Is the stent graft best served frozen or warm Jehangir J Appoo Division of Cardiac Surgery Libin Cardiovascular Institute Cumming School of Medicine University of Calgary wwwaortaca ID: 576450
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Hybrid Arch for Acute Type A Aortic Dissection Is the stent graft best served “frozen” or “warm” ?
Jehangir J. AppooDivision of Cardiac SurgeryLibin Cardiovascular InstituteCumming School of MedicineUniversity of Calgarywww.aorta.ca
9
th Houston Aortic SymposiumFrontiers in Cardiovascular DiseasesMarch 3rd, 2016 Slide2
Today: Focus on Hybrid Arch for Acute Type A Aortic DissectionIntroduce 1 new concept: “Warm Stent Graft” vs. “Frozen Stented Elephant Trunk”
Propose Classification System & outcome of Systematic Review of Hybrid Arch for ATAADShare one case as an exampleThought provoking questions on what’s next step for Aortic CommunityMy objectives for next 8 mins:Slide3
Is the Stented Elephant Trunk best served “FROZEN” or “WARM” ?
vs.
Hybrid Arch for ATAADSlide4
Total Arch Replacement
Total Arch Replacement & Frozen Stented Elephant Trunk - deployed during hypothermic circulatory arrest Hemi-arch Replacement & Frozen Stented Elephant Trunk - deployed during hypothermic circulatory arrest
Total Arch Replacement & Warm Stent Graft - deployed after cardiopulmonary bypass
Proposed Classification of Extended Arch Operations for ATAAD Slide5
38 publications, >2100 patientsPooled op mortality 8.6% (95%CI 7.2-10.0)Pooled stroke 5.7
% (95%CI 3.6-8.2)Pooled spinal cord ischemia 2.0% (95%CI 1.2-3.0)
Systematic Review of Extended Arch Operations for ATAADSmith, HN et al. (in submission)
* Note: 2015 Publications from GERAADA and IRAD suggest 15-20% operative mortalitySlide6
Advantages of:Frozen Elephant Trunk vs. “Warm Stent Graft”
No requirement of Endovascular skill setNo intraop fluoroscopy/hybrid room requiredNo requirement of contrast agentApplicability to large number cardiac surgeons
Visualization of landing zonesConfirmation of resolution of malperfusionRecognition of Stent Induced New Tear
Distal extension of treatmentNo increase in circulatory arrest timeSlide7
Primary Entry Tear Distal to L subclavian artery
49
y.o
male ATAAD Presents to OSH – March 2015Slide8
Clinical and radiologic Visceral Malperfusion
Our Current Practice: Case Example
49 y.o male ATAAD presents to OSH – March 2015Slide9
Tear confirmed distal to left subclavian artery Arch resected and anastamosis done in Zone 2 with individual bypasses to innominate, left carotid and left subclavian
Right axillary cannulation Moderate Hypothermia at 25oC HCA – 14mins with continuous ACP SACP – 28mins
Intraop:Slide10
On Table Angio - after Zone 2 Arch Reconstruction and separating from CPB
Prior to stent graft insertion
Post TEVARSlide11
6 months follow up : Slide12Slide13
CCS/CSCS/CSVS
Joint Position Statement on Interventions for Thoracic Aortic Disease
Presented @ CCC Oct.2015 – Toronto Canadian Journal of Cardiology, In PressSlide14
RECOMMENDATIONSWe recommend an extended distal arch repair technique be considered for patients who present with acute Type A dissection and one of the following:
Primary intimal entry tear in the arch or descending aortaSignificant aneurysmal disease of the arch (Strong recommendation, Low Quality Evidence)Slide15
RECOMMENDATIONSWe suggest that it is reasonable to consider an extended distal arch repair technique for patients who present with acute Type A dissection and one of the following:
Distal malperfusionConcomitant descending thoracic aortic aneurysmYoung patientsPatients with connective tissue disorders (Weak recommendation, Low Quality Evidence)Slide16
Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry dataCONCLUSIONS:
Pooled op mortality 8.6% (95%CI 7.2-10.0)Pooled stroke 5.7% (95%CI 3.6-8.2)Pooled spinal cord ischemia 2.0% (95%CI 1.2-3.0Slide17
Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry dataProposed Classification system of Extended Arch Techniques based on: Total Arch vs. Hemi-Arch &
Frozen Stent Graft vs. Warm Stent GraftCONCLUSIONS:Slide18
Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry dataClassification system of Extended Arch Techniques based on Total Arch vs. Hemi-Arch
Frozen Stent Graft vs. Warm Stent GraftHybrid Repairs for treatment of ATAAD now entering Guidelines 2014 European Guidelines 2015 Canadian Guidelines
CONCLUSIONS:Slide19
Hemi-arch vs. Extended Arch ± Descending Stent Graft ?
NEXT PHASE: Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do?
*Recall no RCT ever done for isolated ascending aortic replacement vs. hemi-arch Slide20
Hemi-arch vs. Extended Arch ± Descending Stent Graft Frozen Elephant Trunk vs.
Warm Stent Graft?NEXT PHASE: Which Multicentre RCT
of Hybrid Arch for ATAAD does Aortic Community wish to do? Slide21
Hemi-arch vs. Extended Arch ± Descending Stent Graft Frozen Elephant Trunk vs
. Warm Stent Graft Hybrid Arch vs. Hybrid Arch + BareMetal Stent Distally?
NEXT PHASE: Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do? Slide22
Introduce new concept of “Warm Stent Graft” vs. Frozen Stented Elephant Trunk Propose Classification System & Results of Hybrid Arch for ATAADShare a caseProvoke thought on what’s next step for Aortic Community
My objectives for past 8 mins:Slide23
Calgary Thoracic Aortic Program,
www.aorta.ca
,
Jehangir.Appoo@AlbertaHealthServices.ca