1. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery The efficacy of debranching TEVAR for arch aneurysm in high risk patients. Department of Cardiovascular surgery Osaka university graduate school of medicine Y Shirakawa, T Kuratani, K Shimamura, M Takeuchi, K.Kin, T.Yoshida Y Sawa

2. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery Background The traditional treatment of thoracic aortic aneurysms is open surgical graft replacement. Despite progressive surgical advances, conventional surgical repair is still associated with substantial morbidity and mortality, especially in elderly patients with other major medical conditions. Aortic arch aneurysms present a particular challenge to endovascular repair due to the involvement of supra-aortic vessels and the anatomic curvature of the arch. A variety of maneuvers have been recommended for thoracic endografting to address the landing zone limitations imposed by the arch vessels.

3. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery Objectives This report presents the results of a review of our 10-year clinical experience with endovascular treatment of aortic arch aneurysms after debranching of arch vessels (debranching TEVAR).

4. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery Number of Patients : 90 cases (Jan. 1998 ～ Nov. 2009) Sex : Male 65, Female 25 Age : 68.9 ±11.7 （ 27 ～ 95 ） years old pathology Type B dissection37 cases （ acute case 10 ） Degenerative44 cases （ rupture case 4 ） Infective/inflammatory3 cases Traumatic4 cases cancer invasion2 cases co-morbidity High age (over 80 y.o)17 cases (18.8 %) COPD 30 cases (33.3 %) Concomitant cancer 17 cases (18.8 %) CAD 12 cases (13.3 %) previous cardiac surgery 4 cases (4.4 %) Debranching TEVAR Logistic Euroscore : 15.93% +/- 9.77 % (2.76 ~ 43.67)

5. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery Proximal landing zone 101961 Arch reconstruction procedure Debranching TEVAR Ao-rt.SCA-lt.CCA-lt.SCA bypass 9 bil.FA-rt.SCA-lt.CCA-lt.SCA bypass 1 Zone 0 rt.SCA-lt.CCA-lt.SCA bypass19 Zone 1 Zone 2 rt.SCA-lt.SCA bypass 32 lt.CCA-lt.SCA bypass 5 Simple sacrifice of lt.SCA24

6. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery Ao-rt.SCA-lt.CCA-lt.SCA bypass Approach : Median sternotomy Inflow : Side clamp of Ascending Aorta. Prosthesis : 12mm Hemashield for rt. SCA 8mm Hemashield for lt.CCA & lt.SCA Ao – rt. SCA bypass ~ avoid direct clamp of BCA

7. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery Debranching TEVAR Primary success 97.8% (88/90) type Ⅰ b ~ 1, type Ⅱ ~ 1 30 days Mortality 1.1 % (1/90) due to iliac rupture Postopeative Complication Stroke2 (2.2%) (Z2 ~ 2) Respiratory failure1 (1.1%) Paraplegia0 Early results

8. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery 1 year 88.1 % 3 year 77.2% 5 year 69.5% 10 year 69.5% 1 year 96.7 % 3 year 93.6% 5 year 84.2% 10 year 84.2% 135 710 100 20 40 60 80 0 Late results All cause survival Freedom from aneurysm related death 135710 100 20 40 60 80 0 (y) Debranching TEVAR (%)

9. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery 1 year 96.5 % 3 year 83.1% 5 year 83.1% 10 year 69.3% Freedom from Aortic event Re-TEVAR 3 distal enlargement 1 type Ⅰ b endoleak 2 in dissection case. Open conversion 1 Graft infection 1 Rupture 1 13 5710 100 20 40 60 80 0 Debranching TEVAR (y) (%)

10. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery Discussion Operative mortality : 4.3 % In-hospital mortality : 7.2 % Strokes : 5.8 % Paraplegia : 2.9 % Freedom from Aortic events

11. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery Strategy for Arch Aneurysm Debranched TEVAR Arch and distal arch aneurysm Open Surgery High risk patientsFirst choice Patients condition Anatomical condition First choice Anatomical limitations Proximal neck diameter 34 ~ 37mm, length 20mm diameter 23 ~ 33mm, length 15mm Character of Aortic wall (ascending aorta)

12. Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery Conclusion Debranched TEVAR for aortic arch aneurysms appears to reduce the early mortality and morbidity and long-term durability is very acceptable. Our results suggested that this procedure might be an alternative procedure for low risk patients. In the future, ready made branched endoprostheses will be installed, which may expand the applications of this procedure.