Patient-tailored endovascular therapy of the thoracic aorta

Patient / Anatomy

• A 65-year-old male patient.
• Extensive coronary artery disease – PCI to RIM; chronic total occlusion of RCA.
• Smoking history: 50 pack-years.
• COPD.
• Type 2 diabetes mellitus.
• CKD II.
• Severe depression.
• Hyperlipidemia (HLP).
• Progressive aneurysm, diameter 58 mm.
• Kinked anatomy (proximal descending!).
• Diseased aorta and Iliac arteries.
   

Distal Arch / Proximal descending

Length & extent 

Distal landing zone

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Proximal sealing concept

• From our perspective, adequate proximal sealing is feasible with a branched solution.
• We always try to preserve the left subclavian artery.
• In this case, we propose the GORE® TAG® Thoracic Branch Endoprosthesis (TBE) as an off-the-shelf option with good conformability to kinked aortic pathology.

Step 1

GORE® TAG® Thoracic Branch Endoprosthesis (TBE) 

Challenging branch take-offs may require specific angulations!

Step 1: result

Staged approach for spinal cord protection

• Planning of a staged procedure to minimise the risk of spinal cord ischaemia.
• TBE in 1^st step followed by two TEVAR components after 8 weeks.
   

Step 2 (after 8 weeks):

Distal optimisation and future treatment option

• Further extension of the 37 x 200 mm Gore® TAG® Conformable with a large diameter tapered 37/31 x 150 mm TAG® Conformable
• At the same time, preparation for a potential later extension into the abdominal aorta, should the disease progress and become treatment-indicated in this segment.
• Reduction of the risk of a distal stent graft–induced new entry (dSINE) and improved adaptation to the patient’s anatomy.

37 TAG® Conformable in 37 TBE -> Long overlap! 

Staged deployment of the tapered TAG® Conformable with precise control of the distal landing zone.

Ballooning under controlled hypotension with a Tri-Lobe balloon.

• No peri-operative complications.
• Uneventful hospital course.
• No neurological events.
• Uneventful follow-up.

Conclusions

• Branched and tapered endovascular solutions can optimise both proximal and distal sealing zones.
• Tapered stent-graft configurations may reduce wall-stress–related stent graft–induced new entry (SINE).
• Both concepts enable an endovascular repair strategy tailored to the individual patient’s anatomy and pathology.
• Tapered solutions provide an additional option to facilitate future extensions without the need for further custom-made components.

Concept / Strategy Overview 

Proximal sealing concept

• Multimorbid patient – endovascular approach is proposed.
• Proximal sealing zone is limited.
• Adequate proximal sealing is considered achievable with a branched solution.
• Proposed device: GORE® TAG® Thoracic Branch Endoprosthesis (TBE).
• Advantages: off-the-shelf availability and good conformability to kinked aortic pathology.

Two-stage approach for spinal cord protection

• Planning of a staged procedure to minimise the risk of spinal cord ischaemia.

Patient-specific anatomical adaptation / distal optimisation and future treatment option

• Adaptation to the patient’s individual anatomy by extending the 37 mm TBE with an additional 37 mm TAG® Conformable with long overlap.
• Further extension of the 37 mm TAG® Conformable with Large Diameter Tapered TAG® Conformable to match the distal aortic diameter.
• At the same time, preparation for a potential later extension into the abdominal aorta, should the disease progress and become treatment-indicated in this segment.
• Reduction of the risk of a distal stent graft–induced new entry (dSINE) and improved adaptation to the patient’s anatomy.

Access strategy and procedural technique

• Both procedures are performed completely percutaneously with ultrasound-guided access and use of a preclose technique.
• This optimises the staged approach and reduces the risk of access-vessel complications.
   

Dr. Florian Elger: workshops and speaker for W.L. Gore, workshops and proctor for Terumo Aortic

Supported through an unrestricted educational grant from Gore