Các trường hợp stent graft ĐMC liên quan đến nhánh bên quan trọng phẫu thuật hybrid hay dùng kỹ thuật chimney

Hybrid approaches and chimney techniques as
treatment options for TAA/TAD

Nguyễn Hoàng Định, MD.
University Medical Center, Ho Chi Minh City, Viet Nam


Thoracic aortic aneurysms/dissections

Incidence of TAA is approximately 10.4 per 100,000 people.
Only about 20 to 30 percent of patients who get to the hospital with a
ruptured TAA survive.
For those over 65, the incidence of TAA is 3-4%.
Death from TAA is one of the 15 major causes of death.


Treatment options for TAA/TAD including neck vessels

1.

Conventional open surgery.

2.

Total endovascular approach.

3.

Hybrid surgery approach and chimney techniques.

Open surgery remains the gold standard, but with a cost!


Open surgery remains the gold standard, but with a cost!

Mortality and morbidity

Mortality
Stroke

Open surgery

Hybrid

35%

8.3%

9%

4%

(*) Antoniou GA et al, Hybrid repair of the aortic arch in patients with extensive aortic disease, Eur J Vasc
Endovasc Surg 2010 Dec;40(6):715-21.
(**) Milewski RK et al, Have hybrid procedures replaced open aortic arch reconstruction in high-risk
patients? A comparative study of elective open arch debranching with endovascular stent graft
placement and conventional elective open total and distal aortic arch reconstruction, J Thorac Cardiovasc
Surg. 2010 Sep;140(3):590-7

Total endovascular options:
fenestrated and branched stent-grafts: the future is near!


Total endovascular options:
fenestrated and branched stent-grafts: the future is near!


Landing zones in TEVAR
Zone 1: đặt stent
graft sau ĐM thân
cánh tay đầu, yêu
cầu tái thông lại ĐM
cảnh chung trái và
ĐM đòn trái

Zone 0: đặt stent
graft ở động mạch
chủ lên, cần tái thông
(revascularizaiton) 3
mạch nuôi não

- Zone 2 : đặt stent
graft sau ĐM cảnh
chung trái, có thể tái
thông hoặc che phủ
hoàn toàn ĐM đòn
trái tuỳ từng trường
hợp

- Zone 3 : đặt stent graft
sau ĐM đòn trái
- Zone 4 : đặt stent graft
ở động mạch chủ xuống


Zone 2: LSA coverage
Bắc cầu động mạch dưới đòn
bằng mạch máu nhân tạo nối
với ĐM cảnh chung trái

Chuyển vị động mạch dưới đòn
và nối tận bên với ĐM cảnh
chung trái


Zone 2: LSA coverage



When do we need to revascularize LSA

- History of CABG with patent LIMA – LAD graft
- Small right vertebral artery
- Left vertebral artery ends up at PICA (posterior inferior cerebellar artery)
- Axillary – femoral bypass

- High risks of paraplegia: long thoracic stent-graft of history of AAA surgery
- Occlusion of hypogastric artery

Zone 1: landing zone distal to innominate artery


Zone 0: landing zone at ascending aorta

- Requires medial sternotomy
- Trifurcated graft to revascularize
neck vessels and LSA
- Deliver stent-graft distal to ascending
aorta-graft anastomosis


Zone 0: Chimney of the innominate artery

- Carotid – carotid – subclavian bypass
- Deliver chimney stent graft (Endurant
limb) through cut down Rt. axillary artery
- Deliver thoracic stent graft retrograde
from the groin
- Mark the position of 2 stent then deploy
thoracic stent graft first then chimney
stent graft

Initial experiences at UMC
Landing zones

TAA (arch and

Type B TAD

descending)
Chimneys of
innominate artery: 5

0

Zone 0 (6)
Total debranching: 1

Zone 1 (2)

2 RCA-LCA + LCALSA

0

0
LCA-LSA: 1

Zone 2 (4)

1

LSA chimney T: 1

LSA covered: 1

Total

12 (6 chimneys)


Outcomes
Early:

Paraprosthetic leaks:

Follow-up (2 – 36 mo)

Mortality

1

Stroke

1

Paraplegia

0

Retrograde diss. A

0

Type I

1

Type II

1

Need for re-entervention

0

Mortality

1

Paraprothetic leak I

1


CA LÂM SÀNG 1
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•
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Lê Thị T., 86 tuổi.
LDNV: Đau ngực.
Tiền căn: THA kéo dài không điều trị.

Đặt stent graft quai ĐMC 9/2013 tại Trung tâm Tim mạch BV ĐHYD
TPHCM.