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Using the sandwich technique for
thoraco-abdominal aneurysm repair
Petroula Nana1, Georgios Kouvelos1, Aikaterini Bouzia2, Eleni
Arnaoutoglou2, Athanasios Giannoukas1, Miltiadis Matsagkas1
1 Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece2 Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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2019
✓Endovascular approach of thoraco-abdominal aneurysms
(TAAA) is challenging
✓Sandwich technique is an off-the-shelf assessment in these
cases
Background
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2019
To present a patient with a TAAA type II
treated in two stages
Sandwich technique & standard TEVAR
Aim
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Medical History
✓ 72 year-old, male
Medical history significant for
• Previous EVAR (Talent, Medtronic, 2000)
• Current smoker
• Hypertension
• Dyslipidaemia
• CAD (Spect 7% of reversible ischemic lesion at LV, EF 50%)
• COPD
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After a 7-year lost follow-up, CTA revealed
• Graft migration
• Development of a TAAA type II, d=75mm
• LCIA aneurysm
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Pre-operative CTA RRA
LRA
SMA
CT occlusion
Para-visceral aorta
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Treatment options
✓FEVAR
✓T-Branch
✓Sandwich technique
✓Open repair
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Sandwich techniqueIn a few words…
• Thoracic endograft in the distal descending aorta
• Three target vessels (coeliac trunk occlusion) ✓ 2 catheterized antegradely from the axillary arteries (LRA, SMA) ✓ RRA via the left iliac artery (periscope)
• Thoracic graft down to the bifurcation of the previous endograft
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Pre-operative Planning
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AccessAccess via✓Both axillary arteries✓Both femoral arteries
• General anesthesia
• 5000iu UFH, continuous
re-evaluation with ACT
measurements
• Cerebral oximetry
Catheterization of LRACatheterization of SMA
Catheterization of RRA
• Rosen wires• ANL sheaths 8Fr
Main graft
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1st thoracic endograft
Bolton Relay, Vascutek,
42x34x135mm
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Target Vessels
CT
SMA
LRA
RRA
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Catheterization of target vessels
RRA
LRA
SMA
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Sandwich technique
CT occlusionSelf-expanding stent 9X100mm
Balloon expandable covered stent 6x57mmSelf-expanding covered stent 7x100mm
Relining with self-expanding stent
7x60, 7x60 & 8x40mm
Relining with self-expanding stent
10x40 & 9X100mm
SMA
LRA
RRASelf-expanding covered stent 5x100mm
Relining with self-expanding stent 6x60 & 6x60mm
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Sandwich technique
Periscope
Insertion & deployment of 2nd Bolton relay,
Vascutek, 40x38x150mm
Gore, Excluder limb,
16x14.5x120mm
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Intra-operative details
Intra-operative data✓ 2 RBC✓Contrast 250ml✓Radiation 735mGy (135min)✓Duration of operation 300min
Patient transferred to ward under close monitoring
No need for ICU
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Post-operative CTA before discharge
SMA
LRA
LRARRA
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Discharge & Initial Follow-upDischarged the 6th post-operative day✓ No complication recorded ✓ Good general status ✓ Mild renal impairment (GFR 44ml/min/1.73m²)
Close follow-up• Clinical reevaluation the 15 & 25th post-operative day• Laboratory exams every 10 days ( Creat, 20-day GFR 58ml/min/1.73m²)
A second procedure for the proximal part of the aneurysm was scheduled in the 3rd post-operative month
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40 days after the procedure
✓Atypical thoracic pain
✓Hemodynamically stable
✓Normal evaluation by cardiologist
D 68.9mm
D 90.5mm
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School of Medicine, University of Barcelona27th to 29th MARCH 2019
Access-TEVAR
Relay Bolton, Vascutek, 38x38x145mm
Percutaneous puncture of L brachial for angiography
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TEVAR
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Intra-operative details
Intra-operative data✓No RBC✓Contrast 50ml✓Radiation 75.4mGy (14,5 min)✓Duration of operation 60 min
Patient transferred to ward
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Post-operative CTA before discharge
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6th month follow-up
✓No complication recorded ✓Good general status ✓Normal GFR 71ml/min/1.73m²
D 80.4mm
D 72.4mm
No endoleakPatent TV
Sacs exclusion
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School of Medicine, University of Barcelona27th to 29th MARCH 2019
1st year follow-up
✓No complication recorded ✓Good general status ✓Normal GFR 71ml/min/1.73m²
TAA Dmax 62
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1st year follow-up TAAA Dmax 76mm
SMA
LRA
Patent RAs stents
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Conclusion
✓Sandwich technique was a safe option for this patient
✓A two-stage treatment eliminated the risk of spinal cord ischemia
✓Re-intervention in these patients may be associated with
difficulties in access
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Thank you
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