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PGY 4 > TAA & Thoracic Dissection > Flashcards

TAA & Thoracic Dissection Flashcards

1
Q

Name 5 risk factors that are associated with TAAA rupture

A
  1. Age
  2. Pain
  3. COPD
  4. Descending aortic diameter
  5. Abdominal aortic diameter
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2
Q

Name 2 differences in the composition of the aortic wall as you progress from the ascending aorta to the iliac bifurcation

A
  1. Ascending aorta has greater concentration of elastin (therefore more compliant)
  2. Media becomes thinner from proximal to distal aorta
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3
Q

Name 5 causes for TAAA from most frequent to least.

A
  1. Degenerative/atherosclerotic 80%
  2. Dissections 15-20%
  3. Infection 2%
  4. Connective tissue disorders (Loeys Dietz, Marfans, EDIV)
  5. Vasculitis: takayasu, giant cell, rheumatoid
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4
Q

What percentage of TAAA are type 4?

A

< 25%

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5
Q

What percentage of TAAA are type 3?

A

< 25%

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6
Q

What percentage of TAAA are type 2?

A

30%

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7
Q

What percentage of TAAA are type 1?

A

25%

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8
Q

What is a Type 4 TAAA?

A

Confined to abdo aorta, including visceral and renal arteries

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9
Q

What is a Type 3 TAAA?

A

Involves variable lengths of the descending thoracic and abdo aorta

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10
Q

What is a Type 2 TAAA?

A

Involves entire descending thoracic aorta and most of the abdominal aorta

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11
Q

What is a Type 1 TAAA?

A

Involves entire descending thoracic aorta

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12
Q

What percentage of TAAAs also have an AAA?

A

20-30%

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13
Q

Name 4 chest xray findings in keeping with TAAA?

A
  1. Widened mediastinum
  2. Dilated aortic knob
  3. Tracheal deviation
  4. Left main stem bronchus displacement

Inadequate to definitively exclude TAAA

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14
Q

What is the threshold size for repair of TAAA?

A

> 6 cm.

Maybe more or less.

More: Type 1 - 3 because of spinal cord ischemia

Less: Symptomatic, connective tissue disease, Type 4.

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15
Q

Name 5 risk factors predictive of periop mortality following TEVAR

A
  1. Age
  2. Renal insufficiency
  3. History of stroke
  4. Placement of > 2 devices
  5. Maximal aortic diameter
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16
Q

How do you treat an aberrant right subclavian artery?

A

Hybrid approach:

  1. Embolize side branches off the aberrant subclavian pre-op
  2. R CCA to distal R SCA bypass with ligation of RSCA prox to vertebral artery
  3. Stent the abnormal descending thoracic aorta
  4. Often to achieve proximal seal may need to cover L SCA so it may need a left carotid subclavian bypass/transposition as well.
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17
Q

How do Gore C-tag TEVARs prevent the “wind sock” effect?

A

Deploys from middle of the graft

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18
Q

What is the lowest profile TEVAR?

A

Cook Alpha (16F)

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19
Q

What device diameters are available for TEVARs?

A

21 (Gore) to 46 mm (Medtronic, Bolton Relay, Cook Alpha)

20
Q

How does coverage of the left subclavian impact spinal cord ischemia (via which vessels?)

A

Provides blood flow through the internal mammary and anterior intercostal branches.

21
Q

What percentage of people are left vertebral artery dominant (therefore at higher risk of stroke if LSCA covered during TEVAR)

A

60%

22
Q

What are 8 indications for left subclavian revascularization during TEVAR?

A
  1. Dominant left vertebral artery
  2. LIMA to coronary artery bypass
  3. Left arm hemodialysis access
  4. Aberrant right SCA
  5. Hypoplastic or absent right vertebral artery
  6. Termination of left vertebral artery in PICA
  7. Occluded internal iliac arteries
  8. Anamolous origin of left vertebral artery from the arch.
23
Q

How do you tunnel a carotid carotid bypass for debranching for TEVAR?

A

Retroesophageal

24
Q

What are the theoretical advantages of a hybrid TAAA repair (ie debranching visceral vessels)

A

Avoids thoracoabdominal incision (can be midline), cutting through diaphragm or clamping aorta. Most appropriate indication is COPD but with enough CV reserve to withstand the open debranching.

25
Q

Name 5 ways of dealing with difficult (occlusive/tortuous) access for TEVAR

A
  1. Angioplasty
  2. Koons dilators
  3. Through and through wire for tortuous (femoral-brachial)
  4. Retroperitoneal incsiion with direct puncture of EIA/CIA or 10 mm dacron iliac conduit
  5. Pave and crack with 10-12 mm covered stent in EIA/CIA
26
Q

What is the risk of stroke with TEVAR with and without left subclavian artery coverage?

A

11% with coverage vs. 3% without

27
Q

Name 3 ways of occluding the origin of the left subclavian artery when covering with a TEVAR

A
  1. Coil embolization from ipsilateral brachial after TEVAR deployment
  2. Amplatz plug via femoral access before TEVAR insertion
  3. Amplatz plug from left arm after TEVAR.
28
Q

When performing TEVAR for TAAA, what are 3 strategies to deal with a short distal landing zone (proximal to celiac).

A
  1. Hybrid procedure - TEVAR plus open bypass to celiac
  2. CMD with distal scallop or fenestration
  3. Intentional celiac coverage if adequate collateral supply to UGI tract (open SMA and GDA).
29
Q
A
30
Q

What are 4 techniques to try if a TEVAR migrates proximally and a supra-aortic trunk is covered

A
  1. Manual balloon traction
  2. Parallel stent placement (chimney or stenting of target vessel
  3. Open conversion
  4. Surveillance
31
Q

Which 4 vessel beds provide blood supply to the spinal cord?

A
  1. Lumbars
  2. Subclavian
  3. Intercostals
  4. Internal iliacs
32
Q

Name 7 described neuroprotective strategies to prevent spinal cord ischemia during TEVAR

A
  1. Preserve/revascularize vessel beds that supply spinal cord (lumbars, subclavian, intercostals, internal iliacs)
  2. Ischemic preconditioning - staged repair or pre-op embolization
    1. CSF drainage at 10 cm H2O.
  4. Pharmacologic neuroprotection: intrathecal papaverine, steroids, naloxone
  5. Hypothermia
  6. Intentional hypertension MAP > 90
  7. Oxygenation - Hgb > 80, O2 sat > 95%
33
Q

Name 5 risks of CSF drainage

A
  1. Catheter fracture - 0.2%
  2. Postdural puncture headache -10%
  3. Neuraxial hematoma -
  4. ICH (2.8%) - subdural cerebellar SAH intraventricular and intrapenchymal hematomas.
    - NB SDH associated with 14% mortality!
  5. Meningitis
34
Q

What are treatment options for headache after CSF drain removal?

A
  1. Bedrest
  2. Hydration
  3. Caffeine
  4. Epidural blood patch
35
Q

Name 12 complications of TEVAR

A

  1. AKI - 17% (dialysis < 1%)
  2. Access - 9%
  3. Spinal drain complications - 12.7%
  4. Spinal cord ischemia - 3%
  5. Endoleaks/reintervention - 10% at 3 years
  6. Stroke - 2-8%
  7. Retrograde type A dissection - < 2%
  8. CV complications
  9. Mechanical problems with stent (collapse, migration, component separation)
  10. Infection - < 5%
  11. Aortoesopheageal/bronchial fistulae - 1%
  12. Mortality - 16%
36
Q

Describe the anatomic site of a TEVAR distal landing zone 11

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

37
Q

Describe the anatomic site of a TEVAR distal landing zone 10

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

38
Q

Describe the anatomic site of a TEVAR distal landing zone 9

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

39
Q

Describe the anatomic site of a TEVAR distal landing zone 8

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

40
Q

Describe the anatomic site of a TEVAR distal landing zone 7

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

41
Q

Describe the anatomic site of a TEVAR distal landing zone 6

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

42
Q

Describe the anatomic site of a TEVAR distal landing zone 5

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

43
Q

Describe the anatomic site of a TEVAR distal landing zone 4

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

44
Q

Describe the anatomic site of a TEVAR distal landing zone 3

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

45
Q

Describe the anatomic site of a TEVAR distal landing zone 2

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

46
Q

Describe the anatomic site of a TEVAR distal landing zone 1

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

47
Q

Describe the anatomic site of a TEVAR distal landing zone 0

A

zone 0: proximal to the innominate artery;

zone 1: proximal to left common carotid artery (CCA);

zone 2: proximal to origin of the left subclavian artery (SCA);

zone 3: proximal descending thoracic aorta (<2 cm from left SCA);

zone 4: 2 cm distal to SCA extending to proximal half descending thoracic aorta (T6 vertebral body);

zone 5: distal half descending thoracic aorta to celiac artery;

zone 6: celiac artery to top of superior mesenteric artery (SMA);

zone 7: SMA to suprarenal aorta;

zone 8: perirenal aorta;

zone 9: infrarenal aorta;

zone 10: common iliac arteries;

zone 11: external iliac arteries.

PGY 4 (25 decks)

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