THORACIC AORTIC PATHOLOGY
CHALLENGES AND SOLUTIONS
Thomas C. Naslund, M.D.
Vanderbilt University Medical Center
CONFLICT OF INTEREST
WL Gore
Investigator, Speaker, Consultant
Boston Scientific
Consultant
LeMaitre Vascular
Scientific Advisory Board
OFF LABEL USE
• WL Gore TAG
• Cook Zenith
• WL Gore Excluder
FREQUENTLY SEEN
PATHOLOGY
• Aneurysm
-fusiform *
-saccular (concern for infection)
• Aortic Dissection – Type A* and B
• Traumatic transection
• Penetrating ulcer
• Intramural hematoma
*labeled use for TAG
*surgical management
PENETRATING ULCER
INTRAMURAL HEMATOMA
THORACIC AORTIC ANEURYSM
• Atherosclerosis of iliacs
– 8-9 mm EI make most TEVAR easy
– 7-8 mm EI make some TEVAR difficult
– <6 mm EI is a clear danger zone (alternate access)
• Dilation with serial dilators if EI normal
• KY jelly helps
• Extreme caution with dilators and atherosclerosis
• Tortuosity of iliacs and TA (arch)
• Neck
– <2cm in straight distal attachment can work
– 2cm with angle in arch will not work
ACCESS FOR THE DISEASED
ILIAC
• Conduit
– Sutured to the CI artery end to side
– Complete TEVAR via conduit
– Consider anastomosis to CFA after completion
• May need secondary intervention
• CFA may already be exposed/opened/damaged
• Direct CI/Abdominal Aorta Access
–
–
–
–
–
Transverse incision over rectus sheath
Retract rectus laterally/RP dissection
CI/terminal aorta easily exposed
Counter puncture in lower quadrant
Direct arterial closure
GOALS OF ENDOVASCULAR
MANAGEMENT
Acute Type B Aortic Dissection
• Redirect flow into true lumen
• Cover entire descending thoracic
aorta
• Provide satisfactory visceral flow
• Facilitate aortic healing
• Avoid surgical repair
DISSECTION TREATMENT
ALGORITHM
• Type A- Medical Therapy &Emergency Cardiac
Surgery Evaluation
• Type B- Medical therapy
» Stent graft for complications in acute phase
» Stent graft for aneurysm formation in late follow up
» Long term follow up for all Type B to assess aneurysm
formation/stent graft
NECK
PROBLEMS/SOLUTIONS
• Big (>36mm)
– 45mm TAG in EU
• Small (<23mm)
– 18-23mm diameter graft
• Short (< 2cm)
– Debranching/fenestration
• Angled (>?)
– Specific design/fenestration
LENGTHENING THE NECK
Covering Branch Vessels
• Left Subclavian
– Consider vertebrobasilar circulation
• Contralateral vertebral/carotid disease
• Celiac
– Consider pancreaticoduodenal and gastroduodenal
• SMA disease
• Coiling typically not needed
– Subclavian for Type II leak
• Transbrachial
– Celiac
• Flow robust
– Catheterize, cover celiac/trap catheter, coil
SURGICAL DEBRANCHING
• Viscerals
– Celiotomy
• Midline gets all 4
• Left flank gets 3,maybe 4
• Arch
– Left subclavian to carotid transposition
– Carotid-carotid bypass (retroesophageal)
– Aortoinnominant & carotid bypass
ARCH REPAIR
TRAUMATIC TRANSECTION
• Deceleration injury
–MVA
–falls
• Sudden movement of
aortic arch
• Circumferential tear of
arterial intima and media
• Survivors have intact
adventitia and possibly
some media
TRAUMATIC TRANSECTION
• Innominate artery second most
common site
VANDERBILT SERIES
Open Repair 1987
• 41 Patients
• 5 Died without repair
– 3 preoperatively
– 2 en route with emergency thoracotomy
• 5/36 Repaired died during operation
– 3/5 associated with aortic clamping
• 2/36 Paraparesis
TRANSECTION
PRE OP MEDICAL MANAGEMENT
• Beta Blockade
• BP/HR control
• Discontinue after repair
STENT GRAFT REPAIR OF
TRAUMATIC TRANSECTION
n = 20
• Since 2005
• Age 35 (15 – 72)
• Mortality 1/20 (5%) – 72 yo MSOF
STENT GRAFT REPAIR OF
TRAUMATIC TRANSECTION
n = 20
•
•
•
•
Mean procedure time 103min
Mean blood loss 390ml
Mean intraoperative transfusion 1 unit
Grafts utilized
– TAG - 9
– Cook Iliac extenders- 9
– Excluder aortic cuffs - 2
STENT GRAFT REPAIR OF
TRAUMATIC TRANSECTION
n = 20
• Technical success 100%
– graft exclusion of injured
segment
– No deaths pre operatively
• Operative complications
– groin access site – 2
– TAG graft collapse – 2
– spinal cord injury – 0
– dialysis – 0
LATE FOLLOW UP
•
•
•
•
•
Erosions – 0
Endoleaks/aneurysm – 0
Access site false aneurysm – 0
Paraplegia – 0
Secondary interventions – 0
USE OF COOK ILIAC LIMB
EXTENDER
• Aorta diameter too small for TAG prosthesis
(<23mm)
• 55 mm length (satisfactorily covers entire area
of injury)
• Z stent design (no collapse)
• Requires manual loading into long sheath to
reach aortic arch
ZENITH
Delivery and Deployment
USE OF ABDOMINAL AORTIC
CUFF EXTENDERS
• 33 – 36 mm length
• Reported in several series with success
• Requires 3 or more individual cuffs to bridge
injured region
• Requires inventory of substantial numbers of
aortic cuffs
• Cook, Medtronic, and Gore
TIGHT ARCH
• Typical of adolescence
and young adults
• Implant can either
poorly oppose the inner
arch and collapse
FOLLOW UP
• Interval CT in 1 – 3
days (renal function
considerations)
• Follow up CT 1 -3
months after discharge
• Annual CT
• Eventually CT each 3-5
years
• Emphasis on permanent
life-long follow up
LATE CONCERNS
• Erosion
• False aneurysm formation
• Infections
MINIMAL AORTIC INJURY
•
•
•
•
Focal-non-circumferential intimal disruption
No false aneurysm
No periaortic hematoma
Suitable for medical therapy and CT follow up
rather than intervention
– Healing typical in 3-6 months
– Persistent fixed lesions identified after 1 year
followup