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?