Multidisciplinary Thoracic Aortic RoundsFoothills Medical Centre

November 28th, 2014

Case Presentations: Advanced Thoracic Aortic Reconstructions

Eric Herget & Jehangir Appoo

The Evolution of Endovascular• Stentgrafts

• Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease

• Hybrid

• Fenestrated• Custom / pre-fabricated

• In-situ

• Branched grafts

• Chimney/Snorkel technique

• Sandwich technique

Dr. Herget 2012 Th Ao Rounds:

Case 1 Zone 2 Hybrid Arch

81 year old male with incidental finding of diffuse aortomegaly

Cardiovascular ProfileMod AIMod LV dysfunctionChronic AfibNo sig CAD

81 year old male with incidental finding of diffuse aortomegaly

Other issuesRetrosternal Thyroid Goiter

-compressing trachea-seen by Pulm Med & Gen Surg

Temporal artery biopsy remote - ?Giant Cell arteritis

BPH

Case presented at cath conferenceOpinions solicited

AV may not need to be replacedCeliac origin occluded

81 year old male with incidental finding of diffuse aortomegaly

Social HistoryLives independentlySkated 150 times previous season to play/referee hockey games

Operative Plan

Collar incision and sternotomy to resect thyroid

Hybrid Arch:Zone 2 arch replacement with branched dacron graftTEVAR of distal arch/descending thoracic aorta

Intraop:Thyroid Specimen

Intraop

Exposure

Intraop

HCA 13minsSACP 23minsXCT 110minsCPB 151mins

Moderate Hypothermia 25degrees C

CSF Drain

Post op:

Extubated night of surgeryNeuro intactCSF drain removed on POD 2

Delayed CSF leak noted 1 week post removal – H/A & nausea

Post op Imaging – exclusion of aneurysm

VR Images

Take away points from Hybrid Arch Case

Exposure dissect out head vessels before going on CPB if possible

Creating suitable landing zonesZone 2

Antegrade vs. retrograde deployment – pros and cons

CSF drain management

Case 2 : Chimney Technique

56 year old male

6.5cm aortic root

4+ AI

8cm LVEDD with Severe LV Dysfunction

NYHA Class IV CHF

6cm Descending Thoracic Aortic Aneurysm

Dominant Left Vertebral

Staged Treatment Plan:

Proximal reconstruction with a mechanical composite root

Ascending aorta – left axillary bypass

Issues with carotid-subclavian at same time as proximal root operation in ill patient with 4+ aortic insufficiency

TEVAR post op

Sept 6, 2012:

27mm CarboSeal Composite Root

Ascending aortic replacement

Extra-anatomic ascending aorta to left subclavian bypass

Post op:

Renal insufficiency resolved

Tolerating ACE-I and B-Blockers

Sept 12, 2012

Brought to OR for TEVAR

After 1st device deployed:cardiac arrestnot responsive to therapyprolonged resuscitation

chest openedplaced on CPB, LV ventedSuccessfully defibrillated

Woke up next day neuro intact!

Allowed to ‘stabilize’ over the next 3 months

Dec 2012 (3 months post op) completion TEVAR – Zone 2

LV function markedly improved “low normal” on good medical therapy

Follow-up CTA’s – type IA endoleak with associated progressive aneurysmal expansion of descending thoracic aorta

Numerous external expert opinions obtained

Options considered to treat endoleak included:

Additional stentgraft or Palmaz to reinforce birdbeak

Aptus endovascular stapler

Carotid subclavian bypass and TEVAR extension to Zone 1

Redo sternotomy and open/hybrid arch reconstruction

Left Carotid-Subclavian bypass

Extended TEVAR to zone 1

access from right brachial as bailout

device maldeployed –salvaged with balloon assisted repositioning technique

aggressive positioning in relation to inominate required to achieve seal (based on CT measurements)

Intraop angio – Hybrid Suite

Intraop Angios

device maldeployed –salvaged with balloon assisted repositioning technique

brisk inflow to inominate

extubated on OR table

Embolization left subclavian origin to eliminate outflow from aneurysm sac (thought to be contributing to endoleak persistence)

POD 2 – asymmetric BP noted and CTA revealed thrombus at inominate origin

Patient remained asympotomatic

Heparin/Plavix/ASA instituted

POD 3

Symptomatic TIA’s

Risk of major stroke

Neurology, Neuro-IR, Neurosurgery & ICU involved

Attempted clot retrieval via right brachial access - unsuccessful

POD 3

Nitinol (bare) stent at inominate origin to trap thrombus and displace TEVAR device

Improved BP in right arm – now symmetric with left arm

Carotid-Subclavian Bypass

No bird beak

Clot resolved entirely

No further neurologic events

But…nitinol stent crimped due to large TEVAR device

BP in both arms significantly lower than legs

Palmaz Balloon Expanded Stent

No residual pressure gradient

D/C home POD 12 with ASA/Plavix/Warfarin x3/12

POD 15 sudden swelling of right arm

Seen at SHC ER

Ultrasound shows large hematoma and 4cm pseudoaneurysm (with 3mm neck –thrombin injection?)

Open repair

Final CTA shows inominate widely patent and no further endoleak

Learning Points

In 2014, we may be more aggressive with initial proximal operation CREATE GOOD LANDING ZONES to avoid complications

Intraop fluoro has limitations – need to navigate around

CT imaging gold standard

Case 3: Snorkel and Sandwich

72 year old petite female

7cm ascending aortic aneurysm

5cm descending aortic aneurysm

Plan:

open proximal repair and observation of descending aorta

OR (April 2012):

replacement of ascending aorta and hemiarch

Ongoing enlargement of descending thoracic aorta over 2 year observation period – rate of 5mm/yr –now 6cm

Challening anatomy due to distal landing zone

Multiple options considered

Isolated TEVAR to celiac

Custom branched TEVAR to SMA

Snorkel

Hybrid laparotomy with bypass to SMA

Open thoracoabdominal

MARS

• Snorkel technique

• Sandwich technique

The Evolution of Endovascular

• Sandwich technique

OR - Oct 20, 2014 –snorkel/sandwich technique

Extubated on OR table

CSF drain removed POD 2

Discharged home POD 4

1 month clinic follow-up:Back to normal activities

Post op CTA Snorkel/Sandwich