Disclosures A Reasonable Option in Off label use will be presented - PowerPoint PPT Presentation

4/4/2014 Hybrid Repair for Aortic Pathology: Disclosures A Reasonable Option in • Off label use will be presented Selected Patients • Device companies not promote or assure safety and efficacy of off label use of their products • Speaker/consultant William J. Quinones-Baldrich MD Professor of Surgery W.L. Gore Director UCLA Aortic Center Endologix UCLA Medical Center Medtronic Los Angeles, California 73y/o with R pelvic kidney s/p repair Type IV TAA, Hybrid Repair for Aortic Pathology presents with contained visceral patch rupture • Rationale: Reduce magnitude of surgical intervention - Thoraco-abdominal aorta - Aortic Arch • Use currently available endovascular devices • Allow treatment of complex pathology in high risk patients 1

4/4/2014 71 y/o with severe COPD, Type III TAA, acute on chronic 71 y/o with severe COPD, Type II TAA, acute on chronic mesenteric ischemia and severe claudication mesenteric ischemia and severe claudication Stage 1: IR Replacement, Visceral debranching, distal endograft 71 y/o with severe COPD, Type III TAA, acute on chronic 45 y/o female with type B aortic dissection and mesenteric ischemia and severe claudication: aberrant R subclavian artery (BMI 42) Stage 2 – L CS bypass + TEVAR 2

4/4/2014 Type B aortic dissection and aberrant R subclavian artery: Follow up 68 y/o with enlarging aneurysm with Type B aortic dissection Stage 1 RCCA to LCCA bypass; LCCA to L SC transposition Stage 2: TEVAR Zone 1 37 y/o s/p Aortic Coarctation repair (age 14) and Endovascular Elephant Trunk Apico – DTA bypass (age 27; thrombosed for 14 mo) with severe HTN and claudication 3

4/4/2014 Staged Approach …. Expanded! Staging Decreases Risk S taged retroperitoneal debranching for hybrid repair of type III TAA Combined Endovascular and Surgical Approach • Patient selection Surgical vs. hybrid vs. endovascular repair • Individualized plan Reduce risk of debranching component Must accomplish adequate seal zones • Staging reduces risk Single stage: Urgent indications Antegrade deployment zone 0 (arch) • Interval rupture is a risk Second stage during same admision 4

4/4/2014 Infrarenal Aortic Replacement as Part of Aortic Wrap Debranching Pledgeted proximal anastomosis Graft size to match available endograft May require distal tapering Circumference = � x diameter (endograft) Combined Endovascular and Surgical Approach to Thoraco-abdominal Pathology: Conduit placement (1rst stage) and thrombectomy (2 nd stage) 5

4/4/2014 North American Complex Abdominal Aortic Debranching (NACAAD) Registry • High risk patients with complex TAA • Spinal cord ischemia : 159 patients Transient 10 / 159; 6.2% Permanent 12 / 159; 7.5% 2009 1998 - 2013 – 51 high risk patients Mortality 16% Risk Type II, coverage, rupture, 40 TAA – 8 II, 23 III, 9 IV renal insufficiency 5.8 % mortality: 2 interval aneurysm ruptures • Ischemic colitis : 208 patients – 6% 1 arch debranching / retrograde dissection Mortality w/o IC – 14% Paraplegia – 2/40 at risk (5 %); II,III 1/ (3.2%) Mortality w IC – 46% Risk Single stage, age, 2 year cumulative survival – 78% comorbidity score CESA (Hybrid) Repair Aortic Arch Pathology Arch debranching and Endovascular repair 13 reported series > 10 cases reported as of 2011 • Mortality 0 - 20% Avg 7.9% UCLA 5.2% Durable? • Stroke 0 – 19% Avg 5% UCLA No strokes • All patients “high risk” • Some series include cases with CPBP/ deep hypothermia • CESA for Arch << CESA for TAA 6

4/4/2014 Durable Durable? Combined Combined Endovascular Endovascular and and Surgical Surgical Approach Approach (CESA or (CESA or Hybrid Hybrid Approach) Approach) 11 yr 13 yr follow up follow up Durable “Hybrid” vs. Total Endovascular Repair Hybrid Combined � More invasive Endovascular � Surgical skill > endovascular skill � Less affected by tortuosity and and or occlusive disease Surgical � Great for surgical training � Available today Approach (CESA or Total endovascular repair � Less invasive Hybrid � Endovascular skill > surgical skill Approach) � Significantly affected by tortuosity, occlusive disease � Evolving technology; risk EV Cx long term � Not available for now; to all 13 yr follow up 7

4/4/2014 The hybrid approach has a role today and in the future Vascular surgeons are best (only?) to offer all alternatives 8