1. Dr R H Stables Cardiothoracic Centre Liverpool, UK Thoracic Aortic Stent Grafting

2. Introduction Pathology of the thoracic aorta Referred to cardiologists / cardiac surgeons Investigated and treated in cardiac units Conventional surgical treatment associated with High mortality Significant morbidity (including paraplegia) ? improved Tx with endovascular techniques Requires genuine collaborative working

3. ‘Liverpool cardiologist dies in drive-by shooting’

4. Collaborative Working Cardiologists / Interventional radiologists Interventional radiologists have much to offer Equipment and techniques More related to peripheral intervention (Unlike carotid stenting !) Experience with abdominal aortic procedures

5. Collaborative Working Cardiologists / Interventional radiologists Vascular surgeons / Cardiothoracic surgeons Vascular surgical skills Issues of vascular access Femoral / Iliac / Aorta Complications related to device passage Iliac vessels Cardiothoracic techniques Conversion to open procedure

6. Collaborative Working Cardiologists / Interventional radiologists Vascular surgeons / Cardiothoracic surgeons MRI / CT Imaging specialists Radiographic and surgical facilities Availability of open surgical conversion Anaesthesia ITU Post op - care Industrial partners

7. Thoracic Stent Grafting Developing treatment strategy Mainly descending aorta Indications Aneurysm Dissection Transection Perforation Open surgical graft procedures (may include Type A) Coarctation of the aorta

8. MRI Image – Thoracic Aneurysm

9. MRI Image – Thoracic Aneurysm – Post Stent

10. Angio Images – Thoracic Aneurysm Slides courtesy of Prof. Rousseau

11. Mrs MB Female 56 years CRF - Failing renal transplant (after 20 years) Recent return to haemodialysis Subclavian dialysis line - septicaemia Staph Aureus - Tx Antibiotics through line Readmitted with back pain Ix Osteoporosis Vomits bright red blood Endoscopy and CT scan Transfer to CTC Liverpool

12. Mrs MB 3 x simultaneous blood infusions Hb 5.4 g/dl Left haemothorax PaO 2 = 8 kPa on 40% O 2 Infected dialysis line in situ No immediate evidence of septic shock CT scan imaging Emergency thoracic stent procedure

13. Peripheral Vessel Anatomy

14. Leaking (x2) Thoracic Aneurysm

15. Sizes 26, 28, 30, 32, 34, 38, 42, 44, 46 mm Nitinol rings Dacron graft Talent LPS Thoracic Stent Graft System

16. Thoracic Delivery System

17. Stent Device (TALENT) Before Deployment

18. Acute Result

19. Subacute EndoLeak / Perforation

20. Use of Forming Balloon

21. Deployment of Additional Proximal Stent

22. Deployment of Additional Distal Stent

23. Final Result

24. Thoracic Stent Grafting Complications Problems with peripheral vascular access Low incidence of paraplegia Migration Endo-leaks and perforation Multiple stents common Post implant syndrome 

25. Thoracic Stent Grafting Initial case series reports Many cases surgical contraindication ? Risk Acute success 80 - 90% 3 year event-free survival 50 - 70% 

26. Questions and Discussion

27. Angio Images – Thoracic Aneurysm Slides courtesy of Prof. Rousseau