1. Imaging Experience of Type II Hybrid Aortic Arch Repair: Lessons learned from Zone 0 Debranching & Evolution to Zone 2 Arch Repair Vamshi Kotha, Eric J Herget & Jehangir J. Appoo Depts of Radiology & Libin Cardiovascular Institute University of Calgary Calgary, Canada 52 nd STS Annual Meeting Phoenix, Arizona January 25th, 2016

2. Endovascular repair changed paradigm of descending aortic surgery Evolution of Endovascular Repair

3. Endovascular repair changed paradigm of descending aortic surgery Proximal arch and ascending aorta are next frontiers in pathway to closed chest aortic surgery Evolution of Endovascular Repair

4. Endovascular repair changed paradigm of descending aortic surgery Proximal arch and ascending aorta are next frontiers in pathway to closed chest aortic surgery Hybrid operations intermediate step offers unique opportunity to learn about behaviour of endografts in proximal aorta Evolution of Endovascular Repair

5. Bavaria Classification for Hybrid Arch

6. PENN Classification Type II Hybrid Diffuse Aortomegaly Complicated Type A Dissection Indications for Type II Hybrid

7. The Operation *Proximal Landing Zone of Stent Graft is in Dacron Ascending Aorta 1.Replacement Ascending Aorta 2.Debranch arch vessels with proximalization of ostium to level of STJ 3.Antegrade Stent graft insertion after CPB

8. Purpose Assess radiologic outcome of endografts placed in the ascending aorta during Type II Hybrid Repair

9. Results 20 patients Type II Hybrid Arch from 2009 to 2014 Mean age – 66 years (Range: 47-82) Indications: 8/20Acute Type A with primary intimal tear in distal arch or prox descending aorta 6/20Diffuse atherosclerotic aortomegaly of asc, arch and descending aorta 4/20Previous Type A repair with arch and descending aneurysms in pt 2/20Contained arch rupture with diffuse descending aortic disease 50% Emergencies 25% Redo sternotomy

10. Periop Results Mortality1/20 Permanent Neuro deficit2/20 Paraparesis2/20 – complete recovery

11. Follow Up One pt lost to f/u (moved to Europe) No late mortality Mean imaging f/u 34months (Range 12-64 months)

12. Nice straight proximal landing zone after Type II Hybrid in acute Debakey Type I dissection Ideal Proximal Landing Zone

13. >5mm protrusion and non-apposition of stent graft along lesser curve of ascending aorta at prox LZ Bird beaking at the proximal landing zone has been described as > 5mm non- apposition of the endovascular stent graft within the surgical Dacron graft. 23mm Bird Beaking

14. Bird Beaking: 12/20 (60%) Severe Bird Beaking >20mm: 7/20 (35%) 23.0 mm 58.6 o Bird beaking at the proximal landing zone has been described as > 5mm non- apposition of the endovascular stent graft within the surgical Dacron graft. 23mm

15. Proximal Landing Zone complications 4/20 patients Type 1a endoleak Day 4 Graft Migration on initial post op CT Day 5 Type 1a endoleak Day 11 Delayed infolding of graft Day 755 3 patients underwent re-intervention – endovascularly 1 patient with Type 1a endoleak continues to be followed

16. Stent graft migration n =1 Treated with additional proximal device

17. 2 year follow up Graft buckling n=1 1 year follow up

18. Rescued with Palmaz Stent

19. Pts. With Prox LZ complications Pts. Without Prox LZ complications Mean bird beak length 22.0mm10.9mmP=0.07 Significance of Bird Beak?

20. While we wait for technology to improve, we have transitioned towards a “Zone 2” Approach Changed our Surgical Approach Transect the arch between the left carotid and left subclavian

21. Zone 2 Arch – next generation of Hybrid Arch Zone 2 Arch Mod HCA 12 to 15 mins SACP 22 to 25 mins

22. Type II Hybrid 2009-2014 Zone 2 Arch 2014-Present Next: Zone 2 Arch with branched stent graft ?

23. Imaging Experience of Type II Hybrid Arch Repair Lessons Learned from Zone 0 Debranching : 1) Good midterm survival in challenging patient population

24. Imaging Experience of Type II Hybrid Arch Repair Lessons Learned from Zone 0 Debranching: 1) Good midterm survival in challenging patient population 2) Challenges in conforming to sharp angulation of ascending aorta

25. Imaging Experience of Type II Hybrid Arch Repair Lessons Learned from Zone 0 Debranching : 1) Good midterm survival in challenging patient population 2) Challenges in conforming to sharp angulation of ascending aorta 3) Significant bird beaking when landing in dacron of ascending aorta

26. Imaging Experience of Type II Hybrid Arch Repair Lessons Learned from Zone 0 Debranching : 1) Good midterm survival in challenging patient population 2) Challenges in conforming to sharp angulation of ascending aorta 3) Significant bird beaking when landing in dacron of ascending aorta 4) Endovascular devices in ascending aorta may be prone to complications

27. Imaging Experience of Type II Hybrid Arch Repair Lessons Learned from Zone 0 Debranching : 1) Good midterm survival in challenging patient population 2) Challenges in conforming to sharp angulation of ascending aorta 3) Significant bird beaking 4) Endovascular devices in ascending aorta may be prone to complications 5) Angulation issues will need to be overcome by stent graft refinement to enable future closed chest approaches to the ascending aorta “Innovation: Something Different that has an Impact”

28. Calgary Thoracic Aortic Program, www.aorta.ca, Jehangir.Appoo@AlbertaHealthServices.cawww.aorta.ca