Pro- and cons of staging complex EVAR Is there more to staging than - - PowerPoint PPT Presentation

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pro and cons of staging complex evar is there more to

Pro- and cons of staging complex EVAR Is there more to staging than - - PowerPoint PPT Presentation

Jun 01, 2023 184 likes •533 views

Pro- and cons of staging complex EVAR Is there more to staging than lower paraplegia? Barend Mees, Michiel de Haan, Geert Willem Schurink Waar gaan we naar toe? Disclosures Consulting: Cook, Bentley, Abbott, Getinge Complex EVAR = endo TAAA

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Pro- and cons of staging complex EVAR Is there more to staging than lower paraplegia?

Barend Mees, Michiel de Haan, Geert Willem Schurink

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Waar gaan we naar toe? Consulting: Cook, Bentley, Abbott, Getinge

Disclosures

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Complex EVAR = endo TAAA repair

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Types of staging

Historical staging
Arch/TEVAR first with/without debranching/access conduit
Temporary sac perfusion
Minimal Invasive Segmental Artery Coil Embolisation (MISACE)

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Historical staging

20-47% of patients with TAAA have had previous aortic repair
Previous aortic repair is protective for mortality and

development of SCI.

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Previous Aortic Repair

Gustavo Oderich; Endovascular Aortic Repair

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Iliofemoral conduit staging

Gustavo Oderich; Endovascular Aortic Repair

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Gustavo Oderich; Endovascular Aortic Repair

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Ascending, Arch, FET first

Gustavo Oderich; Endovascular Aortic Repair

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TEVAR first

In Type I and II TAAAs TEVAR first is common staging strategy, especially in combination with carotid-LSA bypass

Gustavo Oderich; Endovascular Aortic Repair

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Historical and TEVAR staging

Reduce operative time
Reduce limb ischemia
Reduce complications
Reduce mortality and morbidity
Reduce paraplegia

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Temporary Aneurysm Sac Perfusion

Perfusion branches
Open branch
Stent between stent graft components
Unconnected iliac limb

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Perfusion branches

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Open branch strategy

Sac perfusion (n=40) No Sac Perfusion (n=43) Paraplegia 5% 21%

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MISACE

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MISACE

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What are the cons of staging?

Rupture
Occlusion of target vessel
Disturbed flow in sac causing emboli
General anesthesia 2x
Complication of coiling segmental arteries
Patient satisfaction

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Rupture/Mortality before completion 2nd stage

Cleveland 2/27
Birmingham 1/92
Regensburg 1/40
Maastricht 0

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Target vessel occlusion

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Target vessel occlusion

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What are the cons of staging?

Rupture
Occlusion of target vessel
Disturbed flow in sac causing emboli
General anesthesia 2x
Complication of coiling segmental arteries
Patient satisfaction

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General anesthesia

Maastricht axillary access and MEPS
Regensburg 23% local anesthesia

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What are the cons of staging?

Rupture
Occlusion of target vessel
Disturbed flow in sac causing emboli
General anesthesia 2x
Complication of coiling segmental arteries
Patient satisfaction

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What are the cons of staging?

Rupture
Occlusion of target vessel
Disturbed flow in sac causing emboli
General anesthesia 2x
Complication of coiling segmental arteries
Patient satisfaction

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Waar gaan we naar toe?

There is no doubt that staging endo TAAA repair is beneficial

Staging has reduced paraplegia rates dramatically
It also reduces mortality and morbidity
Only retrospective evidence
Low or very low GRADE

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2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Year, month

 161 patients (from 2018)  mortality 10/161 (6,2%)  paraplegia 2/151 (1,3%)  good clinical outcome 92,5%

542

endovascular thoracoabdominal / juxtarenal procedures

Department of General, Vascular and Transplant Surgery, Poland

Number of patients