repair of aortic dissection of the arch and branches chang shu m.d., phd. dept. of vascular surgery,...

Repair of Aortic Dissection of

the Arch and Branches

Repair of Aortic Dissection of

the Arch and Branches

Chang Shu M.D., PhD.Chang Shu M.D., PhD.

Dept. of Vascular Surgery,The 2nd Xiang-Ya Hospital, Central-South University

中南大学湘雅二医院血管外科湖南省大血管疾病外科及微创介入诊疗中心

Email ： [email protected]

Chang Shu M.D., PhD.Chang Shu M.D., PhD.

Dept. of Vascular Surgery,The 2nd Xiang-Ya Hospital, Central-South University

中南大学湘雅二医院血管外科湖南省大血管疾病外科及微创介入诊疗中心

Email ： [email protected]

Clinical Materials

• 2002.7 ～ 2014.2,

• 958 cases with aortic dissection treated with TEVAR• Acute (<2w): 670 cases• Sub-acute and chronic (>2w): 264 cases

• Male: 627 / Female: 331

• age: 20-87; mean age: 51.1

• follow-up: 25.1±7.3 months

Techniques for aortic arch

Hybrid techniques: aorta - supra aortic branches RSA (RCCA) – LCCA RSA (RCCA) – LSA RSA (RCCA) – LCCA – LSA LCCA – LSA

Fenestrated stent-graft

Branched stent-graft

Chimney / double chimney technique

Hybrid technique

aorta - supra aortic branchesRSA (RCCA) – LCCARSA (RCCA) – LSA

RSA (RCCA) – LCCA – LSALCCA – LSA

Extra-anatomic bypass

• needs several operation incisions.

• post-operative anticoagulant treatment is needs.

• reliable/stable/durable outcome

RCCA – LCCA – LSARSA– LCCA RSA– LSA

Extra-anatomic bypass

If left subclavian artery steal syndrome happens post-TEVAR, extra-anatomic bypass can be used.

Hybrid technique

aorta - supra aortic branchesRSA (RCCA) – LCCARSA (RCCA) – LSA

RSA (RCCA) – LCCA – LSALCCA – LSA

A man, 36y, suffered from an aortic arch pseudoaneurysm because of a severe traffic accident.

Hybrid technique was adopted.Ascending aorta – innominate artery – left carotid artery – LSA bypass was achieved first.

Hybrid technique was adopted.Then TEVAR was used. The patient recovered unevertfully.

fenestrated SG

Some of the stenting-grafts has been modified to fit the aortic arch area

Fenestration—treatment

• Step 1: CT and DSA for

accurate measurement were performed pre-operation.

Fenestration—treatment

• Step 2: deploy partial of the

proximal stent graft in vitro, and eliminate part of the lateral fabric.

Fenestration—treatmentFenestration—treatment

Step 3Step 3

Fenestration—follow up

The fenestrated stent graft covered the aortic arch dissection completely

With patent supra-aortic branches

The patient, 70y, male

abrupt severe chest pain for 3

days

history of hypertension, coronary

heart disease, DM

CT scanning indicated an acute

aortic dissection with the primary

entry tear next to LSA.


6 months later, CT

angiography indicated

excellent aortic remodeling

without any complications.

Blood stream of the

reconstructed LSA is fluent.


Chimney technique

Has been applied from 2007.Used to treat the aortic arch disease.

A female, 49 years old, the aortic arch dissection related LSA. There was not enough proximal landing zone.

Chimney in LCCA

the patient, 36y, male

suffered from abrupt chest pain

for 4 days.

CT angiograph indicated a acute

type B aortic dissection and

aberrant right subclavian artery.

Chimney for aberrant RSA


It was an aberrant right subclavian artery, which was invaded by the AD, and the

LSA was invaded that should be covered by TEVAR too.

So, chimney technique should be used to reconstruct the invaded LSA.


The aberrant right subclavian

artery was covered. The LSA

reconstructed with a chimney

stent-graft was patent.

Chimney for type Ia endoleak

Chimney technique for AD + Marfan syndrome+ pregnancy

A female,29 years old, suffered from abrupt severe back pain 1 week after caesarean section.

The primary entry tear located at the orifice of the LSA ( white arrow ).

MFS associated with puerperal state

One month later, the patient recovered well without any symptoms.

However, CT angiography detected mild contrast in the false lumen, and the patent false lumen

communicated with LSA.

MFS associated with puerperal state

Chimney for MFS + puerperal state

• 13 months later, the patient recovered uneventfully.

• Endoleak disappeared ! • No migration, new entry tear formation.

Chimney technique+ PDA occlude for LSA

If chimney technique is used in the common carotid artery, the covered LSA has the risk of

type II endoleak. PDA occlude technique is a ideal management

• TBAD related LSA• Chimney technique should be used

Chimney technique+ PDA occlude

Chimney technique+ PDA occlude

2 weeks after TEVAR, no type II endoleak lasted.

Double-chimney technique

Double-chimney technique can replace the conventional open surgery, and be used to

reconstruct all supra-aortic branches.

The patient suffer from an acute aortic dissection, which the left common carotid artery was invaded and leaded to severe carotid artery stenosis.

Double-Chimney Technique

Bi-chimney technique was used.

Two Fluency stent-grafts were used to reconstruct IA and LCCA. The LSA was covered.

The patient recovered well, without any complications.

Double Chimney Technique

A 50y male, suffered from abrupt chest and back pain. The primary entry tear was unclear in CT scans. Angiography indicated a typical non-A-non-B aortic dissection involve aortic arch. The primary entry tear was between the orifices of innominate artery and LCA.


The patient recovered well, without any serious complications


Double-chimney technique

Double-chimney technique is an experimental technique, with some unclear complications.


It’s a patient with acute type B aortic dissection. According to the CT scan, it’s hard to distinguish the primary entry tear. So, we need DSA.


the primary entry tear is next to the orifice of left subclavian artery. The proximal landing zone is insufficient.


Double chimney technique could increase the proximal landing zone, extending to ascending aorta. During TEVAR, there was no complications. However, the vital signs during post-anesthesia recovery were unstable~~


After double chimney stent-graft deployed

30 min later, when we punctured brachial artery

and performed angiography again.

30 minobvious migration

30 minobvious migration


So, we inserted another two Fluency stent-grafts, overlapped with the previous two, to reconstruct innominate artery and left carotid artery. The patient recovered gradually.

Left subclavian artery dissected post-operation

A 42y male received TEVAR for type B AD one year ago. After operation, a proximal endoleak was found, and was treated conservatively. However, the endoleak persisted. CTA indicated that TEVAR caused LSA dissection, which was inexistent previously.

Is it a type I endoleak definitely ?

DSA confirmed the secondary LSA dissection. The active blood flow in the false lumen was coming from the secondary LSA dissection.

A balloon was inflated in the LSA and DSA was performed again.

It’s obviously that there is no type I endoleak, the active blood flow in the false lumen was originated from the secondary LSA dissection.

A Fluency stent-graft was deployed in the LSA to seal the secondary dissection.

DSA indicated cessation of blood flow in the false lumen.

The patient recovered well after the stent-graft deployed in the proximal LSA.

Conclusions

1. The management of aortic arch diseases became popularity now.

2. Hybrid technique/fenestrated stent-graft/ branched stent-graft/ chimney technique are suitable.

3. Extra-anatomic bypass can be replaced by chimney technique.

4. Better technique is to be expected !

Thank u very much!

repair of aortic dissection of the arch and branches chang shu m.d., phd. dept. of vascular surgery,...

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