Thoracic Aortic Frontier: Review of Current Applications and Directions of Thoracic Endovascular Aortic Repair (TEVAR) Jehangir J. Appoo, MDCM, FRCSC,

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Presentation transcript:

Thoracic Aortic Frontier: Review of Current Applications and Directions of Thoracic Endovascular Aortic Repair (TEVAR) Jehangir J. Appoo, MDCM, FRCSC, Leonard W. Tse, MD, FRCSC, MASc, Zlatko I. Pozeg, MD, FRCSC, Jason K. Wong, MD, FRCPC, Stuart J. Hutchison, MD, FRCPC, FACC, FAHA, Alex J. Gregory, MD, FRCPC, Eric J. Herget, MD, FRCPC Canadian Journal of Cardiology Volume 30, Issue 1, Pages 52-63 (January 2014) DOI: 10.1016/j.cjca.2013.10.013 Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

Figure 1 Contrast-enhanced computed tomography images of a 47-year-old female patient, before (A) and after (B,C) thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection with rupture. Note the blood in the left pleural space (A). Note that after TEVAR there has been expansion of true lumen and obliteration of false lumen (B,C). Canadian Journal of Cardiology 2014 30, 52-63DOI: (10.1016/j.cjca.2013.10.013) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

Figure 2 Retrograde type A aortic dissection. (A) Three-dimensional volume-rendered contrast-enhanced computed tomography scan images of a 66-year-old male patient 1 month after thoracic endovascular aortic repair (TEVAR) for acute symptomatic type B intramural hematoma. (B) Two months after TEVAR, the patient presented with a retrograde type A aortic dissection. Note the intimal flap in the ascending aorta, extending down as low as the right sinus of Valsalva, and also extending up the right brachiocephalic artery and the left subclavian artery. Canadian Journal of Cardiology 2014 30, 52-63DOI: (10.1016/j.cjca.2013.10.013) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

Figure 3 Three-dimensional volume-rendered contrast-enhanced computed tomography scan images of a 37-year-old female patient with a 5.8-cm saccular aneurysm of the proximal descending aorta (A). Open surgical and endovascular repair were both technically feasible. Endovascular treatment was performed (B) and the patient was discharged on postoperative day 3 and back at work on postoperative day 7. Canadian Journal of Cardiology 2014 30, 52-63DOI: (10.1016/j.cjca.2013.10.013) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

Figure 4 Sagittal view of contrast-enhanced computed tomography scan image of a 56-year-old male patient with aneurysmal dilatation of chronic type B dissection treated with thoracic endovascular aortic repair (TEVAR). Note the clinically asymptomatic “intimal blowout” at the distal landing zone resulting in communication between true and false lumen identified on routine screening at 15 months after surgery. Canadian Journal of Cardiology 2014 30, 52-63DOI: (10.1016/j.cjca.2013.10.013) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

Figure 5 Hybrid aortic arch repair, types I, II, and III. Types I and II involve arch debranching along with ascending aortic thoracic endovascular aortic repair (TEVAR). Note that in type I, the stent graft is landed in the native ascending aorta and in type II the native ascending aorta is replaced with Dacron. Note the stent graft deployed antegrade through the ascending aorta. Type III involves formal surgical resection of the entire arch, creation of elephant trunk, and deployment of the stent graft in the elephant trunk in the descending aorta. Reproduced from Bavaria et al.55 with permission from Elsevier. Canadian Journal of Cardiology 2014 30, 52-63DOI: (10.1016/j.cjca.2013.10.013) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

Figure 6 Closed chest total arch replacement. Three-dimensional volume-rendered contrast-enhanced computed tomography scan image of a 6.5-cm saccular arch aneurysm (A) in a 79-year-old patient with previous coronary artery bypass surgery treated with a Cook multibranched arch graft (B). Note 1 branch is placed in the left subclavian artery because the patient had bovine arch anatomy. The left carotid is revascularized via a carotid-subclavian bypass. Images courtesy of Dr Cherrie Abraham, Montreal, Canada. Canadian Journal of Cardiology 2014 30, 52-63DOI: (10.1016/j.cjca.2013.10.013) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

Figure 7 Prototype design of Gore single-branched conformable thoracic aortic graft device that could be used to revascularize the subclavian artery, left carotid artery, or the innominate artery. Note when used in conjuction with extra-anatomic supra-aortic reconstruction, closed chest total arch reconstruction can theoretically be accomplished. Image printed with permission of Gore Medical. Canadian Journal of Cardiology 2014 30, 52-63DOI: (10.1016/j.cjca.2013.10.013) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

Figure 8 Maximum image projection of carotid chimney thoracic endovascular aortic repair (TEVAR) performed as a neoadjuvant procedure to facilitate oncologic resection of a tumour involving left chest and distal arch. Note the self-expanding covered stent extending from the ascending aorta into the carotid artery, with the aortic stent graft deployed up to the innominate artery. Canadian Journal of Cardiology 2014 30, 52-63DOI: (10.1016/j.cjca.2013.10.013) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

Figure 9 Three-dimensional volume-rendered contrast-enhanced computed tomography scan image of an ascending aortic aneurysm (A) and 9 months after treatment with a multilayer flow modulator graft from the ascending aorta across the arch (B). Note supra-aortic branches are perfused. Image courtesy of Dr Edward Dietrich (Arizona Heart Institute) and Cardiatis. Canadian Journal of Cardiology 2014 30, 52-63DOI: (10.1016/j.cjca.2013.10.013) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions