1. 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

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

3. 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

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

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

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

7. 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

8. 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.

9. 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.

10. 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

11. 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

12. History and Presentation
72 y/o M with an incidentally found Type IIIb dissection
Size on CT
10/ cm
12/ cm
6/ cm

13. Visceral Vessels
3 of 4 Mesentaric Blood Vessels off true lumen

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

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

16. Aortography Pre and Post TEVAR
Step on Pedal

17. CTA Pre and Post TEVAR
Pre
Post 22

18. 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 ( )
For Chronic Distal dissections

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

20. 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