aortic arch/ thoracoabdominal aortic replacement · pdf filejoseph s. coselli, m.d. vice...
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Joseph S. Coselli, M.D.Vice Chair, Department of Surgery
Professor, Chief, and Cullen Foundation Endowed Chair
Division of Cardiothoracic Surgery
Baylor College of Medicine
Aortic Arch/Thoracoabdominal
Aortic Replacement
AATS International Cardiovascular Symposium 2017Session 13: Live in Box – Complex Cardiac Scenarios
São Paulo, Brazil • Saturday, December 9, 2017
Disclosure
Medtronic, Inc PI Clinical Trials
Consultant
Vascutek
Terumo
Consultant
PI Clinical Trials
Royalties Coselli
branched graft
WL Gore &
Associates
PI Clinical Trials
Consultant
Bolton Medical PI Clinical Trials
Followed successful 1956 ascending aortic repair with CPB
Wanted to move away from all of the "shunt" anastomoses and shorten operative time (perfused for 43 minutes)
Early Aortic Arch Replacement
• First successful attempt
• Homograft
• Cardiopulmonary bypass used to perform early antegrade cerebral perfusion
• Felt 60 minutes CPB was safe
• No hypothermia
DeBakey et al SGO 1957
• 1st time profound HCA used to protect the brain during repair
• Profound: 14°C
• 4 patients →
3 survivors (75%)
• Mainstay of arch repair for > 4 decades
Profound Hypothermic Circulatory Arrest (HCA)
14°C esophageal temperature
18°C rectal temperature
Griepp et al
J Thorac Cardiovasc Surg 1975
• Aortic arch repair
▪ Reimplant brachiocephalic arteries
▪ Almost always use hypothermic
circulatory arrest (HCA) to protect brain
Type of repair varies (pathology)
▪ Hemiarch
▪ Total (full) arch
▪ Total arch + elephant trunk (ET)
• Hybrid/endovascular options
▪ Experimental/off-label
▪ Debranch arch vessels
Complex Aortic Repair
Hemiarch
Total arch + ET
Trifurcated (Y) Graft
Hemiarch• Replaces lesser
curvature of arch
• Blood to brain
interrupted
• Less risk than total arch
• Branching arteries are
left intact
• Often used in cases
involving acute aortic
dissection or if
pathology is limited
Arch Repair
Total Arch Reconstruction
Island Branched
Y-graft ET
Y-graft
Island ETSingle branch ET
Total ArchBeyond the Arch
Frozen ET
ET
Trifurcated Approach: Extensive Repair
• Early results using trifurcated
graft technique compare favorably
to traditional approaches
• 7/150 (4.7%) early death
Spielvogel 2007 ATS
• Enables effective delivery of
SCP→ axillary perfusion
• Minimizes unprotected cerebral
ischemic time
• Facilitates the “full arch”approach of extensive repair
Y-Graft Approach
During Cooling: Left common carotid and left subclavian arteries are transected, ligated, and bypasses onto prefabricated Y-graft
Cooled to 24-28°C: Once target temp-erature attained, flows are reduced to 10-15 mL/kg/min and the innominate artery is snared
Bilateral ACP: 9 Fr balloon perfusion catheter
Distal anastomosis of graft collar: Collar
helps reduce tension on graft and aids hemostasis
Y-Graft
Approach
▲Head
Proximal anastomosis of main graft complete:
Proximal anastomosis of trifurcated graft underway
Y-Graft
Approach
Distal perfusion:
Side branch
Bilateral ACP: Flow
rate 10-15mL/kg/min
▲Head
Elephant Trunk (Island)
Elephant Trunk + TEVAR Repair
Mortality of Elephant Trunk
Cumulative Mortality Table SummaryRange of Percentages from Authors
Reporting Elephant Trunk Surgical Outcomes
1st Stage Mortality
Interval or Nonreturning
Mortality2nd Stage Mortality
All Cause Total
Mortality
2.3 – 13.9% 0 – 24.6% 0 – 10.0% 8.3 – 35.8%
Etz et al, 2008LeMaire et al, 2006Svensson et al, 2004Heinemann et al, 1995Safi et al, 2005Sundt et al, 2004
Frozen Elephant Trunk Repair
Cannulation Sites
Carotid artery
Subclavian artery
Brachiocephalic trunk
Apical (apex)
▪ All above sites are in contemporary use
▪ Alternate cannulation sites useful in cases of
redo surgery and acute aortic dissection
Femoral artery
Axillary artery
Innominate artery
Ascending aorta
Preventza et al 2013 ACTS [Coselli]
Frozen Elephant Trunk: Devices
ThoraflexEvita plus
Unlike frozen elephant
trunk (FET), not a total
arch replacement
Only a small part of the
transverse arch is native
Hemiarch + Antegrade TEVAR
Evolution of Open Aortic Arch
▪Femoral cannulation
Axillary/Innominate cannulation
▪Retrograde cerebral perfusion
Bilateral antegrade cerebral perfusion
▪Profound hypothermia
Moderate hypothermia
▪Island technique
Y-graft technique
▪Elephant trunk
Collared grafts
Preoperative characteristics n (%)
Age, years 60±14
Male 1341 (66%)
Heritable thoracic aortic disease 217 (11%)
Marfan syndrome 149 (7%)
Bicuspid aortic valve 410 (20%)
Acute/subacute aortic dissection 384 (19%)
Chronic aortic dissection
(redo or previously unrepaired)
454 (22%)
2026 Open Arch Repairs Consecutive from January 1999 to November 2017
Includes data on 138 hybrid arch repairs
Operative Details n (%)
Elective repair 1414 (70%)
Urgent repair 280 (14%)
Emergent repair (including salvage) 332 (16%)
Repeat sternotomy 626 (31%)
HCA + ACP only 1630 (80%)
HCA alone 134 (7%)
Lowest mean temperature, °C 20.8±4.1
2026 Open Arch Repairs Consecutive from January 1999 to November 2017
Includes data on 138 hybrid arch repairs
Operative Details n (%)
Concomitant root or valve procedure 1519 (75%)
Valve-sparring ARR 134 (7%)
Hemiarch 1486 (73%)
Full arch 515 (25%)
Full arch with elephant trunk 319 (16%)
Y-graft approach to full arch 185 (9%)
Cannulation: innominate artery 627 (31%)
Cannulation: right axillary artery 934 (46%)
2026 Open Arch Repairs Consecutive from January 1999 to November 2017
Includes data on 138 hybrid arch repairs
Select 30-Day Mortality Rates n (%)
Overall 30-Day death 141 (7%)
Elective repair (n=1414) 75 (5%)
Emergent repair (n=332) 44 (13%)
Redo sternotomy (n=626) 65 (10%)
Acute aortic dissection (n=345) 43 (12%)
Heritable thoracic aortic disease (n=217) 11 (5%)
Total arch (with or without ET) (n=515) 53 (10%)
2026 Open Arch Repairs Consecutive from January 1999 to November 2017
30-day death is death within 30 days at any location including after discharge
Includes data on 138 hybrid arch repairs
Hybrid Aortic Arch Surgery
138 Hybrid Arch RepairsConsecutive from January 1999 to November 2017
Operative
Details
n (%)
Zone 0 44 (32%)
Zone 1 2 (1%)
Zone 2 11 (8%)
Zone 3 78 (57%)
Zone 4 3 (2%)
Above zones use
Criado classification
Early Outcomes n (%)
Early death (hospital + 30-day) 18 (13%)
30-day death 16 (12%)
138 Hybrid Arch RepairsConsecutive from January 1999 to November 2017
Early death includes all deaths during entire period of hospitalization
(including any transfer) as well as any 30-day death (within 30 days at any
location including after discharge)
• Thoracoabdominal aortic repair
▪ Reimplant visceral arteries
▪ Use of adjuncts varies (pathology)
• Repair itself risks ischemic damage to downstream organs
▪ Spinal cord
▪ Kidneys
▪ Visceral organs
• Hybrid/endovascular options
▪ Experimental/off-label
▪ Debranch visceral vessels
Complex Aortic Repair
Crawford – 1509 TAAA repairsSvensson et al. J Vasc Surg 1993
SvenssonJ Vasc Surg 1993;17:357
31-year experience
1960 to 1991 n (%)
Early death 123 (8%)
Paraplegia 105 (7%)
Renal dialysis 136 (9%)
GI complications 101 (7%)
Lifetime Experience
I → 378 patients
II → 442 patients
III → 343 patients
IV → 346 patients
Cited as reference ~600 times (SCOPUS)
For extent II TAAA repair, the rate of
paraplegia or paraparesis increased to 31%
Evolving TAAA Repair
Improved
Outcomes
Evolution of Open TAAA Repair
▪No use of heparin
Moderate heparinization
▪Clamp-and-sew
Selective use left heart bypass
Selective use of CSF drainage
Selective use visceral perfusion
Whenever possible cold renal perfusion
▪Island technique
Selective use branched grafts
▪Select reattachment of intercostals
Aggressive reattachment of intercostals
Intraoperative Strategies
All extents
• Moderate heparinization
• Permissive mild hypothermia
• Aggressive reattachment of segmental arteries
• Cold renal perfusion whenever renal ostia can be accessed
• Expeditious repair
Extent I and II repairs
• Cerebrospinal fluid drainage
• Left heart bypass
• Selective celiac/SMA perfusion
Left inferior
pulmonary vein
Distal descending
thoracic aorta
Left Heart Bypass
LeMaire et al J Vasc Surg 2009
• We have performed 2
randomized clinical trials
regarding cold renal perfusion
• Cold renal perfusion was found
to benefit patients and reduce
postoperative renal failure over
normothermic
▪ P=0.03 [Köksoy 2002]
• Cold crystalloid and cold blood
provide equivalent renal benefit
▪ P=1.0 [LeMaire 2009]
Cold Crystalloid
Renal Perfusion
Cold Renal Perfusion
9-Fr Pruitt cathetersLR + 12.5 g/L Mannitol
+ 125 mg/L methylprednisolone
Isothermic centrifugal circuit
?
95th Annual Meeting, American Association of Thoracic Surgery (AATS)Plenary Scientific Session: Abstract 1
Seattle, Washington • Monday, April 27, 2015
Coselli et al JTCVS 2016
Outcomes of 3309 Thoracoabdominal
Aortic Aneurysm Repairs
October 1986 to December 2014
Coselli JTCVS 2016
3309 Open TAAA Repairs
~30 year experience
1986 to 2014 n (%)
Operative death 249 (7.5%)
30-day death 159 (4.8%)
Permanent paraplegia 97 (2.9%)
Permanent paraparesis 81 (2.4%)
Renal failure (dialysis) 189 (5.7%)
Gastrointestinal
ischemia
31 (0.9%)n=914 n=1066 n=660 n=669
3522 Open ThoracoabdominalAortic Aneurysm RepairsRepairs performed between 1986 and November 2017
Patient Characteristics n (%)
Median age, y [IQR]; range 10y to 92y 67 [59-73]
Heritable thoracic aortic disease 364 (10%)
Marfan syndrome 318 (9%)
Aortic dissection involving distal aorta 1266 (36%)
Acute or subacute dissection 179 (5%)
Chronic dissection 1087 (31%)
Symptomatic 2254 (64%)
Rupture 184 (5%)
Early Outcomes n (%)
Operative mortality 283 (8%)
30-day death 186 (5%)
Persistent*
Paraplegia 109 (3%)
Paraparesis 78 (2%)
Stroke 87 (2%)
Renal failure necessitating dialysis 211 (6%)
Adverse event (composite endpoint) 526 (15%)
*Persisting to the time of hospital discharge or early death
3522 Open ThoracoabdominalAortic Aneurysm RepairsRepairs performed between 1986 and November 2017
• Contemporary Arch/TAAA repair is highly
varied—multitude of approaches
• Good-to-excellent outcomes in experienced
centers
• Variety of techniques/adjuncts have lowered
risk in contemporary practice
• Many options for your patient
Conclusions
Obrigado!