Hybrid Arch for Acute Type A Aortic Dissection

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Presentation transcript:

Hybrid Arch for Acute Type A Aortic Dissection Hybrid Arch for Acute Type A Aortic Dissection 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 www.aorta.ca Canadian Thoracic Aortic Collaborative Meeting April 16th, 2016

Today: Focus on Hybrid Arch for Acute Type A Aortic Dissection My objectives for next 10 mins: Introduce 1 new concept: “Warm Stent Graft” vs. “Frozen Stented Elephant Trunk” Propose Classification System & Outcome of Systematic Review of Hybrid Arch for ATAAD Discuss Pros and Cons of “Warm” vs. “Frozen” Thought provoking questions on what’s next step for Aortic Community

Controversy: Extent of Arch Replacement in Type A Dissection 1980’s & 1990’s: Ascending only vs. Hemiarch Today: Hemiarch vs. Hybrid Arch (Extended Arch ± Descending Aorta)

Hybrid Arch for Acute Type A Aortic Dissection What is Hybrid Arch? Vague term – combines open chest and endovascular Variety of techniques No standardized nomenclature exists for discussion of technique & comparison of results

Systematic Review of published Extended Arch Operations for ATAAD Smith, HN et al. (in submission) 38 publications till Fall 2015; >2,100 patients

Proposed Classification of Extended Arch Operations for ATAAD Based on 2 concepts: 1) Extent of arch reconstruction: Total Arch vs. Hemiarch 2) Method of Stent Graft deployment: Frozen vs. Warm

Frozen vs. Warm Stent Graft:

Proposed Classification of Extended Arch Operations for ATAAD Smith, HN et al. (in submission) 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

Systematic Review of Extended Arch Operations for ATAAD Smith, HN et al. (in submission) 38 publications, >2100 patients 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 1.2-3.0) *Note: 2015 Publications from GERAADA and IRAD suggest 15-20% operative mortality

Conclusion of Systematic Review Extended arch repair for ATAAD with or without distal stent grafting shows surprisingly low incidence of early mortality and major complications Now that we know extended arch repair for ATAAD can be done safely & we have a classification system, we can discuss pros and cons of various technical options

Advantages of: Frozen Elephant Trunk vs. Warm Stent Graft No requirement of Endovascular skill set – can be more widely adopted by cardiac surgeons

Advantages of: Frozen Elephant Trunk vs. Warm Stent Graft No requirement of Endovascular skill set – can be more widely adopted by cardiac surgeons No intraop fluoroscopy/hybrid room required and operative time not increased

Advantages of: Frozen Elephant Trunk vs. Warm Stent Graft No requirement of Endovascular skill set – can be more widely adopted by cardiac surgeons No intraop fluoroscopy/hybrid room required and operative time not increased No requirement of nephrotoxic contrast agent

Advantages of: Frozen Elephant Trunk vs. Warm Stent Graft No requirement of Endovascular skill set – can be more widely adopted by cardiac surgeons No intraop fluoroscopy/hybrid room required and operative time not increased No requirement of nephrotoxic contrast agent More published data on this technique than “Warm Stent Graft”

Advantages of: Frozen Elephant Trunk vs. Warm Stent Graft No requirement of Endovascular skill set – can be more widely adopted by cardiac surgeons No intraop fluoroscopy/hybrid room required and operative time not increased No requirement of nephrotoxic contrast agent More published data on this technique than “Warm Stent Graft” No access issues

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones Assessment of Endoleaks/Stent Induced New EntryTear (SINE)

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones Assessment of Endoleaks/Stent Induced New EntryTear Assessment of branch vessel patency

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones Assessment of Endoleaks/Stent Induced New EntryTear Assessment of branch vessel patency Confirmation of resolution of malperfusion

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones Assessment of Endoleaks/Stent Induced New EntryTear Assessment of branch vessel patency Confirmation of resolution of malperfusion Distal extension of treatment

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones Assessment of Endoleaks/Stent Induced New EntryTear Assessment of branch vessel patency Confirmation of resolution of malperfusion Distal extension of treatment Use of tapered devices/tromboned fashion

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones Assessment of Endoleaks/Stent Induced New EntryTear Assessment of branch vessel patency Confirmation of resolution of malperfusion Distal extension of treatment Use of tapered devices/tromboned fashion Extent of coverage can be individualized

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones Assessment of Endoleaks/Stent Induced New EntryTear Assessment of branch vessel patency Confirmation of resolution of malperfusion Distal extension of treatment Use of tapered devices/tromboned fashion Extent of coverage can be individualized No increase in hypothermic circulatory arrest time

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones Assessment of Endoleaks/Stent Induced New EntryTear Assessment of branch vessel patency Confirmation of resolution of malperfusion Distal extension of treatment Use of tapered devices/tromboned fashion Extent of coverage can be individualized No increase in hypothermic circulatory arrest time

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones Assessment of Endoleaks/Stent Induced New EntryTear Assessment of branch vessel patency Confirmation of resolution of malperfusion Distal extension of treatment Use of tapered devices/tromboned fashion Extent of coverage can be individualized No increase in hypothermic circulatory arrest time Deployment at normothermia allows for nitinol stent expansion

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones Assessment of Endoleaks/Stent Induced New EntryTear Assessment of branch vessel patency Confirmation of resolution of malperfusion Distal extension of treatment Use of tapered devices/tromboned fashion Extent of coverage can be individualized No increase in hypothermic circulatory arrest time Deployment at normothermia allows for nitinol stent expansion Can be done in a staged fashion permitting assessment of whether stent graft is needed

Advantages of “Warm Stent Graft” vs. Frozen Elephant Trunk Assessment of adequate proximal and distal sealing zones Assessment of Endoleaks/Stent Induced New EntryTear Assessment of branch vessel patency Confirmation of resolution of malperfusion Distal extension of treatment Use of tapered devices/tromboned fashion Extent of coverage can be individualized No increase in hypothermic circulatory arrest time Deployment at normothermia allows for nitinol stent expansion Can be done in a staged fashion permitting assessment of whether stent graft is needed Lots of sizes available off the shelf

49 y.o male ATAAD Presents to OSH – March 2015 Primary Entry Tear Distal to L subclavian artery

Our Current Practice: Case Example 49 y.o male ATAAD presents to OSH – March 2015 Clinical and radiologic Visceral Malperfusion

Intraop: 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

On Table Angio - after Zone 2 Arch Reconstruction and separating from CPB Prior to stent graft insertion Post TEVAR

6 months follow up :

CCS/CSCS/CSVS Joint Position Statement on Interventions for Thoracic Aortic Disease Presented @ CCC Oct.2015 – Toronto Canadian Journal of Cardiology, In Press

RECOMMENDATIONS We 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 aorta Significant aneurysmal disease of the arch (Strong recommendation, Low Quality Evidence)

RECOMMENDATIONS We 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 malperfusion Concomitant descending thoracic aortic aneurysm Young patients Patients with connective tissue disorders (Weak recommendation, Low Quality Evidence)

CONCLUSIONS: Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data 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 1.2-3.0

CONCLUSIONS: Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data Proposed Classification system of Extended Arch Techniques based on: Total Arch vs. Hemi-Arch & Frozen Stent Graft vs. Warm Stent Graft

CONCLUSIONS: Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data Classification system of Extended Arch Techniques based on Total Arch vs. Hemi-Arch Frozen Stent Graft vs. Warm Stent Graft Pros of Frozen vs. Warm Stent Graft Technique Broader applicability vs. visualization/intraop assmt

CONCLUSIONS: Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data Classification system of Extended Arch Techniques based on Total Arch vs. Hemi-Arch Frozen Stent Graft vs. Warm Stent Graft Pros of Frozen vs. Warm Stent Graft Technique Broader applicability vs. visualization/intraop assmt Hybrid Repairs for treatment of ATAAD now entering Guidelines 2014 European Guidelines 2015 Canadian Guidelines

NEXT PHASE: Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do? Hemi-arch vs. Extended Arch ± Descending Stent Graft ? *Recall no RCT ever done for isolated ascending aortic replacement vs. hemi-arch

NEXT PHASE: Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do? 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? Hemi-arch vs. Extended Arch ± Descending Stent Graft Frozen Elephant Trunk vs. Warm Stent Graft Hybrid Arch vs. Hybrid Arch + BareMetal Stent Distally?

Novel Hybrid Arch Techniques for ATAAD Zone 2 Arch Zone 2 Arch with branched stent graft

My objectives for past 10 mins: Introduce new concept of “Warm Stent Graft” vs. Frozen Stented Elephant Trunk Propose Classification System & Results of Hybrid Arch for ATAAD Discuss Pros and Cons of “Warm” vs. “Frozen” Provoke thought on what’s next step for Aortic Community

Calgary Thoracic Aortic Program, www. aorta. ca,. Jehangir Calgary Thoracic Aortic Program, www.aorta.ca, Jehangir.Appoo@AlbertaHealthServices.ca