TO ENTERIC FISTULA:1GRAFT TO ENTERIC FISTULA:1

TYPE II ENDOLEAK : 4 ( 3 of them due to delayed occlusion of celiac trunk)TYPE II ENDOLEAK : 4 ( 3 of them due to delayed occlusion of celiac trunk)

GRAFTS WERE SOAKED WITH RIFAMPIN AND COVERED BY OMENTUM

GRAFTS WERE SOAKED WITH RIFAMPIN AND COVERED BY OMENTUM

CONCLUSIONCONCLUSION

-There are no pure comparative reports that demonstrate a definite advantageof hybrid TAAA repair. It may offer advantages in a selected population who are considered high risk for open repair.

-There are no pure comparative reports that demonstrate a definite advantageof hybrid TAAA repair. It may offer advantages in a selected population who are considered high risk for open repair.

Technology of fenestrated and branched stent grafts is still emerging. Imaging,sizing and graft construction all require time. In addition, the high cost of these stent grafts are prohibitive to many centers.

Technology of fenestrated and branched stent grafts is still emerging. Imaging,sizing and graft construction all require time. In addition, the high cost of these stent grafts are prohibitive to many centers.

Similar to conventional repair, results are likely to be better in higher volume centers with the necessary infrastructure.

Similar to conventional repair, results are likely to be better in higher volume centers with the necessary infrastructure.

Disadvantages of one stage operation are1-longer duration of operation2-increased risk of renal failure due to renal ischemia and contrastAdministration.