1. Repair of Aortic Dissection of the Arch and Branches
Chang Shu M.D., PhD.
Dept. of Vascular Surgery,
The 2nd Xiang-Ya Hospital, Central-South University
中南大学湘雅二医院血管外科
湖南省大血管疾病外科及微创介入诊疗中心

2. Clinical Materials
2002.7～2014.2,
958 cases with aortic dissection treated with TEVAR
Acute (<2w): 670 cases
Sub-acute and chronic (>2w): 264 cases
Male: 627 / Female: 331
age: 20-87; mean age: 51.1
follow-up: 25.1±7.3 months

3. Techniques for aortic arch
Hybrid techniques: aorta - supra aortic branches RSA (RCCA) – LCCA RSA (RCCA) – LSA RSA (RCCA) – LCCA – LSA LCCA – LSA
Fenestrated stent-graft
Branched stent-graft
Chimney / double chimney technique

4. Hybrid technique
aorta - supra aortic branches RSA (RCCA) – LCCA RSA (RCCA) – LSA RSA (RCCA) – LCCA – LSA LCCA – LSA

5. Extra-anatomic bypass
needs several operation incisions.
post-operative anticoagulant treatment is needs.
reliable/stable/durable outcome

6. Extra-anatomic bypass
RSA– LCCA
RCCA – LCCA – LSA
RSA– LSA

7. If left subclavian artery steal syndrome happens post-TEVAR, extra-anatomic bypass can be used.

8. Hybrid technique
aorta - supra aortic branches RSA (RCCA) – LCCA RSA (RCCA) – LSA RSA (RCCA) – LCCA – LSA LCCA – LSA

9. A man, 36y, suffered from an aortic arch pseudoaneurysm because of a severe traffic accident.

10. Hybrid technique was adopted.
Ascending aorta – innominate artery
– left carotid artery – LSA bypass was achieved first.

11. Hybrid technique was adopted.
Then TEVAR was used.
The patient recovered unevertfully.

12. fenestrated SG Some of the stenting-grafts has been modified
to fit the aortic arch area

13. Fenestration—treatment
Step 1:
CT and DSA for accurate measurement were performed pre-operation.

14. Fenestration—treatment
Step 2:
deploy partial of the proximal stent graft in vitro, and eliminate part of the lateral fabric.

15. Fenestration—treatment
Step 3

16. Fenestration—follow up
The fenestrated stent graft covered the aortic arch dissection completely
With patent supra-aortic branches

17. Branched stent-graft

18. Branched stent-graft The patient, 70y, male
abrupt severe chest pain for 3 days
history of hypertension, coronary heart disease, DM
CT scanning indicated an acute aortic dissection with the primary entry tear next to LSA.

21. Branched stent-graft
6 months later, CT angiography indicated excellent aortic remodeling without any complications.
Blood stream of the reconstructed LSA is fluent.

22. Used to treat the aortic arch disease.
Chimney technique
Has been applied from 2007.
Used to treat the aortic arch disease.

23. Chimney in LCCA
A female, 49 years old, the aortic arch dissection related LSA. There was not enough proximal landing zone.

24. Chimney in LCCA
A female, 49 years old, the aortic arch dissection related LSA. There was not enough proximal landing zone.

25. Chimney for aberrant RSA
the patient, 36y, male
suffered from abrupt chest pain for 4 days.
CT angiograph indicated a acute type B aortic dissection and aberrant right subclavian artery.

26. Chimney for aberrant RSA
It was an aberrant right subclavian artery, which was invaded by the AD, and the LSA was invaded that should be covered by TEVAR too.
So, chimney technique should be used to reconstruct the invaded LSA.

27. Chimney for aberrant RSA

28. Chimney for aberrant RSA

29. Chimney for aberrant RSA
The aberrant right subclavian artery was covered. The LSA reconstructed with a chimney stent-graft was patent.

30. Chimney for type Ia endoleak

31. Chimney for type Ia endoleak

32. Chimney technique for AD + Marfan syndrome + pregnancy

33. MFS associated with puerperal state
A female,29 years old, suffered from abrupt severe back pain 1 week after caesarean section.
The primary entry tear located at the orifice of the LSA ( white arrow ).

34. MFS associated with puerperal state
One month later, the patient recovered well without any symptoms.
However, CT angiography detected mild contrast in the false lumen, and the patent false lumen communicated with LSA.

35. Chimney for MFS + puerperal state
13 months later, the patient recovered uneventfully.
Endoleak disappeared !
No migration, new entry tear formation.

36. Chimney technique + PDA occlude for LSA
If chimney technique is used in the common carotid artery, the covered LSA has the risk of type II endoleak. PDA occlude technique is a ideal management

37. Chimney technique+ PDA occlude
TBAD related LSA
Chimney technique should be used

39. Chimney technique+ PDA occlude

40. Chimney technique+ PDA occlude

41. 2 weeks after TEVAR, no type II endoleak lasted.

42. Double-chimney technique
Double-chimney technique can replace the conventional open surgery, and be used to reconstruct all supra-aortic branches.

43. Double-Chimney Technique
The patient suffer from an acute aortic dissection, which the left common carotid artery was invaded and leaded to severe carotid artery stenosis.

44. Double Chimney Technique
Bi-chimney technique was used.
Two Fluency stent-grafts were used to reconstruct IA and LCCA. The LSA was covered.
The patient recovered well, without any complications.

45. Double Chimney Technique
A 50y male, suffered from abrupt chest and back pain. The primary entry tear was unclear in CT scans.
Angiography indicated a typical non-A-non-B aortic dissection involve aortic arch. The primary entry tear was between the orifices of innominate artery and LCA.

47. Double Chimney Technique

48. Double Chimney Technique
The patient recovered well, without any serious complications

49. Double-chimney technique
Double-chimney technique is an experimental technique, with some unclear complications.

50. Double Chimney Technique
It’s a patient with acute type B aortic dissection.
According to the CT scan, it’s hard to distinguish the primary entry tear.
So, we need DSA.

51. Double Chimney Technique

52. Double Chimney Technique
the primary entry tear is next to the orifice of left subclavian artery. The proximal landing zone is insufficient.

53. Double Chimney Technique
Double chimney technique could increase the proximal landing zone, extending to ascending aorta.
During TEVAR, there was no complications.
However, the vital signs during post-anesthesia recovery were unstable~~

54. Double Chimney Technique
30 min
obvious migration
After double chimney stent-graft deployed
30 min later, when we punctured brachial artery and performed angiography again.

55. Double Chimney Technique
So, we inserted another two Fluency stent-grafts, overlapped with the previous two, to reconstruct innominate artery and left carotid artery.
The patient recovered gradually.

56. Left subclavian artery dissected post-operation

57. A 42y male received TEVAR for type B AD one year ago
A 42y male received TEVAR for type B AD one year ago. After operation, a proximal endoleak was found, and was treated conservatively. However, the endoleak persisted.
CTA indicated that TEVAR caused LSA dissection, which was inexistent previously.
Is it a type I endoleak definitely ?

58. DSA confirmed the secondary LSA dissection.
The active blood flow in the false lumen was coming from the secondary LSA dissection.

59. A balloon was inflated in the LSA and DSA was performed again.
It’s obviously that there is no type I endoleak, the active blood flow in the false lumen was originated from the secondary LSA dissection.

60. A Fluency stent-graft was deployed in the LSA to seal the secondary dissection.
DSA indicated cessation of blood flow in the false lumen.

61. The patient recovered well after the stent-graft deployed in the proximal LSA.

62. Conclusions
The management of aortic arch diseases became popularity now.
Hybrid technique/fenestrated stent-graft/ branched stent-graft/ chimney technique are suitable.
Extra-anatomic bypass can be replaced by chimney technique.
Better technique is to be expected !

63. Thank u very much!