ASCVTS 2011 Shaggy aorta & TEVAR
“Shaggy aorta” is a highly dangerous sign of
TEVAR for aortic arch aneurysm
Department of Cardiovascular Surgery
Fukushima Medical University, School of Medicine
Fukushima, JAPAN
Shinya Takase, Hirono Satokawa, Yoichi Sato,
Hiroki Wakamatsu, Yoshiyuki Sato, Hiroyuki Kurosawa,
Takashi Igarashi, Akihito Kagoshima, Tsuyoshi Yamabe,
Hitoshi Yokoyama
1
ASCVTS 2011 Shaggy aorta & TEVAR
Background
•Conventional surgery for thoracic aortic aneurysm still has high
morbidity and mortality.
•In this condition, stentgraft is applied to descending thoracic aortic
disease more than graft replacement.
•For arch aorta, stentgraft is only deployed to high risk patients in
general. However, in TEVAR for this lesion, stroke is concerned
because of atheromatous embolization.
•Conventional surgery for arch aortic aneurysm even with severe
atherom induces catastrophic complication followed by early death.
2
ASCVTS 2011 Shaggy aorta & TEVAR
Purpose
This paper is to explore whether TEVAR for
aortic arch aneurysm with “shaggy aorta”
is acceptable or not.
3
ASCVTS 2011 Shaggy aorta & TEVAR
Severely atheromatous aorta
Definition of “Shaggy aorta”
Intimal thickness > 2mm
No irregularity
IT>2mm + Irregularity but
not projected
Noraml
Intimal thickness(IT) < 2mm
No irregularity
Irregularity (+)
4
IT>2mm + Irregularity with
projection
ASCVTS 2011 Shaggy aorta & TEVAR
Case 4 77 y.o. male,
True aortic arch aneurysm, Angina
ASCVTS 2011 Shaggy aorta & TEVAR
Case 1；82y.o. female
Arch Aneurysm with aberrant artery
ASCVTS 2011 Shaggy aorta & TEVAR
Treatment Strategy
Indication of Conventional Surgery?
•Age>75 y.o.,
•Severity of co-morbidity
•Concomittant Procedure (CABG, Valve Surgery)?
Possible
Impossible
Concomittant Proc.
Difficult Treans-femoral Access
CS
Yes
No
Zone0~1
debranched SG
Fenestrated SG
Zone2
SG
ASCVTS 2011 Shaggy aorta & TEVAR
SG deployment
•Examination
•MD-CT＞Angiography
•Endoluminal Stentgraft (tailered made)
•GiantrucoZ stent ; d30-40X l 50-75mm
•UBE Ultrathin graft ; d28-40X l 50-150mm
•Delivery system (Pull through)
•COOK Guiding Sheath (straight / bending)
•0.035” Super stiffness / TERMO J type 230cm
•Deployment
•Hypotension (60-80mmHg) / ATP 0.2-0.4mg/kg /
•Rapid pacing 120-140 ppm
•Monitoring
•INVOS / MEP ( in some cases)
8
ASCVTS 2011 Shaggy aorta & TEVAR
Fenestrated ＳＧ for aortic arch aneurysm
Max diameter;42mm
Saccular type
ASCVTS 2011 Shaggy aorta & TEVAR
(Debranching) + Transaortic SG
8X16mm Y-graft
3) Reconstruction of
cerebral arteries
(debraching)
8mm
8mm
5F Pigtail
10mm
1) Branched Graft
SG (22F Guiding
Sheath) over the
wire
2) Side clamping
and
anastomosis
4) Trans-aortic SG
ASCVTS 2011 Shaggy aorta & TEVAR
Patients
Jan., 2001～May, 2010
SG repair for aortic arch aneurysm
(Non-dissecting aneurysm)
23 Cases
Male:Female = 19：4,
Age ; 74±7 y.o.,
Observation ; 30～3219 （848±1058） days
11
ASCVTS 2011 Shaggy aorta & TEVAR
Patients’ Profile with “Shaggy aorta” or not
Shaggy aorta, n(%)
Non “Shaggy aorta”, n(%)
n=23
n=8
n=15
Male:Female
Age
HT
HL
DM
7:1
12:3
75±6
8(100)
6(75)
1(13)
73±7
15(100)
10(67)
0(0)
0.65
0.59
1.00
0.67
0.35
Cerebrovascular diseases
Cardiac disorders
Respiratory dysfunction
Renal insufficiency
2(22)
3(38)
2(50)
2(25)
5(33)
3(20)
3(53)
3(20)
0.12
0.62
1.00
1.00
PAD
4(50)
1(7)
0.033
Multiple aortic aneurysm
2(25)
2(13)
0.59
Logistic EuroSCORE
30.1±24.6
23.1± 20.1
0.76
ASCVTS 2011 Shaggy aorta & TEVAR
Postoperative Outcome
Shaggy aorta, n=8
Non Shaggy aorta, n=15
Approach from aorta
5(63)
4(27)
0.18
CPB use
1(13)
2(13)
1.00
Debranching
5(63)
7(47)
0.67
SG top;Zone0/1/2/3
3(38)/3(38)/0(0)/2(25)
2(13)/3(20)/5(33)/5(33)
0.19
2(25)
0(0)
1(13)
1(13)
1(13);dissection
2(13)
1(7)
0(0)
2(13)
1(7); aorta rupture*
0.59
1.00
0.35
1.00
1.00
Primary Outcome
Endoleak
Surgical conversion
Additional SG
Access trouble
Aorta injury
13
ASCVTS 2011 Shaggy aorta & TEVAR
Postoperative Outcome
14
Non Shaggy aorta, n=14
Cerebral infarction
Respiratory failure
Pneumonia
Shaggy aorta, n=9
1(13)
3(38)
2(25)
0(0)
2(13)
0(0)
0.35
0.30
0.11
Renal dysfucntion
Hemodialysis
Bowel ischemia
Gastric bleeding
3(38)
3(38)
0(0)
0(0)
1(7)
1(7)
0(0)
1(7)
0.10
0.10
1.00
1.00
Paraparesis
2(25)
0(0)
0.11
Any morbidities
5(63)
2(13)
0.026
MOF
1(13)
0(0)
0.35
Death in 30days
1(13)
1(7)
1.00
Hospital death
4(50)
2(13)
0.13
*MOF;1, Pneumonia;2, AAA rupture;1,
ASCVTS 2011 Shaggy aorta & TEVAR
Actual Survival
71%
50%
Non-shaggy
Shaggy
Log-rank p=0.13
15
ASCVTS 2011 Shaggy aorta & TEVAR
Summary
• SG treatment for aortic arch aneurysm is technically
successful with debranching and/or fenestrated SG.
• There were no differences in preoperative comorbidities between patients group w/ and w/o
“shaggy aorta”.
• Embolim was induced around 50% in the group with
“shaggy aorta”, whereas it was 0% in that without
“shaggy aorta”.
• As the result, once one or more organ dysfunctions
were occurred in such high risk patients, it led to
death.
• Once the patients with “shaggy aorta” can tolerate
this treatment, they could survive in long time period.
ASCVTS 2011 Shaggy aorta & TEVAR
Conclusion
“Shaggy aorta“ is a dangerous sign.
Special caution of handling in this procedure is
required.
Adequate informed consent to such patients is also
required.
Invention of completely preventive measures against
embolism is aspired.