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Aortic dissection: current percutaneous options. Advanced Angioplasty BSET Jan 2008. MY CONFLICTS OF INTEREST ARE Preceptor for complex endografts for Cook. Multidisciplinary. Radiology Vascular Surgery Cardiology Anaesthesia Cardiothoracic surgery. Imaging.

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Aortic dissection current percutaneous options l.jpg

Aortic dissection: current percutaneous options

Advanced Angioplasty BSET Jan 2008


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MY CONFLICTS

OF INTEREST ARE

Preceptor for complex endografts for Cook


Multidisciplinary l.jpg
Multidisciplinary

  • Radiology

  • Vascular Surgery

  • Cardiology

  • Anaesthesia

  • Cardiothoracic surgery


Imaging l.jpg
Imaging

  • Pre-operative CT and workstation review

  • Intra-operative angiography

  • TOE

  • IVUS


Acute type b aortic dissection l.jpg
Acute type B aortic dissection

  • Endovascular intervention for:

  • 1. Failure of medical therapy

  • Malperfusion

  • Rupture

  • Rapid enlargement


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Haemodynamics

  • True lumen collapse

  • Depends on ratio of inflow capacity to outflow capacity in true and false lumina

  • Reduce FL inflow - endografts

  • Increase FL outflow - fenestration


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Primary treatment aim

  • Cover the primary tear

  • Stent grafts:

  • PTFE, Dacron

  • Nitinol, stainless steel

  • Bare metal?

  • Barbs proximally?





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Distal bare metal scaffolding

  • PETTICOAT concept

  • Provisional extension to induce complete attachment after stent graft placement in acute type B dissection

    C Nienaber

    JEVT 2006; 13:738-746


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PETTICOAT

  • 12 patients

  • Primary tear covered

  • Persistent distal true lumen collapse and perfused abdominal false lumen

  • Adjunctive or staged

  • Uncovered stents: Sinus, Fortress, Z-stents

  • 120-230mm

  • True lumen increase 4 – 21mm


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Fenestration techniques

  • Via natural fenestrations

  • Punctured with guidewires, TIPS needles, re-entry devices

  • Guided by angiography, snares, balloons, IVUS

  • Enlarged by balloons, or guidewires - push cuts (scissor technique) or pulled




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Percutaneous recanalisation devices

Courtesy of Roy Greenberg








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Conclusions

  • Challenging and complex multidisciplinary area

  • Evolving role and understanding of percutaneous options

  • Stent grafts, visceral stents

  • Fenestration

  • Uncovered stents - scaffolding


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