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

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Presentation on theme: "Aortic dissection: current percutaneous options Advanced Angioplasty BSET Jan 2008."— Presentation transcript:

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

2 MY CONFLICTS OF INTEREST ARE Preceptor for complex endografts for Cook

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

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

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

6 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

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

8 Hybrid theatre

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12 Arch angiogram

13 Length of stent graft?

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16 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; 13:738-746

17 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 ► 120-230mm ► True lumen increase 4 – 21mm

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19 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

20 Fenestration: natural

21 Percutaneous recanalisation devices

22 Courtesy of Roy Greenberg Percutaneous recanalisation devices

23 Outback catheter

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26 Other techniques: TIPS needle

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28 Hartnell, Radiographics 2005

29 Chronic dissections?

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

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