1. Endovascular Repair of Thoracic Arch Aneurysms
Postgraduate Course
Southern Association for Vascular Surgery
H. Edward Garrett, Jr. M.D.
Professor of Surgery
University of Tennessee Health Sciences Center
Memphis, TN

2. Financial & Regulatory Disclosure
Principal investigator for
Gore TAG post-approval study and
Medtronic VALOR Trials (Talent thoracic stent graft system)
W.L. Gore sponsors the University of Tennessee Vascular Conference and the Edward Garrett Sr. Midsouth Vascular Society

3. Surgical results for open repair of aneurysms involving the aortic arch:
30 day mortality %
Neuro events %
5 year survival %
Death primarily related to neurological and cardiac events
Many patients denied open surgical treatment because of comorbidities
Kirklin/Barratt-Boyes Cardiac Surgery, Third Edition , N.T. Kouchoukos et al

4. Landing zones in the thoracic aorta

5. Coverage of the left subclavian artery: Carotid-subclavian bypass or not?
Gore TAG IFU: “If occlusion of the left subclavian artery ostium is required to obtain adequate neck length for fixation and sealing, transposition of the left subclavian artery should be considered.”
Vertebral circulation must be evaluated ?Impact on paraplegia
Presence of internal mammary artery graft to LAD mandates revascularization
Debatable whether left subclavian bypass necessary

6. LIMA bypass graft off the left subclavian artery pre-implant post-implant

7. Arizona Heart Institute
255 thoracic endograft pts reviewed (2/00-12/05)
LSA covered in 71 pts; partially covered in 47 pts
15 of 71 pts had pre-stent bypass → CVA (this pt also had car-car bypass)
3 of 56 pts without pre-stent bypass had complications: 2 TIA’s, 1 paraparesis (full recovery)
1 of 56 pts without pre-stent bypass had lt arm claudication → car-SC bypass
Many other high volume centers are aggressive about subclavian revascularization
-Data used with permission of Grayson Wheatley III, MD

8. Results of subclavian revascularization
Prosthetic carotid-subclavian bypass:
Patency: 7 yr
Mortality: %
Stroke rate: 1-5%
Carotid-subclavian transposition:
Patency: 7 yr
Mortality: %
Stroke rate: 0-2%
Rutherford, Vascular Surgery

9. Coverage of left carotid &/or innominate arteries not included in IFU but allows expansion of endovascular technique. Debranching the aortic arch mandates some type of reconstruction:
Carotid-carotid bypass
Ascending aorta to innominate & carotid bypass
Proximal carotid stenting
Femoral-axillary bypass
Chuter graft

10. Ascending aorto – innominate &/or carotid bypass
Patency 100% at 7 years
Mortality 5%
Stroke 7%
Crawford et al, Surgery 1983;94:

11. Ascending aorta to innominate & carotid bypass (Saleh & Inglese, JVS 2006;44:461)

12. Results of surgical carotid-carotid and aorto-innominate / left carotid (Y-graft) bypass
Selected case reports

13. TOTAL Carotid- Carotid 30d Mortality / CVA Aorto-innominate/ L carotid
Other
Kato et al 1
0 / 0 2
1 / 1
(same pt)
Bergeron
et al 15 11
1 retro type A dissection
Czerny et al 9
Mangialardi et al
Zhou et al 16
1 / 0
Saleh & Ingles
w/ Ao banding
Buth at al
(Ao-L car-LSC
TOTAL 26 47
4 / 2

14. Carotid stenting (T. Larzon et al, Eur J Vasc Endovasc Surg 2005;30:148)

15. Chuter Graft Chuter et al, JVS 2003;38:861

16. Chuter Graft Chuter et al, JVS 2003;38:861

17. Hybrid techniques (Zhou et al, JVS 2006;44:691)

18. Hybrid techniques (Zhou et al, JVS 2006;44:691)

19. Hybrid techniques ( Diethrich at al, J Endovasc Ther 2005;12:663 )

20. Case Study: 77 y/o WF with 6.3cm saccular TAA
Evaluation of left vocal cord paralysis → CT of chest Feb 2006 → large saccular TAA off lateral aspect of distal arch
History of extensive spinal surgery in 2004 (Harrington rods at lumbar spine); surgical repair of perforated gastric ulcer in May 2005

21. Baseline CTA – 3D

22. Baseline CTA

23. Baseline arch & cerebral arteriogram

24. Operative procedures
Right to left carotid-carotid, left carotid-subclavian bypass using 8mm ringed Goretex graft
Right common iliac artery conduit using 10mm Hemashield graft
34 mm x 15 cm Gore TAG deployed just distal to innominate via 22 Fr sheath
No spinal drain due to previous lumbar surgery and hardware

25. Intraoperative aortogram

26. 1-month CTA

27. Open surgical repair still an option Case study:
41 y/o WM s/p patch repair of thoracic aortic coarctation 23 yr ago
Severe AI and MR; no sig CAD
CTA of chest 3/06: recurrent coarctation w/ marked aneurysmal dilatation distally

29. Left carotid-subclavian bypass and attempted endovascular repair

30. Persistent type I proximal endoleak 4 days post-op → open chest repair

31. 5 days post tube graft repair

32. Fenestrated Graft: Is This the Future Solution?

33. Questions?