Hybrid approaches and chimney techniques as treatment options for TAA/TAD - Nguyễn Hoàng Định
Thoracic aortic aneurysms/dissections
Incidence of TAA is approximately 10.4 per 100,000 people.
Only about 20 to 30 percent of patients who get to the hospital with a
ruptured TAA survive.
For those over 65, the incidence of TAA is 3-4%.
Death from TAA is one of the 15 major causes of death
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Hybrid approaches and chimney techniques as treatment options for TAA/TAD Nguyễn Hoàng Định, MD. University Medical Center, Ho Chi Minh City, Viet Nam Thoracic aortic aneurysms/dissections Incidence of TAA is approximately 10.4 per 100,000 people. Only about 20 to 30 percent of patients who get to the hospital with a ruptured TAA survive. For those over 65, the incidence of TAA is 3-4%. Death from TAA is one of the 15 major causes of death. Treatment options for TAA/TAD including neck vessels 1. Conventional open surgery. 2. Total endovascular approach. 3. Hybrid surgery approach and chimney techniques. Open surgery remains the gold standard, but with a cost! Open surgery remains the gold standard, but with a cost! Mortality and morbidity Open surgery Hybrid Mortality 35% 8.3% Stroke 9% 4% (*) Antoniou GA et al, Hybrid repair of the aortic arch in patients with extensive aortic disease, Eur J Vasc Endovasc Surg 2010 Dec;40(6):715-21. (**) Milewski RK et al, Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction, J Thorac Cardiovasc Surg. 2010 Sep;140(3):590-7 Total endovascular options: fenestrated and branched stent-grafts: the future is near! Total endovascular options: fenestrated and branched stent-grafts: the future is near! Landing zones in TEVAR - Zone 3 : đặt stent graft sau ĐM đòn trái - Zone 4 : đặt stent graft ở động mạch chủ xuống Zone 0: đặt stent graft ở động mạch chủ lên, cần tái thông (revascularizaiton) 3 mạch nuôi não Zone 1: đặt stent graft sau ĐM thân cánh tay đầu, yêu cầu tái thông lại ĐM cảnh chung trái và ĐM đòn trái - Zone 2 : đặt stent graft sau ĐM cảnh chung trái, có thể tái thông hoặc che phủ hoàn toàn ĐM đòn trái tuỳ từng trường hợp Zone 2: LSA coverage Bắc cầu động mạch dưới đòn bằng mạch máu nhân tạo nối với ĐM cảnh chung trái Chuyển vị động mạch dưới đòn và nối tận bên với ĐM cảnh chung trái Zone 2: LSA coverage When do we need to revascularize LSA - History of CABG with patent LIMA – LAD graft - Small right vertebral artery - Left vertebral artery ends up at PICA (posterior inferior cerebellar artery) - Axillary – femoral bypass - High risks of paraplegia: long thoracic stent-graft of history of AAA surgery - Occlusion of hypogastric artery Zone 1: landing zone distal to innominate artery Zone 0: landing zone at ascending aorta - Requires medial sternotomy - Trifurcated graft to revascularize neck vessels and LSA - Deliver stent-graft distal to ascending aorta-graft anastomosis Zone 0: Chimney of the innominate artery - Carotid – carotid – subclavian bypass - Deliver chimney stent graft (Endurant limb) through cut down Rt. axillary artery - Deliver thoracic stent graft retrograde from the groin - Mark the position of 2 stent then deploy thoracic stent graft first then chimney stent graft Initial experiences at UMC Landing zones TAA (arch and descending) Type B TAD Zone 0 (6) Chimneys of innominate artery: 5 0 Total debranching: 1 0 Zone 1 (2) 2 RCA-LCA + LCA- LSA 0 Zone 2 (4) 1 LCA-LSA: 1 LSA chimney T: 1 LSA covered: 1 Total 12 (6 chimneys) Outcomes Early: Mortality 1 Stroke 1 Paraplegia 0 Retrograde diss. A 0 Paraprosthetic leaks: Type I 1 Type II 1 Need for re-entervention 0 Follow-up (2 – 36 mo) Mortality 1 Paraprothetic leak I 1 CA LÂM SÀNG 1 • Lê Thị T., 86 tuổi. • LDNV: Đau ngực. • Tiền căn: THA kéo dài không điều trị. • Đặt stent graft quai ĐMC 9/2013 tại Trung tâm Tim mạch BV ĐHYD TPHCM. KẾT QUẢ ĐIỀU TRỊ CA LÂM SÀNG 2 • Lê Xuân H., 77 tuổi. • LDNV: Đau ngực. • Tiền căn: THA điều trị không thường xuyên. • Đặt stent graft quai ĐMC 12/2013 tại Trung tâm Tim mạch BV ĐHYD TPHCM. CA LÂM SÀNG 2 • Hoàng Hoa C., 84 tuổi. • LDNV: Đau ngực. • Tiền căn: THA điều trị không thường xuyên. • Đặt stent graft quai ĐMC 01/2014 tại Trung tâm Tim mạch Bệnh viện ĐHYD TPHCM. Conclusions 1. Treatment of thoracic aortic (arch) aneurysm remains a challenge. 2. Conventional open surgery and hybrid surgery should be complementary. 3. Chimney of the innominate artery is a viable hybrid option in high operative risk patients.
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