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PC004. Thoracic Endovascular Aortic Repair of the Ascending and Descending Thoracic Aorta Utilizing Left Ventricular Transapical Access
JOURNAL OF VASCULAR SURGERY Volume 63, Number 6S
Abstracts 153S
successfully treated using endovascular technologies. Patient selection is critical in order to align aortic anatomy with specific device designs. Aortic- related mortality in high-risk patients was comparable to open surgery. Author Disclosures: R. Menon: Nothing to disclose; C. Muetterties: Nothing to disclose; G. Wheatley: Abbott Vascular, Bolton Medical, Lombard Medical, Medtronic, and TriVascular: consulting fees (eg, advisory boards). PC004. PC004 Thoracic Endovascular Aortic Repair of the Ascending and Descending Thoracic Aorta Utilizing Left Ventricular Transapical Access Keith B. Allen, MD, Sanjeev Aggarwal, MD, J. Russell Davis, MD, Steven Laster, MD, Karthik Vamanan, MD, A. Michael Borkon, MD. Saint Luke’s Hospital, Kansas City, Mo Objectives: Thoracic endovascular aortic repair (TEVAR) using transfemoral or iliac access is an established treatment option for patients with aortic pathology. Unfortunately, despite a general trend toward smaller profiles for endovascular devices, thoracic stents still require large-diameter vascular access. The apex of the left ventricle is the “front door” to the arterial system, and we describe using transapical access to perform ascending and descending TEVAR in patients with inadequate iliofemoral access. Methods: Between January 2012 and December 2015, nine patients presented with ascending (3) or descending (6) thoracic aortic pathology felt amenable to endovascular repair. Iliofemoral access, however, was inadequate for safe device delivery, and all nine patients were felt to be at prohibitive risk for open surgical repair. Pathology included penetrating ascending aortic ulcers (3), descending thoracic aortic aneurysms (4), or complications from previous type B dissections (2). Preoperative imaging included CTA of the chest/abdomen/pelvis. Operations occurred in a hybrid room with cardiopulmonary bypass backup. Transesophageal echocardiography and fluoroscopy were used to determine the appropriate thoracic interspace for exposure of the left ventricular apex. Off-the-shelf thoracic stent grafts, with and without back-table modification, were used in all cases. Rapid ventricular pacing was used during deployment of the ascending aortic stents only. Surgical technique included direct exposure of the left ventricular apex via a limited anterolateral thoracotomy (Fig, A); antegrade transapical or retrograde transfemoral angiography was performed to determine landing zones (Fig, B); sheath insertion and wire access was obtained across the aortic valve (Fig, C); postprocedure angiography was performed to access for endoleaks (Fig, D); follow-up CTAs were obtained in all patients. Results: Six patients presented as emergencies, while three patients were elective or urgent. Left subclavian artery coverage was intentionally done in two patients without sequelae. Concomitant procedures included transapical transcatheter aortic valve replacement for critical aortic stenosis in two patients. Procedural success was 100% without intraoperative or perioperative complications.
Fig.
JOURNAL OF VASCULAR SURGERY June Supplement 2016
154S Abstracts
In-hospital/30-day mortality was zero. Median length of stay was 5 days (range, 3-11 days). With a median followup of 20 months (range, 3-48 months) survival remains 89% (8 of 9), with one late death in an 89-year-old patient from pneumonia. No late graft complications or endoleaks have been seen on routine CTA surveillance (Fig, E). Conclusions: Thoracic endovascular aortic repair of the ascending and descending thoracic aortic can be successfully performed using transapical access through the apex of the left ventricle in highly selected patients with inadequate iliofemoral access. Author Disclosures: S. Aggarwal: Nothing to disclose; K. B. Allen: Nothing to disclose; A. Borkon: Nothing to disclose; J. Davis: Nothing to disclose; S. Laster: Nothing to disclose; K. Vamanan: Nothing to disclose.
PC006. PC006 Fate of the Descending Thoracic Aorta After DeBakey Type I Aortic Dissection in Patients With Genetically Triggered Thoracic Aortic Disease Sherene Shalhub, MD, MPH1, Scott A. LeMaire, MD2, Kim A. Eagle, MD, MACC3, Norma Pugh, MS4, Dianna M. Milewicz, MD, PhD5. 1University of Washington, Seattle, Wash; 2Baylor College of Medicine, Houston, Tex; 3 University of Michigan Medical School, Ann Arbor, Mich; 4 Center for Clinical Research Network Coordination, RTI International, Durham, NC; 5University of Texas Medical School, Houston, Tex Objectives: Dissection-related aneurysmal degeneration (DRAD) is a known long-term complication of the dissected descending thoracic aorta (DTA) that may or may not occur in a given patient. Postdissection surveillance recommendations are similar for all patients with dissections since there are no reliable predictors for DRAD. The aim of this study was to investigate the incidence and treatment of DRAD in the DTA after acute DeBakey type I aortic dissection in specific groups of patients from a cohort with genetically triggered aortic disease. Methods: The GenTAC Registry is an NIH-funded, multicenter database created in 2006 to improve the diagnosis and management of patients with known or suspected genetically induced thoracic aortic aneurysms and dissections. We analyzed data from survivors of DeBakey type I aortic dissection who were diagnosed with Marfan syndrome (MFS), familial thoracic aortic aneurysm and dissection (FTAAD), or early-onset dissection occurring at age #50 years (TAD #50). Results: A total of 139 cases (75.5% male) had DeBakey I dissection (MFS ¼ 52, FTAAD ¼ 34, and TAD#50 ¼ 53), with a median follow-up of 4.5 years (range, 0.1-25 years). The dissection occurred at a younger median age in MFS (35 years; range, 14-55) compared to FTAAD (41 years; range, 23-72) and TAD#50 (43 years; range, 17-54; P ¼ .002). Subsequent DTA repair was performed in 59 cases (42.4%),
with five during the initial hospitalization. MFS had the highest rates of subsequent DTA repair, at 61.5% compared to 38.2% in the FTAAD and 20.9% in TAD#50 groups (P < .001). The median time to repair was 3.6 years (range, 0.03-26). Interval to repair was shortest in MFS, with 32.7% requiring repair by 3 years from onset of dissection vs 8.8% in the FTAAD group and 15.1% in the TAD#50 group (P ¼ .01). Median maximum aortic diameters at repair were 5.5 cm (range, 3.9-8.4 cm) in MFS, 5.8 cm (range, 2.9-12 cm) in FTAAD, and 6.4 cm (range, 4.6-8.5 cm) in TAD#50; the differences were not statistically significant (P ¼ .3). MFS underwent more anatomically extensive repairs: 26.9% of MFS required Crawford extent II thoracoabdominal repair vs 14.7% in the FTAAD and in 3.8% in the TAD#50 groups (P ¼ .02). Conclusions: Patients with MFS have earlier and more extensive DRAD when compared to patients with FTAAD or early onset dissections, thus justifying aggressive follow-up imaging of the DTA. Further studies focused on predicting DRAD based on clinical and genetic factors will allow tailoring of the postdissection surveillance and counseling of all patients. Author Disclosures: K. A. Eagle: Medtronic, Terumo, and W. L. Gore; S. A. LeMaire: Baxter Healthcare: consulting fees (eg, advisory boards) and contracted research, CytoSorbants, Glaxo Smith Kline, Medtronic, Vascutek Terumo, and W. L. Gore: contracted research; D. M. Milewicz: Nothing to disclose; N. Pugh: Nothing to disclose; S. Shalhub: Nothing to disclose.
PC008 PC008. Number of Reentry Tears Influences Flap Motion and Flow Reversal in an In Vitro Model of Type B Aortic Dissection Joav Birjiniuk, BS1, Mark Young, PhD2, Lucas H. Timmins, PhD1, Bradley G. Leshnower, MD1, John N. Oshinski, PhD1, David N. Ku, MD, PhD3, Ravi K. Veeraswamy, MD1. 1Emory University School of Medicine, Atlanta, Ga; 2Medtronic Inc, Santa Rosa, Calif; 3 Georgia Institute of Technology, Atlanta, Ga Objectives: Aortic remodeling after dissection is poorly understood. Thus, the optimal treatment of patients after dissection and patient-specific recommendations are lacking. We have developed an in vitro aortic model of type B dissection to interrogate changes in the local aortic hemodynamic parameters that are implicated in thrombosis and aneurysm formation. We hypothesize that dissections with multiple re-entry tears will exhibit decreased flap motion and, as a result, flow reversal. Clinically, this may impact likelihood of aneurysmal degeneration over time. Methods: Anatomic models of aortic dissection with fidelity to actual patient CT images were fabricated out of silicone using rapid prototyping techniques. Models with primary entry and single fenestration (Fig 1, A), two fenestrations (Fig 1, B), and three fenestrations
Abstracts 153S
successfully treated using endovascular technologies. Patient selection is critical in order to align aortic anatomy with specific device designs. Aortic- related mortality in high-risk patients was comparable to open surgery. Author Disclosures: R. Menon: Nothing to disclose; C. Muetterties: Nothing to disclose; G. Wheatley: Abbott Vascular, Bolton Medical, Lombard Medical, Medtronic, and TriVascular: consulting fees (eg, advisory boards). PC004. PC004 Thoracic Endovascular Aortic Repair of the Ascending and Descending Thoracic Aorta Utilizing Left Ventricular Transapical Access Keith B. Allen, MD, Sanjeev Aggarwal, MD, J. Russell Davis, MD, Steven Laster, MD, Karthik Vamanan, MD, A. Michael Borkon, MD. Saint Luke’s Hospital, Kansas City, Mo Objectives: Thoracic endovascular aortic repair (TEVAR) using transfemoral or iliac access is an established treatment option for patients with aortic pathology. Unfortunately, despite a general trend toward smaller profiles for endovascular devices, thoracic stents still require large-diameter vascular access. The apex of the left ventricle is the “front door” to the arterial system, and we describe using transapical access to perform ascending and descending TEVAR in patients with inadequate iliofemoral access. Methods: Between January 2012 and December 2015, nine patients presented with ascending (3) or descending (6) thoracic aortic pathology felt amenable to endovascular repair. Iliofemoral access, however, was inadequate for safe device delivery, and all nine patients were felt to be at prohibitive risk for open surgical repair. Pathology included penetrating ascending aortic ulcers (3), descending thoracic aortic aneurysms (4), or complications from previous type B dissections (2). Preoperative imaging included CTA of the chest/abdomen/pelvis. Operations occurred in a hybrid room with cardiopulmonary bypass backup. Transesophageal echocardiography and fluoroscopy were used to determine the appropriate thoracic interspace for exposure of the left ventricular apex. Off-the-shelf thoracic stent grafts, with and without back-table modification, were used in all cases. Rapid ventricular pacing was used during deployment of the ascending aortic stents only. Surgical technique included direct exposure of the left ventricular apex via a limited anterolateral thoracotomy (Fig, A); antegrade transapical or retrograde transfemoral angiography was performed to determine landing zones (Fig, B); sheath insertion and wire access was obtained across the aortic valve (Fig, C); postprocedure angiography was performed to access for endoleaks (Fig, D); follow-up CTAs were obtained in all patients. Results: Six patients presented as emergencies, while three patients were elective or urgent. Left subclavian artery coverage was intentionally done in two patients without sequelae. Concomitant procedures included transapical transcatheter aortic valve replacement for critical aortic stenosis in two patients. Procedural success was 100% without intraoperative or perioperative complications.
Fig.
JOURNAL OF VASCULAR SURGERY June Supplement 2016
154S Abstracts
In-hospital/30-day mortality was zero. Median length of stay was 5 days (range, 3-11 days). With a median followup of 20 months (range, 3-48 months) survival remains 89% (8 of 9), with one late death in an 89-year-old patient from pneumonia. No late graft complications or endoleaks have been seen on routine CTA surveillance (Fig, E). Conclusions: Thoracic endovascular aortic repair of the ascending and descending thoracic aortic can be successfully performed using transapical access through the apex of the left ventricle in highly selected patients with inadequate iliofemoral access. Author Disclosures: S. Aggarwal: Nothing to disclose; K. B. Allen: Nothing to disclose; A. Borkon: Nothing to disclose; J. Davis: Nothing to disclose; S. Laster: Nothing to disclose; K. Vamanan: Nothing to disclose.
PC006. PC006 Fate of the Descending Thoracic Aorta After DeBakey Type I Aortic Dissection in Patients With Genetically Triggered Thoracic Aortic Disease Sherene Shalhub, MD, MPH1, Scott A. LeMaire, MD2, Kim A. Eagle, MD, MACC3, Norma Pugh, MS4, Dianna M. Milewicz, MD, PhD5. 1University of Washington, Seattle, Wash; 2Baylor College of Medicine, Houston, Tex; 3 University of Michigan Medical School, Ann Arbor, Mich; 4 Center for Clinical Research Network Coordination, RTI International, Durham, NC; 5University of Texas Medical School, Houston, Tex Objectives: Dissection-related aneurysmal degeneration (DRAD) is a known long-term complication of the dissected descending thoracic aorta (DTA) that may or may not occur in a given patient. Postdissection surveillance recommendations are similar for all patients with dissections since there are no reliable predictors for DRAD. The aim of this study was to investigate the incidence and treatment of DRAD in the DTA after acute DeBakey type I aortic dissection in specific groups of patients from a cohort with genetically triggered aortic disease. Methods: The GenTAC Registry is an NIH-funded, multicenter database created in 2006 to improve the diagnosis and management of patients with known or suspected genetically induced thoracic aortic aneurysms and dissections. We analyzed data from survivors of DeBakey type I aortic dissection who were diagnosed with Marfan syndrome (MFS), familial thoracic aortic aneurysm and dissection (FTAAD), or early-onset dissection occurring at age #50 years (TAD #50). Results: A total of 139 cases (75.5% male) had DeBakey I dissection (MFS ¼ 52, FTAAD ¼ 34, and TAD#50 ¼ 53), with a median follow-up of 4.5 years (range, 0.1-25 years). The dissection occurred at a younger median age in MFS (35 years; range, 14-55) compared to FTAAD (41 years; range, 23-72) and TAD#50 (43 years; range, 17-54; P ¼ .002). Subsequent DTA repair was performed in 59 cases (42.4%),
with five during the initial hospitalization. MFS had the highest rates of subsequent DTA repair, at 61.5% compared to 38.2% in the FTAAD and 20.9% in TAD#50 groups (P < .001). The median time to repair was 3.6 years (range, 0.03-26). Interval to repair was shortest in MFS, with 32.7% requiring repair by 3 years from onset of dissection vs 8.8% in the FTAAD group and 15.1% in the TAD#50 group (P ¼ .01). Median maximum aortic diameters at repair were 5.5 cm (range, 3.9-8.4 cm) in MFS, 5.8 cm (range, 2.9-12 cm) in FTAAD, and 6.4 cm (range, 4.6-8.5 cm) in TAD#50; the differences were not statistically significant (P ¼ .3). MFS underwent more anatomically extensive repairs: 26.9% of MFS required Crawford extent II thoracoabdominal repair vs 14.7% in the FTAAD and in 3.8% in the TAD#50 groups (P ¼ .02). Conclusions: Patients with MFS have earlier and more extensive DRAD when compared to patients with FTAAD or early onset dissections, thus justifying aggressive follow-up imaging of the DTA. Further studies focused on predicting DRAD based on clinical and genetic factors will allow tailoring of the postdissection surveillance and counseling of all patients. Author Disclosures: K. A. Eagle: Medtronic, Terumo, and W. L. Gore; S. A. LeMaire: Baxter Healthcare: consulting fees (eg, advisory boards) and contracted research, CytoSorbants, Glaxo Smith Kline, Medtronic, Vascutek Terumo, and W. L. Gore: contracted research; D. M. Milewicz: Nothing to disclose; N. Pugh: Nothing to disclose; S. Shalhub: Nothing to disclose.
PC008 PC008. Number of Reentry Tears Influences Flap Motion and Flow Reversal in an In Vitro Model of Type B Aortic Dissection Joav Birjiniuk, BS1, Mark Young, PhD2, Lucas H. Timmins, PhD1, Bradley G. Leshnower, MD1, John N. Oshinski, PhD1, David N. Ku, MD, PhD3, Ravi K. Veeraswamy, MD1. 1Emory University School of Medicine, Atlanta, Ga; 2Medtronic Inc, Santa Rosa, Calif; 3 Georgia Institute of Technology, Atlanta, Ga Objectives: Aortic remodeling after dissection is poorly understood. Thus, the optimal treatment of patients after dissection and patient-specific recommendations are lacking. We have developed an in vitro aortic model of type B dissection to interrogate changes in the local aortic hemodynamic parameters that are implicated in thrombosis and aneurysm formation. We hypothesize that dissections with multiple re-entry tears will exhibit decreased flap motion and, as a result, flow reversal. Clinically, this may impact likelihood of aneurysmal degeneration over time. Methods: Anatomic models of aortic dissection with fidelity to actual patient CT images were fabricated out of silicone using rapid prototyping techniques. Models with primary entry and single fenestration (Fig 1, A), two fenestrations (Fig 1, B), and three fenestrations