New Techniques / Devices in Endovascular Treatment of Aortic Diseases Dr. Haji Zeinali Interventional Cardiologist Tehran Heart Center

Disclosure Statement Within the past two years: I have not had an affiliation (financial or otherwise) with a commercial organization that may have a direct or indirect connection to the content of my presentation I have had an affiliation (financial or otherwise) with a commercial organization that may have a direct or indirect connection to the content of my presentation. Details: Proctor Consulting Trials Other Does your presentation describe the off-label use of a device, product or drug that is approved for another purpose? No Yes (If yes, you must disclose this within your presentation)

Summary Chimney Fenestrated: Custom-made / off-the-shelf Sandwich Iliac Branch Device (IBD) Ascending aortic stent-grafts Physician made fenestrated stent-grafts Aortic Arch PEVAR STABLE (for complicated type B dissection)

Nellix Nellix system aims to treat the sac and does not rely on proximal-neck fixation With this system, the aneurysm itself is anchored with a set of 2 thin-walled polyester polymer-filled endobags that freeze the sac in a definitive and permanent manner  Only 34 patients treated so far, but device performance and clinical outcomes so far seem promising.1 1. EVAR Using the Nellix Sac-anchoring Endoprosthesis: Treatment of Favourable and Adverse Anatomy, European Journal of Vascular and Endovascular Surgery Volume 42, Issue 1, July 2011, Pages 38–46

Trivascular Ovation The Trivascular Ovation is a 14Fr stent-graft CE marked in January 2011 and 800 worldwide implantations worlwide so far It has suprarenal stents for fixation to prevent migration, two sealing “rings” around the trunk to prevent endoleak,  and channels in the main body are then filled with polymer to create a seal against the aorta and provide support for the graft. It has severeal additional steps (preparation and filling of the polymer) but clinical results so far seem promising

Aorto-iliac Aneurysms: Sandwich Technique The ‘sandwich technique’ aims to preserve flow into the internal iliac artery (IIA) when conducting EVAR for aorto-iliac aneurysms First the main body is deployed in the aorta, then the IIA is cannulated from contralateral or brachial access, then a peripheral covered stent graft is inserted in the IIA and deployed concurrently with the stent- graft in the external iliac artery One study of 21 patients showed technical success rate of 88%, limb occlussion was 9%, primary patency at 6mnths for EIA was 95% and for IIA was 88%.1 (also called the double barrel technique) Results of a double-barrel technique with commercially available devices for hypogastric preservation during aortoilac endovascular abdominal aortic aneurysm repair, Journal of Vascular Surgery, Volume 56, Issue 5, November 2012, Pages 1259-1260

Aorto-iliac Aneurysms: IBD Cook Medical Iliac Branch Device (IBD) is the first and only system ever approved specifically for preserving flow to the internal iliac artery in aorto-iliac aneurysms The IBD helps avoid complications such as buttock claudication, necrosis, ischemia, impotence that may result from iliac embolization

Type B Dissection: STABLE Procedure STABLE: Staged thoraco-abdominal and branch vessel endoluminal repair STABLE Procedure: Antihypertensive therapy; staged thoracoabdominal and branch vessel endoluminal repair: First, the covered and bare stents are deployed, then covered or bare stent reconstruction of branch vessels and re-entry tears is conducted if necessary to promote false lumen thrombosis and remodeling

Type B Dissection Cook Medical Zenith Dissection System is the first system ever approved specifically for treating Type B Dissections. Features a proximal covered stent to seal the primary entry tear, and a distal bare stent to support the delimanitaed aortic segment, remodel the true lumen, and promote false lumen thrombosis New devices recently launched: Wider 8mm taper No barbs Flared bare stent

Chimney Chimney EVAR (CHEVAR) In juxta-renal AAA (where there is no infrarenal landing zone) a covered balloon expandable stent-graft is deployed in the renal arteries, and extended proximally in the supra-renal aorta, therefore allowing the aortic stent graft to also be extended proximally in the aorta, thereby increasing the landing zone Literature shows technical success rate to be 91%, peri-operative major morbidity of 17%, mortality rates of 5%, and early type 1 endoleaks of 13%.1 1. Chimney technique in the endovascular management of complex aortic disease, Vascular Journal, October 2012 vol. 20 no. 5 251-261

Fenestrated: Custom-Made Cook Medical Zenith Fenestrated is the first stent-graft designed for precise positioning in patients with juxtra-renal AAA Custom made device specifically designed for each patient, contains two ‘fenestrations’ for the renal arteries, and one scallop for the SMA

Fenestrated: Custom-Made

Fenestrated: Off-the-shelf Cook Medical Zenith t-Branch is the only off-the-shelf endovascular stent-graft indicated to treat thoraco-abdominal aortic aneurysms (TAAA) No need to wait for custom made device (CMD) Of the patients suitable for CMD, 88% fit the criteria for the t-Branch1 Figure legend: Scatter plot of branch position of the 59 patients meeting the initial 4 criteria with standard endograft overlaid. The angled lines indicate the boundary conditions as outlined in the text. The 3 branches that fall outside the boundary conditions are circled. CA: celiac artery, SMA: superior mesenteric artery, RRA: right renal artery, LRA: left renal artery. 1. J Endovas Ther. 2009;16:359-364

Future: Ascending Aortic EVAR Figure legend: Scatter plot of branch position of the 59 patients meeting the initial 4 criteria with standard endograft overlaid. The angled lines indicate the boundary conditions as outlined in the text. The 3 branches that fall outside the boundary conditions are circled. CA: celiac artery, SMA: superior mesenteric artery, RRA: right renal artery, LRA: left renal artery.

Thank you!