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Dr R H Stables Cardiothoracic Centre Liverpool, UK

Thoracic Aortic Stent Grafting. Dr R H Stables Cardiothoracic Centre Liverpool, UK. Introduction. Pathology of the thoracic aorta Referred to cardiologists / cardiac surgeons Investigated and treated in cardiac units Conventional surgical treatment associated with High mortality

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Dr R H Stables Cardiothoracic Centre Liverpool, UK

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  1. Thoracic Aortic Stent Grafting • Dr R H Stables • Cardiothoracic Centre • Liverpool, UK

  2. Introduction • Pathology of the thoracic aorta • Referred to cardiologists / cardiac surgeons • Investigated and treated in cardiac units • Conventional surgical treatment associated with • High mortality • Significant morbidity (including paraplegia) • ? improved Tx with endovascular techniques • Requires genuine collaborative working

  3. ‘Liverpool cardiologist dies in drive-by shooting’

  4. Collaborative Working • Cardiologists / Interventional radiologists • Interventional radiologists have much to offer • Equipment and techniques • More related to peripheral intervention • (Unlike carotid stenting !) • Experience with abdominal aortic procedures

  5. Collaborative Working • Cardiologists / Interventional radiologists • Vascular surgeons / Cardiothoracic surgeons • Vascular surgical skills • Issues of vascular access • Femoral / Iliac / Aorta • Complications related to device passage • Iliac vessels • Cardiothoracic techniques • Conversion to open procedure

  6. Collaborative Working • Cardiologists / Interventional radiologists • Vascular surgeons / Cardiothoracic surgeons • MRI / CT Imaging specialists • Radiographic and surgical facilities • Availability of open surgical conversion • Anaesthesia ITU Post op - care • Industrial partners

  7. Thoracic Stent Grafting • Developing treatment strategy • Mainly descending aorta • Indications • Aneurysm • Dissection • Transection • Perforation • Open surgical graft procedures (may include Type A) • Coarctation of the aorta

  8. MRI Image – Thoracic Aneurysm

  9. MRI Image – Thoracic Aneurysm – Post Stent

  10. Angio Images – Thoracic Aneurysm Slides courtesy of Prof. Rousseau

  11. Mrs MB • Female 56 years • CRF - Failing renal transplant (after 20 years) • Recent return to haemodialysis • Subclavian dialysis line - septicaemia • Staph Aureus - Tx Antibiotics through line • Readmitted with back pain Ix Osteoporosis • Vomits bright red blood • Endoscopy and CT scan • Transfer to CTC Liverpool

  12. Mrs MB • 3 x simultaneous blood infusions • Hb 5.4 g/dl • Left haemothorax PaO2 = 8 kPa on 40% O2 • Infected dialysis line in situ • No immediate evidence of septic shock • CT scan imaging • Emergency thoracic stent procedure

  13. Peripheral Vessel Anatomy

  14. Leaking (x2) Thoracic Aneurysm

  15. Talent LPS Thoracic Stent Graft System Sizes 26, 28, 30, 32, 34, 38, 42, 44, 46 mmNitinol ringsDacron graft

  16. Thoracic Delivery System

  17. Stent Device (TALENT) Before Deployment

  18. Acute Result

  19. Subacute EndoLeak / Perforation

  20. Use of Forming Balloon

  21. Deployment of Additional Proximal Stent

  22. Deployment of Additional Distal Stent

  23. Final Result

  24. Thoracic Stent Grafting • Complications • Problems with peripheral vascular access • Low incidence of paraplegia • Migration • Endo-leaks and perforation • Multiple stents common • Post implant syndrome 

  25. Thoracic Stent Grafting • Initial case series reports • Many cases surgical contraindication ? Risk • Acute success 80 - 90% • 3 year event-free survival 50 - 70% 

  26. Questions and Discussion

  27. Angio Images – Thoracic Aneurysm Slides courtesy of Prof. Rousseau

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