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