TEVAR for Chronic Type B Dissection Ryan LP

TEVAR for Chronic Type B Dissection Ryan LP 1, Herdrich BJ 2, Moser GW 1, Moeller P 1, Wang GJ 2, Bavaria JE 1 Divisions of Cardiovascular 1 and Vascular 2 Surgery University of Pennsylvania School of Medicine Penn Medicine Department of Surgery

Descending Aneurysm TEVAR with Elective Left Subclavian Coverage and Zone 2 LZ

Indications for TEVAR FDA Approved Thoracic Aortic Aneurysm Off-Label: Standard of Care Traumatic Aortic Rupture Off-Label: Investigational Chronic Type B Dissection Acute Complicated Type B Dissection

Chronic Dissection: Either Residual Type B after Type A Repair or simple Chronic Type B

Chronic Type B Dissection: TEVAR Prospective RCT of 140 patients with chronic type B dissection

Chronic Type B Dissection: TEVAR TL diameter FL diameter 91. 3% thoracic FL thrombosis Nienaber CA, et al. Circulation. 2009; 120: 2519 -28.

Cardiac Surgery Dept. University of Bologna Dir. Prof. R. Di Bartolomeo Note: All 4 vessels off TL 1 week after surgery After 3 months

Chronic Type B Dissection: TEVAR Thrombosis of the False Lumen Total Thrombosis Thoracic Thrombosis Total 14 (50%) 24 (85%) IIIa (11) 11 (100%) IIIb (17) 3 (18%)* 13 (76%) *4 vessels off the true lumen is a predictor of total thrombosis (P=. 08) Leshnower B, Szeto W, Pochetino A, Desai N, Nathan D, Jackson B, Fairman R, Bavaria J. TEVAR promotes successful thoracic aortic remodeling in the treatment of aneurysms secondary to chronic Debakey type III aortic dissection. Society of Thoracic Surgery 2012.

Chronic Type B Dissection: TEVAR True Lumen Index (Goal=1) Pre-TEVAR Post-TEVAR Total 0. 28 0. 50 IIIa 0. 41 IIIb 0. 21 False Lumen Index (Goal=0) P Pre-TEVAR Post-TEVAR P <0. 001 0. 77 0. 55 <0. 001 0. 66 <0. 01 0. 72 0. 41 <0. 05 0. 42 <0. 001 0. 80 0. 61 <0. 05 Leshnower B, Szeto W, Pochetino A, Desai N, Nathan D, Jackson B, Fairman R, Bavaria J. TEVAR promotes successful thoracic aortic remodeling in the treatment of aneurysms secondary to chronic Debakey type III aortic dissection. Society of Thoracic Surgery 2012.

Chronic Type B Dissection: TEVAR § Zero in-hospital deaths (vs. 8%) § Zero permanent neurological events (vs. 14%) § Zero acute renal failure (vs. 11%) § Mean stay of 7 days (vs. 20 days) § Two patients required additional intervention § Mean aortic diameter ratio = 0. 96 Leshnower B, Szeto W, Pochetino A, Desai N, Nathan D, Jackson B, Fairman R, Bavaria J. TEVAR promotes successful thoracic aortic remodeling in the treatment of aneurysms secondary to chronic Debakey type III aortic dissection. Society of Thoracic Surgery 2012.

Chronic Type B Dissection: Neurological Outcomes Open (N = 66) TEVAR (N = 28) N Percentage Total Neurological Deficit 9 14% 0 0% 0. 0045 Stroke 1 2% 0 0% 1 Permanent/Partial Paraplegia 8 12% 0 0% 0. 1 Most Open Cases Very Complex Left Chest Combination Distal Arch with “Open Proximal Anastomosis” under Circulatory Arrest with Hypothermia and Extent I/II TAAA

History and Presentation 72 y/o M with an incidentally found Type IIIb dissection Size on CT 10/19 - 5. 2 cm 12/10 - 5. 1 cm 6/11 - 5. 8 cm

Visceral Vessels 3 of 4 Mesentaric Blood Vessels off true lumen

Management Plan § Device: Gore TAG 37 mm X 20 cm § Pre-TEVAR left carotid-subclavian bypass § Lumbar Drain and SSEP monitoring § Coverage of proximal tear

Dissection CTA vs. IVUS Courtesy: R. White, UCLA Celiac SMA IMA

Aortography Pre and Post TEVAR Pre Post Step on Pedal

CTA Pre and Post TEVAR Pre Post

Present Approach to Chronic Type B Dissection with late Aneurysm: Either Type B or “Residual” Debakey Type I § § Satisfactory Proximal LZ (Usually in Zone 2) No severe pseudo-coarctation (to guard against Stent collapse) § Anatomy allows for Coverage of the Main primary tear site and any large thoracic fenestrations § All 4 Mesentaric vessels off true lumen (sometimes ¾) Note/Perspective : 31 TEVAR, 72 Open TAAA (2003 -2011) For Chronic Distal dissections

Chronic Type B aortic dissection: Again all 4 vessels off true lumen Pre-stenting Post-stenting

Conclusions In patients with chronic type B dissection, TEVAR: § can promote aortic remodeling § Has the potential to prevent aortic complications § Selection and Conceptual Understanding Important