Intravascular Ultrasound-Guided Thoracic Endovascular Aortic Repair
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0180
Submission Type:
Abstract Submission
Authors:
Michael Kirsch (1), Adam Carroll (1), Donald Jacobs (1), Rafael Malgor (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions:
(1) University of Colorado Anschutz, Denver, CO
Submitting Author:
Michael Kirsch
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University of Colorado Anschutz
University of Colorado Anschutz
Co-Author(s):
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Donald Jacobs
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University of Colorado Anschutz
University of Colorado Anschutz
Rafael Malgor
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University of Colorado Anschutz
University of Colorado Anschutz
*Muhammad Aftab
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University of Colorado Anschutz
University of Colorado Anschutz
*T. Brett Reece
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University of Colorado Anschutz
University of Colorado Anschutz
Presenting Author:
Michael Kirsch
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Abstract:
Objective: During thoracic endovascular aortic repair (TEVAR), it is crucial to deploy the stent into the true lumen of the aorta. Intravascular ultrasound (IVUS) can be used as an adjunct to or independent of transesophageal echocardiogram (TEE), as it allows for visualization of wire placement from insertion site to the distal extent of the wire. We describe a case in which we use intravascular ultrasound (IVUS) to confirm wire positioning within the true lumen prior to placement of the TEVAR stent.
Methods: A 76-year-old male with a history of Stanford Type A aortic dissection status post aortic valve resuspension and arch replacement presented with aneurysmal degeneration and Type B dissection. The patient underwent aortic debranching and vertebral artery transposition, followed by TEVAR with a thoracic branched endograft.
Results: The intraoperative decision algorithm is shown in Figure 1. After reviewing the preoperative imaging to delineate the surgical anatomy, we accessed the patient's left common femoral artery (CFA) and placed a glidewire and glide-catheter into the ascending aorta. We advanced the IVUS over the glidewire and confirmed positioning in the true lumen from access site to the ascending aorta. We positioned a 40mm x 15cm Gore TAG TBE with 12mm portal within the aortic arch, with the portal at the distal edge of the left subclavian artery origin, and deployed the stent graft. We used left subclavian artery angiography to confirm graft position and then placed a 12mm x 40mm armada balloon within the subclavian artery portal to provide endograft stability while the proximal endograft was advanced.
We performed an arch aortogram to identify the coronary arteries and determine the proximal landing zone of the endograft. A 40mm x 40mm x 10cm Gore TAG conformable was advanced into the ascending aorta and deployed with the proximal aspect at the sinotubular junction. Aortogram demonstrated patent coronary arteries. We advanced a 15mm x 12mm x 6cm Gore TAG TBE from the CFA and positioned it into the left subclavian artery, ensuring accurate overlap in the portal. This stent was deployed, post-dilated with the 12mm x 40mm armada balloon, and the stent overlap was stented. Angiography demonstrated good filling of the extracranial circulation and the right subclavian artery from the left subclavian artery, as well as good filling of the visceral vessels and predominant filling of the true lumen of the aorta.
Conclusions: IVUS is an easy and well-established way to confirm appropriate wire position in TEVAR. After stent deployment, a pull-back can be performed and recorded for future reference. Concerning changes in blood flow can be re-evaluated with repeat IVUS to determine need for extension of graft coverage. However, it's important to note the increased risk associated with upsizing the groin sheath from 6 Fr to 9 Fr when using IVUS. Therefore, in cases where TEE provides adequate visualization, the additional risk of sheath upsizing may not be justified. This is particularly pertinent in patients with previous ascending aortic replacement, who may not have a strong indication for TEE or have contraindications for it. In such scenarios, IVUS obviates the need for TEE in TEVAR deployment, but careful consideration should be given to the risks and benefits of sheath upsizing.
Methods: A 76-year-old male with a history of Stanford Type A aortic dissection status post aortic valve resuspension and arch replacement presented with aneurysmal degeneration and Type B dissection. The patient underwent aortic debranching and vertebral artery transposition, followed by TEVAR with a thoracic branched endograft.
Results: The intraoperative decision algorithm is shown in Figure 1. After reviewing the preoperative imaging to delineate the surgical anatomy, we accessed the patient's left common femoral artery (CFA) and placed a glidewire and glide-catheter into the ascending aorta. We advanced the IVUS over the glidewire and confirmed positioning in the true lumen from access site to the ascending aorta. We positioned a 40mm x 15cm Gore TAG TBE with 12mm portal within the aortic arch, with the portal at the distal edge of the left subclavian artery origin, and deployed the stent graft. We used left subclavian artery angiography to confirm graft position and then placed a 12mm x 40mm armada balloon within the subclavian artery portal to provide endograft stability while the proximal endograft was advanced.
We performed an arch aortogram to identify the coronary arteries and determine the proximal landing zone of the endograft. A 40mm x 40mm x 10cm Gore TAG conformable was advanced into the ascending aorta and deployed with the proximal aspect at the sinotubular junction. Aortogram demonstrated patent coronary arteries. We advanced a 15mm x 12mm x 6cm Gore TAG TBE from the CFA and positioned it into the left subclavian artery, ensuring accurate overlap in the portal. This stent was deployed, post-dilated with the 12mm x 40mm armada balloon, and the stent overlap was stented. Angiography demonstrated good filling of the extracranial circulation and the right subclavian artery from the left subclavian artery, as well as good filling of the visceral vessels and predominant filling of the true lumen of the aorta.
Conclusions: IVUS is an easy and well-established way to confirm appropriate wire position in TEVAR. After stent deployment, a pull-back can be performed and recorded for future reference. Concerning changes in blood flow can be re-evaluated with repeat IVUS to determine need for extension of graft coverage. However, it's important to note the increased risk associated with upsizing the groin sheath from 6 Fr to 9 Fr when using IVUS. Therefore, in cases where TEE provides adequate visualization, the additional risk of sheath upsizing may not be justified. This is particularly pertinent in patients with previous ascending aortic replacement, who may not have a strong indication for TEE or have contraindications for it. In such scenarios, IVUS obviates the need for TEE in TEVAR deployment, but careful consideration should be given to the risks and benefits of sheath upsizing.
Aortic Symposium:
Endoluminal Prostheses
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