TOTAL AORTIC ARCH REPLACEMENT WITH THORAFLEX HYBRID FROZEN ELEPHANT TRUNK PROSTHESIS: RESULTS OF FIRST 100 PATIENTS Malakh Shrestha, Heike Krueger, Tim.

Slides:

Advertisements

Similar presentations

(1) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Arch Debranching versus Elephant Trunk Procedures for Hybrid Repair.

Advertisements

Background (1) ・ In 1998, we developed a modified elephant trunk (ET) technique using a single four-branched arch graft with a sewing “collar” and “long.

THE FUTURE PA Gaines Sheffield Vascular Institute.

Optimal Graft Diameter and Location Reduces Postoperative Complications Following Total Arch Replacement with a Long Elephant Trunk K. Taniguchi K.Toda.

Antegrade Stent Grafting of Descending Thoracic Aorta During Acute Debakey I Dissection: Early and Midterm Outcomes Prashanth Vallabhajosyula MD, Joseph.

Division of Cardiovascular Surgery Xijing Hospital, Xi’an, China

Conventional and frozen elephant trunk surgery for extensive aneurysmal disease of the thoracic aorta: a retrospective comparative study Marco Di Eusanio.

Results of “Type II” Hybrid Arch Repair with Zone 0 Stent Graft Deployment Jehangir Appoo, William Kent, Eric Herget, Jason Wong, Alberto Pochettino and.

Open Repair of Ruptured Descending Thoracic and Thoracoabdominal Aortic Aneurysms in 100 Consecutive Cases Mario F. Gaudino, Christopher Lau, Monica Munjal,

Stent Assisted Balloon Induced Intimal Disruption and Relamination in Aortic Dissection Repair: The STABILISE Concept Sophie C. Hofferberth 1, Andrew E.

New York Aortic Surgery Symposium 2010 Mohamad Bashir, Aaron Ranasinghe, David Quin, Ben Holloway, Jorge Mascaro, Robert Bonser The limited potential for.

SIR-RFS AngioClub Ethan M. Dobrow, PGY-4 Maine Medical Center, Portland, Maine (The Freeman Hospital, Newcastle-Upon-Tyne, UK)

The Use of Thoracic Endovascular Stent Grafting in Acute Aortic Tragedies as Compared to Open Surgical Repair Tyler J. Wallen, BA, Wilson Y. Szeto, MD,

Giampiero Esposito MD 2010-A-10-AATS Cardiovascular Surgery Unit CITTA’ DI LECCE HOSPITAL - ITALY GVM Hospitals of Care and Research Hybrid Approach to.

1 Wei Zhang, Wei-Guo Ma, Long-Fei Wang, Jun Zheng, Bulat A. Ziganshin, Paris Charilaou, Xu-Dong Pan, Yong-Min Liu, Jun-Ming Zhu, Qian Chang, John A. Elefteriades.

The assessment of the new hybrid procedure for extensive aortic aneurysms compared with the conventional open surgery Department of Cardiovascular surgery,

Without Deep Hypothermia

Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery The efficacy of debranching TEVAR for arch.

One-stage repair for Stanford Type B Aortic Dissection concomitant with cardiac diseases Open stented elephant trunk technique combined with cardiac operation.

Secondary Intervention in Unfavorable AAA Neck Anatomy Congress Symposium 2007 John T. Collins, MD Borgess Medical Center Kalamazoo, MI.

How I would want my Elephant Trunk Procedure to be done.

Does Operative Technique of Performing Distal Anastomosis in Acute type A Dissection Affect Early And Late Clinical Outcomes? Sotiris C. Stamou, MD, Ph.D,

University of Lübeck Department of Cardiac and Thoracic Vascular Surgery Diagnostics in pre and post-op managment in AF patiens Thorsten Hanke.

PREDICTORS FOR IN HOSPITAL MORTALITY IN PATIENTS WITH TYPE A AORTIC DISSECTION FROM A TWO CENTRE EXPERIENCE S Leontyev, J Légaré, MA Borger, K Buth, AK.

Imaging Experience of Type II Hybrid Aortic Arch Repair: Lessons learned from Zone 0 Debranching & Evolution to Zone 2 Arch Repair Vamshi Kotha, Eric J.

Hybrid Arch for Acute Type A Aortic Dissection

Hybrid Arch for Acute Type A Aortic Dissection

Columbia University Medical Center

Ali Khoynezhad, MD1, Carlos E. Donayre, MD2,

Concomitant valve sparing root remodeling with extra aortic ring annuloplasty and e-vita stented elephant trunk implantation Igor Rudez, Marko Kusurin,

Stent graft repair of descending aortic dissection in patients with Marfan syndrome: An effective alternative to open reoperation? Luca Botta, MD, Vincenzo.

TEVAR for Chronic Type B Dissection

PP-355 Endovascular Stenting Extension of Elephant Trunk Surgical Graft to Lower Descending Thoracic Aorta in a Patient with Aortic Arch and Descending.

Open Repair of Ruptured Descending Thoracic and Thoracoabdominal Aortic Aneurysms in 100 Consecutive Cases Mario F. Gaudino, Christopher Lau, Monica Munjal,

A new staged hybrid total arch repair procedure using a branched proximal elephant trunk technique with implantation of stent grafts to the ascending.

Use of custom Dacron branch grafts for “hybrid” aortic debranching during endovascular repair of thoracic and thoracoabdominal aortic aneurysms G. Chad.

Total aortic arch replacement with a novel 4-branched frozen elephant trunk prosthesis: Single-center results of the first 100 patients Malakh Shrestha,

Open Distal Fenestration of Chronic Dissection Facilitates Endovascular Elephant Trunk Completion: Late Outcomes Muhammad Aftab, MD, Jay J. Idrees, MD,

Branched Endovascular Therapy of the Distal Aortic Arch: Preliminary Results of the Feasibility Multicenter Trial of the Gore Thoracic Branch Endoprosthesis

Stent graft repair of descending aortic dissection in patients with Marfan syndrome: An effective alternative to open reoperation? Luca Botta, MD, Vincenzo.

Simplified total arch repair with a stented graft for acute DeBakey type I dissection Enyi Shi, MD, PhD, Tianxiang Gu, MD, PhD, Yang Yu, MD, Chun Wang,

Clinical outcomes of different surgical approaches for proximal descending thoracic aneurysm involving the distal arch Hyun-Chel Joo, MD, Young-Nam Youn,

Stented Elephant Trunk Technique for Retrograde Type A Aortic Dissection After Endovascular Stent Graft Repair Bin Li, MD, Xu-Dong Pan, MD, Wei-Guo Ma,

Stent graft coarctation after frozen elephant trunk procedure: An unusual complication Davide Pacini, MD, Alessandro Armaro, MD, Luca Di Marco, MD, Vincenzo.

Joseph S. Coselli, MD, Peter Oberwalder, MD

Custom-Made E-Vita Graft for Frozen Elephant Trunk With Arch-First Technique Luca Bertoglio, MD, Alessandro Castiglioni, MD, Alessandro Grandi, MD, Tommaso.

Midterm results from a physician-sponsored investigational device exemption clinical trial evaluating physician-modified endovascular grafts for the treatment.

A new staged hybrid total arch repair procedure using a branched proximal elephant trunk technique with implantation of stent grafts to the ascending.

Successful surgical treatment of multilevel aortic aneurysms combined with renal transplantation Ivan Matia, MD, PhD, Jan Pirk, MD, PhD, Květoslav Lipar,

Nicholas D. Andersen, MD, Michael E. Barfield, MD, Jennifer M

The Frozen Elephant Trunk Technique for Treatment of Thoracic Aortic Aneurysms Hassina Baraki, MD, Christian Hagl, MD, PhD, Narwid Khaladj, MD, Klaus.

Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair Adel Bin Jabr, MD, Bengt Lindblad, MD,

The Reversed Elephant Trunk Technique Used for Treatment of Complex Aneurysms of the Entire Thoracic Aorta Joseph S. Coselli, MD, Scott A. LeMaire, MD,

Extended aortic replacement for acute type a dissection with the tear in the descending aorta Terushisa Kazui, MD, Yukihiko Tamiya, MD, Toshiaki Tanaka,

Staged total aortic hybrid repair for DeBakey type I dissection: Report of a case Marco Di Eusanio, MD, PhD, Paolo Berretta, MD, Luigi Lovato, MD, Roberto.

The Frozen Elephant Trunk for the Treatment of Chronic Dissection of the Thoracic Aorta: A Multicenter Experience Davide Pacini, MD, Konstantinos Tsagakis,

Retrograde segmental aortic repair for type II thoracoabdominal aortic aneurysm Teruhisa Kazui, MD, Katsushi Yamashita, MD, Hitoshi Terada, MD, Naoki.

Thoraflex Hybrid Endovascular Frozen Elephant Trunk Device for Treatment of Complex Aortic Arch Disease John H. Landau, Luc A. Dubois, Adam H. Power,

Aortic root replacement with composite valve graft

Fenestrated and branched endovascular aortic repair for chronic type B aortic dissection with thoracoabdominal aneurysms Atsushi Kitagawa, MD, Roy K.

The elephant trunk is freezing: The Hannover experience

Scott A. LeMaire, MD, Susan Y

The frozen elephant trunk: An interesting hybrid endovascular-surgical technique to treat complex pathologies of the thoracic aorta Florian S. Schoenhoff,

Staged Hybrid Repairs of Acute Type A Aortic Dissection Involving the Right Aortic Arch with Retroesophageal Aortic Segment S. Sato, H. Matsuda, T. Fukuda,

Surgical treatment of an aneurysm involving ascending aorta, aortic arch, and a rupture of a descending aortic aneurysm 26 years following acute type.

The frozen elephant trunk technique: A new treatment for thoracic aortic aneurysms Matthias Karck, MD, Ajay Chavan, MD, Christian Hagl, MD, Holger Friedrich,

G. Chad Hughes, MD, Asvin M. Ganapathi, MD, Jeffrey E

A staged replacement of the entire aorta from the ascending arch to the hypogastric arteries using a hybrid approach Juan Carlos Jimenez, MD, Wesley.

Presentation transcript:

TOTAL AORTIC ARCH REPLACEMENT WITH THORAFLEX HYBRID FROZEN ELEPHANT TRUNK PROSTHESIS: RESULTS OF FIRST 100 PATIENTS Malakh Shrestha, Heike Krueger, Tim Kaufeld, Erik Beckmann, Nurbol Koigeldiyev, Felix Fleissner, Julia Umminger, Axel Haverich and Andreas Martens. Hannover Medical School

Disclosures Consultant Vascutek Terumo

“Elephant Trunk Technique“ Stage 1 1. Aneurysm:15th March 1982 2. CADA: 28th October 1983 3. AADA: 22nd May 1989 Modifications of the Classical Elephant Trunk Borst HG et al. Extensive aortic replacement using the ‚elephant trunk prosthesis‘ Thorac Cardiovasc Surg 1983; 31 (1): 37-40

The second stage completion is inevitable! METHODS: March 1982 to March 2012, 179 patients (112 males, age 56 ± 13years) (91 aneurysms, 88 dissections (47 acute)). The second stage completion is inevitable!

Is branched graft technique better for total aortic arch replacement? Ann Thorac Surg. 2004 Jun;77(6):2021-8. Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch. Di Eusanio M, Schepens MA, Morshuis WJ, Dossche KM, Kazui T, Ohkura K, Washiyama N, Di Bartolomeo R, Pacini D, Pierangeli A. Spielvogel 2005

Thoraflex Hybrid FET graft Unstented proximal part & stented distal part 4 ‘fingers’, three for supra-aortic vessels, one for ECC Stent length: 100 & 150 mm Unstented & stented part available in different sizes sewing collar Radio-opaque markers Fully Sealed Device, gelatine

Delivery System Release Clip Tip Splitter Splittable Sheath with side guide wire access Splitter Splittable Sheath Completely removed from system after deployment Malleable Shaft Handle Strap Release Clip

Thoraflex Hybrid FET Graft Plexus 4 Branched graft Sewing Collar for distal anastmosis Fully Sealed Device Radio opaque markers

Hannover Concept Core temperature 25°C Bilateral SACP (22-24°C) ‘Beating Heart‘ arch surgery Minimize lower body ischaemia CSF drainage CO2 Sufflation FET

Pre-operative Data All Acute Dissection Chronic Dissection Aneurysm P All Acute Dissection Chronic Dissection Aneurysm P Patients (n) n = 100 n = 37 n = 21 n = 42 Sex (Male (n,%)) n = 65 (65%) n = 28 (76%) n = 12 (57%) n = 25 (60%) 0.226 Age (Years) 59 ± 14 56 ± 13 54 ± 16 64 ± 11 0.004 Marfan Syndrome (n,%) n = 11 (11%) n = 4 (11%) n = 5 (24%) n = 2 (5%) 0.075 Previous surgery (n,%) n = 28 (28%) n = 1 (3%) n = 15 (71%) n = 12 (29%) <0.0001

Intra-operative Data All Acute Dissection Chronic Dissection Aneurysm All Acute Dissection Chronic Dissection Aneurysm P Patients (n) n =100 n = 37 n = 21 n = 42 Operation time (min) 367 ± 80 391 ± 62 393 ± 64 334 ± 90 0.001 CPB time (min) 241 ± 61 267 ± 46 244 ± 52 217 ± 68 0.0007 Cardiac ischemia time (min) 123 ± 62 146 ± 56 117 ± 61 105 ± 63 0.011 Distal CA time (min 57 ± 55 60 ± 39 64 ± 34 51 ± 32 0.354 SACP time (min) 98 ± 36 110 ± 35 104 ± 36 84 ± 31 0.003 “Beating Heart” arch repair n = 47 (47%) n=14 (38%) n = 9 (43%) n = 24 (57%) 0.210 Concomitant procedures: - Bentall - Valve sparing root - CABG - MVR - AVR n = 52 (52%) n = 10 n = 30 n = 12 n = 3 n = 2 n = 26 (70%) n = 5 n = 4 n = 1 n = 0 n = 17 (40%) n = 8 n = 6 n =1 0.019

Post-operative Data *1 pt. has permanent Paraplegia All Acute Dissection Chronic Dissection Aneurysm P Patients (n) n = 100 n = 37 n = 21 n = 42 Ventilation (days) 1.0 (0.6-3.7) 2.8 (0.8-6.0) 0.9 (0.4-7.2) 0.7 (0.5-1.7) 0.0019 Rethoracotomy for bleeding (n,%) n = 16 (16%) n = 8 (22%) n = 3 (14%) n = 5 (12%) 0.487 Stroke (n,%) n = 10 (10%) n = 5 (14%) n = 2 (5%) 0.330 Paraparesis * (n/%) n = 7 (7%) n = 3 (8%) n = 2 (10%) 0.741 Recurrent nerve palsy (n,%) n = 25 (25%) n = 9 (24%) n = 8 (38%) n = 8 (19%) 0.256 Renal failure; dialysis ** (n,%) n = 14 (14%) n = 4 (11%) n = 4 (19%) n = 6 (14%) 0.684 30 day mortality (n,%) n = 1 (5%) n = 3 (7%) 0.890 *1 pt. has permanent Paraplegia ** 1 pt. needs permanent Dialysis

Distal aortic reinterventions All Acute Dissection Chronic Dissection Aneurysm P Patients (n) n = 100 n = 37 n = 21 n = 42 Second procedure downstream aorta (n,%) n = 20 (20%) n = 2 (3%) n = 7 (33%) n = 11 (26%) 0.016 Time to reoperation (months) 7.0 (1.8-9.7) 6.8 (1.9-8.1) 9.2 (6.9-11) 5.3 (0.7-9.9) 0.295 - open surgical - thoraco-abdominal - descending aorta - abdominal/iliac - endo-vascular n = 7 (7%) n = 2 n = 3 n = 13 (13%) n = 0 (0%) n = 0 n = 2 (5%) n = 3 (14%) n = 1 n = 4 (19%) n = 4 (10%) n = 7 (17%) 0.086 0.216

Aortic imaging Segment A Segment B Segment C

Aortic remodeling: False lumen thrombosis in AADA Pre-OP Post-OP Last Follow Up Patent Partial Thromb. P vs. Pre Segment A 22 (85%) 1 (4%) 3 (12%) 4 (16%) 20 (80%) <0.001 1 (6%) 2 (11%) 15 (83%) Segment B 21 (84%) 10 (41%) 8 (33%) 6 (25%) 0.006 5 (31%) 16 (38%) Segment C 0 (0%) 14 (58%) 4 (17%) 0.056 11 (69%) 4 (25%) 0.3233

Aortic remodeling in AADA Aortic diameters Post-OP vs. Pre-OP Last Follow Up vs. Pre-OP Aortic diameter difference (%, P) Aortic diameter difference (%,P) AL TL FL Segment A +0.0% (0.506) +66% (0.001) -32% (0.0001) -3.0% (0.179) +92 (<0.0001) -68% Segment B +0.5% (0.854) +53% (0.015) -23% (0.020) +31% (0.704) +60% (0.005) -13% (0.023) Segment C +3.3% (0.267) +43% (0.104) -26% (0.066) +8.5% (0.331) +44% (0.051) -8.2% (0.330)

Aortic remodeling: False lumen thrombosis in CAD Pre-OP Post-OP Last Follow Up Patent Partial Thromb. P vs. Pre Segment A 15 (71%) 1 (5%) 5 (24%) 4 (20%) 6 (30%) 10 (50%) 0.003 3 (18%) 5 (29%) 9 (53%) Segment B 15 (75%) 2 (10%) 3 (15%) 14 (74%) 3 (16%) 2 (11%) 0.815 15 (94%) 1 (6%) 0 (0%) 0.232 Segment C 16 (89%) 14 (82%) 2 (12%) 0.295 12 (92%) 1 (8%) 0.242

Aortic remodeling in CAD Aortic diameters Post-OP vs. Pre-OP Last Follow Up vs. Pre-OP Aortic diameter difference (%, P) Aortic diameter difference (%,P) AL TL FL Segment A -4.7 % (0.454) +45 % (0.100) -19 % (0.049) -14 % (0.133) +77 % (0.003) -31 % (0.001) Segment B -3.3 % (0.560) +15 % (0.500) -11 % (0.227) -0.6 % (0.967) +25 % (0.668) -2.6 % (0.528) Segment C -2.4 % (0.673) +9.4 % (0.718) -10 % (0.452) -0.8 % (0.725) +1.2 % +2 % (0.676)

Kaplan Meier Curve: Freedom from Re-intervention

Kaplan Meier Curve: Survival

Conclusion The Thoraflex Hybrid FET: 1. Combines advantages of FET and Plexus arch graft 2. Ease of FET delivery 3. Unique features , e.g. “Sewing Collar“ 4. Aortic “remodelling“ in Aortic dissections 5. Potentially „single stage“ therapy in Aneurysms 6. Excellent peri-operative and mid-term results. ‘Beating Heart’ in Aortic Arch Surgery 1983 1988 1991/93 1997/2003 2004 2006 2013 Borst Svensson Kazui Usui, Karck Neri ‘Siena graft‘ Shrestha, Haverich

Thank You! “The Aortic Team“ Hannover Medical School!