Vamshi Kotha Eric J Herget amp Jehangir J Appoo Depts of Radiology amp Libin Cardiovascular Institute University of Calgary Calgary Canada 52 nd STS Annual ID: 588980
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Imaging Experience of Type II Hybrid Aortic Arch Repair: Lessons learned from Zone 0 Debranching & Evolution to Zone 2 Arch Repair Vamshi Kotha, Eric J Herget & Jehangir J. Appoo Depts of Radiology & Libin Cardiovascular InstituteUniversity of CalgaryCalgary, Canada52ndSTS Annual MeetingPhoenix, ArizonaJanuary 25th, 2016Slide2
Endovascular repair changed paradigm of descending aortic surgeryEvolution of Endovascular RepairSlide3
Endovascular repair changed paradigm of descending aortic surgeryProximal arch and ascending aorta are next frontiers in pathway to closed chest aortic surgeryEvolution of Endovascular RepairSlide4
Endovascular repair changed paradigm of descending aortic surgeryProximal arch and ascending aorta are next frontiers in pathway to closed chest aortic surgeryHybrid operations intermediate step offers unique opportunity to learn about behaviour of endografts in proximal aortaEvolution of Endovascular RepairSlide5
Bavaria Classification for Hybrid ArchSlide6
PENN Classification Type II HybridDiffuse AortomegalyComplicated Type A DissectionIndications for Type II HybridSlide7
The Operation*Proximal Landing Zone of Stent Graft is in Dacron Ascending AortaReplacement Ascending AortaDebranch arch vessels with proximalization of ostium to level of STJAntegrade Stent graft insertion after CPBSlide8
Purpose Assess radiologic outcome of endografts placed in the ascending aorta during Type II Hybrid Repair Slide9
Results20 patients Type II Hybrid Arch from 2009 to 2014Mean age – 66 years (Range: 47-82)Indications:8/20 Acute Type A with primary intimal tear in distal arch or prox descending aorta6/20 Diffuse atherosclerotic aortomegaly of asc, arch and descending aorta4/20 Previous Type A repair with arch and descending aneurysms in pt2/20 Contained arch rupture with diffuse descending aortic disease 50% Emergencies 25% Redo sternotomySlide10
Periop Results Mortality 1/20 Permanent Neuro deficit 2/20 Paraparesis 2/20 – complete recoverySlide11
Follow Up One pt lost to f/u (moved to Europe)No late mortalityMean imaging f/u 34months (Range 12-64 months)Slide12
Nice straight proximal landing zone after Type II Hybrid in acute Debakey Type I dissectionIdeal Proximal Landing Zone Slide13
>5mm protrusion and non-apposition of stent graft along lesser curve of ascending aorta at prox LZBird beaking at the proximal landing zone has been described as > 5mm non-apposition of the endovascular stent graft within the surgical Dacron graft. 23mmBird BeakingSlide14
Bird Beaking: 12/20 (60%)Severe Bird Beaking >20mm: 7/20 (35%) 23.0 mm58.6o
Bird beaking at the proximal landing zone has been described as > 5mm non-apposition of the endovascular stent graft within the surgical Dacron graft.
23mmSlide15
Proximal Landing Zone complications4/20 patients Type 1a endoleak Day 4Graft Migration on initial post op CT Day 5Type 1a endoleak Day 11 Delayed infolding of graft Day 7553 patients underwent re-intervention – endovascularly1 patient with Type 1a endoleak continues to be followedSlide16
Stent graft migration n =1Treated with additional proximal deviceSlide17
2 year follow up
Graft bucklingn=1
1 year follow upSlide18
Rescued with Palmaz StentSlide19
Pts. With Prox LZ complicationsPts. Without Prox LZ complicationsMean bird beak length22.0mm10.9mmP=0.07Significance of Bird Beak?Slide20
While we wait for technology to improve, we have transitioned towards a “Zone 2” Approach
Changed our Surgical Approach
Transect the arch between the left carotid and left subclavian Slide21
Zone 2 Arch – next generation of Hybrid Arch
Zone 2 Arch Mod HCA
12 to 15
mins
SACP 22 to 25
minsSlide22
Type II Hybrid2009-2014Zone 2 Arch2014-PresentNext: Zone 2 Arch with branched stent graft ?Slide23
Imaging Experience of Type II Hybrid Arch RepairLessons Learned from Zone 0 Debranching :1) Good midterm survival in challenging patient populationSlide24
Imaging Experience of Type II Hybrid Arch RepairLessons Learned from Zone 0 Debranching:1) Good midterm survival in challenging patient population2) Challenges in conforming to sharp angulation of ascending aortaSlide25
Imaging Experience of Type II Hybrid Arch RepairLessons Learned from Zone 0 Debranching :1) Good midterm survival in challenging patient population2) Challenges in conforming to sharp angulation of ascending aorta3) Significant bird beaking when landing in dacron of ascending aortaSlide26
Imaging Experience of Type II Hybrid Arch RepairLessons Learned from Zone 0 Debranching :1) Good midterm survival in challenging patient population2) Challenges in conforming to sharp angulation of ascending aorta3) Significant bird beaking when landing in dacron of ascending aorta4) Endovascular devices in ascending aorta may be prone to complicationsSlide27
Imaging Experience of Type II Hybrid Arch RepairLessons Learned from Zone 0 Debranching :1) Good midterm survival in challenging patient population2) Challenges in conforming to sharp angulation of ascending aorta3) Significant bird beaking4) Endovascular devices in ascending aorta may be prone to complications5) Angulation issues will need to be overcome by stent graft refinement to enable future closed chest approaches to the ascending aorta“Innovation: Something Different that has an Impact” Slide28
Calgary Thoracic Aortic Program,
www.aorta.ca
,
Jehangir.Appoo@AlbertaHealthServices.ca