Joseph S. Coselli, M.D.Vice Chair, Department of Surgery

Professor, Chief, and Cullen Foundation Endowed Chair

Division of Cardiothoracic Surgery

Baylor College of Medicine

Aortic Arch/Thoracoabdominal

Aortic Replacement

AATS International Cardiovascular Symposium 2017Session 13: Live in Box – Complex Cardiac Scenarios

São Paulo, Brazil • Saturday, December 9, 2017

Disclosure

Medtronic, Inc PI Clinical Trials

Consultant

Vascutek

Terumo

Consultant

PI Clinical Trials

Royalties Coselli

branched graft

WL Gore &

Associates

PI Clinical Trials

Consultant

Bolton Medical PI Clinical Trials

Followed successful 1956 ascending aortic repair with CPB

Wanted to move away from all of the "shunt" anastomoses and shorten operative time (perfused for 43 minutes)

Early Aortic Arch Replacement

• First successful attempt

• Homograft

• Cardiopulmonary bypass used to perform early antegrade cerebral perfusion

• Felt 60 minutes CPB was safe

• No hypothermia

DeBakey et al SGO 1957

• 1st time profound HCA used to protect the brain during repair

• Profound: 14°C

• 4 patients →

3 survivors (75%)

• Mainstay of arch repair for > 4 decades

Profound Hypothermic Circulatory Arrest (HCA)

14°C esophageal temperature

18°C rectal temperature

Griepp et al

J Thorac Cardiovasc Surg 1975

• Aortic arch repair

▪ Reimplant brachiocephalic arteries

▪ Almost always use hypothermic

circulatory arrest (HCA) to protect brain

Type of repair varies (pathology)

▪ Hemiarch

▪ Total (full) arch

▪ Total arch + elephant trunk (ET)

• Hybrid/endovascular options

▪ Experimental/off-label

▪ Debranch arch vessels

Complex Aortic Repair

Hemiarch

Total arch + ET

Trifurcated (Y) Graft

Hemiarch• Replaces lesser

curvature of arch

• Blood to brain

interrupted

• Less risk than total arch

• Branching arteries are

left intact

• Often used in cases

involving acute aortic

dissection or if

pathology is limited

Arch Repair

Total Arch Reconstruction

Island Branched

Y-graft ET

Y-graft

Island ETSingle branch ET

Total ArchBeyond the Arch

Frozen ET

ET

Trifurcated Approach: Extensive Repair

• Early results using trifurcated

graft technique compare favorably

to traditional approaches

• 7/150 (4.7%) early death

Spielvogel 2007 ATS

• Enables effective delivery of

SCP→ axillary perfusion

• Minimizes unprotected cerebral

ischemic time

• Facilitates the “full arch”approach of extensive repair

Y-Graft Approach

During Cooling: Left common carotid and left subclavian arteries are transected, ligated, and bypasses onto prefabricated Y-graft

Cooled to 24-28°C: Once target temp-erature attained, flows are reduced to 10-15 mL/kg/min and the innominate artery is snared

Bilateral ACP: 9 Fr balloon perfusion catheter

Distal anastomosis of graft collar: Collar

helps reduce tension on graft and aids hemostasis

Y-Graft

Approach

▲Head

Proximal anastomosis of main graft complete:

Proximal anastomosis of trifurcated graft underway

Y-Graft

Approach

Distal perfusion:

Side branch

Bilateral ACP: Flow

rate 10-15mL/kg/min

▲Head

Elephant Trunk (Island)

Elephant Trunk + TEVAR Repair

Mortality of Elephant Trunk

Cumulative Mortality Table SummaryRange of Percentages from Authors

Reporting Elephant Trunk Surgical Outcomes

1st Stage Mortality

Interval or Nonreturning

Mortality2nd Stage Mortality

All Cause Total

Mortality

2.3 – 13.9% 0 – 24.6% 0 – 10.0% 8.3 – 35.8%

Etz et al, 2008LeMaire et al, 2006Svensson et al, 2004Heinemann et al, 1995Safi et al, 2005Sundt et al, 2004

Frozen Elephant Trunk Repair

Cannulation Sites

Carotid artery

Subclavian artery

Brachiocephalic trunk

Apical (apex)

▪ All above sites are in contemporary use

▪ Alternate cannulation sites useful in cases of

redo surgery and acute aortic dissection

Femoral artery

Axillary artery

Innominate artery

Ascending aorta

Preventza et al 2013 ACTS [Coselli]

Frozen Elephant Trunk: Devices

ThoraflexEvita plus

Unlike frozen elephant

trunk (FET), not a total

arch replacement

Only a small part of the

transverse arch is native

Hemiarch + Antegrade TEVAR

Evolution of Open Aortic Arch

▪Femoral cannulation

Axillary/Innominate cannulation

▪Retrograde cerebral perfusion

Bilateral antegrade cerebral perfusion

▪Profound hypothermia

Moderate hypothermia

▪Island technique

Y-graft technique

▪Elephant trunk

Collared grafts

Preoperative characteristics n (%)

Age, years 60±14

Male 1341 (66%)

Heritable thoracic aortic disease 217 (11%)

Marfan syndrome 149 (7%)

Bicuspid aortic valve 410 (20%)

Acute/subacute aortic dissection 384 (19%)

Chronic aortic dissection

(redo or previously unrepaired)

454 (22%)

2026 Open Arch Repairs Consecutive from January 1999 to November 2017

Includes data on 138 hybrid arch repairs

Operative Details n (%)

Elective repair 1414 (70%)

Urgent repair 280 (14%)

Emergent repair (including salvage) 332 (16%)

Repeat sternotomy 626 (31%)

HCA + ACP only 1630 (80%)

HCA alone 134 (7%)

Lowest mean temperature, °C 20.8±4.1

2026 Open Arch Repairs Consecutive from January 1999 to November 2017

Includes data on 138 hybrid arch repairs

Operative Details n (%)

Concomitant root or valve procedure 1519 (75%)

Valve-sparring ARR 134 (7%)

Hemiarch 1486 (73%)

Full arch 515 (25%)

Full arch with elephant trunk 319 (16%)

Y-graft approach to full arch 185 (9%)

Cannulation: innominate artery 627 (31%)

Cannulation: right axillary artery 934 (46%)

2026 Open Arch Repairs Consecutive from January 1999 to November 2017

Includes data on 138 hybrid arch repairs

Select 30-Day Mortality Rates n (%)

Overall 30-Day death 141 (7%)

Elective repair (n=1414) 75 (5%)

Emergent repair (n=332) 44 (13%)

Redo sternotomy (n=626) 65 (10%)

Acute aortic dissection (n=345) 43 (12%)

Heritable thoracic aortic disease (n=217) 11 (5%)

Total arch (with or without ET) (n=515) 53 (10%)

2026 Open Arch Repairs Consecutive from January 1999 to November 2017

30-day death is death within 30 days at any location including after discharge

Includes data on 138 hybrid arch repairs

Hybrid Aortic Arch Surgery

138 Hybrid Arch RepairsConsecutive from January 1999 to November 2017

Operative

Details

n (%)

Zone 0 44 (32%)

Zone 1 2 (1%)

Zone 2 11 (8%)

Zone 3 78 (57%)

Zone 4 3 (2%)

Above zones use

Criado classification

Early Outcomes n (%)

Early death (hospital + 30-day) 18 (13%)

30-day death 16 (12%)

138 Hybrid Arch RepairsConsecutive from January 1999 to November 2017

Early death includes all deaths during entire period of hospitalization

(including any transfer) as well as any 30-day death (within 30 days at any

location including after discharge)

• Thoracoabdominal aortic repair

▪ Reimplant visceral arteries

▪ Use of adjuncts varies (pathology)

• Repair itself risks ischemic damage to downstream organs

▪ Spinal cord

▪ Kidneys

▪ Visceral organs

• Hybrid/endovascular options

▪ Experimental/off-label

▪ Debranch visceral vessels

Complex Aortic Repair

Crawford – 1509 TAAA repairsSvensson et al. J Vasc Surg 1993

SvenssonJ Vasc Surg 1993;17:357

31-year experience

1960 to 1991 n (%)

Early death 123 (8%)

Paraplegia 105 (7%)

Renal dialysis 136 (9%)

GI complications 101 (7%)

Lifetime Experience

I → 378 patients

II → 442 patients

III → 343 patients

IV → 346 patients

Cited as reference ~600 times (SCOPUS)

For extent II TAAA repair, the rate of

paraplegia or paraparesis increased to 31%

Evolving TAAA Repair

Improved

Outcomes

Evolution of Open TAAA Repair

▪No use of heparin

Moderate heparinization

▪Clamp-and-sew

Selective use left heart bypass

Selective use of CSF drainage

Selective use visceral perfusion

Whenever possible cold renal perfusion

▪Island technique

Selective use branched grafts

▪Select reattachment of intercostals

Aggressive reattachment of intercostals

Intraoperative Strategies

All extents

• Moderate heparinization

• Permissive mild hypothermia

• Aggressive reattachment of segmental arteries

• Cold renal perfusion whenever renal ostia can be accessed

• Expeditious repair

Extent I and II repairs

• Cerebrospinal fluid drainage

• Left heart bypass

• Selective celiac/SMA perfusion

Left inferior

pulmonary vein

Distal descending

thoracic aorta

Left Heart Bypass

LeMaire et al J Vasc Surg 2009

• We have performed 2

randomized clinical trials

regarding cold renal perfusion

• Cold renal perfusion was found

to benefit patients and reduce

postoperative renal failure over

normothermic

▪ P=0.03 [Köksoy 2002]

• Cold crystalloid and cold blood

provide equivalent renal benefit

▪ P=1.0 [LeMaire 2009]

Cold Crystalloid

Renal Perfusion

Cold Renal Perfusion

9-Fr Pruitt cathetersLR + 12.5 g/L Mannitol

+ 125 mg/L methylprednisolone

Isothermic centrifugal circuit

?

95th Annual Meeting, American Association of Thoracic Surgery (AATS)Plenary Scientific Session: Abstract 1

Seattle, Washington • Monday, April 27, 2015

Coselli et al JTCVS 2016

Outcomes of 3309 Thoracoabdominal

Aortic Aneurysm Repairs

October 1986 to December 2014

Coselli JTCVS 2016

3309 Open TAAA Repairs

~30 year experience

1986 to 2014 n (%)

Operative death 249 (7.5%)

30-day death 159 (4.8%)

Permanent paraplegia 97 (2.9%)

Permanent paraparesis 81 (2.4%)

Renal failure (dialysis) 189 (5.7%)

Gastrointestinal

ischemia

31 (0.9%)n=914 n=1066 n=660 n=669

3522 Open ThoracoabdominalAortic Aneurysm RepairsRepairs performed between 1986 and November 2017

Patient Characteristics n (%)

Median age, y [IQR]; range 10y to 92y 67 [59-73]

Heritable thoracic aortic disease 364 (10%)

Marfan syndrome 318 (9%)

Aortic dissection involving distal aorta 1266 (36%)

Acute or subacute dissection 179 (5%)

Chronic dissection 1087 (31%)

Symptomatic 2254 (64%)

Rupture 184 (5%)

Early Outcomes n (%)

Operative mortality 283 (8%)

30-day death 186 (5%)

Persistent*

Paraplegia 109 (3%)

Paraparesis 78 (2%)

Stroke 87 (2%)

Renal failure necessitating dialysis 211 (6%)

Adverse event (composite endpoint) 526 (15%)

*Persisting to the time of hospital discharge or early death

3522 Open ThoracoabdominalAortic Aneurysm RepairsRepairs performed between 1986 and November 2017

• Contemporary Arch/TAAA repair is highly

varied—multitude of approaches

• Good-to-excellent outcomes in experienced

centers

• Variety of techniques/adjuncts have lowered

risk in contemporary practice

• Many options for your patient

Conclusions

Obrigado!