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Eric E. Roselli, MD, Akshat C. Pujara, BA

Distal Aortic Fenestration Facilitates Endovascular Elephant Trunk Completion And Eliminates Retrograde False Lumen Filling Of Chronic Dissection. Eric E. Roselli, MD, Akshat C. Pujara, BA. Chronic Dissection Repair. Controversy: Open vs Endovascular Open - Morbid - Need for reoperation

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Eric E. Roselli, MD, Akshat C. Pujara, BA

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  1. Distal Aortic Fenestration Facilitates Endovascular Elephant Trunk Completion And Eliminates Retrograde False Lumen Filling Of Chronic Dissection Eric E. Roselli, MD, Akshat C. Pujara, BA

  2. Chronic Dissection Repair Controversy: Open vs Endovascular Open - Morbid - Need for reoperation not always eliminated Endovascular - Anatomic limitations - Thromboexclusion of FL unpredictable – retrograde filling

  3. Novel Treatment Strategy Objective: Construct distal landing zone during 1st stage elephant trunk repair to facilitate endovascular completion

  4. Patients July 2007 to August 2009 n = 15 Age 57 + 10 years Max aortic diameter 6.0 + 1.0 cm 1st Stage Elective n = 5 Urgent n = 10

  5. Operative Technique Initial Presentation Time from Initial Event to 1st Stage Elephant Trunk 17 months (range 3-33) 7 Type A 8 Type B Proximal Landing Zone

  6. Open Fenestration Heart retracted and aorta exposed through posterior pericardium Dissection Flap Fenestrated

  7. Modified Distal Landing Zone Pre-Op Post-Op Fenestrated Segment Dissection Flap DHCA 19 ± 6 min ACP 55 ± 10 min

  8. Endovascular Completion Emergent Urgent n = 2 n = 3 2nd Stage n = 10 Elective Median interval ET to completion: 60 days (IQR 4 - 114)

  9. Endovascular Completion Antegrade 4, Retrograde 11 Circumferential Seal Clips Marking Seal Zone Commercially available devices

  10. Early Outcomes Technical success in all patients One hospital death - Left leg weakness, BMI 46 kg/m2 - Pulmonary embolism POD 19 No strokes No renal failure No respiratory failure

  11. Intermediate Outcomes Median follow-up 11 months (IQR 6 - 17) • 93% overall survival • Mean decrease aortic diameter 0.5 cm • No retrograde false lumen filling • 7 endoleaks (1 type I, 6 type II) • 2 endovascular reinterventions

  12. Distal Aortic Fenestration Safe technique for constructing distal landing zone Good intermediate-term outcomes Eliminates retrograde false lumen filling Promotes aortic remodeling

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