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TEVAR for the Ruptured TEVAR for the Ruptured Aneurysms Aneurysms
Jamal J. Hoballah MD, MBA, FACSJamal J. Hoballah MD, MBA, FACSProfessor and ChairmanProfessor and ChairmanDepartment of SurgeryDepartment of Surgery
American University of BeirutAmerican University of Beirut
14th Congress of Asian Society for Vascular Surgery & 8th Asian Venous Forum14th Congress of Asian Society for Vascular Surgery & 8th Asian Venous Forum16thCongress of Turkish Society for Vascular and Endovascular Surgery16thCongress of Turkish Society for Vascular and Endovascular Surgery
ObjectivesObjectives
• Review available data on TEVAR Review available data on TEVAR for Ruptured Thoracic Aneurysmsfor Ruptured Thoracic Aneurysms
• Recommendations for successful Recommendations for successful Emergency TEVAR programEmergency TEVAR program
Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsScope of the problem Scope of the problem
Incidence:Incidence: 5/100,0005/100,000
Ascending & ArchAscending & Arch 70%70%Descending Aorta Descending Aorta 30%30%
Johansson et al JVS 1995Johansson et al JVS 1995
Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsICD 9 cm Cases/ year
2011
Thoracic Aneurysm 7601
Ruptured Thoracic Aneurysm
798
Abdominal Aortic Aneurysm
43466
Ruptured AAA 5023
2011 Nationwide In Patient Sample Data US Department of Health & Human Services
TAA : 7 times less than AAATAA Rupture: 7 times less than Ruptured AAA
Ruptured Thoracic Aortic Ruptured Thoracic Aortic AneurysmsAneurysms
ICD 9 cm Mortality Routine Discharge
Home health care
Short term hospital/Rehab center/nursing home
Ruptured Thoracic Aneurysm
37% 15% 12% 36%
2011 Nationwide In Patient Sample DataUS Department of Health & Human Services
Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsHeterogeneous PathologyHeterogeneous Pathology
LocationLocation
• Ascending AortaAscending Aorta• Aortic ArchAortic Arch• Descending AortaDescending Aorta• Thoraco-Abdominal AortaThoraco-Abdominal Aorta
Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsHeterogeneous PathologyHeterogeneous Pathology
EtiologyEtiology
• Degenerative Thoracic AneurysmDegenerative Thoracic Aneurysm• Traumatic blunt injury PseudoaneurysmTraumatic blunt injury Pseudoaneurysm• Complicated Dissection ( Acute or Chronic)Complicated Dissection ( Acute or Chronic)• Miscellaneous ( Mycotic)Miscellaneous ( Mycotic)
Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic Aneurysms Heterogeneous Pathology Heterogeneous Pathology
PresentationPresentation
UnstableUnstableStable/ Contained ruptureStable/ Contained rupture
Ruptured Thoracic Aortic Aneurysms: Ruptured Thoracic Aortic Aneurysms: ManagementManagement
• Open Surgical InterventionOpen Surgical Intervention
• TEVARTEVAR
– Chimney/ SnorkelChimney/ Snorkel– Hybrid Approach (Debranching)Hybrid Approach (Debranching)
Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsOpen Surgical InterventionOpen Surgical Intervention
• Traditional approachTraditional approach• Requires thoracic surgical expertiseRequires thoracic surgical expertise• Limited Thoracic CentersLimited Thoracic Centers• Techniques:Techniques:
– Clamp and sewClamp and sew– Heart lung Machine; Left Heart BypassHeart lung Machine; Left Heart Bypass– Deep hypothermic circulatory arrestDeep hypothermic circulatory arrest
Ruptured Thoracic Aortic AneurysmsRuptured Thoracic Aortic AneurysmsOpen Surgical InterventionOpen Surgical Intervention
Contemporary ResultsContemporary Results
Mortality rate: 18- 27%Mortality rate: 18- 27%
Girardi et al Ann Thorac Surg 2002Girardi et al Ann Thorac Surg 2002Barbato et al JVS 2007Barbato et al JVS 2007
Population-based outcomes of Population-based outcomes of open descending thoracic aortic open descending thoracic aortic
aneurysm repairaneurysm repair
Schermerhorn ML et al J Vasc Surg 2008 Oct.
2549 patients Mortality rateEntire group
Age>75
Intact 10% 17.6%
Ruptured 45% 52%
TEVAR for Ruptured Thoracic TEVAR for Ruptured Thoracic Aortic AneurysmsAortic Aneurysms
• First EVAR for ruptured AAA reported in 1994First EVAR for ruptured AAA reported in 1994– Yusuf SW, Whitaker SC, Chuter TA, et al. Yusuf SW, Whitaker SC, Chuter TA, et al. Emergency endovascular repair Emergency endovascular repair
of leaking aortic aneurysms. Lancet 1994; 344:of leaking aortic aneurysms. Lancet 1994; 344:1645.1645.
• First TEVAR for ruptured TAA reported in 1997First TEVAR for ruptured TAA reported in 1997– Semba CP, et al. Acute rupture of the descending thoracic aorta: repair Semba CP, et al. Acute rupture of the descending thoracic aorta: repair
with use of endovascular stent-grafts. J Vasc Interv Radiol 1997;8:337-42with use of endovascular stent-grafts. J Vasc Interv Radiol 1997;8:337-42
TEVAR Advantages TEVAR Advantages
• Can be provided by experienced Vascular or Cardio Can be provided by experienced Vascular or Cardio Thoracic SurgeonsThoracic Surgeons
• Can be provided at non cardiac surgery centersCan be provided at non cardiac surgery centers• Increase availability of expertise capable of dealing with Increase availability of expertise capable of dealing with
the problemthe problem• Still needs Cardio Thoracic Surgery back up Still needs Cardio Thoracic Surgery back up
TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic AneurysmsAvailable DataAvailable Data
• Case reportsCase reports• Single Institution ExperienceSingle Institution Experience• Multi Institution ExperienceMulti Institution Experience• Meta analysis studiesMeta analysis studies• Nationwide Data baseNationwide Data base
Endovascular stent-graft placement for acute Endovascular stent-graft placement for acute and contained rupture of the descending and contained rupture of the descending
thoracic aorta.thoracic aorta.
• 17 patients; July 1999 - November 2004,17 patients; July 1999 - November 2004,• Rupture due to: Rupture due to: • Thoracic Aortic Aneurysm TAA n=6 Thoracic Aortic Aneurysm TAA n=6 • Acute aortic dissection AAD, n=6 Acute aortic dissection AAD, n=6
Penetrating aortic ulcer PAU, n=3 Penetrating aortic ulcer PAU, n=3 • Blunt chest trauma n=2Blunt chest trauma n=2
– Eggebrecht at al Eggebrecht at al Catheter Cardiovasc Interv. 2005 Dec 2005 Dec
Endovascular stent-graft placement for acute Endovascular stent-graft placement for acute and contained rupture of the descending and contained rupture of the descending
thoracic aorta.thoracic aorta.
• Technical feasibility 100%Technical feasibility 100%• Complete exclusion 65%Complete exclusion 65%• 30 day mortality 24%30 day mortality 24%• 1 yr survival 52%1 yr survival 52%• 3 yr survival 52%3 yr survival 52%
– Eggebrecht at al Eggebrecht at al Catheter Cardiovasc Interv. 2005 Dec 2005 Dec
Endovascular stent-graft placement for Endovascular stent-graft placement for acute and contained rupture of the acute and contained rupture of the
descending thoracic aortadescending thoracic aorta
Pre-procedural determinants of mortalityPre-procedural determinants of mortality• Etiology of rupture TAA or AAD (P=0.024)Etiology of rupture TAA or AAD (P=0.024)• Maximum aortic diameter>5 cm (P=0.024)Maximum aortic diameter>5 cm (P=0.024)• Presence of mediastinal hematoma (P=0.056)Presence of mediastinal hematoma (P=0.056)• Estimated lesion length requiring >1 stent-graft Estimated lesion length requiring >1 stent-graft
to be covered (P=0.009to be covered (P=0.009
– Eggebrecht at al Eggebrecht at al Catheter Cardiovasc Interv. 2005 Dec 2005 Dec
Endovascular stent-graft placement for acute Endovascular stent-graft placement for acute and contained rupture of the descending and contained rupture of the descending
thoracic aorta.thoracic aorta.
Post-procedural determinants of mortalityPost-procedural determinants of mortality• residual leakage at the conclusion (P=0.009), residual leakage at the conclusion (P=0.009), • postprocedural need for dialysis (P=0.004), postprocedural need for dialysis (P=0.004), • prolonged ventilation (P=0.043) prolonged ventilation (P=0.043)
– Eggebrecht at al Eggebrecht at al Catheter Cardiovasc Interv.Catheter Cardiovasc Interv. 2005 Dec 2005 Dec
A comparative analysis of open and A comparative analysis of open and endovascular repair for the ruptured descending endovascular repair for the ruptured descending
thoracic aorta.thoracic aorta.Single Institution ( University of Michigan)Single Institution ( University of Michigan)
• TEVAR: Older patientsTEVAR: Older patients• Independent predictors of early mortality, stroke, permanent Independent predictors of early mortality, stroke, permanent
spinal cord ischemiaspinal cord ischemia– Hemodynamic instability Hemodynamic instability – Open repairOpen repair
Patel et al J Vasc Surg. 2009 DePatel et al J Vasc Surg. 2009 Decc
TEVAR OPEN
Patients: 69 35 34
Mortality % 11 26
Open surgery versus endovascular repair of Open surgery versus endovascular repair of ruptured thoracic aortic aneurysms.ruptured thoracic aortic aneurysms.
..• 161 patients at 7 Institutions161 patients at 7 Institutions
• Risk factor for composite event : Risk factor for composite event : – Increasing ageIncreasing age– Hypotension Hypotension
Jonker et al Jonker et al J Vasc Surg.J Vasc Surg. 2011 May 2011 May
TEVAR OPEN
Patients 92 69
Mortality 30 day% 17 24
Composite mortality , stroke paraplegia%
21 36
4 yr survival % 75 64
Endovascular repair of ruptured thoracic aortic Endovascular repair of ruptured thoracic aortic aneurysms.aneurysms.
..• 92 TEVAR patients at 7 Institutions92 TEVAR patients at 7 Institutions
• Jonker et al Eur Jonker et al Eur J EndoVasc Surg.J EndoVasc Surg. 2011 2011
<75yrs >75yrs
Patients 67 25
Mortality 30 day% 13.4 32
Postoperative stroke% 1.5 24
2 yr survival % 84 52
Meta-analysis of open versus endovascular Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic repair for ruptured descending thoracic aortic
aneurysmaneurysm
• 28 studies; 224 patients;28 studies; 224 patients;
– Jonker FH et al, J Vasc Surg.Jonker FH et al, J Vasc Surg. 2010 Apr 2010 Apr
TEVAR Open Repair
Patients 143 (63.2%) 81 (36.2%)
30 d Mortality 18.9% 33.3%
Myocardial Infarction 3.5% 11.1%
Stroke 4.1% 10%
Paraplegia 3.1% 5.5%
Additional Vascular Intervention 9.1% 2.3%
3 yr Aneurysm related survival 70.6% unavailable
Endovascular versus open repair of ruptured Endovascular versus open repair of ruptured descending thoracic aortic aneurysms: a descending thoracic aortic aneurysms: a
nationwide risk-adjusted study of 923 patients.nationwide risk-adjusted study of 923 patients.
• 923 between 2006-2008923 between 2006-2008• TEVAR 39% OTR 60%TEVAR 39% OTR 60%• Mortality Rate; TEVAR :23% Open: 28%Mortality Rate; TEVAR :23% Open: 28%• Odds of mortality , complications and failure to Odds of mortality , complications and failure to
rescue:rescue: comparablecomparable• TEVAR 3X higher odds of routine dischargeTEVAR 3X higher odds of routine discharge
– Gopaldas RR et al J Thorac Cardiovasc Surg.Gopaldas RR et al J Thorac Cardiovasc Surg. 2011 2011
Endovascular versus open repair of ruptured Endovascular versus open repair of ruptured descending thoracic aortic aneurysms: a descending thoracic aortic aneurysms: a
nationwide risk-adjusted study of 923 patients.nationwide risk-adjusted study of 923 patients.
Smaller hospitals: Smaller hospitals:
• Lower mortality rate for TEVAR vs Open repairLower mortality rate for TEVAR vs Open repair
Smaller hospital vs Larger HospitalSmaller hospital vs Larger Hospital
• Mortality, complication , failure to rescueMortality, complication , failure to rescue– TEVAR : comparableTEVAR : comparable– Open repair : higher Open repair : higher
• Gopaldas RR et al J Thorac Cardiovasc Surg.Gopaldas RR et al J Thorac Cardiovasc Surg. 2011 2011
Endovascular versus open repair of ruptured Endovascular versus open repair of ruptured descending thoracic aortic aneurysms: a descending thoracic aortic aneurysms: a
nationwide risk-adjusted study of 923 patients.nationwide risk-adjusted study of 923 patients.
TEVARTEVAR
• May be an ideal alternative to OAR for ruptured descending May be an ideal alternative to OAR for ruptured descending thoracic aortic aneurysmthoracic aortic aneurysm
• Particularly in small hospitals where expertise in OAR may Particularly in small hospitals where expertise in OAR may be lacking be lacking
– Gopaldas RR et al J Thorac Cardiovasc Surg.Gopaldas RR et al J Thorac Cardiovasc Surg. 2011 2011
Meta-analysis of endovascular vs open repair for Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture.traumatic descending thoracic aortic rupture.
• 17 studies17 studies• 589 patients; 369 Open 220 TEVAR589 patients; 369 Open 220 TEVAR
• TEVAR Lower 30 day mortality ODD ratio 0.44TEVAR Lower 30 day mortality ODD ratio 0.44• TEVAR Lower Procedure related mortality ODD Ratio TEVAR Lower Procedure related mortality ODD Ratio
0.310.31
– Xenos ES et al, J Vasc Surg 2008 NovXenos ES et al, J Vasc Surg 2008 Nov
Tends and Outcomes of endovascular and open Tends and Outcomes of endovascular and open treatment for traumatic thoracic aortic injurytreatment for traumatic thoracic aortic injury
New York State SPARCS data base 2000-20007New York State SPARCS data base 2000-20007328 patients; Open 80% TEVAR 20%328 patients; Open 80% TEVAR 20%
• TEVAR rates exceeded Open as of 2006TEVAR rates exceeded Open as of 2006• TEVAR lower mortality rate and post operative TEVAR lower mortality rate and post operative
pulmonary complicationspulmonary complications• No difference in cardiac complication, renal failure, No difference in cardiac complication, renal failure,
stroke or paraplegiastroke or paraplegia• TEVAR device related complications 9%TEVAR device related complications 9%
– Jonker et al, J Vasc Surg 2010 MarchJonker et al, J Vasc Surg 2010 March
Update on blunt thoracic aortic injury: fifteen-year Update on blunt thoracic aortic injury: fifteen-year single-institution experiencesingle-institution experience
• Level I Trauma Center 1997-2012Level I Trauma Center 1997-2012
– Estrera et alEstrera et al J Thorac Cardiovasc Surg 2013 March.J Thorac Cardiovasc Surg 2013 March.
TEVAR Open repair distal perfusion
Open repair Cross clamp
patients 69 77 29
Early Mortality 4% 14% 31%
I yr survival 92% 76% 76%
5 yr survival 87% 75% 75%
Expanding TEVAR into Ascending and Arch Expanding TEVAR into Ascending and Arch Aortic RupturesAortic Ruptures
• TTotal endovascular repair of acute ascending otal endovascular repair of acute ascending aortic rupture: a case report and review of the aortic rupture: a case report and review of the literatureliterature– McCallum JCMcCallum JC Vasc Endovascular Surg.Vasc Endovascular Surg. 2013 Jul 2013 Jul
• Emergency One-Stage Hybrid Surgery for Emergency One-Stage Hybrid Surgery for Ruptured Aneurysm of the Distal Aortic ArchRuptured Aneurysm of the Distal Aortic Arch– Kim et al Tex Heart Inst J. 2013Kim et al Tex Heart Inst J. 2013
TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic AneurysmsSummarySummary
• Successful Delivery: >95% Successful Delivery: >95% • Very Low rate of conversion to openVery Low rate of conversion to open• Mortality rate 30 days : 12-15%Mortality rate 30 days : 12-15%
– Traumatic: Traumatic: 5%5%– Degenerative >75 yr:Degenerative >75 yr:32% 32%
• Morbidity rate lower than openMorbidity rate lower than open• Reintervention may be neededReintervention may be needed• Acceptable 1-4 yr follow upAcceptable 1-4 yr follow up
• Can be Safely done at smaller hospitals Can be Safely done at smaller hospitals
TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic AneurysmsRecommendations for Success Recommendations for Success
• Establish a team ( Vascular / Thoracic /Interventional)Establish a team ( Vascular / Thoracic /Interventional)• Develop Your protocolDevelop Your protocol• Plan a Hybrid OR suitePlan a Hybrid OR suite• Graft InventoryGraft Inventory• Preoperative CT 1mm imaging to include pelvisPreoperative CT 1mm imaging to include pelvis• Large Sheaths/ Possible need for iliac conduitsLarge Sheaths/ Possible need for iliac conduits• Coverage of subclavian or celiac/ debranchingCoverage of subclavian or celiac/ debranching• CSF DrainageCSF Drainage• Case selectionCase selection
TEVAR for Ruptured Thoracic AneurysmsTEVAR for Ruptured Thoracic AneurysmsInto the Future Into the Future
• Here to stayHere to stay• Hybrid Approach to include Ascending and Hybrid Approach to include Ascending and
Arch aneurysms rupturesArch aneurysms ruptures• Newer Off the Shelf GraftsNewer Off the Shelf Grafts
A multicenter clinical trial of endovascular A multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the stent graft repair of acute catastrophes of the
descending thoracic aorta.descending thoracic aorta.
59 patients; 59 patients; Dissection: cTBD Dissection: cTBD n = 19n = 19Degenerative: RDADegenerative: RDA n = 20n = 20 Traumatic TT:Traumatic TT: n = 20 n = 20
– Cambria et al Cambria et al J Vasc Surg.J Vasc Surg. 2009 Dec 2009 Dec
TEVAR Open
30 day Mortality 12% 24%Mortality or Paraplegia 13.6% 30%
A multicenter clinical trial of endovascular A multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the stent graft repair of acute catastrophes of the
descending thoracic aorta.descending thoracic aorta.
– Cambria et al Cambria et al J Vasc Surg.J Vasc Surg. 2009 Dec 2009 Dec
At I yr TEVAR
Actuarial survival 66 %
Dissection 79 %
Traumatic 79%
Degenerative 37 %
Conversion 1 patient
Major device related events 2 patients
A multicenter clinical trial of endovascular A multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the stent graft repair of acute catastrophes of the
descending thoracic aorta.descending thoracic aorta.
• TEVAR for thoracic aortic catastrophes has TEVAR for thoracic aortic catastrophes has advantages when compared with literature-advantages when compared with literature-based results of open repair. based results of open repair.
• One-year treatment results indicate a low One-year treatment results indicate a low incidence of graft-related complications. incidence of graft-related complications.
• TEVAR is the preferred initial treatment for the TEVAR is the preferred initial treatment for the DTA catastrophes.DTA catastrophes.
– Cambria et al Cambria et al J Vasc Surg.J Vasc Surg. 2009 Dec 2009 Dec