Single stage hybrid repair for DeBakey Type I Aortic Dissection · Single stage hybrid repair for...

Single stage hybrid repair

for DeBakey Type I Aortic Dissection

Col. Vassilios D Tzilalis MD, MSc, PhD

Head of Vascular Surgery Department

Lt Col. Ioannis P Panagiotou, MD, PhD

Cardiothoracic Surgeon

Col. Eleftherios S Chouliaras, MD

Deputy Head of Anaesthesiology Department

Lt Col. Ioannis G Kantounakis, MD

Head of Interventional Radiology Department

Col. Emmanouil G. Koutoulakis, MD, PhD

Interventional Cardiology Department

401 General Army Hospital, Athens, Greece1

Thoracic Aorta Dissections Type A or DeBakey I, II

67% 33%

60-75% 25-40%

1965

1970

2017 Stanford non A - non B ?

Col. Vassilios D Tzilalis MD, MSc, PhD , Head of Vascular Surgery Department 401 General Army Hospital

IRAAD 2018 IRAAD 2018

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Single stage hybrid repair for DeBakey Type I Aortic Dissection

Type B or DeBakey III

Osler W, Silverman ME, Murray TJ, Bryan CS. American College of Physicians. The quotable Osler , page 120.

Philadelphia: American College of Physicians, 2008

DeBakey Type I dissection: what a tragedy!

Aortic dissection is the most common catastrophe of the aorta,

2-3 times more common than rupture of the abdominal aorta.

When left untreated:

about 33% of patients die within the first 24 hours, and

50% die within 48 hours.

The 2-week mortality rate approaches 75%

in patients with undiagnosed ascending aortic dissectionIRAAD 2018, RS Elsayed, RG Cohen, F Fleischman, ME Bowdish. Acute Type A Aortic Dissection, Cardiol Clin 35 (2017) 331–345


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In early 2006, at age 97, DeBakey underwent surgery for a damaged aorta — a procedure he developed

Micheal DeBakey as a patient:

complicated DeBakey Type III - Stanford B dissection:

what an irony!

15 July 2008: died Friday night in Houston. He was 99


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Head of Vascular Surgery Department 401 General Army Hospital


Classes of recommendations

Levels of evidence

Ishimaru zones

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Stanford non A - non B

Col. Vassilios D Tzilalis MD, MSc, PhD , Head of Vascular Surgery Department 401 General Army Hospital6


Stanford non A - non B


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when ET : Cardiothoracic surgeons

8Col. Vassilios D Tzilalis MD, MSc, PhD , Head of Vascular Surgery Department 401 General Army Hospital


when FET: Cardiothoracic surgeons

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TEVAR in zone 0 after previous debranching

Where : Centralized in centres - Aortic experienced Teams


Case 1

Palm Sunday evening, 2019

female 58 from Airforce 251 General Hospital

acute DeBakey I (Stanford ? A)

threatened visceral - renal - limb ischaemia

bovine arch

Euroscore II: 11.12

pre op 128 CTA : 251 AirForce


Case 1 6-7 days before Orthodox Easter 2019

Female 58 from Airforce 251 General Hospital

Acute DeBakey I (Stanford non A - non B ?)

Threatened visceral - renal ischaemia

Bovine arch

Euroscore II: 11.12

extremely narrow

true lumenfalse

lumen

Stanford

non A -

non B ?

pre op 128 CTA: Osirix reconstruction

dissection flap


Case 1: female 58

false

lumen

final angio result

left CCA - left LSA

bypass

Aorto - ‘BCT’ - LCCA

bypass

LCCA - LLSA

bypass

orifice LSA plug

int. mammary

left VA

tapering 44-36 with: 40-36-150 (first implanted - distal graft)

44-44-100 (second - proximal graft)

left CFA: 26Fr Graft

right CFA (helical EIA - CIA): distal angio

left axillary art: proximal angio - PLUG (AGA Amplatzer Vascular Plug II 12)

contrast 330ml / 270

angio procedure: 31.6 min

dose: 527 Gycm2

dissection flap

…“off-the-self”… Valiant Captivia (Medtronic) grafts

LCCA - LSA bypass(8mm ringed ePTFE Impra Bard)

Aorto BCT - LCCA bypass(18-9-9mm, AlboGraft, LeMaitre)

ready for, but no DHCA, no CPB


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extremely narrow

true lumen

plug

bypassbypass

post op 128 CTA : 401 GAH

tapering 44-36 with:

40-36-150 (first graft)

44-44-100 (second)

post op 128 CTA: Osirix reconstruction

Case 1: female 58 ICU 24h discharge 6th post day

but left EIA: 25Fr Graft


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July 2019

Male 75, interventional cardiologist !

Chronic (8yrs) complicated iatrogenic

DeBakey III dissecting aneurysm 7 cm

Retro (last 2-3yrs)

DeBakey I (Stanford non A - non B)

Euroscore II: 15.96

time to plan: custom 50-26-250mm

26-26-204

pre op 128 CTA : 401 GAH

IADSA

Custom Bolton graft: 50 - 26 - 250 mm

Case 2

true lumen

false lumen - large aneurysm

chronic

dissection flap

thrombosed false lumen

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AP

PA

Stanford

non A - non B

IADSA

Case 2: male 75

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pre TEVAR IADSA

post TEVAR IADSA

all

branches

from true

lumen

left VA

int. mammary

left CCA - left LSA

bypass

plug

right CFA: 26Fr Graft

left CFA: distal angio

left axillary art: proximal angio - PLUG(AGA Amplatzer Vascular Plug II 12)

contrast 200ml / Iomeron 40%

angio procedure: 25.3 min

dose: 417 Gycm2

Case 2: male 75

LCCA - LSA bypass(8mm ringed ePTFE Impra Bard)

Aorto BCT - LCCA bypass(18-9-9mm, AlboGraft, LeMaitre)

ready for, but no DHCA, no CPB

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plug

bypass

post op 128 CTA : 401 GAH

Case 2: male 75 ICU 24h discharge 5th post day

post op 128 CTA: Osirix reconstruction18


TIPS and TRICKS 1

Cardiovascular AORTIC Team - “Indication” for Hybrid

Debranching Plan

Find healthy ascending aorta from CTA

Endovascular Plan - “Tapered” Grafts - order materials

Cardiovascular environment (ready pump)

Debranching procedures Hybrid OR eg: LCCA - LSA bypass

Aorto BCT - LCCA bypass

Mark the central anastomosis (eg wire from pacemaker - adventitia - perpendicular C-Arm)


Lt Col. Ioannis P Panagiotou, MD, PhD, Cardiothoracic Surgeon,

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TIPS and TRICKS 2

Do not tie origin LSA - angio till the end - and then plug it

Ascending Wires into True Lumen! - guide from CTA - staged ascending course - angio

Angio from LSA and from contralateral leg

Extra stiff Wire with long soft tip into left ventricle (from TAVI procedures)

Tapering: - If tapered custom largest diameter long graft, first the proximal one

- if two, first the smaller diameter distal one and then the proximal.

Ballooning only distally if necessary

Plug the LSA origin - keep internal mammary and vertebral arteries, patent

Be careful with the access sites (CFAs - EIAs - large profile of the grafts - coiling - women)


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Analyse the outcomes of endovascular exclusion of the entire aortic arch

(proximal landing zone 0 - distal zone III or beyond)

Complete surgical debranching of the supra-aortic vessels, Group I: 429 pts

Endovascular supra-aortic revascularization (chimney, fenestrated or branched) with partial debranching,

Group II: 190 pts

Total endovascular supra-aortic revascularization was additionally performed,

Group III: 402 pts

2000-2016, 53 studies, 1853 pts, eligible 1021 pts - 35 different total aortic arch procedures

How to debranch:


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Surgical

debranching

procedures

1/3

2/3

401 General Army Hospital: 5 hybrid Arches

Three (3) cases zone 0 (Group I)

One 8 cm arch aneurysm

Two (2) DeBakey type I dissections

Tzilalis VD, Panagiotou IP, et al

Complete surgical debranching

of the supra-aortic vessels,

Group I: 429 pts

How to debranch:



Partial endovascular supra-aortic revascularization

Group II:

190 pts

Chimneys + bypasses

Branched grafts + bypasses

How to debranch:



trifurcated + stents common fen BCT-LCCA

LCCA - LSA bypass

fen - branched and bypass

fenestrated grafts and bypass

Group II:

190 pts

Partial endovascular supra-aortic revascularization

How to debranch:

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Group III:

402 pts

Chimneys

fenestrated grafts

combination of fenestrated- branched grafts

How to debranch:


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Overall early mortality higher group I vs II and III but

exceeded in group III (18.3%) and group II (14%) vs group I (8%) for diseases involving zone 0

Mortality was higher in all subgroups treated for zone 0 disease

compared with corresponding subgroups treated for zone 1-3)

Incidence of Cerebral Ischaemic Events (CIE) was increased in groups I and II vs III

and correlated with early mortality

Type II endoleak and endovascular reintervention was similar between groups and correlated with each other

Type Ia endoleak more often in groups II and III than in group I and correlated with midterm mortality

Retrograde type A dissection was low in all groups

Aneurysm growth was higher in group III, correlating with midterm mortality

Surgical revision slightly correlated with surgical complications but not with mortality

Group I, 429 pts: Surgical debranching of the supra-aortic vessels.

Group II, 190 pts: Supra-aortic revascularization (chimney, fenestrated or branched) with partial debranching.

Group III, 402 pts: Endovascular supra-aortic revascularization was additionally performed.


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• Retrospective review of prospectively collected data 2010-16, 1926 pts with dissection:

120 consecutive pts in 7.5 yrs (HAR without DHCA, but CPB)

• Mean Euroscore II = 11.6, urgent/emergency 97 pts (80.8%)

• Multivariable analysis of 27 potential pre-operative and intra-operative risk factors

• Early composite endpoint and short and long term overall mortality


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• Mortality 30d or in hospital: 9.2% (11pts)

• Composite endpoint: 11.7% (14 pts)

• Predictors of composite endpoint:

malperfusion and

previous cerebrovascular accident

• Predictors of short and long-term overall mortality:

previous cerebrovascular accident

myocardial ischaemia time

• Overall survival: 84.7% during a median FU 3.4 yrs

• Freedom from late aortic adverse events: 93.1% at 5 yrs incl. secondary aortic interv. and endoleak

• Favourable anatomic remodelling

Results


Freedom from late aortic adverse events:

93.1% at 5 yrs

incl. secondary aortic interv. and endoleak

Overall survival:

84.7% during a median FU 3.4 yrs

Freedom from adverse events curvesKaplan-Meier long-term survival curves


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Renal outcomes

Single stage HAR without DHCA VS conventional total AR (CTAR)

Thoracic Aortic Diseases

Retrospective review 2013-16, 757 pts: 651 CTAR - 106 HAR

Primary end point: postoperative Acute Kindney Injury (AKI)

Secondary end point: postoperative (short term outcomes):

in-hospital mortality

paraplegia

HAR pts older, diabetic, hyperlipidemic, CAD

HAR: Shorter CPB time and avoided circulatory arrest

The incidence of postoperative AKI between HAR and CTAR was

significantly different before and after match


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From 102 pts feasible in 68:

37 tube

8 CCA - CCA bypass

και tube

13 Arch branched stent graft

THE FUTURE

We know from anatomy of Non A - Non B and studies that Endo/HAR has a role in the Arch


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THE FUTURE ?


TEVAR / zone 0:

pts unfit for open and suitable anatomy

in centres

if open prepare for future endovascular distal extension

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… “In our opinion, there is no single correct operation for a patient with type A dissection,

but there is a correct operation for each surgeon and clinical scenario”…


Extent of Aortic Replacement in Type A Dissection: Current Answers for an Endless Debate

HAR has a role in non A - non B dissection as the Aortic Team in every single patient indicates

but

Conclusions:

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IRON WILL

Infrastructure - Hospitals:

Hybrid ORs

Personel - Departments

Vascular

Cardiothoracic

Interventional Radiologists

Cardiologists

Anesthesiologists

ICU

Nurses

Funding - Support

Aortic Dissections


Aortic teams

Aortic Centres

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Head of Vascular Surgery Department

Lt Col. Ioannis P Panagiotou, MD, PhD

Cardiothoracic Surgeon,

Col. Eleftherios S Chouliaras, MD

Deputy Head of Anaesthesiology Department

Lt Col. Ioannis G Kantounakis, MD

Head of Interventional Radiology Department

Col. Emmanouil G. Koutoulakis, MD, PhD

Interventional Cardiology Department


Thank you for your attention!

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