Aortic dissection: current percutaneous options Advanced Angioplasty BSET Jan 2008.

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Presentation transcript:

Aortic dissection: current percutaneous options Advanced Angioplasty BSET Jan 2008

MY CONFLICTS OF INTEREST ARE Preceptor for complex endografts for Cook

Multidisciplinary ► Radiology ► Vascular Surgery ► Cardiology ► Anaesthesia ► Cardiothoracic surgery

Imaging ► Pre-operative CT and workstation review ► Intra-operative angiography ► TOE ► IVUS

Acute type B aortic dissection ► Endovascular intervention for: ► 1. Failure of medical therapy ► Malperfusion ► Rupture ► Rapid enlargement

Haemodynamics ► True lumen collapse ► Depends on ratio of inflow capacity to outflow capacity in true and false lumina ► Reduce FL inflow - ► Reduce FL inflow -endografts ► Increase FL outflow -fenestration

Primary treatment aim ► Cover the primary tear ► Stent grafts: ► PTFE, Dacron ► Nitinol, stainless steel ► Bare metal? ► Barbs proximally?

Hybrid theatre

Arch angiogram

Length of stent graft?

Distal bare metal scaffolding ► PETTICOAT concept ► Provisional extension to induce complete attachment after stent graft placement in acute type B dissection C Nienaber JEVT 2006; 13:

PETTICOAT ► 12 patients ► Primary tear covered ► Persistent distal true lumen collapse and perfused abdominal false lumen ► Adjunctive or staged ► Uncovered stents: Sinus, Fortress, Z-stents ► mm ► True lumen increase 4 – 21mm

Fenestration techniques ► Via natural fenestrations ► Punctured with guidewires, TIPS needles, re-entry devices ► Guided by angiography, snares, balloons, IVUS ► Enlarged by balloons, or guidewires - push cuts (scissor technique) or pulled

Fenestration: natural

Percutaneous recanalisation devices

Courtesy of Roy Greenberg Percutaneous recanalisation devices

Outback catheter

Other techniques: TIPS needle

Hartnell, Radiographics 2005

Chronic dissections?

Conclusions ► Challenging and complex multidisciplinary area ► Evolving role and understanding of percutaneous options ► Stent grafts, visceral stents ► Fenestration ► Uncovered stents - scaffolding