Aortic Arch Aneurysms – What Is Currently Available? - VascularWeb

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Aortic Arch Aneurysms – What Is Currently Available? - VascularWeb

Arch AneurysmsRoss Milner, MDAssociate Professor of SurgeryCo-Director, Center for Aortic DiseasesSVS Post-Graduate CourseJune 6, 2012


Disclosure – Ross Milner, MD• Consultant – WL Gore• Consultant - Medtronic


Overview• Arch Aneurysms• Emerging Technique• Emerging Technologies


Overview• Arch Aneurysms• Emerging Technique• Emerging Technologies


Traditional Surgical Repair• Two-stage, two-cavity procedure(Elephant trunk)• Requires CPB (Circulatory arrest)


Traditional Surgical Repair• Two-stage, two-cavity procedure(Elephant trunk)• Can be reduced to single cavityapproach (sternotomy) and then TEVAR


Single-Stage, Single CavityApproach• Surgical Debranching• TEVAR (antegrade vs. retrograde)


Hybrid Options• Surgical Debranching• TEVAR (antegrade vs. retrograde)• Endovascular debranching (snorkel orchimney)


Overview• Arch Aneurysms• Emerging Technique• Emerging Technologies


Emerging Technique• Frozen Elephant Trunk– Aneurysms– Dissections


Emerging Technique• Frozen Elephant Trunk– Aneurysms– Dissections• Well-described in European Literature(e-Vita graft – not available in US)• Small series in US


www.ucaorta.org


UCCAD Approach• Axillary cannulation for CPB• Right femoral artery sheath insertion• Sternotomy• Wire advanced via TEE visualization• Complete proximal anastomosis• Open arch and secure wire• Exchange for long, stiff wire• Antegrade TEVAR deployment


UCCAD ApproachCollaboration of specialties


Overview• Arch Aneurysms• Emerging Technique• Emerging Technologies


Emerging Technologies• None FDA-approved yet• Clinical trials to begin in the near future• Minimize risks of open surgicalapproaches


Medtronic


Endovascular Solutions to Aortic Arch DiseaseStartingPointUltimateGoalDevelopment Roadmap


LSA Thoracic Branch Stent Graft• Modified Valiant Thoracic Stent Graft and branch graft32


LSA Branch Thoracic Stent Graft Delivery SystemModified Valiant Captivia Delivery System• Dual wire• Pre-cannulated LSA lumen• Tip capture33


LSA Branch Stent Graft• Niti helical wireform / polyester• Distal flare• Diameter: 10, 12 and 14mm diameters• Length: 40mm• Delivery system: 14Fr profile, designed for femoral accessProximalDistal34


Cook


Arch branch


Arch Branch


Arch Branch


WL Gore


W. L. Gore &AssociatesGORE TAG ® Branched Endoprosthesis• Currently undergoing pre-clinical testing• Modular Construction– Off-the-shelf components– Inner lumen for anchoring and sealingbranch component• Complete system– Aortic and branch components designedfor the use in the arch– Accompanying accessory devices tofacilitate delivery• Ease of Use– Single femoral access– Minimal catheter maneuvers• Safe– Zero Ischemic time– Low risk of branch vessel coverage


W. L. Gore &AssociatesGORE TAG ® Branched EndoprosthesisAnticipated clinical utility in all zones of the aortic archZone 2 Zone 1 Zone 0


W. L. Gore &AssociatesGORE TAG ® Branched EndoprosthesisImplantation StepsStep 1:- Insert guidewires in aorta and branch vesselStep 2:- Introduce aortic component over bothguidewires into position within the archStep 3:- Deploy aortic component and withdrawcatheterStep 4:- Advance introducer sheath and dilatorStep 5:- Advance and deploy branch component


Conclusions• Traditional surgical approach fraughtwith morbidity and mortality


Conclusions• Traditional surgical approach fraughtwith morbidity and mortality• Unique solutions have minimized someof the risks


Conclusions• Traditional surgical approach fraughtwith morbidity and mortality• Unique solutions have minimized someof the risks• Entirely endovascular solutions withminimal surgical exposures are evolving

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