TEVAR for Chronic Type B Dissection

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Presentation transcript:

TEVAR for Chronic Type B Dissection Ryan LP1, Herdrich BJ2, Moser GW1, Moeller P1, Wang GJ2, Bavaria JE1 Divisions of Cardiovascular1 and Vascular2 Surgery University of Pennsylvania School of Medicine

Descending Aneurysm TEVAR with Elective Left Subclavian Coverage and Zone 2 LZ

Indications for TEVAR Thoracic Aortic Aneurysm FDA Approved Acute Complicated Type B Dissection Off-Label: Standard of Care Traumatic Aortic Rupture Off-Label: Investigational Chronic Type B Dissection

Chronic Dissection: Either Residual Type B after Type A Repair or simple Chronic Type B

Chronic Type B Dissection: TEVAR Prospective RCT of 140 patients with chronic type B dissection

Chronic Type B Dissection: TEVAR TEVAR TL diameter FL diameter 91.3% thoracic FL thrombosis Nienaber CA, et al. Circulation. 2009;120:2519-28. 6

Dir. Prof. R. Di Bartolomeo Cardiac Surgery Dept. University of Bologna Dir. Prof. R. Di Bartolomeo Note: All 4 vessels off TL 1 week after surgery After 3 months

Chronic Type B Dissection: TEVAR Chronic Type B Dissection: TEVAR Thrombosis of the False Lumen Total Thrombosis Thoracic Thrombosis Total 14 (50%) 24 (85%) IIIa (11) 11 (100%) IIIb (17) 3 (18%)* 13 (76%) *4 vessels off the true lumen is a predictor of total thrombosis (P=.08) Leshnower B, Szeto W, Pochetino A, Desai N, Nathan D, Jackson B, Fairman R, Bavaria J. TEVAR promotes successful thoracic aortic remodeling in the treatment of aneurysms secondary to chronic Debakey type III aortic dissection. Society of Thoracic Surgery 2012.

Chronic Type B Dissection: TEVAR Chronic Type B Dissection: TEVAR True Lumen Index (Goal=1) False Lumen Index (Goal=0) Pre-TEVAR Post-TEVAR P Total 0.28 0.50 <0.001 0.77 0.55 IIIa 0.41 0.66 <0.01 0.72 <0.05 IIIb 0.21 0.42 0.80 0.61 Leshnower B, Szeto W, Pochetino A, Desai N, Nathan D, Jackson B, Fairman R, Bavaria J. TEVAR promotes successful thoracic aortic remodeling in the treatment of aneurysms secondary to chronic Debakey type III aortic dissection. Society of Thoracic Surgery 2012.

Chronic Type B Dissection: TEVAR Chronic Type B Dissection: TEVAR Zero in-hospital deaths (vs. 8%) Zero permanent neurological events (vs. 14%) Zero acute renal failure (vs. 11%) Mean stay of 7 days (vs. 20 days) Two patients required additional intervention Mean aortic diameter ratio = 0.96 Leshnower B, Szeto W, Pochetino A, Desai N, Nathan D, Jackson B, Fairman R, Bavaria J. TEVAR promotes successful thoracic aortic remodeling in the treatment of aneurysms secondary to chronic Debakey type III aortic dissection. Society of Thoracic Surgery 2012. 10

Chronic Type B Dissection: Neurological Outcomes Chronic Type B Dissection: Neurological Outcomes Open (N = 66) TEVAR (N = 28) N Percentage Total Neurological Deficit 9 14% 0% 0.0045 Stroke 1 2% Permanent/Partial Paraplegia 8 12% 0.1 Most Open Cases Very Complex Left Chest Combination Distal Arch with “Open Proximal Anastomosis” under Circulatory Arrest with Hypothermia and Extent I/II TAAA 11

History and Presentation 72 y/o M with an incidentally found Type IIIb dissection Size on CT 10/19- 5.2cm 12/10- 5.1cm 6/11- 5.8cm

Visceral Vessels 3 of 4 Mesentaric Blood Vessels off true lumen

Management Plan Device: Gore TAG 37mm X 20cm Pre-TEVAR left carotid-subclavian bypass Lumbar Drain and SSEP monitoring Coverage of proximal tear

Dissection CTA vs. IVUS Courtesy: R. White, UCLA Celiac SMA IMA

Aortography Pre and Post TEVAR Step on Pedal

CTA Pre and Post TEVAR Pre Post 22

Satisfactory Proximal LZ (Usually in Zone 2) Present Approach to Chronic Type B Dissection with late Aneurysm: Either Type B or “Residual” Debakey Type I Satisfactory Proximal LZ (Usually in Zone 2) No severe pseudo-coarctation (to guard against Stent collapse) Anatomy allows for Coverage of the Main primary tear site and any large thoracic fenestrations All 4 Mesentaric vessels off true lumen (sometimes ¾) Note/Perspective : 31 TEVAR, 72 Open TAAA (2003-2011) For Chronic Distal dissections

Chronic Type B aortic dissection: Again all 4 vessels off true lumen Pre-stenting Post-stenting

Conclusions In patients with chronic type B dissection, TEVAR: can promote aortic remodeling Has the potential to prevent aortic complications Selection and Conceptual Understanding Important