Endovascular Repair of Thoracic Arch Aneurysms

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Endovascular Repair of Thoracic Arch Aneurysms

• Postgraduate Course
• Southern Association for Vascular Surgery
• H. Edward Garrett, Jr. M.D.
• Professor of Surgery
• University of Tennessee Health Sciences Center
• Memphis, TN

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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

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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

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Landing zones in the thoracic aorta
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Coverage of the left subclavian
arteryCarotid-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

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LIMA bypass graft off the left subclavian
arterypre-implant post-implant

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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 TIAs, 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

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Results of subclavian revascularization

• Prosthetic carotid-subclavian bypass
• Patency 85 _at_ 7 yr
• Mortality 0-2
• Stroke rate 1-5

• Carotid-subclavian transposition
• Patency 100 _at_ 7 yr
• Mortality 1-2
• Stroke rate 0-2
• Rutherford, Vascular Surgery

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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

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Ascending aorto innominate /or carotid bypass

• Patency 100 at 7 years
• Mortality 5
• Stroke 7
• Crawford et al, Surgery
  198394781-791

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Ascending aorta to innominate carotid bypass
(Saleh Inglese, JVS 200644461)
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Results of surgical carotid-carotid and
aorto-innominate / left carotid (Y-graft) bypass

• Selected case reports

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Carotid stenting (T. Larzon et al, Eur J Vasc
Endovasc Surg 200530148)
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Chuter GraftChuter et al, JVS 200338861
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Chuter GraftChuter et al, JVS 200338861
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Hybrid techniques(Zhou et al, JVS 200644691)
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Hybrid techniques(Zhou et al, JVS 200644691)
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Hybrid techniques( Diethrich at al, J Endovasc
Ther 200512663 )
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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
  

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Baseline CTA 3D
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Baseline CTA
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Baseline arch cerebral arteriogram
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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

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Intraoperative aortogram
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1-month CTA
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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

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Left carotid-subclavian bypass and attempted
endovascular repair
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Persistent type I proximal endoleak 4 days
post-op ? open chest repair
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5 days post tube graft repair
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Fenestrated Graft Is This the Future Solution?
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Questions?