1. THORACIC AORTIC PATHOLOGY CHALLENGES AND SOLUTIONS Thomas C. Naslund, M.D. Vanderbilt University Medical Center

2. CONFLICT OF INTEREST WL Gore Investigator, Speaker, Consultant Boston ScientificConsultant LeMaitre VascularScientific Advisory Board

3. OFF LABEL USE WL Gore TAG Cook Zenith WL Gore Excluder

4. FREQUENTLY SEEN PATHOLOGY Aneurysm -fusiform * -saccular (concern for infection) Aortic Dissection – Type A * and B Traumatic transection Penetrating ulcer Intramural hematoma *labeled use for TAG *surgical management

6. PENETRATING ULCER

7. INTRAMURAL HEMATOMA

8. THORACIC AORTIC ANEURYSM Atherosclerosis of iliacs –8-9 mm EI make most TEVAR easy –7-8 mm EI make some TEVAR difficult –<6 mm EI is a clear danger zone (alternate access) Dilation with serial dilators if EI normal KY jelly helps Extreme caution with dilators and atherosclerosis Tortuosity of iliacs and TA (arch) Neck –<2cm in straight distal attachment can work –2cm with angle in arch will not work

9. ACCESS FOR THE DISEASED ILIAC Conduit –Sutured to the CI artery end to side –Complete TEVAR via conduit –Consider anastomosis to CFA after completion May need secondary intervention CFA may already be exposed/opened/damaged Direct CI/Abdominal Aorta Access –Transverse incision over rectus sheath –Retract rectus laterally/RP dissection –CI/terminal aorta easily exposed –Counter puncture in lower quadrant –Direct arterial closure

10. GOALS OF ENDOVASCULAR MANAGEMENT Acute Type B Aortic Dissection Redirect flow into true lumen Cover entire descending thoracic aorta Provide satisfactory visceral flow Facilitate aortic healing Avoid surgical repair

11. DISSECTION TREATMENT ALGORITHM Type A- Medical Therapy &Emergency Cardiac Surgery Evaluation Type B- Medical therapy »Stent graft for complications in acute phase »Stent graft for aneurysm formation in late follow up »Long term follow up for all Type B to assess aneurysm formation/stent graft

12. NECK PROBLEMS/SOLUTIONS Big (>36mm) –45mm TAG in EU Small (<23mm) –18-23mm diameter graft Short (< 2cm) –Debranching/fenestration Angled (>?) –Specific design/fenestration

13. LENGTHENING THE NECK Covering Branch Vessels Left Subclavian –Consider vertebrobasilar circulation Contralateral vertebral/carotid disease Celiac –Consider pancreaticoduodenal and gastroduodenal SMA disease Coiling typically not needed –Subclavian for Type II leak Transbrachial –Celiac Flow robust –Catheterize, cover celiac/trap catheter, coil

15. SURGICAL DEBRANCHING Viscerals –Celiotomy Midline gets all 4 Left flank gets 3,maybe 4 Arch –Left subclavian to carotid transposition –Carotid-carotid bypass (retroesophageal) –Aortoinnominant & carotid bypass

17. ARCH REPAIR

18. TRAUMATIC TRANSECTION Deceleration injury –MVA –falls Sudden movement of aortic arch Circumferential tear of arterial intima and media Survivors have intact adventitia and possibly some media

19. TRAUMATIC TRANSECTION Innominate artery second most common site

20. VANDERBILT SERIES Open Repair 1987 41 Patients 5 Died without repair –3 preoperatively –2 en route with emergency thoracotomy 5/36 Repaired died during operation –3/5 associated with aortic clamping 2/36 Paraparesis

21. TRANSECTION PRE OP MEDICAL MANAGEMENT Beta Blockade BP/HR control Discontinue after repair

22. STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION n = 20 Since 2005 Age 35 (15 – 72) Mortality 1/20 (5%) – 72 yo MSOF

23. STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION n = 20 Mean procedure time 103min Mean blood loss 390ml Mean intraoperative transfusion 1 unit Grafts utilized –TAG - 9 –Cook Iliac extenders- 9 –Excluder aortic cuffs - 2

24. STENT GRAFT REPAIR OF TRAUMATIC TRANSECTION n = 20 Technical success 100% –graft exclusion of injured segment –No deaths pre operatively Operative complications –groin access site – 2 –TAG graft collapse – 2 –spinal cord injury – 0 –dialysis – 0

25. LATE FOLLOW UP Erosions – 0 Endoleaks/aneurysm – 0 Access site false aneurysm – 0 Paraplegia – 0 Secondary interventions – 0

26. USE OF COOK ILIAC LIMB EXTENDER Aorta diameter too small for TAG prosthesis (<23mm) 55 mm length (satisfactorily covers entire area of injury) Z stent design (no collapse) Requires manual loading into long sheath to reach aortic arch

28. ZENITH Delivery and Deployment

30. USE OF ABDOMINAL AORTIC CUFF EXTENDERS 33 – 36 mm length Reported in several series with success Requires 3 or more individual cuffs to bridge injured region Requires inventory of substantial numbers of aortic cuffs Cook, Medtronic, and Gore

31. TIGHT ARCH Typical of adolescence and young adults Implant can either poorly oppose the inner arch and collapse

33. FOLLOW UP Interval CT in 1 – 3 days (renal function considerations) Follow up CT 1 -3 months after discharge Annual CT Eventually CT each 3-5 years Emphasis on permanent life-long follow up

34. LATE CONCERNS Erosion False aneurysm formation Infections

35. MINIMAL AORTIC INJURY Focal-non-circumferential intimal disruption No false aneurysm No periaortic hematoma Suitable for medical therapy and CT follow up rather than intervention –Healing typical in 3-6 months –Persistent fixed lesions identified after 1 year followup