Endovascular Repair of Thoracic Arch Aneurysms
Postgraduate CourseSouthern Association for Vascular Surgery
H. Edward Garrett, Jr. M.D.Professor of Surgery
University of Tennessee Health Sciences CenterMemphis, TN
Financial & Regulatory Disclosure
• Principal investigator for – Gore TAG post-approval study and – Medtronic VALOR Trials (Talent thoracic stent
graft system)
• W.L. Gore sponsors the University of Tennessee Vascular Conference and the Edward Garrett Sr. Midsouth Vascular Society
Surgical results for open repair of aneurysms involving the aortic arch:
• 30 day mortality 15%• Neuro events 10-15%• 5 year survival 75%• Death primarily related to neurological and cardiac
events• Many patients denied open surgical treatment because
of comorbidities Kirklin/Barratt-Boyes Cardiac Surgery, Third Edition , N.T. Kouchoukos et
al
Landing zones in the thoracic aorta
Coverage of the left subclavian artery:Carotid-subclavian bypass or not?
• Gore TAG IFU: “If occlusion of the left subclavian artery ostium is required to obtain adequate neck length for fixation and sealing, transposition of the left subclavian artery should be considered.”
• Vertebral circulation must be evaluated. ?Impact on paraplegia
• Presence of internal mammary artery graft to LAD mandates revascularization
• Debatable whether left subclavian bypass necessary
LIMA bypass graft off the left subclavian artery
pre-implant post-implant
Arizona Heart Institute
• 255 thoracic endograft pts reviewed (2/00-12/05)• LSA covered in 71 pts; partially covered in 47 pts• 15 of 71 pts had pre-stent bypass → 1
CVA (this pt also had car-car bypass)• 3 of 56 pts without pre-stent bypass had
complications: 2 TIA’s, 1 paraparesis (full recovery)• 1 of 56 pts without pre-stent bypass had lt arm
claudication → car-SC bypass• Many other high volume centers are aggressive about
subclavian revascularization -Data used with permission of Grayson Wheatley III, MD
Results of subclavian revascularization
• Prosthetic carotid-subclavian bypass:
– Patency: 85% @ 7 yr– Mortality: 0-2%– Stroke rate: 1-5%
• Carotid-subclavian transposition:
– Patency: 100% @ 7 yr– Mortality: 1-2%– Stroke rate: 0-2%
Rutherford, Vascular Surgery
Coverage of left carotid &/or innominate arteries not included in IFU
but allows expansion of endovascular technique.Debranching the aortic arch mandates some type
of reconstruction:
• Carotid-carotid bypass • Ascending aorta to innominate &
carotid bypass• Proximal carotid stenting• Femoral-axillary bypass• Chuter graft
Ascending aorto – innominate &/or carotid bypass
• Patency 100% at 7 years• Mortality 5%
• Stroke 7%
Crawford et al, Surgery 1983;94:781-791
Ascending aorta to innominate & carotid bypass (Saleh & Inglese, JVS 2006;44:461)
Results of surgical carotid-carotid and aorto-innominate / left carotid
(Y-graft) bypass
Selected case reports
Carotid-
Carotid
30d Mortality /
CVA
Aorto-innominate/
L carotid
30d Mortality /
CVAOther
Kato et al 1 0 / 0 2 1 / 1(same pt)
Bergeron
et al
15 1 / 1 11 1 / 1 1 retro type A dissection
Czerny et al 9 0 / 0 2 0 / 0
Mangialardi et al
1 0 / 0
Zhou et al 16 1 / 0
Saleh & Ingles
15w/ Ao banding
1 / 0
Buth at al 1(Ao-L car-LSC
0 / 0
TOTAL 26 1 / 1 47 4 / 2
Carotid stenting (T. Larzon et al, Eur J Vasc Endovasc Surg 2005;30:148)
Chuter GraftChuter et al, JVS 2003;38:861
Chuter GraftChuter et al, JVS 2003;38:861
Hybrid techniques(Zhou et al, JVS 2006;44:691)
Hybrid techniques(Zhou et al, JVS 2006;44:691)
Hybrid techniques( Diethrich at al, J Endovasc Ther 2005;12:663 )
Case Study: 77 y/o WF with 6.3cm saccular TAA
• Evaluation of left vocal cord paralysis → CT of chest Feb 2006 → large saccular TAA off lateral aspect of distal arch
• History of extensive spinal surgery in 2004 (Harrington rods at lumbar spine); surgical repair of perforated gastric ulcer in May 2005
Baseline CTA – 3D
Baseline CTA
Baseline arch & cerebral arteriogram
Operative procedures
• Right to left carotid-carotid, left carotid-subclavian bypass using 8mm ringed Goretex graft
• Right common iliac artery conduit using 10mm Hemashield graft
• 34 mm x 15 cm Gore TAG deployed just distal to innominate via 22 Fr sheath
• No spinal drain due to previous lumbar surgery and hardware
Intraoperative aortogram
1-month CTA
Open surgical repair still an option
Case study:
• 41 y/o WM s/p patch repair of thoracic aortic coarctation 23 yr ago
• Severe AI and MR; no sig CAD
• CTA of chest 3/06: recurrent coarctation w/ marked aneurysmal dilatation distally
Left carotid-subclavian bypass and attempted endovascular repair
Persistent type I proximal endoleak 4 days post-op → open chest repair
5 days post tube graft repair
Fenestrated Graft: Is This the Future Solution?
Questions?