Chapter 78 - TAAA endovascular Flashcards
When was the first TEVAR approved by FDA
2005
Approved devices in US for TEVAR
1) Gore CTAG (2012) 2) Medtronic valiant (2014) 3) Cook TX2 with proform (2008) 4) Cook Zenith alpha (2015) 5) Bolton relay plus (2012)
Gore CTAG device diameter length delivery profile
CTAG = Comformable thoracic aortic graft 21-45 mm 10, 15, 20 cm ID 18-24
Medtronic valiant device diameter length delivery profile
22-46 mm 107-224 mm OD 22, 24, 25
Cook TX2 with proform device diameter length delivery profile
28-42 120-216 mm proximal 136-207 mm distal ID 20, 22
Cook Zenith alpha device diameter length delivery profile
24-46 mm 105-233mm proximal 142-211 mm distal ID 16, 18, 20
Bolton relay plus device diameter length delivery profile
22-46 mm 10, 15, 20, 25 cm OD 22, 23, 24, 25, 26 no tapering component
Material of Gore CTAG and key features
ePTFE with nitinol deploys from middle of graft passive fixation oversize 7-22%
Material of Medtronic valiant captivia device
monofilament woven polyester to sinusoidal nitinol spring (outside of graft) passive fixation 8 peaked bare metal proximal FREEFLO configuration oversize 10-20%
Cook TX2 with proform material
Woven dacron with stainless steel z-stents stents on inside at seal zone and outside for rest barbs provide active fixation
Cook zenith alpha material
woven polyester and nitinol active fixation bare stents
Bolton relay material
woven polyester to nitinol stents active fixation with bare stents (also available with non-bare stents) oversize 10-15%
Ideal access vessel size
> 7 mm
Internal iliac conduit
Covered stents crack and pave controlled rupture of iliac then use it as conduit for TEVAR
11 zones of SVS TEVAR landing
Zone 0 = proximal to innominate Zone 1: proximal to left CCA Zone 2: proximal to left SCA Zone 3: < 2cm from left SCA Zone 4: 3cm distal to SCA to T6 Zone 5: T6 to celiac Zone 6: celiac to top of SMA Zone 7: SMA to suprarenal aorta Zone 8: perirenal aorta Zone 9: infrarenal aorta Zone 10: CIA Zone 11: EIA
Problem with excessive oversizing
1) graft infolding 2) gutter formation 3) aortic neck degeneration
How often do TEVAR have to land in zone 2
20%
Percentage of people with dominant left vert
> 60%
Risk of stroke without and with left SCA revasc
5.5 vs 1.2%
European collaborators on stent/graft techniques for aortic aneurysm repair EUROSTAR on spinal ischemia
left SCA coverage without revasc is associated with 3.49x more spinal ischemia
Mandatory left SCA revascularization reasons:
1) dominant left vert 2) LIMA CABG 3) left arm hemodialysis 4) aberrant right SCA 5) hypoplastic/absent right vert 6) left vert terminate in posterior cerebellar artery 7) occluded IIA 8) anomalous origin of left vert from arch 9) high risk for spinal ischemia (extensive coverage or previous AAA repair)
SVS guidelines on left SCA revasc
for all elective TEVAR prior to TEVAR
TEVAR with celiac coverage outcome mesenteric ischemia paraplegia rate
6% mesenteric ischemia 6% paraplegia
periscope technique for celiac/sma during TEVAR
1) femoral access 2) self-expanding sent into celiac/sma 3) refinforcement maybe needed
Complication with spinal drain placement
3%
MAP associated with spinal cord ischemia
< 70 mmHg
EUROSTAR on spine level coverage and spinal cord ischemia
40% with spinal cord ischemia had T10 coverage not clear no clear recommendations here
Overlap between grafts if two are the same diameter
7.5-10 cm
Post TEVAR care key points
CSF < 10 cm H2O MAP > 80 mmHg if neuro deficit, decrease CSF increase MAP to 100
Pivotal trials of Cook Gore Medtronic spinal cord ischemia mortality endoleak, tech success long term aneurysm-mortality
TABLE 78.2
Conduits used in the pivotal trials
9.4-21% most to CIA, some to Ao
TEVAR mortality
1-2% compared to 7% of open
one year aneurysm-related survival for TEVAR
95% vs 89% open
5 year survival TEVAR vs open
comparable 63-68%
STARZ trial morbidity between TEVAR and open
TEVAR 15.6% open 44.3% mostly attributable to pulmonary complications
Vascular complication rate of TEVAR
5-7%
EUROSTAR factors in risk of stroke after TEVAR
1) female 2) prolonged procedure > 160 min
Stroke rate after TEVAR
3-7%
Rate of paraplegia and paraparesis between TEVAR and OPEN
6.2 vs 13% permanent paraplegia 1.6 vs 5.1 higher centres of open say 2.5-3% only for open but bias
Percentage contribution to spinal cord perfusion of lumbar and pelvic collaterals
25%
Risk factors associated with spinal cord ischemia after TEVAR
1) prev AAA repair 2) extensive thoracic aortic coverage 3) renal insufficiency 4) intraoperative hypotension (SBP < 80mmHg) 5) coverage of hypogastric artery and left SCA
Endoleak from the pivotal trials
Talent had highest leak 10% persistent Tag had higher type 1 and 3 leaks lots of bias not sure what it means
1 year sac enlargement > 5 mm in TEVAR
7-14% higher in old TAG because porous PTFE
Endograft migration
0.7-3.9% with current devices
Revision after TEVAR
higher than open repair higher in the talent grafts
Hybrid visceral debranching and TEVAR key results
Complication 19-59% Graft thrombosis 6-11% 30d mortality: 13-14%
Predictors of mortality in hybrid procedure
1) 3+ vessel revasc 2) CAD 3) CHF 4) high SVS clinical comorbidity score 5) CKD
1 years survival after hybrid TAAA repair
77%
Branch devices for visceral TAAA
1) Cook off-shelf t-branch 2) Cook custom-made device 3) Cook ZFEN 4) Gore 4 downward cuff 5) Gore 2 up 2 down cuff 6) medtronic moedular graft
Thoracic arch branch devices
1) Medtronic valiant mona LSA 2) Gore tag thoracic branch endoprosthesis 3) cook zenith arch branched device 4) Endospan nexus aortic arch system 5) bolton medical ascending thoracic
