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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3751_Библиотеки_им_академика_М_И_Перельмана

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Kawasumi No Yes No 0
a. CookArchBranchdevice(CookMedical,Bloomington,IN):Thisisatwo-branchendograft
designedfordeploymentintozone0.Itismadeofalow-profilewovenpolyestermaterialanda combinationofnitinolandstainlesssteel,withtwointegralbranchescorrespondingtothe innominatearteryandtheleftcommoncarotidartery.
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b. BoltonArchBranchdevice(BoltonMedical,Sunrise,FL):Thedeviceisofferedunder“custom-
made”ordersoutsidetheUnitedStates.ItisbasedontheRelayNBSplatformandmadeofpolyester fabricandnitinolstentswithoutaproximalbare-springsegment.Branchesareinternalandare referredastunnels:theseareorientedsothattheanterioronecanbeoptimallyjoinedtotheleft carotidandtheposterioronetotheinnominateartery.
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c. MedtronicArchBranchdevice(Medtronic,SantaRosa,CA):Thisdevice,referredtoasMona-
LSA,isasingle-branchdeviceusedforzone2deployments.ItisbasedontheValiantthoracic endograftplatformandismadeofpolyesterandnitinolmaterial.Inprinciple,thedevicecanbeused formoreproximalarchzonesaslongasindispensablecoveredvesselscanberevascularized.The geometryisamodifiedfenestrationwithaninvertedfunnelappearancethatallowstheexternal segmenttoengagetheoriginofthesubclavianarteryoranyalternatearchvesselandthebridging stenttoflarewiththewidenedmouthofthefenestration.
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d. W.L.GoreArchBranchdevice(W.L.GoreMedical,Flagstaff,AZ):Thisdevice,referredtoas
GORETAGthoracicbranchendoprosthesis,isasingle-brancharchdevice,basedonthecTAG platformandmadeofexpandedpolytethrafluoroethylene(ePTFE)coveringanitinolframe.Itwas designedfordeploymentinzone0andzone2;however,moreproximalarchzoneswouldrequire surgicalrevascularizationofindispensablearchbranches.
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C.InSituFenestration
1. This technique was first described in 2004 by McWilliams and colleagues.
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This technique is
reserved for zone 1 and zone 2 without the use of extracorporeal perfusion to maintain cerebral circulationduetoonlytemporarycoverageofthesupra-aorticbranches.
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2. The basic principle is to allow blood flow to the vital arch branches by fenestrating a thoracic
endograftafterdeployment.
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3.Initialeffortsinvolvedastiffguidewirefollowedbyaneedleandacuttingballoonangioplasty.Itwas
found later that this technique causes tears in the expanded ePTFE stent graft. Therefore, laser or radiofrequency puncture has been invoked to create a retrograde in situ fenestration during TEVAR, followedbyballoonangioplastyanddeploymentofacoveredstent.
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4. In addition to the fenestration technique, the following fenestrated graft, developed by Kawasumi
LaboratoriesNajuta,hasbeendescribed:
a. TheNajutaendograftsystem(KawasumiLaboratoriesNajuta,Tokyo,Japan):Itisa
fenestratedgraftwithoutbranchesthatwasconstructedwithlongitudinallyconnectedZstents coveredwithePTFE.
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D.Physician-ModifiedStentGrafts
1. Custom-made branched and fenestrated endografts can be useful during elective cases but are not
easily applicable during urgent and emergent cases, because of the prolonged manufacturing delay. Therefore,physicianshaveoptedtomodifyinfrarenalandthoracicdevices“onthebacktable”byadding
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branchesandfenestrations.
2. Devices are usuallycreated with reinforcedfenestrations or branches constructedfrom portionsof
self-expandingstentgrafts.Suchcreativeeffortsmakethesehomemadedevicesanoptionforpatientsin needofurgentoperation.However,long-termoutcomesarenotknown,placingagreatresponsibilityon the physician,especiallyif theurgent case is not done under a formal investigationdevice exemption (IDE)studywithintheUnitedStates.
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VI.HybridProcedureApproachfortheAorticArch
A.
A. Inanattempttoreducetherisksassociatedwithanopenprocedure,butatthesametimetoavoidthe
limitationsofan endovascular approach,hybridtechniquesare described.Thereare two typesof hybrid interventions: first,anopen aortic archrepair with distalextensionusing the stentgraftor frozenelephanttrunkprocedure, and second, anextra-anatomic bypass involvingthe supra-aortic branchescombinedwithathoracicstentplacementtoallowforaproximalextensionofthelanding zonesordebranchingprocedure(Fig.5B.6).
FIGURE5B.6 DeploymentofE-vitaopenplusandreconstructionoftheaorticarch.
©JOTECGmbH,afullownedsubsidiaryofCryoLifeInc.
B.FrozenElephantTrunkProcedure
1.TheelephanttrunkprocedurewasfirstdescribedbyBorstandcolleagues
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in1983totreatextensive
aneurysmaldiseaseoftheentirethoracicaorta.Inthisprocedure,afreeelephantgraftisleftdandlingin thedescendingaortaforlaterutilizationinthereplacementofthedescendingaortaduringasecondstage. Katoandcolleagues48reportedthefirstexperiencewithamodificationofthetwo-stagedelephanttrunk procedure. It consisted in the open surgical approach of the aortic arch with a deployment of an endovascularstent totreatthe descendingaorta.The originaltechniquehasbeenmodifiedfrom afree distal anastomosis to a hand-sewnproximal endof thefrozen elephanttrunk toavoid migration. This techniqueallowsforthemanagementofextensiveaortic aneurysmaldisease withanopenrepairofthe aortic arch and an antegrade deployment of the thoracic endograft. Additionally, it is used in the managementoftypeAaorticdissectionstoreduceaneurysmaldegenerationofthedescendingaorta.
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2.TherearetwoprefabricatedgraftsavailableoutsidetheUnitedStates.
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a. TheE-VitaOpenandtheE-VitaPlus(JOTEC,Hechingen,Germany):Thesedeviceshavethe
longestregistrydatingbackto2005.Theyhavedemonstratedratesofin-hospitalmortalityof16% foraorticdissectionand13%fornondissections;postoperativestrokeandspinalcordinjuryhave beenfoundtobe8%and4%,respectively.Withthesedevices,alandingzonelowerthanT10has beenidentifiedasariskfactorforparaplegia(Fig.5B.7).
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FIGURE5B.7 TheE-vitaopenplushybridprosthesisanditsdeliverysystem.
©JOTECGmbH,afullownedsubsidiaryofCryoLifeInc.
b. ThoraflexTMHybridPlexusandThoraflexTMHybridAnte-Flo.TerumoAortic(Inchinnan,
UnitedKingdom):Thisdevicehasafour-branch(Plexus)configurationaswellasastraightversion (Ante-Flo)thatpermittheimplantationoftheaorticarchesindividuallyorasacarrelpatch, respectively.Ithasreportedratesof7%forperioperativemortalityand7%forspinalinjury.The ThoraflexTMHybriddevicesiscurrentlyunderinvestigationintheUnitedStatesforaortic dissection,aneurysmandrupture(Fig.5B.8).
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FIGURE5B.8 TheThoraflexTMhybridprosthesisanditsdeliverysystem.
©2019TerumoAortic.
C.SurgicalDebranchingProcedure
1. An extra-anatomical bypass from the ascending aorta to the supra-aortic branches using a median
sternotomywasfirstdescribedinthelate1990s.In2000,thefirstextra-anatomicalbypassfromtheleft commoncarotidtoleftsubclavianassociatedwithaTEVARwasdescribedfortreatmentofanacutetype Baorticdissection.Debranchingproceduresmaybeperformedwithorwithoutsternotomy.Optionsvary basedonthelocationofthepathologicprocessalongtheaorticarchzones.
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2.Thesedebranchingproceduresmaybeperformedinastagedfashionoratthesameoperationtogether
withTEVAR.39Carefulconsiderationisessentialforpatientswithdiseasesaffectingzone0.
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a. Zone0surgicaldebranching:Zone0deploymentofendograftsisusedwhentheaorticpathology
coverstheascendingaortaandtheproximalaorticarch.Abypassfromtheascendingaortacanbe usedtocircumventtheoriginsoftheaorticarchbranchesthatarecoveredwiththethoracicstent.If theoriginoftheinnominatearteryiscompromised,anextra-anatomicbypassformtheascending aortatotheinnominatearteryisdone.Incaseofneededrevascularizationfortheleftcommon carotid,anextra-anatomicbypassfortheleftcommoncarotidarteryisconstructedusingthebypass oftheinnominatearteryasaninflow.Incaseofcoverageoftheleftsubclavianartery,abypasscan beanastomosedtotheleftcommoncarotidarterygraft.Iftheleftsubclavianarteryisdifficultto access,itcanbelaterrevascularizedwithsubclaviantranspositionorleftsubclaviantocarotid arterybypass.Postoperativemortalityhasbeenreportedtobe0%-8%andstrokeratetobe 0%-17%.
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b. Zone1surgicaldebranching:Zone1debranchingisindicatedforpatientswithdistalaorticarch
pathologythathasaproximallandingzonegreaterthan2cmfromtheinnominateartery.First,an extrathoracicleftcarotidtorightcarotidbypassisperformedusingan8mmDacrongraft;thiscan beperformedviatheanteriorsubplatysmalplaneortheretroesophagealroute,thelatterproviding
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theshortestandthemostsecureroutebecauseofthedeeppositionofthegraftintheneck.Also, somesurgeonspreferthetranspositiontechniqueavoidingtheuseofprostheticmaterial;however, thatproceduremustbedoneusingasternotomyorhemisternotomy.Inthiscase,atthetimeofbypass theproximalleftcarotidarteryisligatedtopreventtypeIIendoleak,andtheproximalleft subclavianisalsoligatedasneeded.Finally,TEVARisperformed.Postoperativemortalityhasbeen reportedtobe0%-11%andstrokeratetobe11%.
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c. Zone2surgicaldebranching:Zone2TEVARrequirespreoperativesurgicalrevascularizationof
theleftsubclavianarterytoavoidischemiccomplications.Subclavianrevascularizationis especiallyimportantinspecificcircumstances.Thesearelistedhere,withthepotentialcomplication ofnonrevascularizationindicatedinparentheses:whenthereisapatentleftinternalmammarygraft (immediatemyocardialinfarction),functionalleftupperextremityarteriovenousfistula(fistula closure),plannedlongsegmentalcoverage(>20cm)ofthedescendingaorta(paraplegia),absentor atreticrightvertebralartery(posteriorfossastroke),priorinfrarenalaorticoperation(paraplegia), hypogastricarteryocclusion(various),andthepresenceofaneurysmswhereupcomingintervention involvingtheaorticarchisanticipated(paraplegia).Usually,azone2debranchingprocedureis usedfortreatmentoftypeBaorticdissectionandproximaldescendingaorticaneurysms. Postoperativemortalityhasbeenreportedtobe0%-3.4%andstrokerate3%tobe8.7%.
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V.Summary
Endovascularmanagementofaorticpathologyhasemergedasaneargoldstandardforthetreatmentofthe abdominal aorta. The good results from these abdominal interventions have generated enthusiasm for expanding thetechnology intomore proximalaortic segments. Thedescendingaorta hasbeenthemore proximalaorticsegmentinwhichmostoftheinteresthasbeenplaced.However,theascendingaortaand theaorticarchhavebeenapproachedaswell—perhapstheultimatefrontiersforimplementationofthe endovasculartreatment. Despite the interest in handling more proximal segments endovascularly, many difficulties arise. The ascendingaortaisahigh-stakezoneduetotheproximallocationoftheaorticvalveandcoronaryostia andthedistalpresenceoftheheadvessels.Anymisplacementofathoracicstentcanresultindevastating consequencessuch as myocardial infarctionor stroke.Finally, the hemodynamic forcesexperiencedin these segments increase the difficulty for adequate deployment,requiring techniques that decrease the bloodpressureandthecardiacoutput. Moreover,theaorticarchrequiresmeticuloussurgicalplanningtobestdecidetheapproachthatwilllimit theriskofstrokeduetoinstrumentationoftheheadvessels. Thelackofspecificdevicesfortheascendingaortaandtheinvestigationalnatureofaorticarchdevices make endovascular management of these segments a new anddeveloping area; such interventions are largelylimited to high-riskpatients inwhom conventional opensurgeryis notpossible or safe.Thus, endovascular techniques provide analternative tosole medical management (in nonsurgical patients), whichwouldbeexpectedtoresultinhighmortalityandmorbidity. It mustbe remembered that open surgical techniqueshaveachieved previouslyunimaginable levels of effectiveness and safety. An experienced open surgical opinion should be invoked before pursuit of excitingbutcomplexendovasculartherapieswithunprovenlarge-scale,long-termresults.
ClinicalPearls
■Aortic aneurysmis a silent disease requiring close monitoring because the first clinical
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manifestationcanbealife-threateningcomplication.
■Aorticdissectionrequiresahighindexofsuspicion,especiallyinpatientswithabruptonset
ofchestorbackpain.
■Theopensurgicalapproachforthemanagementoftheascendingaortaandtheaorticarchis
thegoldstandardfortreatmentofthoracicaorticpathology, withdramaticimprovementsin safetycomparedwithearliereras.
■Endovascularmanagementoftheascendingaortaandtheaorticarchislargelyreservedfor
high-risksurgicalpatientsinwhomconventionalapproachesareprohibited.
RecommendedReading
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C H A P T E R  6
EndovascularRepairoftheDescendingAorta
AymanSaeyeldinMD
YoungErbenMD
MohammadA.ZafarMD
AfshaAurshinaMBBS
CamiloA.VelasquezMD
Wei-GuoMaMD
ChandniPatelMD
JeremyD.AsnesMD
BulatZiganshinMD,PhD
JohnA.ElefteriadesMDPhD(hon),andBauerE.Sumpio,MD,PhD
I.Introduction
II.AnatomicBackground
A.LandingZones
B.SpinalPerfusion
III.IndicationsforTEVAR
A.ThoracicAorticAneurysms
B.ThoracicAorticDissection
C.OtherPathologies
IV.EndograftStructure
A.DeliverySystem
B.MainDevice
C.Extensions
V.AvailableEndograftsforTEVAR
A.TAGandCTAG
B.ZenithTX2andZenithAlpha
C.ValiantThoracicStent-GraftSystem
D.Relay
VI.InvestigationalDevices
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A.TAArget
B.E-Vita
C.StreamlinerMultilayerFlowModulator
VII.PreproceduralPlanning
A.Imaging
B.LandingZones
C.ChoosingtheCorrectGraft
D.DebranchingProcedures
E.OtherApproaches
VIII.PreoperativePreparation
A.Antibiotics
B.RenalInjury
C.CerebrospinalFluidDrainage
IX.TechniqueofPlacement
A.AccessVessels
B.Deployment
C.EvaluatingforEndoleaks
D.PostoperativeImaging
X.Complications
A.PerioperativeMortalityandMorbidity
B.Endoleaks
C.SpinalCordIschemia
D.Stroke
E.Ischemia
F.AccessComplications
G.PostimplantationSyndrome
XI.LateComplications
A.SurvivalandOutcomes
B.MigrationoftheGraft
C.SecondaryIntervention
XII.Conclusion
KeyPoints
■TEVARisasafeandeffectivemethodfortreatmentofvariouspathologiesaffectingthe
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