1. ASCVTS 2011 Shaggy aorta & TEVAR 1 “Shaggy aorta” is a highly dangerous sign of TEVAR for aortic arch aneurysm “Shaggy aorta” is a highly dangerous sign of TEVAR for aortic arch aneurysm Department of Cardiovascular Surgery Fukushima Medical University, School of Medicine Fukushima, JAPAN Shinya Takase, Hirono Satokawa, Yoichi Sato, Hiroki Wakamatsu, Yoshiyuki Sato, Hiroyuki Kurosawa, Takashi Igarashi, Akihito Kagoshima, Tsuyoshi Yamabe, Hitoshi Yokoyama

2. ASCVTS 2011 Shaggy aorta & TEVAR 2 Background Conventional surgery for thoracic aortic aneurysm still has high morbidity and mortality.Conventional surgery for thoracic aortic aneurysm still has high morbidity and mortality. In this condition, stentgraft is applied to descending thoracic aortic disease more than graft replacement.In this condition, stentgraft is applied to descending thoracic aortic disease more than graft replacement. For arch aorta, stentgraft is only deployed to high risk patients in general. However, in TEVAR for this lesion, stroke is concerned because of atheromatous embolization.For arch aorta, stentgraft is only deployed to high risk patients in general. However, in TEVAR for this lesion, stroke is concerned because of atheromatous embolization. Conventional surgery for arch aortic aneurysm even with severe atherom induces catastrophic complication followed by early death.Conventional surgery for arch aortic aneurysm even with severe atherom induces catastrophic complication followed by early death.

3. ASCVTS 2011 Shaggy aorta & TEVAR 3 Purpose This paper is to explore whether TEVAR for aortic arch aneurysm with “shaggy aorta” is acceptable or not.

4. ASCVTS 2011 Shaggy aorta & TEVAR 4 Severely atheromatous aorta Definition of “Shaggy aorta” Noraml Intimal thickness(IT) < 2mm No irregularity Intimal thickness > 2mm No irregularity Irregularity (+) IT>2mm + Irregularity but not projected IT>2mm + Irregularity with projection

5. ASCVTS 2011 Shaggy aorta & TEVAR Case 4 77 y.o. male, True aortic arch aneurysm, Angina

6. ASCVTS 2011 Shaggy aorta & TEVAR Case 1 ； 82y.o. female Arch Aneurysm with aberrant artery

7. ASCVTS 2011 Shaggy aorta & TEVAR Treatment Strategy Indication of Conventional Surgery? Indication of Conventional Surgery? PossibleImpossible Age>75 y.o.,Age>75 y.o., Severity of co-morbiditySeverity of co-morbidity Concomittant Procedure (CABG, Valve Surgery)?Concomittant Procedure (CABG, Valve Surgery)? CS Concomittant Proc. Difficult Treans-femoral Access Yes No debranched SG Zone0~1Zone2 SG Fenestrated SG

8. ASCVTS 2011 Shaggy aorta & TEVAR 8 SG deployment Examination MD-CT ＞ Angiography Endoluminal Stentgraft (tailered made) GiantrucoZ stent ; d30-40X l 50-75mm UBE Ultrathin graft ; d28-40X l 50-150mm Delivery system (Pull through) COOK Guiding Sheath (straight / bending) 0.035” Super stiffness / TERMO J type 230cm Deployment Hypotension (60-80mmHg) / ATP 0.2-0.4mg/kg / Rapid pacing 120-140 ppm Monitoring INVOS / MEP ( in some cases)

9. ASCVTS 2011 Shaggy aorta & TEVAR Fenestrated ＳＧ for aortic arch aneurysm Max diameter;42mm Saccular type

10. ASCVTS 2011 Shaggy aorta & TEVAR (Debranching) + Transaortic SG 1) Branched Graft 2) Side clamping and anastomosis 3) Reconstruction of cerebral arteries (debraching) 4) Trans-aortic SG SG (22F Guiding Sheath) over the wire 5F Pigtail 8X16mm Y-graft 8mm 10mm 8mm

11. ASCVTS 2011 Shaggy aorta & TEVAR 11 Patients Jan., 2001 ～ May, 2010 SG repair for aortic arch aneurysm (Non-dissecting aneurysm) 23 Cases Male:Female = 19 ： 4, Age ; 74±7 y.o., Observation ; 30 ～ 3219 （ 848±1058 ） days

12. ASCVTS 2011 Shaggy aorta & TEVAR Patients’ Profile with “Shaggy aorta” or not Shaggy aorta, n(%)Non “Shaggy aorta”, n(%) n=23n=8n=15 Male:Female7:112:30.65 Age 75±673±7 0.59 HT8(100)15(100)1.00 HL6(75)10(67)0.67 DM1(13)0(0)0.35 Cerebrovascular diseases2(22)5(33)0.12 Cardiac disorders3(38)3(20)0.62 Respiratory dysfunction2(50)3(53)1.00 Renal insufficiency2(25)3(20)1.00 PAD4(50)1(7)0.033 Multiple aortic aneurysm2(25)2(13)0.59 Logistic EuroSCORE30.1±24.623.1± 20.10.76

13. ASCVTS 2011 Shaggy aorta & TEVAR 13 Postoperative Outcome Shaggy aorta, n=8 Non Shaggy aorta, n=15 Approach from aorta5(63) 4(27) 0.18 CPB use1(13) 2(13) 1.00 Debranching5(63) 7(47) 0.67 SG top;Zone0/1/2/33(38)/3(38)/0(0)/2(25) 2(13)/3(20)/5(33)/5(33) 0.19 Primary Outcome Endoleak2(25)2(13)0.59 Surgical conversion0(0)1(7)1.00 Additional SG1(13)0(0)0.35 Access trouble1(13)2(13)1.00 Aorta injury1(13);dissection1(7); aorta rupture*1.00

14. ASCVTS 2011 Shaggy aorta & TEVAR 14 Postoperative Outcome Shaggy aorta, n=9 Non Shaggy aorta, n=14 Cerebral infarction1(13)0(0)0.35 Respiratory failure3(38)2(13)0.30 Pneumonia2(25)0(0)0.11 Renal dysfucntion3(38)1(7)0.10 Hemodialysis3(38)1(7)0.10 Bowel ischemia0(0) 1.00 Gastric bleeding0(0)1(7)1.00 Paraparesis2(25)0(0)0.11 Any morbidities5(63)2(13)0.026 MOF1(13)0(0)0.35 Death in 30days1(13)1(7)1.00 Hospital death4(50)2(13)0.13 *MOF;1, Pneumonia;2, AAA rupture;1,

15. ASCVTS 2011 Shaggy aorta & TEVAR Actual Survival 15 Log-rank p=0.13 50% 71% Shaggy Non-shaggy

16. ASCVTS 2011 Shaggy aorta & TEVARSummary SG treatment for aortic arch aneurysm is technically successful with debranching and/or fenestrated SG.SG treatment for aortic arch aneurysm is technically successful with debranching and/or fenestrated SG. There were no differences in preoperative co- morbidities between patients group w/ and w/o “shaggy aorta”.There were no differences in preoperative co- morbidities between patients group w/ and w/o “shaggy aorta”. Embolim was induced around 50% in the group with “shaggy aorta”, whereas it was 0% in that without “shaggy aorta”.Embolim was induced around 50% in the group with “shaggy aorta”, whereas it was 0% in that without “shaggy aorta”. As the result, once one or more organ dysfunctions were occurred in such high risk patients, it led to death.As the result, once one or more organ dysfunctions were occurred in such high risk patients, it led to death. Once the patients with “shaggy aorta” can tolerate this treatment, they could survive in long time period.Once the patients with “shaggy aorta” can tolerate this treatment, they could survive in long time period.

17. ASCVTS 2011 Shaggy aorta & TEVARConclusion “Shaggy aorta“ is a dangerous sign. Special caution of handling in this procedure is required. Adequate informed consent to such patients is also required. Invention of completely preventive measures against embolism is aspired.