Chapter 79 - TAAA TEVAR technique Flashcards
Society guidelines on TEVAR in TAAA
TABLE 79.1
GORE CTAG vs open on post-op morbidity and 2 year mortality
Spinal cord 3% vs 14% Resp failure 4% vs 20% renal failure 1% vs 13% mortality - no difference higher reintervention with TEVAR
NIS on TEVAR vs open
TEVAR lower perioperative mortality but worse long term mortality TEVAR in high risk individuals
First generation TEVAR grafts
1) Gore TAG thoracic endoprosthesis 2005 2) Medtronic talent 1999 3) Cook Zenith TX1, TX2 2004 4) LeMaitre EndoFit (two layer PTFE with nitinol)
Cook Zenith TX1-2 evolution
TX1 = one piece system with prox and distal fixation TX2 = two piece system proximal barb caudally and distal barbs cranially ProForm = improved conformability to arch and limit bird beak
Improvement of the modern devices TEVAR
tip-capture mechanism: stabilizes proximal part prevent windsock
Modern 2nd generation TEVAR
1) Gore conformable TAG 2) Cook lower profile Zenith Alpha 3) Medtronic valiant 2008 4) Bolton relay 5) Bolton relay plus with self-positioning system and scallop 6) JOTEC E-Vita thoracic 3G - can be part of a frozen elephant trunk 7) LeMaitre TAArget 2008 - tortuous tracker delivery system
TEVAR minimum seal, maximum diameter, minimum overlap oversizing
2 cm seal 38 mm diameter suggested (42 max) 30 mm overlap 10-20% oversizing more aggressive seal and oversizing if landing in previous dacron graft
Strategies after arch vessel coverage
1) manual balloon traction 2) parallel stent 3) open conversion 4) surveillance
Iliac size that can predict graft deployment failure
< 8 mm
Rate of spinal cord ischemia in TEVAR
3.2% (1.4% permanent) metaanalysis 2-10%
Neuroprotective strategies
INCREASE TOLERANCE 1) Pharmacologic (Intrathecal papaverine, naloxone, mannitol, steroids) 2) Staged repair 3) Intraop hypothermia 34C AUGMENT PERFUSION 1) Hypertension MAP 90-100 2) CSF drain (usually 48 hr) 3) preserving LSCA and IIA 4) maintain hgb > 100, O2 sat > 95
MISACE in TEVAR
minimally invasive segmental artery coil embolization as a first stage procedure before tevar
Complications with CSF drain
12.7% 1) postdural puncture headache (9.7%) 2) catheter fracture (0.2%) 3) neuroaxial hematoma (1.9%) 4) intracranial hemorrhage (2.8%) 5) meningitis
Symptoms of intracranial hemorrhage after CSF drain
1) headache 2) confusion 3) coma 4) motor deficit 5) resp arrest
Treatment for post-CSF headache
1) bed rest 2) hydration 3) caffeine 4) blood patch
Stroke after TEVAR rate
2.7% metaanalysis 2.3-8.2%
Risk of stroke after TEVAR
1) hypertension 2) CKD 3) known CVA 4) higher aortic coverage 5) female 6) long surgery 7) occlusion of LSA 8) CAD 9) shaggy aorta 10) pull through wire 11) blood loss > 800 ml
Rate of retrograde type A dissection
< 2%
Mortality of RTAD
42%
MOTHER registry on RTAD risk factors
1010 patients 1) oversizing 24.4% vs 14.1% no oversize 2) post ballooning 3) proximal landing zone 4) manipulation of guidewire and sheath 5) progression of underlying disease
Rate of AKI and dialysis need after TEVAR
17% 1%
Risk factors of TEVAR collapse
1) small aortic diameter 2) young patients 3) oversizing 4) tight arch curvature
Rate of TEVAR revision
10-15%
Rate of endoleak after TEVAR
3-10%
Rate of TEVAR infection
0.2-5%
CTA findings of TEVAR infection
1) aortic-wall thickening 2) perigraft soft tissue > 5 mm 3) fluid collection 4) perigraft fluid > 6 weeks out 5) increasing air 6) soft tissue stranding 7) abscess formation 8) graft thrombosis/expansion
Vascular low-frequency disease consortium infected TEVAR
26 cases mortality 30 day 11% (80% med mgnt died) pain 66% fever 66% fistula 27%
Rate of aorto-bronchial and aorto-pulmonary fistula after TEVAR
European registry of endovascular aortic repair complication (EuREC) 0.6% aorto-bronchial 1.5% aorto-pulmonary
Limitations of using MRI to follow TEVAR
1) cannot visualize metallic stent struts - need CXR supplement 2) cannot be used with stainless steel grafts - high artifact
Endoleak rates after TEVAR
Type 1a: 7.3% Type 2: 2% Type 3: 1.2%
Aneurysm related death after TEVAR at 3 years
3.2%
ATOM score categories
Age > 70 - 2 points BMI < 30 - 3 points COPD - 2 points Total functional assistance - 4 points BUN > 25 - 3 points WBC > 12 - 2 points emergency - 3 points LSCA coverage - 2 points TAAA extensions - 2 points mesenteric debranching - 7 points
ATOM score legend
Low (< 5 points): 1.3% mortality Moderate (5-9 points): 6.6 % High (> 10 points): 24%
Perioperative all-cause mortality risk-stratification system formula for TEVAR
0.0398 x age 0.516 x renal insufficiency 0.46 x previous CVA 0.352 x previous SMK 0.376 x number divices > 2 0.016 x max aneurysm diameter low = 80% survival 5 years medium = 60% high = 40%
Mortality and morbidity of ruptured descending TAA with TEVAR vs OPEN
30 d: 19% vs 33% open MI 3.5 vs 11.1 stroke 4.1 vs 10.2 paraplegia 3.1 vs 5.5
30 d mortality for age > 80 with thoracic aortic rupture
40%
Percentage of all thoracic ruptures that are in the descending aorta
30%
use of TEVAR in connective tissue disorder special considerations
1) don’t do it 2) bridge to open 3) after open to land in prosthetic grafts
Open conversion after TEVAR rate
0.4 - 7.9%
Perioperative mortality for open conversion of TEVAR
16.6% 20% for infection 33% for retrograde dissection
