1. Multilayer stents for thoracoabdominal aortic aneurysam
Ivo Petrov,MD,PhD,FESC,FACC
Zoran Stankov MD
City Clinic Sofia Bulgaria

2. Crawford classification

3. Historical perspective
The first successful repairs of a TAAA in the United States was reported in 1955 by Etheredge (1)
Cooley and DeBakey’s subsequent report in 1965 included 42 patients in whom knitted Dacron grafts were utilized as the initial shunt and then converted to the formal conduit by stepwise side branch anastomoses of the visceral arteries (2)
Crawford is credited with pioneering the technique of an intra-aortic anastomosis after longitudinal division of the sac. In addition, he also described the technique of a single pedicled visceral segment anastomosis including the celiac, superior mesenteric, and right renal arteries, followed by a left renal anastomosis with sequential reperfusion after the completion of each. His results were superb with only one death in 23 consecutive cases(3)
1.Etheredge SN, Yee J, Smith JV, et al. Successful resection of a large aneurysm of the upper abdominal aorta and replacement with homograft. Surgery 1955;38:
2DeBakey ME, Crawford ES, Garrett HE, et al. Surgical considerations in the treatment of aneurysms of the thoraco-abdominal aorta. Ann Surg 1965;162:
3Crawford ES. Thoraco-abdominal and abdominal aortic aneurysms involving renal, superior mesenteric, celiac arteries. Ann Surg 1974;179:

4. Hybrid Open Visceral Revascularization and Endograft Aneurysm Exclusion
Schema of TAA treated with initial left iliac artery–to–left renal artery–to–superior mesenteric artery bypass graft and subsequent placement of a thoracoabdominal endograft.
Proximal superior mesenteric artery and left renal arteries were ligated.
SMA indicates superior mesenteric artery; and TAA, thoracoabdominal aneurysm.
SOURCE: Adapted from Flye, et al. J Vasc Surg. 2004;39:454–8.

5. Cost EVAR repair, Abularrage CJ, et al. 2005
Open AAA (30pt)
“fast-track”
EVAR (28pt)
Length of surgery (min)
216 ± 7.4
158 ± 6.8
Volume of blood transfusion (un.)
1.8 ± .29
0.32 ± .24
Colloid transfusion (cc)
565 ± 89
32 ± 22
Crystalloid (cc)
4625 ± 252
2627 ± 170
Resume regular diet
1.8 ± .11
0.21 ± .08

6. Cost EVAR repair, Abularrage CJ, et al. 2005
ICU stay (day)
0.87 ± .01
0.50 ± .10
Floor stay ( day)
2.6 ± .21
2.1 ± .23
Total length of stay (day)
3.4 ± .18
2.8 ± .32
Hospital cost ( $$ )
± 736
20,640 ± 1206
Hospital earning ( $$ )
6,141 ± 1280
107 ± 1940

7. 2 year Outcomes after Conventional EVAR of AAA DREAM Trial Group, 2005
Randomized trial, multicenter comparing open repair with EVAR in 26 centers in Netherlands and 4 centers in Belgium.
Open repair EVAR
178 pt pt
2 y survival rate
Aneurysm related death
Survival free of complications
The perioperative survival advantage with EVAR repair as compare with open repair is not sustained after the 1-st postoperative year.

8. The 30-day survival rate was 94.3% (1,672 patients).
Thoracoabdominal aortic aneurysm repair: review and update of current strategies Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY. Joseph S Coselli, Mda,Lori D Conklin, MDa, Scott A LeMaire, MDa a The Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, and The Methodist DeBakey Heart Center, Houston, Texas, USA
The 30-day survival rate was 94.3% (1,672 patients).
Postoperative complications included :
Renal failure requiring hemodialysis in 105 patients (5.9%)
Paraplegia or paraparesis in 79 patients (4.5%).
Actuarial 5-year survival was 73.5% ± 1.6%.

9. Recommendations (open and endovascular )for Descending Thoracic Aorta and Thoracoabdominal Aortic Aneurysms
For patients with chronic dissection, particularly if associated with a connective tissue disorder, but without significant comorbid disease, and a descending thoracic aortic diameter exceeding 5.5 cm, open repair is recommended.
For patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms, endovascular stent grafting should be strongly considered when feasible. I
IIa
IIb
III B I
IIa
IIb
III B

10. Endovascular options for TAAA repair
Chimney/snorkel
Surgeon-modified
In-situ fenestration
Custom fenestrations
MFM

11. Outcomes Ch-EVAR

12. Outcomes FEVAR

13. Primary endpoints were:
Early mid-term results of the first 103 cases of multilayer flow modulator stent done under indication for use in the management of thoracoabdominal aortic pathology from the independent global MFM registry
103 cases
12 countries
Primary endpoints were:
-one-year freedom from rupture and aneurysm-related death
- one year all cause mortality, patency of visceral branches at one year,
- one year incidence of stroke and paraplegia.
Primary technical endpoints were aneurysm sac volume modulation at one year.
Secondary technical endpoints were technical success and one-year freedom from reintervention
J Cardiovasc Surg (Torino) Feb;55(1):21-32.

14. Mean age of 69.2 years (16-93 years),
Early mid-term results of the first 103 cases of multilayer flow modulator stent done under indication for use in the management of thoracoabdominal aortic pathology from the independent global MFM registry
Mean age of 69.2 years (16-93 years),
Mean aneurysm diameter was 6.4±1.66 cm
Mean length was cm.
75 Crawford thoracoabdominal aortic aneurysms (TAAA) :(11 Type I, 14 Type II, 26 Type III, and 24 Type IV),
7 arch aneurysms,
15 suprarenal aortic aneurysms
6 type B dissections.
The mean number of side branches covered for a total number of 378 branches is 3.7 side branches per case.
Total numbers of stents used was 176 with a mean of 1.71 MFM stents per case;
77.77 were ASA IV E,
72.7% had previous thoracic endovascular aortic repair or open TAAA repair.
J Cardiovasc Surg (Torino) Feb;55(1):21-32.

15. Results Thirty-day morbidity was 5.4% with zero mortality.
Aneurysm related survival was 91.7% at one year.
No rupture occurred.
Four cases of consumptive coagulopathy were observed, two of which resulted in death from hemorrhagic cerebrovascular stroke and one of which resulted in death from a gastrointestinal bleed.
Technical success was 97.3%. One-year all-cause survival was 86.8%.
At 12 months 95.1% of all visceral branches were patent. There were no stent fractures.
One-year intervention free survival was 89.4%.
J Cardiovasc Surg (Torino) Feb;55(1):21-32.

16. Cardiatis multilayer stent

18. Streamlines inside an aneurysm without stent(left) and with porous wired stent (right, stent in blue). Steady computation.

21. Our experience. Procedural data:
A/D
TAA/AAA
N. STENT
F.TIME
T.TIME 1 A
TAA 2 12 40
AAA 6 30 3 D 4 22
150* 5 8 50
Average
10,4 min
62 min.

22. Case report 1 White male 71 yo
Admitted in hospital with persistent severe abdominal and peripheral ischemia with abdominal angina.
History of pervious surgical treatment for Type A Ao dissection

23. Diagnostic angiogram

24. Stent implantation

25. Postdilatation

26. Final

27. CT- angio after 2- months

28. CT- angio after 6- months. Centralized blood flow
CT- angio after 6- months. Centralized blood flow. Complete distal healing, patent visceral vessels:

29. CT- angio after 12 months

30. Color codded Doppler of the abdominal aorta
Color codded Doppler of the abdominal aorta. Normal flow into the abdominal aorta and visceral arteries arteries. Thrombosis of the false lumen:

31. Celiac trunk

32. Left common iliac artery

33. Right Common Iliac Artery

34. ABI A.tib. Ant. Dex.- 145 mmHg ABI (right leg)= 1.20
A.tib post. Dex.-155 mmHg
A.tib. Ant sin.-140 mmHg ABI (left leg)=1.15
A.tib post. Sin- 150 mmHg
A.brachialis-140 mmHg

35. Case presentation 2 73 y, male
Comorbidities- CoAD-1VD. PCI +stents/DES/x2 in LAD. Arterial hypertension, hypercholesterolemia, aortic insufficiency II gr., episodes of paroxismal atrial fibrillation
Diagnosed with an asymptomatic abdominal aortic aneurysm, proven by echo doppler, CT and aortograpgy.

36. CT-angio. Distal abdominal aorta aneurysm involving both iliacs
CT-angio. Distal abdominal aorta aneurysm involving both iliacs. Extreme tortuosity.

37. CT-angio. Distal abdominal aorta aneurysm involving both iliacs
CT-angio. Distal abdominal aorta aneurysm involving both iliacs. Extreme tortuosity.

38. Angiography

39. Aorto-uniiliac Cardiatis multilayer stent implantation fully covering the contralateral Common iliac artery:

40. Final

41. CT- angio after 1- months

42. CT-angio after 6 months

43. Abdominal Aorta and both iliac arteries

44. Abdominal aorta and superior mesenteric artery

45. ABI A.tib. Ant. Dex.- 130 mmHg ABIdex= 1.16 A.tib post. Dex.-140 mmHg
A.tib. Ant sin.-140 mmHg ABIsin=1.16
A.tib post. Sin- 130 mmHg
A.brachialis-120 mmHg

46. Case presentation 3 74 y, male
Comorbidities- CoAD-2VD. PCI +stents/ICS/ in RD1. /2004/ Arterial hypertension , Operation due to Ca recti
Diagnosed with an asymptomatic thoracic aortic aneurysm / descending aorta/ , which was treated successfully in 2004 with a stent graft.

47. Angiography
In february 2012 due to chest pain coronaro- and aortography was done and it was found an aneurysm below the stent graft, above the renal arteries.
Angiography of coronary artery- patent stent in RD1, LCx with occlusion in OM2; RCA-degenerative changes.

48. CT- angio

49. Aortography

50. Implantation

51. Final

52. Control CT after 3 monts

54. 12 months f-up

55. Case presentation H.T.H.; 75 year old male;
with a history of an asymptomatic abdominal aortic aneurysm
Comorbidities: Coronary Artery Disease-2vessel disease. PCI + stent x3 in the RCA. And PCI and stent in RIM. Periphery Artery Disease II st. Arterial Hypertension III gr. Operation due to Ca recti.

56. Aortography

57. CT- angio
SMA

58. CT- angio
SMA RR

59. 1 mont CT angio f-up:

60. Conclusion:
The implantation of Cardiatis multilayer stent in the treatment of complicated aneurysms of the thoracic and abdominal aorta is effective and safe.
This treatment allows preservation of blood flow in the branches arising from the stented area.
The early and mid-term follow-up results are promising
We need more systematic procedural and clinical data in order to establish the exact indications of this novel technology

61. Thank you very much for your kind invitation