Repair of Aortic Dissection of the Arch and Branches

1. Repair of Aortic Dissection of the Arch and Branches Chang Shu M.D., PhD. Dept. of Vascular Surgery, The 2nd Xiang-Ya Hospital, Central-South University 中南大学湘雅二医院血管外科 湖南省大血管疾病外科及微创介入诊疗中心 Email：changshu01@yahoo.com

2. Clinical Materials • 2002.7～2014.2, • 958 cases with aortic dissection treated with TEVAR • Acute (<2w): 670 cases • Sub-acute and chronic (>2w): 264 cases • Male: 627 / Female: 331 • age: 20-87; mean age: 51.1 • follow-up: 25.1±7.3 months

3. Techniques for aortic arch • Hybrid techniques: aorta - supra aortic branches RSA (RCCA) – LCCA RSA (RCCA) – LSA RSA (RCCA) – LCCA – LSA LCCA – LSA • Fenestrated stent-graft • Branched stent-graft • Chimney / double chimney technique

4. Hybrid technique aorta - supra aortic branchesRSA (RCCA) – LCCARSA (RCCA) – LSARSA (RCCA) – LCCA – LSALCCA – LSA

5. Extra-anatomic bypass • needs several operation incisions. • post-operative anticoagulant treatment is needs. • reliable/stable/durable outcome

6. Extra-anatomic bypass RSA– LCCA RCCA – LCCA – LSA RSA– LSA

7. If left subclavian artery steal syndrome happens post-TEVAR, extra-anatomic bypass can be used.

8. Hybrid technique aorta - supra aortic branchesRSA (RCCA) – LCCARSA (RCCA) – LSARSA (RCCA) – LCCA – LSALCCA – LSA

9. A man, 36y, suffered from an aortic arch pseudoaneurysm because of a severe traffic accident.

10. Hybrid technique was adopted. Ascending aorta – innominate artery – left carotid artery – LSA bypass was achieved first.

11. Hybrid technique was adopted. Then TEVAR was used. The patient recovered unevertfully.

12. fenestrated SG Some of the stenting-grafts has been modified to fit the aortic arch area

13. Fenestration—treatment Step 1: CT and DSA for accurate measurement were performed pre-operation.

14. Fenestration—treatment Step 2: deploy partial of the proximal stent graft in vitro, and eliminate part of the lateral fabric.

15. Fenestration—treatment Step 3

16. Fenestration—follow up The fenestrated stent graft covered the aortic arch dissection completely With patent supra-aortic branches

17. Branched stent-graft

18. Branched stent-graft The patient, 70y, male abrupt severe chest pain for 3 days history of hypertension, coronary heart disease, DM CT scanning indicated an acute aortic dissection with the primary entry tear next to LSA.

21. Branched stent-graft 6 months later, CT angiography indicated excellent aortic remodeling without any complications. Blood stream of the reconstructed LSA is fluent.

22. Chimney technique Has been applied from 2007. Used to treat the aortic arch disease.

23. Chimney in LCCA A female, 49 years old, the aortic arch dissection related LSA. There was not enough proximal landing zone.

24. Chimney in LCCA A female, 49 years old, the aortic arch dissection related LSA. There was not enough proximal landing zone.

25. Chimney for aberrant RSA the patient, 36y, male suffered from abrupt chest pain for 4 days. CT angiograph indicated a acute type B aortic dissection and aberrant right subclavian artery.

26. Chimney for aberrant RSA It was an aberrant right subclavian artery, which was invaded by the AD, and the LSA was invaded that should be covered by TEVAR too. So, chimney technique should be used to reconstruct the invaded LSA.

27. Chimney for aberrant RSA

28. Chimney for aberrant RSA

29. Chimney for aberrant RSA The aberrant right subclavian artery was covered. The LSA reconstructed with a chimney stent-graft was patent.

30. Chimney for type Ia endoleak

31. Chimney for type Ia endoleak

32. Chimney technique for AD + Marfan syndrome+ pregnancy

33. MFS associated with puerperal state A female,29 years old, suffered from abrupt severe back pain 1 week after caesarean section. The primary entry tear located at the orifice of the LSA ( white arrow ).

34. MFS associated with puerperal state One month later, the patient recovered well without any symptoms. However, CT angiography detected mild contrast in the false lumen, and the patent false lumen communicated with LSA.

35. Chimney for MFS + puerperal state • 13 months later, the patient recovered uneventfully. • Endoleak disappeared ! • No migration, new entry tear formation.

36. Chimney technique+ PDA occlude for LSA If chimney technique is used in the common carotid artery, the covered LSA has the risk of type II endoleak. PDA occlude technique is a ideal management

37. Chimney technique+ PDA occlude • TBAD related LSA • Chimney technique should be used

39. Chimney technique+ PDA occlude

40. Chimney technique+ PDA occlude

41. 2 weeks after TEVAR, no type II endoleak lasted.

42. Double-chimney technique Double-chimney technique can replace the conventional open surgery, and be used to reconstruct all supra-aortic branches.

43. Double-Chimney Technique The patient suffer from an acute aortic dissection, which the left common carotid artery was invaded and leaded to severe carotid artery stenosis.

44. Double Chimney Technique Bi-chimney technique was used. Two Fluency stent-grafts were used to reconstruct IA and LCCA. The LSA was covered. The patient recovered well, without any complications.

45. Double Chimney Technique A 50y male, suffered from abrupt chest and back pain. The primary entry tear was unclear in CT scans. Angiography indicated a typical non-A-non-B aortic dissection involve aortic arch. The primary entry tear was between the orifices of innominate artery and LCA.

47. Double Chimney Technique

48. Double Chimney Technique The patient recovered well, without any serious complications

49. Double-chimney technique Double-chimney technique is an experimental technique, with some unclear complications.

50. Double Chimney Technique It’s a patient with acute type B aortic dissection. According to the CT scan, it’s hard to distinguish the primary entry tear. So, we need DSA.