Hybrid Arch for Acute Type A Aortic Dissection

Hybrid Arch for Acute Type A Aortic Dissection Is the stent graft best served “frozen” or “warm” ? Jehangir J. Appoo Division of Cardiac Surgery Libin Cardiovascular Institute Cumming School of Medicine University of Calgary www. aorta. ca 9 th Houston Aortic Symposium Frontiers in Cardiovascular Diseases March 3 rd, 2016

Today: Focus on Hybrid Arch for Acute Type A Aortic Dissection My objectives for next 8 mins: Introduce 1 new concept: “Warm Stent Graft” vs. “Frozen Stented Elephant Trunk” Propose Classification System & outcome of Systematic Review of Hybrid Arch for ATAAD Share one case as an example Thought provoking questions on what’s next step for Aortic Community

Hybrid Arch for ATAAD Is the Stented Elephant Trunk best served “FROZEN” or “WARM” ? vs.

Proposed Classification of Extended Arch Operations for ATAAD A. Total Arch Replacement B. Total Arch Replacement & Frozen Stented Elephant Trunk - deployed during hypothermic circulatory arrest C. Hemi-arch Replacement & Frozen Stented Elephant Trunk - deployed during hypothermic circulatory arrest D. Total Arch Replacement & Warm Stent Graft - deployed after cardiopulmonary bypass

Systematic Review of Extended Arch Operations for ATAAD Smith, HN et al. (in submission) 38 publications, >2100 patients Pooled op mortality 8. 6% (95%CI 7. 2 -10. 0) Pooled stroke 5. 7% (95%CI 3. 6 -8. 2) Pooled spinal cord ischemia 2. 0% (95%CI 1. 2 -3. 0) * Note: 2015 Publications from GERAADA and IRAD suggest 15 -20% operative mortality

Advantages of: Frozen Elephant Trunk vs. “Warm Stent Graft” Visualization of landing zones No requirement of Endovascular skill set No intraop fluoroscopy/hybrid room required No requirement of contrast agent Applicability to large number cardiac surgeons Confirmation of resolution of malperfusion Recognition of Stent Induced New Tear Distal extension of treatment No increase in circulatory arrest time

49 y. o male ATAAD Presents to OSH – March 2015 Primary Entry Tear Distal to L subclavian artery

Our Current Practice: Case Example 49 y. o male ATAAD presents to OSH – March 2015 Clinical and radiologic Visceral Malperfusion

Intraop: Tear confirmed distal to left subclavian artery Arch resected anastamosis done in Zone 2 with individual bypasses to innominate, left carotid and left subclavian Right axillary cannulation Moderate Hypothermia at 25 o. C HCA – 14 mins with continuous ACP SACP – 28 mins

On Table Angio - after Zone 2 Arch Reconstruction and separating from CPB Prior to stent graft insertion Post TEVAR

6 months follow up :

CCS/CSVS Joint Position Statement on Interventions for Thoracic Aortic Disease Presented @ CCC Oct. 2015 – Toronto Canadian Journal of Cardiology, In Press

RECOMMENDATIONS We recommend an extended distal arch repair technique be considered for patients who present with acute Type A dissection and one of the following: a. Primary intimal entry tear in the arch or descending aorta b. Significant aneurysmal disease of the arch (Strong recommendation, Low Quality Evidence) www. ccs. ca Interventions for Thoracic Aortic Disease Guidelines

RECOMMENDATIONS We suggest that it is reasonable to consider an extended distal arch repair technique for patients who present with acute Type A dissection and one of the following: a. b. c. d. Distal malperfusion Concomitant descending thoracic aortic aneurysm Young patients Patients with connective tissue disorders (Weak recommendation, Low Quality Evidence) www. ccs. ca Interventions for Thoracic Aortic Disease Guidelines

CONCLUSIONS: Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data Pooled op mortality 8. 6% (95%CI 7. 2 -10. 0) Pooled stroke 5. 7% (95%CI 3. 6 -8. 2) Pooled spinal cord ischemia 2. 0% (95%CI 1. 2 -3. 0

CONCLUSIONS: Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data Proposed Classification system of Extended Arch Techniques based on: Total Arch vs. Hemi-Arch & Frozen Stent Graft vs. Warm Stent Graft

CONCLUSIONS: Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data Classification system of Extended Arch Techniques based on Total Arch vs. Hemi-Arch Frozen Stent Graft vs. Warm Stent Graft Hybrid Repairs for treatment of ATAAD now entering Guidelines 2014 European Guidelines 2015 Canadian Guidelines

NEXT PHASE: Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do? Hemi-arch vs. Extended Arch ± Descending Stent Graft ? *Recall no RCT ever done for isolated ascending aortic replacement vs. hemi-arch

NEXT PHASE: Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do? Hemi-arch vs. Extended Arch ± Descending Stent Graft Frozen Elephant Trunk vs. Warm Stent Graft?

NEXT PHASE: Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do? Hemi-arch vs. Extended Arch ± Descending Stent Graft Frozen Elephant Trunk vs. Warm Stent Graft Hybrid Arch vs. Hybrid Arch + Bare. Metal Stent Distally?

My objectives for past 8 mins: Introduce new concept of “Warm Stent Graft” vs. Frozen Stented Elephant Trunk Propose Classification System & Results of Hybrid Arch for ATAAD Share a case Provoke thought on what’s next step for Aortic Community

Calgary Thoracic Aortic Program, www. aorta. ca, Jehangir. Appoo@Alberta. Health. Services. ca