Jean M. Panneton, M.D., discusses thoracic endovascular techniques for aortic arch repair. Dr. Panneton describes the technical innovations and methods of repair. Case presentations include arch debranching with TEVAR, parallel grafting, and situ fenestration technique.
good morning. Yeah, I'm going to share a little bit of so my experience with endovascular arch repair. I decided to focus mainly on the arch because I think this is the area of the order that I think all our specialty probably kind of congregate together the best. These are some of the disclosure, and some of those are very pertinent to the topic. Um uh, these are my objectives. First is to re describe some technical innovations in endovascular arch repair. Now, I want to explore four methods of endovascular arch repaired some of the hybrid procedures that the barrier already discussed. The concept of parallel graphs, the concept of doing inside to ministrations and, uh, devices that are designed either with branch or pre feminist relation. That allows you to also do an endovascular repair. Uh, this, uh, example of one of the patients I've done many years ago, there was a combination of a back table administration for the nominate artery, combined with also an insight to laser administration of the left subclavian artery. Uh, this was done a patient that had had a previous type of repair. As you can see there, uh uh, for a notch that had enlarge and with the descending thoracic Kyoto as well. So why the arch? The arch is an interesting, uh, part of what we do when we do TVR. Because up to 50% of the T bar that we do, uh, will require deployments in zone 01 or two. And obviously, as you can see, there are a few branches that are there that are in the way. So I'm going to start with this This case study, this was a very interesting patient. He was 78 years old. He had a ruptured eight centimeter arch aneurysm. He was hypertensive. And those patients are usually transferred direct directly from the heliport to the hybrid room. Uh, and actually was when he got on the table, we had to start CPR for this ruptured arch. So we as we're doing CPR, we brought a thoracic stand graph into the arch. Was also able retrograde fashion to puncture the left carotid artery. Because in this patient, I had intended to do his own one deployment to try to, uh and all sealed the rupture. So the anti graft was deployed. Obviously, when we did the arch study. Uh, the heart is still arrested. So it was actually very easy to be very precise, because basically, you don't have to go on to, uh, rapid basing. You don't have to lower the pressure because you stop CPR and you can deploy the grab very, uh, accurately, which is what we did after that. We resume CPR. Uh, and then we did a laser administration of the left carotid artery into the thoracic and a graph, and we extended that I added some ando anchors at the inner curve to make sure that we had a good seal at that level. Anchors or an additional, uh, endovascular tool that really helps us to kind of sort of push the limit in in some situation to be able to get a seal. Even in anatomy, that is a little bit less, uh, favorable. This is the completion art study that showed no no indoor leaks and a patent left carotid artery. You can see the right right here. This is these are the markers for the fabric that are flush with the in nominate artery. And this is the laser administrated left karate. The artery. That patient was discharged actually neurologically intact and had over a year, year and a half follow up without any re intervention hybrid approaches. We do a lot of arch de branching. Probably done that by the hundreds by now. Probably the most common one is for Zone two when we need to actually d branch the left subclavian artery. There are two ways that we d branch left subclavian artery on top. Here is the left. Karate into left subclavian bypass. Uh, and the bottom is the left subclavian that is transposed onto the side of the left carotid artery. Mhm. He me arch de branching. This is a lefty. Me, Archie branching. This is usually done when you want to do his own won t bar when the thoracic monograph will be opposed right at the take off of the nominate artery. The technique that I use for this is to do a right corroded to left. So given bypass, and then, as you can see right here, the left carotid artery is then transposed on top of this bypass and is litigated. And then a total Archie branching. This is the case that Dr Barreiro showed, which does unfortunately, uh, is fairly is a bit more invasive because it does require rest anatomy. But in properly selected patient, I think it's a It's a great tool to be able to simply, uh, D branch the entire arch by using just a side biting clamp on the ascending aorta and then go ahead and doing his own zero T bar. As you can see here, mhm paragraph or chimneys is another a way to to do Andrew Vascular Arch repair. And they are certainly advantages to doing parallel grafting. Uh, I think one of them is that it's readily available. It's right off the shelf. I mean, the thoracic India graphs or on the shelf, the smaller stent graft with the branches as well. So you can really customize this and you can you can do zone zero zone one or zone, too. Uh, Steve are by combining a parallel graph into one of the super Ionic trunk. There are, however, major disadvantages to doing this. One of them is that the chimney itself. Actually, if you use a single paragraph, it may still seal, but if you try to do double or triple every time that you add one more parallel graph within that seal zone. It kind of jeopardizes that seal, and it increases the risk of having a type one in the league or in into leaks at the proximal cell zone. And that's obviously a major problem. It creates what we call gutter leaks because the the chimney will push the Jurassic Intergraph away from the aortic wall to keep the the branch refused, and then you end up with an interleague. So it's really usually a technique that I I rarely plan. Uh, electively. It's usually much more for urgent cases or as a bailout technique. Here's an example of a patient in whom that technique of doing parallel grafting was was useful. This was a 70 year old female patient. She actually had an expanding, ascending aortic pseudo aneurysm from a previous ascending and aortic root replacement. Uh, she still has significant coronary artery disease with a positive stress test. She had significant COPD with emphysema. Uh, and she was actually referred, uh, to me by cardiothoracic surgery. She was deemed too high risk for reduced anatomy to try to tackle this ascending pseudo aneurysm that was enlarging and became symptomatic so in in in her I decided to do what I call a reversed genealogy branching so basically decided that instead of deep branching the left side of her of a super electronic i d branch the right side of her super electrons. So to do that, you basically take the left subclavian artery will be the one vessel that is not going to be the branch. And I did a bypass from the left subclavian artery to the right carotid artery, Uh, as well as the left karate that was transposed on that on that bypass. Uh, after this was done, then I was able to bring a thoracic, uh, anti graft into her ascending aorta. I have an ascending graph there, so that's a great location to do his own zero t bar. Uh, you can see that, uh, to do that, we did have to cross her her valve and you see the wire into the L V with some transient AI, which in some ways it's very good during the procedure, uh, temporarily, anyway, because it means she becomes severely hypertensive at that time, which allows us to be deployed the T bar very precisely. And as soon as you get out of there. The I resolved, uh, And then I did a left subclavian artery chimney. This was a periscope style, because the chimney does not go integrate toward the ascending order to jeopardize my seal. But it goes downward toward the descending thoracic aorta, where it's less likely going to actually cause an entire week. Uh, and this is the completion angiogram, And the anchors were also place at the different areas of the seals own D A. I had to resolve completely. As you can see, here there is no and the league and the all the super electronics are or patent. You can appreciate here that the flow goes from that left subclavian chimney up to the left of given artery here, up to that bypass, to the left, corroded and to the right, corroded right here. This is also the leverage of the artery that was also, uh, dominant on the left side. This is a C t. A. At six months. That kind of shows the, uh this is a transfer. Your view that shows the chimney for the left subclavian artery. The descending thoracic aorta. This is the ascending, uh to or the ascending graph because it has been replaced. Uh, and the pseudo aneurysm is excluded completely. That patient, actually, I just saw recently she is now at five year follow up with no re interventions, and her studio museum has resolved completely, Uh, since this this procedure. So that's a I would say, a bit of a rare use of using, uh, parallel grafting and the arch. It's something that a lot of people also will do more for throwing abdominal aortic aneurysm to deal with the multiple visceral vessels. But that's a whole other, uh, bulging inside to ministrations. It's a technique that is also readily available. It's off the shelf. It's highly customizable method of endovascular arch repair. Uh, it's very quick. It's quite simple. It eliminates the need for rotational alignment. You will see that all the next slide that will discuss graphs that are either prefinished rated or pre or have branches. You really need to do a lot of rotational alignment. You need to make sure that when the graph makes its way from the formal artery all the way to the arch, that the graph of pointing toward the Super electron so it does require a lot of manipulation to do that inside the administration completely. Avoid that. All you need to do is bring the thoracic Intergraph into the arch, so there's a lot less Catherine manipulation. It's also a technique that can really be used as a bailout, if inadvertently you're planning, for example, to do a zone to t bar. Uh, and, uh, you you inadvertently cover the left carotid artery. You can just access the left breaking artery, go straight down the carotid artery laser, administrate the carotid artery and then really rescue the brain that way by just doing a a quick inside to laser administration. Here's an example of, uh, this is from a book chapter that that I wrote on that. So this is, uh, example of the technique. The TVA graph is deployed right here. You can see the laser is brought from the break. Your approach is in contact with, uh, the thoracic Intergraph. This is the arch view. We also always do what's called a barrel view because you want to make sure that the laser is really pointed toward the center of the graph, and it's not going to be either. On the back wall or on the front wall. In some cases of arch torture ferocity, the laser is activated. It's about three or four seconds of energy. It penetrates the thoracic and a graph. We then use a pre dilatation, and then we can stand the vessel and flair the inside of the stent graft. We also in cases of more difficult anatomy when the angle is more acute for the takeoff of the subclavian artery Here, we can actually use a directional sheath that will allow you to kind of modify that angle and have a better attack of the laser onto the thoracic Intergraph and then be able to still do laser administration. Mhm. This was our initial experience that we published a few years ago. Uh, and this is an example here of the laser administration. This patient here is at 10 years, uh, post laser Administration for his own to, uh, TiVo. That was done for a ruptured I m. H. So in that initial experience that we published, we had 22 patients with successful laser administration of the left subclavian artery. During emergent T bar, the operative mortality was 4.5%. This is all for you know, an emergent cases? Uh, we had no stroke. We had one cases of paraplegia. There was an extensive ruptured I m h. We had no major administration related complication. No type one or type three in two weeks. Uh, and all stands were patent. We had one patient that did get in asymptomatic stenosis of that left subclavian artery stent. Now, since then, our experience has grown to nearly over 100 inside to leave the administration of the arch and probably around 30 to 35 maybe inside two layers. Administration for abdominal aneurysm. Where would you integrate administration? Into the the visceral branches. So here's an example of inside to ministrations. This is a patient with type A aortic dissection. He was 79 years of age, presenting with typical chest pain and hypertensive crisis. He had very severe COPD. You can see the arch being dissected. You can see the dissection flap going into the ascending order here. Uh, and, uh, this patient was seen jointly with with with CT surgery here down an emergency room, uh, with actually 22 CT surgeon and both of them declined to take this patient back. They thought that he would actually never just never make it through with the standard open repair. I thought it was possible to do a total intravascular art for that acute type A dissection. So this is what I did in this patient. I did, too. Small neck incision to transpose both carotid artery onto the subclavian artery. Uh, and this is the arch study before the deployment. So both both, uh, karate or have been transposed. Uh, and this is the angiogram after doing administration and stenting of the nominate artery so you can see the administration here. This is the nominate artery. This is the, uh, the vertebral artery. And this is the carotid artery that was transposed away from the dominant modification. So I would have enough room to actually get a seal with the with the covered stent. After that, I did the inside to laser administration of the left subclavian artery, and you can see the laser here penetrates the thoracic Intergraph. The wire is then placed into the thoracic Intergraph, and this is then followed by a ministrations of the left subclavian artery. And same thing here on the instagram. You see the leverage of the lottery as well as the left carotid artery that was transposed on top of the subclavian artery. This is the completion art study that shows the the completion. Both, uh, the double laser administration basically, uh, the abdominal sonogram that showed that at this point in time, everything seemed very well perf used. Except we did have delayed filling of the left kidney. And this is one of the things that we often have to do when we fix either types or types that you can still remain with profusion despite a good shoe Lumen expansion. Uh, so that patient required a little bit more work to get the, uh, the branch. The left wing lottery resistant it back into the two women through a small administration. This is his postoperative sita at one month. Uh, he did survive the procedure neurologically intact. Uh, he did, however, required a tracheostomy and took him about three weeks to get off the ventilator. Uh, and that was with only a procedure with two little neck incisions in informal adultery access. So definitely I think the stone army might have been kind of tough on him. Uh, and this is another completion This is a three months three D reconstruction showing a total lack endovascular arch repair for type B dissection with a double double inside to laser administration branch devices. I'm going to quickly finish with these. Uh, there's currently two ongoing i D trials for and this is for zone two zone to branch devices. There's the Mona Lisa mechatronics. There's the TB from Gore. Uh, those two trials are currently the model is a trial actually has has stopped the Kroll. So they're going to submit the same thing for Gore. T b, uh, is currently also on hold for accruing patients. This is an example of a patient that I did, uh, this was a large descending through a security cameras. Um, that patient also had a bit of an aortic buckling here, acting a little bit like a pseudo cork. Despite that, I was able to track the branch graft across to the nominate artery and then bring the branch into the left subclavian artery. Uh, this is an example of a zone zero thoracic branch and a graph that was done. So that patient already has had a left him. Yazdi, branching that you see here Uh, And so this hematology branching was done. Usually we do that just a few days before, and that patient did get a, uh, Jurassic Branch and a graph. As you can see here, that goes into the nominate Autorite. This is both deployment. You can see the, uh, the flu going up that Richard Grady nominate branch and into the left side, uh, as a zone zero total intravascular arch repair. Finally, the device that we just recently did together with the to Barreiro is the nexus, which is an aortic arch stent graft system. It's also a modular system, but it's done in a totally different way because there is an arch stent graph and the graph actually gets deployed into the nominate artery down and across the arch and into the descending thoracic Kyoto. And there is a docking area here where then the ascending stand graph is brought again through that system and docked at that level to then get the seal into the ascending aorta. This is the the deployment. The video shows what we how we do that we do get bilateral thermal access. We do get a right upper break call or write actually artery access at this level. Yeah. The delivery system is then introduced across the arch, but opposite to the other devices where you then come into the ascending order. This device actually goes into the nominate and up into the left. Super give an artery the devices, then and you can see it here. This is the marker that tells us that this is the upper part of the device so that the docking system will be deployed toward the ascending aorta right here before we do the start. The deployment at this level, we bring a catheter to make sure that the, uh, deployment here of the nominee branch is not going to jail or occlude the right carotid artery. It's very important at this time to really make sure to keep a hold on this, uh, nominate graph. You can see how the docking system is getting deployed. We then push upward toward the arch to make sure that that docking really aims towards the ascending aorta here. And then the rest of the device is then deployed. Uh uh. Rapidly. This whole thing here is actually can be is done without using, uh, pacing, rapid pacing which we will we do for some other parts of the procedure. Uh, when we bring a balloon here at this level to do this, we induce first rapid pacing because this caused a complete occlusion of the system. If we don't want to, we really want to try to get that pressure down. And and, uh and, uh, we can then bring the second component. This is the ascending graph component that is brought the wire needs to be usually placed trans valve. And the the docking system needs to be brought right here at the level of the the dark of the arch component. Rapid pacing is also done for that deployment. To be able to be precise, allow the docking at this level. It's then released we remove the delivery system, Uh, and then we're gonna complete the procedure by doing a kissing balloon technique at the level of the, uh, nominate branch as well as the level of the docking, uh, junction. And this is going to be done again. This is the third, the third time in this procedure where we have to use rapid pacing. Uh, and, uh, then the procedure is, uh, is completed. I will show you the the case that we we got to do together. Maybe. I think it's probably six weeks ago or something like that. So this was a seven centimeter archer aneurysm. As you can see here, very large are China's three D really shows that for a patient like that, we really have no choice and to do a zone zero deployment. Uh, the the device is deployed right here. This is this is not playing, but the This is the angiogram that shows the verification of the reclusive Malick trunk to make sure that the branches deployed at the right level. Uh, devices. Uh, yeah, it plays a lot better on my on my computer. Uh, and this is the completion. Uh, ascending aorta. Graham, where? Obviously when we do the deployment of the ascending graph, we have to make sure we don't jail the coronary arteries. This is the kissing balloon technique that we do here. This is the completion in diagram. That shows, uh, the in nominate branch, the rights of Cleveland, right, karate, the bypass that goes from the right karate to the left of Cleveland and the left carotid artery right here. That is transposed. We just saw those patients together that the Barrow and I at the office. I think it was last last week for the one month post op CT scan. No, into league. All the components look. Look. Very good. You can see here the ascending graph, the Nominate branch as well as the This is a back view of the nominal branch and the graph going down into the lower descending thoracic aorta. So I'm gonna stop here so that you have a few minutes, uh, to answer questions. Uh, and thanks. Thanks very much. Chris and John. That's, uh that's really an awesome talk. You guys are doing the work. Are there any questions from into in the room there? A lot of places have been trying to do acute aortic dissection with just in the vascular technique. What would sway you to be more into vascular versus open repair? I mean, I think it comes down to, like the patient that he talked about the question for the audience. Uh, so the question would be, how do you choose between an open repair versus an endovascular repair for acute acute type A dissection? I think the example that you showed of the patient who has comorbidities that really preclude you know them tolerating the stern. Ah, to me when you think that the more morbidity and mortality of the operation is just gonna be so high, um, that we're going to attempt something, you know, uh, less traditional. Who are the results with surgery? Better than with? I don't know if we have results quite yet. I think the experience is probably pretty small. Yeah, well, I mean full and a vascular type of a cute type of repair. There's really no big series. It's really still very anecdotal. Um, clearly, when When you do. And there's a few papers that already showing that when you do a good, uh, cities, cities can analysis of all type a dissection. And when you look at how many of those patients would an endovascular repair even be possible with the current technology that we have, which is, Actually, there's no ascending autograph that are actually available as a T bar off the shelf, so that's it's you take you take, uh, you take graph that are designed for descending thoracic or arch, and you apply it into the arch. There's a lot of an atomic restriction for that. Uh, and those CT scan analysis showed that it may be a third maybe if you push maybe 40%. But clearly less than half of patients with Acute type A could be candidates for an endovascular repair. So, uh, so basically, I don't think one will ever replace the other. And they are definitely patients that are young and good surgical risk that the standard of care remains doing an ascending ascending repair. So there's a question from every question from David Baron, who posted it in the chat area. What anti coagulation or anti platelet therapy is needed after aortic stent or, uh, they were grafting. And for how long? Sort of the standard open surgical techniques there's There's no required anti coagulation, but I'll let you speak to the distance, uh, for for stent grafting of the of the arch because we we actually have, uh, 40 bar. It's zero. But if the T V goes into the arch and incorporates branches, uh, then I think using either Plavix, uh, I think, or polenta or one of those, uh, you know, uh, antibiotic therapy makes sense because you do have stands going into either the subclavian, the corroded or the nominate artery. Uh, so for for that reason, I think it does. It does make sense to keep those patients on Plavix. Uh, well, there's no there's no clear guidelines for that, but I think a year a year should be the minimum. Yes. What about resuscitation? CPR on a patient who has had this procedure done at some point in the future? If they need cardiac resuscitation, I don't think any of these techniques will preclude you from doing CPR. It's about the one thing you presented and you were doing CPR. But I just, you know, the physiology of CPR and someone who's got an aortic aneurysm and aortic dissection. Uh, you know, it's, uh, just wondering, you know, it's amazing that it worked. Um, and you're able to get adequate CPR the most amazing amazing case to present where you have to interrupt your CPR to put in your the T bar draft in that one. Yeah, I would say we probably have maybe a dozen cases like that where patients were undergoing CPR and they either got a an arch or descending, thoracic or or an IV are done for for ruptured aneurysm. But, uh, it's very different. If patient is getting CPR at home and being transported to the hospital, those there's there's really no survivors, really. But if the patient still has a blood pressure and and it's and it's unstable that it occurs, then I think you you do have a chance because, you know within within usually two or three minutes you can have you can have, if not complete seal. You can actually deploy an an autograph and start to get some seal and and then have the time to go to keep up and start to replenish volume to become the premier center for aortic disease. What things do we need to upgrade, you know, like the CT, MRI, the ICU beds or the hybrid war? What types of things do you think we need to have upgraded this center to become? I think we have most of the components already in place. I think it's just sort of setting up the multidisciplinary clinics that we talked about the collaboration so that we all work together and work off our strengths to sort of make the whole, you know, better than the sum of its parts. So anything in particular you think we need upgrading? I think I think I agree with Chris. I think I think we do have the infrastructure. Uh, looking at I mean, obviously, you know, currently with the covid environment. Yeah, we were a lot of time. The ICU beds are not there, but I think this is just a temporary thing, and we'll we'll we'll improve. Um, so I think we do have great. Great. I see you. I think we have great hybrid room. Uh, we have great imaging. We can get CT scan done in two minutes, Uh, right there by the operating room. So it's very it's on the same floor. So it's very all of that is is infrastructure is there. I think it does require a concerted effort to really go to the next step together, As you know, and collaborating, I think just being on the forefront of these trials, um, you know, staying on the cutting edge, uh, and then growing the volumes and and building that reputation so that we get the patient referrals. Mhm. Yeah. I think that being on the forefront of research and and being involved are involved in clinical trials of these new techniques as they come out and, you know, and also continued to publish to try to publish case series. You know, it kind of puts our our name out there. It's gonna be a very important part of establishing a reputation, I think. Great. Well, thank you, everybody appreciate it. Thank you. That's terrific talk. Thanks very much.
