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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

Aortic dissection: current percutaneous options

Advanced Angioplasty BSET Jan 2008

slide2

MY CONFLICTS

OF INTEREST ARE

Preceptor for complex endografts for Cook

multidisciplinary
Multidisciplinary
  • Radiology
  • Vascular Surgery
  • Cardiology
  • Anaesthesia
  • Cardiothoracic surgery
imaging
Imaging
  • Pre-operative CT and workstation review
  • Intra-operative angiography
  • TOE
  • IVUS
acute type b aortic dissection
Acute type B aortic dissection
  • Endovascular intervention for:
  • 1. Failure of medical therapy
  • Malperfusion
  • Rupture
  • Rapid enlargement
haemodynamics
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
primary treatment aim
Primary treatment aim
  • Cover the primary tear
  • Stent grafts:
  • PTFE, Dacron
  • Nitinol, stainless steel
  • Bare metal?
  • Barbs proximally?
distal bare metal scaffolding
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

petticoat
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
fenestration techniques
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
percutaneous recanalisation devices22
Percutaneous recanalisation devices

Courtesy of Roy Greenberg

conclusions
Conclusions
  • Challenging and complex multidisciplinary area
  • Evolving role and understanding of percutaneous options
  • Stent grafts, visceral stents
  • Fenestration
  • Uncovered stents - scaffolding