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Fenestrated or branched prostheses in thoracic and abdominal aorta
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Transcript of Fenestrated or branched prostheses in thoracic and abdominal aorta
Fenestrated and
Branch Devices
Sean P. Lyden, MD FACS
Associate Professor, Cleveland Clinic
College of Medicine at CWRU
Solaci Chile 2011
Disclosures
• Consultant & speaker for Medtronic and
Cook
What Can We Look
Forward To?
• Branch and Fenestrated IDE limited at
present in United States
• Biggest Issue
• Lack of coupling stent graft
What is Happening Now
• Physician off Label
Modification of
Approved Devices
Chimney Grafts
J ENDOVASC THER 2008;15:427–432
Modifications to
Commercial Devices
Courtesy J. Ricotta, MD Mayo ClinicPerspect Vasc Surg Endovasc Ther. 2008 Jun;20(2):174-87; discussion 188-9
Homemade Iliac Branch
Courtesy J. Ricotta, MD Mayo Clinic
Perspect Vasc Surg Endovasc Ther. 2008 Jun;20(2):174-87; discussion 188-9
Mating devices
• Viabahn
• ICast
• Fluency
• No ideal device
• No device designed for this use
• Most are using ICast
Fenestrated Devices
Bifurcated Bifurcated
Device
• Built in
hypogastric
branch
Hypogastric Devices
JoMedAtrium
Helical Hypogastric
Branch
• IDE at CCF
• All helical branch
device
• On HL&B introducer
with preloaded
wire through branch
to allow contra-
lateral snare
Cook Preloaded
Fenestrated
Endologix Off the Shelf
Fenestrated
Medtronic Branch
Device
Gore Branch Device
4 Vessel
Branches
• Helical
• Axial
Proximal Thoracic
Fenestrations
• Frequently aneurysms
encroach upon the arch
vessels
• Tortuous aortic
segment
• Cant cover brain flow
Branched & Fenestrated AAA
Devices
• Can be modified to treat the arch
Problems Unique to the
Arch
• Increased pressure and
migration forces
• Coronary Arteries
• Largest Vessels
• 3D spacial relationships
of the arch vessels
• Imaging difficulty
• Dealing with the aortic
valve
• Delivery system
problems
Brachiocephalic Vessel
Orientation
Evolution of Devices
Cook Arch Device
ARCH BRANCHES
ARE BEING DONE
TODAY
ASCENDING GRAFTS
SOON TO COME
Ascending Devices
• Physician
sponsored IDE
• Australia
• Canada
What is the biggest
limitation?
• Merging TEVAR
devices with
Percutaneous
Valve Technology
will be necessary
to treat the entire
ascending aorta
and provide
proximal fixation
Conclusions
• Branch and fenestrated devices are
needed
• Lack of coupling branch device has
delayed development
• Use in IDE and outside US
• ? When in US
• Multiple Companies working on it