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Multidisciplinary Thoracic Aortic RoundsFoothills Medical Centre
November 28th, 2014
Case Presentations: Advanced Thoracic Aortic Reconstructions
Eric Herget & Jehangir Appoo
The Evolution of Endovascular• Stentgrafts
• Many technical innovations and improvements since these pioneer series to address challenging anatomy inherent with thoraco-abdominal aneurysmal disease
• Hybrid
• Fenestrated• Custom / pre-fabricated
• In-situ
• Branched grafts
• Chimney/Snorkel technique
• Sandwich technique
Dr. Herget 2012 Th Ao Rounds:
81 year old male with incidental finding of diffuse aortomegaly
Cardiovascular ProfileMod AIMod LV dysfunctionChronic AfibNo sig CAD
81 year old male with incidental finding of diffuse aortomegaly
Other issuesRetrosternal Thyroid Goiter
-compressing trachea-seen by Pulm Med & Gen Surg
Temporal artery biopsy remote - ?Giant Cell arteritis
BPH
Case presented at cath conferenceOpinions solicited
AV may not need to be replacedCeliac origin occluded
81 year old male with incidental finding of diffuse aortomegaly
Social HistoryLives independentlySkated 150 times previous season to play/referee hockey games
Operative Plan
Collar incision and sternotomy to resect thyroid
Hybrid Arch:Zone 2 arch replacement with branched dacron graftTEVAR of distal arch/descending thoracic aorta
Post op:
Extubated night of surgeryNeuro intactCSF drain removed on POD 2
Delayed CSF leak noted 1 week post removal – H/A & nausea
Take away points from Hybrid Arch Case
Exposure dissect out head vessels before going on CPB if possible
Creating suitable landing zonesZone 2
Antegrade vs. retrograde deployment – pros and cons
CSF drain management
56 year old male
6.5cm aortic root
4+ AI
8cm LVEDD with Severe LV Dysfunction
NYHA Class IV CHF
6cm Descending Thoracic Aortic Aneurysm
Dominant Left Vertebral
Staged Treatment Plan:
Proximal reconstruction with a mechanical composite root
Ascending aorta – left axillary bypass
Issues with carotid-subclavian at same time as proximal root operation in ill patient with 4+ aortic insufficiency
TEVAR post op
Sept 6, 2012:
27mm CarboSeal Composite Root
Ascending aortic replacement
Extra-anatomic ascending aorta to left subclavian bypass
Post op:
Renal insufficiency resolved
Tolerating ACE-I and B-Blockers
Sept 12, 2012
Brought to OR for TEVAR
After 1st device deployed:cardiac arrestnot responsive to therapyprolonged resuscitation
chest openedplaced on CPB, LV ventedSuccessfully defibrillated
Woke up next day neuro intact!
Dec 2012 (3 months post op) completion TEVAR – Zone 2
LV function markedly improved “low normal” on good medical therapy
Follow-up CTA’s – type IA endoleak with associated progressive aneurysmal expansion of descending thoracic aorta
Numerous external expert opinions obtained
Options considered to treat endoleak included:
Additional stentgraft or Palmaz to reinforce birdbeak
Aptus endovascular stapler
Carotid subclavian bypass and TEVAR extension to Zone 1
Redo sternotomy and open/hybrid arch reconstruction
Left Carotid-Subclavian bypass
Extended TEVAR to zone 1
access from right brachial as bailout
device maldeployed –salvaged with balloon assisted repositioning technique
aggressive positioning in relation to inominate required to achieve seal (based on CT measurements)
Intraop angio – Hybrid Suite
Intraop Angios
device maldeployed –salvaged with balloon assisted repositioning technique
brisk inflow to inominate
extubated on OR table
Embolization left subclavian origin to eliminate outflow from aneurysm sac (thought to be contributing to endoleak persistence)
POD 2 – asymmetric BP noted and CTA revealed thrombus at inominate origin
Patient remained asympotomatic
Heparin/Plavix/ASA instituted
POD 3
Symptomatic TIA’s
Risk of major stroke
Neurology, Neuro-IR, Neurosurgery & ICU involved
Attempted clot retrieval via right brachial access - unsuccessful
POD 3
Nitinol (bare) stent at inominate origin to trap thrombus and displace TEVAR device
Improved BP in right arm – now symmetric with left arm
Carotid-Subclavian Bypass
No bird beak
Clot resolved entirely
No further neurologic events
But…nitinol stent crimped due to large TEVAR device
BP in both arms significantly lower than legs
D/C home POD 12 with ASA/Plavix/Warfarin x3/12
POD 15 sudden swelling of right arm
Seen at SHC ER
Ultrasound shows large hematoma and 4cm pseudoaneurysm (with 3mm neck –thrombin injection?)
Open repair
Learning Points
In 2014, we may be more aggressive with initial proximal operation CREATE GOOD LANDING ZONES to avoid complications
Intraop fluoro has limitations – need to navigate around
CT imaging gold standard
72 year old petite female
7cm ascending aortic aneurysm
5cm descending aortic aneurysm
Plan:
open proximal repair and observation of descending aorta
OR (April 2012):
replacement of ascending aorta and hemiarch
Ongoing enlargement of descending thoracic aorta over 2 year observation period – rate of 5mm/yr –now 6cm
Challening anatomy due to distal landing zone
Multiple options considered
Isolated TEVAR to celiac
Custom branched TEVAR to SMA
Snorkel
Hybrid laparotomy with bypass to SMA
Open thoracoabdominal
MARS
OR - Oct 20, 2014 –snorkel/sandwich technique
Extubated on OR table
CSF drain removed POD 2
Discharged home POD 4
1 month clinic follow-up:Back to normal activities