Chapter 79 - TAAA TEVAR technique

Question 1

Society guidelines on TEVAR in TAAA

Answer 1

TABLE 79.1

Question 2

GORE CTAG vs open on post-op morbidity and 2 year mortality

Answer 2

Spinal cord 3% vs 14% Resp failure 4% vs 20% renal failure 1% vs 13% mortality - no difference higher reintervention with TEVAR

Question 3

NIS on TEVAR vs open

Answer 3

TEVAR lower perioperative mortality but worse long term mortality TEVAR in high risk individuals

Question 4

First generation TEVAR grafts

Answer 4

1) Gore TAG thoracic endoprosthesis 2005 2) Medtronic talent 1999 3) Cook Zenith TX1, TX2 2004 4) LeMaitre EndoFit (two layer PTFE with nitinol)

Question 5

Cook Zenith TX1-2 evolution

Answer 5

TX1 = one piece system with prox and distal fixation TX2 = two piece system proximal barb caudally and distal barbs cranially ProForm = improved conformability to arch and limit bird beak

Question 6

Improvement of the modern devices TEVAR

Answer 6

tip-capture mechanism: stabilizes proximal part prevent windsock

Question 7

Modern 2nd generation TEVAR

Answer 7

1) Gore conformable TAG 2) Cook lower profile Zenith Alpha 3) Medtronic valiant 2008 4) Bolton relay 5) Bolton relay plus with self-positioning system and scallop 6) JOTEC E-Vita thoracic 3G - can be part of a frozen elephant trunk 7) LeMaitre TAArget 2008 - tortuous tracker delivery system

Question 8

TEVAR minimum seal, maximum diameter, minimum overlap oversizing

Answer 8

2 cm seal 38 mm diameter suggested (42 max) 30 mm overlap 10-20% oversizing more aggressive seal and oversizing if landing in previous dacron graft

Question 9

Strategies after arch vessel coverage

Answer 9

1) manual balloon traction 2) parallel stent 3) open conversion 4) surveillance

Question 10

Iliac size that can predict graft deployment failure

Answer 10

< 8 mm

Question 11

Rate of spinal cord ischemia in TEVAR

Answer 11

3.2% (1.4% permanent) metaanalysis 2-10%

Question 12

Neuroprotective strategies

Answer 12

INCREASE TOLERANCE 1) Pharmacologic (Intrathecal papaverine, naloxone, mannitol, steroids) 2) Staged repair 3) Intraop hypothermia 34C AUGMENT PERFUSION 1) Hypertension MAP 90-100 2) CSF drain (usually 48 hr) 3) preserving LSCA and IIA 4) maintain hgb > 100, O2 sat > 95

Question 13

MISACE in TEVAR

Answer 13

minimally invasive segmental artery coil embolization as a first stage procedure before tevar

Question 14

Complications with CSF drain

Answer 14

12.7% 1) postdural puncture headache (9.7%) 2) catheter fracture (0.2%) 3) neuroaxial hematoma (1.9%) 4) intracranial hemorrhage (2.8%) 5) meningitis

Question 15

Symptoms of intracranial hemorrhage after CSF drain

Answer 15

1) headache 2) confusion 3) coma 4) motor deficit 5) resp arrest

Question 16

Treatment for post-CSF headache

Answer 16

1) bed rest 2) hydration 3) caffeine 4) blood patch

Question 17

Stroke after TEVAR rate

Answer 17

2.7% metaanalysis 2.3-8.2%

Question 18

Risk of stroke after TEVAR

Answer 18

1) hypertension 2) CKD 3) known CVA 4) higher aortic coverage 5) female 6) long surgery 7) occlusion of LSA 8) CAD 9) shaggy aorta 10) pull through wire 11) blood loss > 800 ml

Question 19

Rate of retrograde type A dissection

Answer 19

< 2%

Question 20

Mortality of RTAD

Answer 20

42%

Question 21

MOTHER registry on RTAD risk factors

Answer 21

1010 patients 1) oversizing 24.4% vs 14.1% no oversize 2) post ballooning 3) proximal landing zone 4) manipulation of guidewire and sheath 5) progression of underlying disease

Question 22

Rate of AKI and dialysis need after TEVAR

Answer 22

17% 1%

Question 23

Risk factors of TEVAR collapse

Answer 23

1) small aortic diameter 2) young patients 3) oversizing 4) tight arch curvature

Question 24

Rate of TEVAR revision

Answer 24

10-15%

Question 25

Rate of endoleak after TEVAR

Answer 25

3-10%

Question 26

Rate of TEVAR infection

Answer 26

0.2-5%

Question 27

CTA findings of TEVAR infection

Answer 27

1) aortic-wall thickening 2) perigraft soft tissue > 5 mm 3) fluid collection 4) perigraft fluid > 6 weeks out 5) increasing air 6) soft tissue stranding 7) abscess formation 8) graft thrombosis/expansion

Question 28

Vascular low-frequency disease consortium infected TEVAR

Answer 28

26 cases mortality 30 day 11% (80% med mgnt died) pain 66% fever 66% fistula 27%

Question 29

Rate of aorto-bronchial and aorto-pulmonary fistula after TEVAR

Answer 29

European registry of endovascular aortic repair complication (EuREC) 0.6% aorto-bronchial 1.5% aorto-pulmonary

Question 30

Limitations of using MRI to follow TEVAR

Answer 30

1) cannot visualize metallic stent struts - need CXR supplement 2) cannot be used with stainless steel grafts - high artifact

Question 31

Endoleak rates after TEVAR

Answer 31

Type 1a: 7.3% Type 2: 2% Type 3: 1.2%

Question 32

Aneurysm related death after TEVAR at 3 years

Answer 32

3.2%

Question 33

ATOM score categories

Answer 33

Age > 70 - 2 points BMI < 30 - 3 points COPD - 2 points Total functional assistance - 4 points BUN > 25 - 3 points WBC > 12 - 2 points emergency - 3 points LSCA coverage - 2 points TAAA extensions - 2 points mesenteric debranching - 7 points

Question 34

ATOM score legend

Answer 34

Low (< 5 points): 1.3% mortality Moderate (5-9 points): 6.6 % High (> 10 points): 24%

Question 35

Perioperative all-cause mortality risk-stratification system formula for TEVAR

Answer 35

0.0398 x age 0.516 x renal insufficiency 0.46 x previous CVA 0.352 x previous SMK 0.376 x number divices > 2 0.016 x max aneurysm diameter low = 80% survival 5 years medium = 60% high = 40%

Question 36

Mortality and morbidity of ruptured descending TAA with TEVAR vs OPEN

Answer 36

30 d: 19% vs 33% open MI 3.5 vs 11.1 stroke 4.1 vs 10.2 paraplegia 3.1 vs 5.5

Question 37

30 d mortality for age > 80 with thoracic aortic rupture

Answer 37

40%

Question 38

Percentage of all thoracic ruptures that are in the descending aorta

Answer 38

30%

Question 39

use of TEVAR in connective tissue disorder special considerations

Answer 39

1) don’t do it 2) bridge to open 3) after open to land in prosthetic grafts

Question 40

Open conversion after TEVAR rate

Answer 40

0.4 - 7.9%

Question 41

Perioperative mortality for open conversion of TEVAR

Answer 41

16.6% 20% for infection 33% for retrograde dissection