Distal extended branched PETTICOAT- a new endovascular ...€¦ · with Advanta/ ICAST, mostly Gore C3 excluder and 9 IBD´s! 28 aortic branches were supplied with BECS 3 celiac truncs,

Distal extended branched PETTICOAT- a new endovascular technique to induce false

lumen thrombosis in complex aortic dissections

Dr. Lars R. KockVascular and Endovascular Surgery,Albertinen Cardiovascular Center,Albertinen Hospital Hamburg,Germany

LINCThursday, January 28, 2016

Distal extended branched PETTICOAT- a new endovascular technique to induce false

lumen thrombosis in complex aortic dissections

Dr. Lars R. KockVascular and Endovascular Surgery,Albertinen Cardiovascular Center,Albertinen Hospital Hamburg,Germany

No conflict of interest

03.02.16 deeb PETTICOAT

A patent true lumen in the distal aorta after aortic root/arch surgery or thoracic SG-

placement for AD is not benign !

3

Patient with 12 cm ruptured false lumen (FL) aneurysm, who died despite successful arch replacement

•  Close relation in between patent FL, aortic growth rate and late mortality >40%

Persistent FL perfusion through distal entries


Remaining FL- perfusion through tears related to reno-visceral branches still causes aneurysmal degeneration of the aorta

4

Torn out ostium of the celiac trunc

Backflow into thoracic FL

Aneurysmal degeneration of abdominal aorta

Might lead to rupture and death


So far described methods to treat FL-dilatation

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1.  Open repair (Cowan, 2003; Rigberg, 2006)

2.  Hybrid procedures (Böckler 2008)

3.  Endovascular approach with CM fenestrated/branched SG in elective cases (Oikonomou 2014)

!  30 day mortality and spinal cord malperfusion over 10%

!  All reno-visceral branches have to be bypassed or stented

Common features:


Proximal descending aortic stentgraft plus distal bare metal stent: The PETTICOAT

Concept (Nienaber et al., 2006)

6

03.02.16 deeb PETTICOAT 7

Systematic review of outcomes of combined proximal stent graft with distal bare stent,

L. Canaud et al.; Ann Cardiothorac Surg 2014

© AME Publishing Company. All rights reserved. Ann Cardiothorac Surg 2014;3(3):223-233www.annalscts.com

Systematic review of outcomes of combined proximal stent-grafting with distal bare stenting for management of aortic dissection

Ludovic Canaud1,2, Elsa Madeleine Faure2, Baris Ata Ozdemir1, Pierre Alric2, Matt Thompson1

1Department of Outcomes Research, St. George’s Vascular Institute, London, UK; 2Department of Thoracic and Vascular Surgery, A de Villeneuve

Hospital, Montpellier, France

Correspondence to: Ludovic Canaud, MD, PhD. St. George’s Vascular Institute, Room 4.007, St George’s Healthcare NHS Trust, Blackshaw Road,

London SW17 0QT, UK. Email: [email protected].

Objective: Available data on outcomes of combined proximal stent-grafting with distal bare stenting for management of aortic dissection are limited. The objective of this study was to provide a systematic review of outcomes of this approach. Methods: Studies involving combined proximal stent-grafting with distal bare stenting for management of aortic dissection were systematically searched and reviewed through MEDLINE databases. Results: A total of four studies were included: 108 patients treated for management of acute (n=54) and chronic (n=54) aortic dissection. The technical success rate was 95.3% (range, 84-100%). The 30-day mortality rate was 2.7% (range from 0% to 5%). The morbidity rate occurring within 30 days was 51.8% (range from 0% to 65%) and included stroke (2.7%), paraplegia (2.7%), retrograde dissection (1.8%), renal failure (14.8%), severe cardiopulmonary complications (5.5%) and bowel ischemia (0.9%). The incidence of type I endoleak was 9.2% (10/108). During follow-up, 5 (4.6%) deaths were related to aortic rupture or aortic repair. Mean re-intervention rate was 12.9%. Two cases (1.9%) of delayed retrograde type A dissection BOE�POF�DBTF�PG�BPSUPCSPODIJBM�òTUVMB��XFSF�SFQPSUFE��5IF�NPTU�DPNNPO�EFMBZFE�DPNQMJDBUJPO�XBT�thoracic stent-graft migration (4.7%). The rate of device failure was 9.2%. Favorable aortic remodeling was observed: studies reporting midterm follow-up of the true lumen demonstrated a high rate of both false lumen regression and true lumen expansion. At 12 months, complete false lumen thrombosis was observed at the thoracic level in 70.4% and at the abdominal level in 13.5% of patients.Conclusions: Combined proximal stent-grafting with distal bare stenting appears to be a feasible approach for the management of Type B aortic dissection. Although this approach clearly improved true lumen perfusion and diameter, it failed to completely suppress false lumen patency. However, it should be acknowledged that contemporary data on this approach is limited to small studies with variable results.

Keywords: Thoracic aorta; stent-graft; aortic dissection; bare stent; thoracic endovascular aortic repair (TEVAR);

Provisional Extension To Induce Complete Attachment (PETTICOAT)

Submitted Dec 05, 2013. Accepted for publication May 23, 2014.

doi: 10.3978/j.issn.2225-319X.2014.05.12

View this article at: http://dx.doi.org/10.3978/j.issn.2225-319X.2014.05.12

Systematic Review

Introduction

Acute dissection is the most common fatal aortic catastrophe, and the surgical treatment of Stanford type B acute aortic dissection (A-BD) remains a formidable challenge. The standard strategy for uncomplicated A-BD is medical

management, with surgical intervention reserved for cases

complicated by rupture, malperfusion, intractable pain,

uncontrolled hypertension or aneurysmal dilatation.

During the past decade, thoracic endovascular aortic repair

(TEVAR) has been increasingly used to treat this condition

Improvement of true lumen perfusion and diameter

but: complete FL- Thrombosis in the abdominal aorta in only 13,5%

!  For obvious reasons !!!


Intimal fenestrations related to branch vessels = torn out orifices of FL-originating

reno-visceral branches were neglected

celiac trunc SMA renal artery8


Dissection stents alone are not capable to induce complete attachment of delaminated abdominal aortic wall, when major reno-visceral branches

were torn out, adjunctive procedures are needed

9


Solution: branched Petticoat = Implantation of balloon expandable covered stents through preexisting entries and

struts of dissection stents into FL originating arteries

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FL

TLRRA


Re-establishment of blood flow to FL originating target vessels exclusively from TL simultaneously leads to

sealing of corresponding tear in the dissection membrane

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Cook GZSD stent

Advanta V12

SES

FL

TL

LRA


Distal extended branched Petticoat for the sealing of all relevant entries

with off the shelf devices

12

infrarenal aortic entry iliac entry

FLFL

thoracic SG

Dissection stent

Gore C3 Excluder bifurcated SG

IBD

Advanta V12


Deeb Petticoat in a 60y old male patient with 66 mm post dissection TAAA 8 years after

incidence of TBAD

13

!  has the potential to induce total FL thrombosis in the thoracic and abdominal aorta as well as the iliac arteries


Deeb Petticoat for the sealing of all relevant entries

14

SMADeeb Petticoat Petticoat alone



15

renalsDeeb Petticoat Petticoat alone



16

Infrarenal aortaDeeb Petticoat Petticoat alone



17

Infrarenal aortaDeeb Petticoat Petticoat alone



18

iliac arteriesDeeb Petticoat Petticoat alone



19

Iliac bifurcationDeeb Petticoat, IBD right

Petticoat alone


after deeb Petticoat Thoracic SG alone

comparism of status before and after deeb Petticoat in symptomatic 56 y, m, 10 years after initial therapy for type A dissection and 6 years after thoracic SG

Celiac trunc



comparism of status after thoracic SG alone and deeb Petticoat

SMA




Right Renal Artery




Infrarenal aorta




Iliac arteries




Iliac bifurcations with bilateral IBD´s


Results and Comparism of deeb Petticoat with alternative methods

26

!  Deeb Petticoat in 19 patients, 13 Type A, 6 Type B

!  Redo-setting, 2 m to 14 y after initial treatment

!  Exclusively Cook GZSD Dissection stents were used, in combination with Advanta/ ICAST, mostly Gore C3 excluder and 9 IBD´s

!  28 aortic branches were supplied with BECS 3 celiac truncs, 2 SMA`s, 21 RA´s, 7 RRA´s and 16 LRA´s

!  in 12 cases (63%) only 1 FL- originating renal artery had to be stented



!  In contrast to all other techniques renal function was ameliorated

!  No aortic branch vessel obstructions were observed in limited follow-up (3-32m)

!  less branch vessel complications can be expected in long term follow-up compared to other methods, as only 1,5 vessels per patient on average were stented



SG-End!  TL originating spinal arteries in the thoracoabdominal junction are preserved

!  Deeb Petticoat is perfectly designed for a percutaneous staged approach

!  No spinal cord malperfusion observed

!  No 30 day- mortality, no aortic related late death

!  extremly low complication rate (one asymptomatic loss of hypogastric artery, 2 iliac branch obstructions)


Conclusions

!  Thoracoabdominal dissections and TAAA are completely different diseases

!  Dissections have something that aneurysms do not have:

!  an often shrinked and perforated but resilient intimal hose

!  This hose can be reinforced and expanded and perforations can be sealed

!  The distal extended branched Petticoat technique is perfectly able to do so T-branch in acute symptomatic

type B dissection with preexisting TAAA

Documents

Distal extended branched PETTICOAT- a new endovascular ...€¦ · with Advanta/ ICAST, mostly Gore C3 excluder and 9 IBD´s! 28 aortic branches were supplied with BECS 3 celiac truncs,