3-WAY DEBATE Disclosures: Snorkels and other adjuncts to treat Research and educational grants paid to Stanford from • short and difficult necks offer a stable Cook, Medtronic, WL Gore and long term solution No personal financial disclosures • Off Label use of devices • Jason T. Lee, MD UCSF Vascular Symposium 2015 Who can you really trust??? Vascular Surgery Vascular Surgery 1
Who can you really trust??? Who can you really trust??? Vascular Surgery Vascular Surgery Who can you really trust??? 2008-2015 • Referral patterns changed • More devices available and improving • IRB approved protocol for complex EVAR – 70 juxtarenal snorkel cases (2009-current) – 56 commercial fenestrated (2012-current) – 15 double barrel sandwich (internal iliac) (2009-2011) – 27 iliac branch (10 in trials) (2012-current) – 17 periscope/branch TEVAR (2010-current) – 7 homemade fenestrated/branched (2008-2009) Vascular Surgery Vascular Surgery 2
Snorkel graft/chimney • Parallel graft alongside the main aortic endoprosthesis to maintain flow in a covered branch vessel. Self-expanding bare metal stents Effectively raise renal orifice a few mm Ensure graft material in region of renals without compromising renal flow Vascular Surgery Vascular Surgery Encroachment vs. snorkel 6 juxtarenal cases (2 ruptured, 3 urgent) 8 cases of snorkel with neck length 6.9mm Covered stents All single renal to gain additional 10.4mm Valid alternative to fenestrated during 7 out of 8 bare metal stents emergency setting or unsuitable for FBE Emergency setting, no access to FBE Rescue procedure to salvage side branch Vascular Surgery Vascular Surgery 3
What are the Concerns? • Lack of numbers • Gutters • Renal patency • 2 nd interventions 70 consecutive patients (2009-current) IRB approved protocol • Renal function 98% technical success 2.9% 30-day mortality 96% primary patency (mean 29 months, 3-62) Survival 89% at one year, 83% at two years Vascular Surgery Vascular Surgery What are the Concerns? • Lack of numbers • Gutters • Renal patency • 2 nd interventions • Renal function • 898 parallel grafts placed into 517 patients – 692 renal arteries, 156 SMAs, 50 celiacs • 94% patency • 5.7% type I endoleak • 2 year survival 79% Vascular Surgery Vascular Surgery 4
Imaging Follow-Up • 96% overall primary patency at mean 29 months (3-62) – 6 occluded renals • 1 post op (rescued) • 1 at 1 month f/u (asymptomatic) • 2 at 3 months (1 during abdominal operation, rescued) • 1 at 6 month f/u (asymptomatic) • 1 at 2 year f/u (rescued) – 98% secondary patency • 2 nd interventions (7.1%) – 1 Type 3 endoleak – 1 Type 1 endoleak – 3 rescued renals Vascular Surgery Vascular Surgery Long term concerns-Renal Function What are the Concerns? • Lack of numbers • Gutters • Renal patency • 2 nd interventions • Renal function Vascular Surgery Vascular Surgery 5
Open JAAA Open JAAA ◦ RIFLE: 37.3% overall acute renal dysfunction, 4.1% ◦ RIFLE: 37.3% overall acute renal dysfunction, 4.1% dialysis dialysis � Of these, 55.6% lowest level (25-50% GFR decline) � Of these, 55.6% lowest level (25-50% GFR decline) Sn-EVAR ◦ RIFLE: 32.6% overall acute renal dysfunction, 2.3% dialysis ◦ Of these, 71.4% lowest level VASCULAR SURGERY VASCULAR SURGERY VASCULAR SURGERY VASCULAR SURGERY *Defined newly acquired renal insufficiency as *Defined newly acquired renal insufficiency as increase in serum creatinine >.5 and serum increase in serum creatinine >.5 and serum creatinine >1.5 creatinine >1.5 Open JAAA (46 month f/u) Open JAAA (46 month f/u) ◦ 8.5% incidence perioperative, 2% dialysis ◦ 8.5% incidence perioperative, 2% dialysis ◦ 19% of patients at latest follow up, 4.8% dialysis ◦ 19% of patients at latest follow up, 4.8% dialysis Sn-EVAR (21 month f/u) ◦ 9.1% incidence perioperative, 2.3% dialysis ◦ 23% of patients at latest follow up, 0% dialysis VASCULAR SURGERY VASCULAR SURGERY VASCULAR SURGERY VASCULAR SURGERY 6
Open+EVAR Infrarenal AAA repair Open+EVAR Infrarenal AAA repair Sn-EVAR 1 Freedom from Renal Function 0.8 0.6 Decline 0.4 0.2 0 0 10 20 30 40 Time [Months] VASCULAR SURGERY VASCULAR SURGERY VASCULAR SURGERY VASCULAR SURGERY How about now that ZFEN is approved? *Defined as transient or permanent increase in creatinine >2 or 30% increase versus baseline FEVAR (15-25 month f/u) ◦ 22.2% incidence renal dysfuntion ◦ 93.2% branch vessel patency Sn-EVAR (21 month f/u) First case ◦ 29.7% incidence of renal dysfunction Approved September 2012 ◦ 95% branch vessel patency July 2012 VASCULAR SURGERY VASCULAR SURGERY Vascular Surgery 7
Complex Juxtarenal AAA 2009-current 70 snorkel, 56 ZFEN 24 Snorkel 80 56 ZFEN 70 60 50 40 30 81 yo male Prior TEVAR 20 Snorkel 7.5 cm short neck AAA ZFEN 10 32 mm at neck 0 WAIT TIME 3-4 WEEKS 2009 2010 2011 2012 2013 2014 2015 Vascular Surgery Vascular Surgery 78 yo male 48 hours abd pain Used device planned for someone else Vascular Surgery Vascular Surgery 8
71 yo male 9.3 cm AAA Double angle with downgoing renal SMA at same level as renal Vascular Surgery Vascular Surgery Vascular Surgery Vascular Surgery 9
Vascular Surgery Vascular Surgery Summary • On-label use of ZFEN if feasible – Often not feasible…. • Low threshold for snorkel/chimney strategy • Neck angulation distorts renal fenestration and SMA scallop planning • Anatomic limitations of SMA/renal distance • Wait time- need off the shelf strategies • Renal takeoff angulation adds to difficulty • Iliac access Vascular Surgery Vascular Surgery 10
3-WAY DEBATE 3-WAY DEBATE Snorkels and other adjuncts to treat Snorkels and other adjuncts to treat short and difficult necks offer a stable short and difficult necks offer a stable and long term solution and long term solution VOTE YES VOTE YES Vascular Surgery Vascular Surgery 11
Recommend
More recommend
