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How I do it: How I do it: Disclosures My Approach to My Approach to No disclosure Chronic Type B Dissections Chronic Type B Dissections Jean M. Panneton, MD, FRCSC, FACS Professor of Surgery Chief & Program Director Division of

  1. How I do it: How I do it: Disclosures My Approach to My Approach to No disclosure Chronic Type B Dissections Chronic Type B Dissections Jean M. Panneton, MD, FRCSC, FACS Professor of Surgery Chief & Program Director Division of Vascular Surgery Eastern Virginia Medical School Norfolk, VA UCSF Vascular Symposium 2015 San Francisco, CA, April 16-18, 2015 Consultant: Lombard Medical, Medtronic Inc & Volcano Aortic Dissection Chronic Dissection Clinical manifestations Background “The great masquerader” Chronic aortic dissection Aortic rupture, shock remains one of the most Cardiac Tamponade challenging pathologies for Aortic valve incompetence aortic surgeons Myocardial ischemia Stroke, Limb ischemia TEVAR is frequently only the initial procedure and further Visceral ischemia, renal failure interventions are often required Accelerated Hypertension Paraplegia, Paraparesis Patience and persistence are “It is much more important to Back, chest or abdominal pain of the utmost importance know what sort of a patient has a disease than what sort of a Sir William Osler, 1849-1919 disease a patient has.” 1

  2. Chronic Dissection Chronic Dissection Objectives Indications Rupture with hemothorax Aneurysm rupture Aneurysm expansion > 5.5 - 6 cm growth rate > 5mm/yr Arch aneurysm DTA TAAA AAA Chronic malperfusion • Understand the complexity of treating patients with chronic aortic dissection Mesenteric angina Renovascular HTN • Explore the surgical options to treat chronic aortic Claudication dissection TEVAR with delayed VAT Chronic Dissection Chronic Dissection Chronic Malperfusion Surgical options Open repair: How different from Acute Malperfusion ? thoracoabdominal aortic replacement aortic fenestration Not as common as Acute dissection with malperfusion Endovascular repair: Different pathophysiology than Acute Dissection TEVAR Percutaneous aortic fenestration Less Dynamic Obstruction of true lumen Fenestrated or Branched EVAR More Static Obstruction of the Branch vessel Hybrid Repairs: proximal TEVAR with Open distal aortic Some organ / limb perfusion may be false lumen dependent replacement Visceral debranching followed by TEVAR Nearly always associated with Aneurysm Tailored therapy to minimize the physiologic impact on the patient 2

  3. Chronic Dissection Chronic Dissection Surgical options Surgical options Preoperative Planning Preoperative Planning Preoperative considerations Preoperative considerations Imaging Patient related Aortic related Chest / Abdomen & Pelvis CTA • Age • Type A vs B Head CT with Circle of Willis • Comorbidities • Arch involvement Carotid & Visceral Duplex • Prior sternotomy / thoracotomy • Visceral involvement TEE, MRA • Cardiac / Coronary status • Marfan or CTD Patient Preparation • Pulmonary function • Fixation zones • Renal function • Prior TEVAR Hold anticoagulation & Plavix Preoperative hydration Young patients and those with CTD are best treated by Respiratory therapy open repair whereas older patients or those with Optimize myocardium comorbidities are selected for endovascular repair Chronic Dissection Chronic Dissection Surgical options Open aortic fenestration Open Thoracoabdominal Aortic Open Thoracoabdominal Aortic Replacement Replacement Paravisceral aortic septum resection w or w/o infrarenal aortic replacement Posterolateral Thoracotomy Medial visceral rotation 4.4% of 321 procedures Diaphragm sparing for aortic dissection Creech technique Visceral patch reimplantation Motor evoked potentials 0 % operative mortality for elective Intercostal revascularization fenestration procedure combined with infrarenal aortic grafting CSF drainage Distal aortic perfusion Partial left heart bypass Panneton JM et al, J Vasc Surg 2000;32:711-21 3

  4. Chronic Dissection Chronic Dissection Surgical options Surgical options Paravisceral aortic fenestration with Paravisceral aortic fenestration with Chronic TBAD with expanding symptomatic TAAA Aorto-bi-iliac replacement for chronic malperfusion Aorto-bi-iliac replacement for chronic malperfusion 58 y o male patient with Chronic type B, Aberrant RSA SMA & RRA w TL max diam DTA at 3.2cm; with 6cm AAA Chronic mesenteric ischemia R leg claudication Entry tear LRA w FL SMA & RRA true lumen Right iliac occlusion Chronic Dissection Chronic Dissection Surgical options Surgical options 1. Create a proximal landing zone with Pre TEVAR deployment angiogram Post TEVAR deployment angiogram bilateral subclavian to carotid transpositions 2. Zone 1 TEVAR deployment 3. Retrograde embolization of LSA 4. Distal TEVAR with a tapered graft 5. Percutaneous fenestration to reconnect the LRA with the true lumen 6. Kissing iliac stenting to restore left iliac perfusion 4

  5. Chronic Dissection Chronic Dissection Surgical options Surgical options Left renal malperfusion induced by TEVAR Completion arch angiogram Retrograde Percutaneous fenestration angiogram type II endoleak from LSA Resolution after Amplatzer plug embolization Chronic Dissection Chronic Dissection TEVAR Surgical options Aims of TEVAR for Chronic Dissection Aims of TEVAR for Chronic Dissection 1. Cover the entry tear 2. Treat or Prevent Rupture 3. Reestablish organ / limb perfusion 4. Cover the distal reentry tears 5. Induce false lumen thrombosis 6. Promote aortic remodeling 5

  6. Chronic Dissection Chronic Dissection Post TEVAR Surveillance Learning points 2 yr post TEVAR 2 yr post TEVAR 4 yr post TEVAR TEVAR for chronic dissection Proximal landing zone is more likely to require arch vessels procedures • Graft sizing is similar with < 10% oversizing • The septum is thicker, percutaneous fenestration may be harder • The true lumen may remain compressed • 4 cm The false lumen is more likely to remain patent because of reentries • 6.5 cm Graft tapering is more likely to be needed • Extensive aortic coverage is required • Distal malperfusion may be induced by the TEVAR • Chronic Dissection Chronic Dissection Surgical options Surgical options Endovascular option: False Lumen interventions after TEVAR Fenestrated or Branched EVAR Direct FL embolization with plugs or coils Technical Challenges Narrow true lumen: fenestration are preferred over branches and staging TEVAR first may help In 30 patients with TAAA from chronic type B dissection, FEVAR was feasible Branch vessels originating from without technical problems from narrow true lumen and with low false lumen and there’s a thicker postoperative mortality / morbidity and septum separating them from TL favorable aortic remodeling but required multiple reinterventions in Landing zones are inexistent and extensive dissection with visceral Covered stent placement in branches may need to be created involvement “Knickerbocker” technique Hofferberth SC et al, J Endovasc Ther 2012;19:538-45 Kitagawa A et al, J Vasc Surg 2013;58:625-34 6

  7. Chronic Dissection Chronic Dissection Surgical options Surgical Options Staged Hybrid repair with Visceral Staged Hybrid Repair: Debranching followed by TEVAR Proximal TEVAR from LSA to celiac followed by distal open repair of type IV TAAA with visceral patch reimplantation or multibranch graft Johnston WF et al, J Vasc Surg 2012;56:1495-1502 Chronic Dissection Chronic Dissection Additional considerations Summary Spinal Cord Ischemia TEVAR for chronic aortic dissection is feasible, relatively Indications for CSF Drainage safe and offers reduced morbidity and mortality Excessive aortic coverage ( > 20 cm ) Critical aortic coverage ( T8-T12 ) After TEVAR for chronic History of AAA repair ( open / EVAR ) dissection, imaging surveillance is Associated severe PAD, HA occlusion essential because of lesser paravisceral aortic remodeling and Concomitant TEVAR and EVAR higher need for reintervention than Coverage of LSA w/o revascularization for acute dissection 7

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