1. Hybrid Arch for Acute Type A Aortic Dissection
Hybrid Arch for Acute Type A Aortic Dissection Is the stent graft best served “frozen” or “warm” ?
Jehangir J. Appoo
Division of Cardiac Surgery
Libin Cardiovascular Institute
Cumming School of Medicine
University of Calgary
9th Houston Aortic Symposium
Frontiers in Cardiovascular Diseases
March 3rd, 2016

2. Today: Focus on Hybrid Arch for Acute Type A Aortic Dissection
My objectives for next 8 mins:
Introduce 1 new concept: “Warm Stent Graft” vs. “Frozen Stented Elephant Trunk”
Propose Classification System & outcome of Systematic Review of Hybrid Arch for ATAAD
Share one case as an example
Thought provoking questions on what’s next step for Aortic Community

3. Hybrid Arch for ATAAD
Is the Stented Elephant Trunk best served “FROZEN” or “WARM” ?
vs.

4. Proposed Classification of Extended Arch Operations for ATAAD
Total Arch Replacement
Total Arch Replacement & Frozen Stented Elephant Trunk - deployed during hypothermic circulatory arrest
Hemi-arch Replacement & Frozen Stented Elephant Trunk - deployed during hypothermic circulatory arrest
Total Arch Replacement & Warm Stent Graft - deployed after cardiopulmonary bypass

5. Systematic Review of Extended Arch Operations for ATAAD
Smith, HN et al. (in submission)
38 publications, >2100 patients
Pooled op mortality 8.6% (95%CI )
Pooled stroke 5.7% (95%CI )
Pooled spinal cord ischemia 2.0% (95%CI )
* Note: 2015 Publications from GERAADA and IRAD suggest 15-20% operative mortality

6. Advantages of:
Frozen Elephant Trunk vs. “Warm Stent Graft”
Visualization of landing zones
Confirmation of resolution of malperfusion
Recognition of Stent Induced New Tear
Distal extension of treatment
No increase in circulatory arrest time
No requirement of Endovascular skill set
No intraop fluoroscopy/hybrid room required
No requirement of contrast agent
Applicability to large number cardiac surgeons

7. 49 y.o male ATAAD
Presents to OSH – March 2015
Primary Entry Tear Distal to L subclavian artery

8. Our Current Practice: Case Example
49 y.o male ATAAD presents to OSH – March 2015
Clinical and radiologic Visceral Malperfusion

9. Intraop:
Tear confirmed distal to left subclavian artery
Arch resected and anastamosis done in Zone 2 with individual bypasses to innominate, left carotid and left subclavian
Right axillary cannulation
Moderate Hypothermia at 25oC
HCA – 14mins with continuous ACP
SACP – 28mins

10. On Table Angio - after Zone 2 Arch Reconstruction and separating from CPB
Prior to stent graft insertion
Post TEVAR

11. 6 months follow up :

13. CCS/CSCS/CSVS Joint Position Statement on Interventions for Thoracic Aortic Disease
CCC Oct.2015 – Toronto
Canadian Journal of Cardiology, In Press

14. RECOMMENDATIONS
We recommend an extended distal arch repair technique be considered for patients who present with acute Type A dissection and one of the following:
Primary intimal entry tear in the arch or descending aorta
Significant aneurysmal disease of the arch
(Strong recommendation, Low Quality Evidence)

15. RECOMMENDATIONS
We suggest that it is reasonable to consider an extended distal arch repair technique for patients who present with acute Type A dissection and one of the following:
Distal malperfusion
Concomitant descending thoracic aortic aneurysm
Young patients
Patients with connective tissue disorders
(Weak recommendation, Low Quality Evidence)

16. CONCLUSIONS:
Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data
Pooled op mortality 8.6% (95%CI )
Pooled stroke 5.7% (95%CI )
Pooled spinal cord ischemia 2.0% (95%CI

17. CONCLUSIONS:
Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data
Proposed Classification system of Extended Arch Techniques based on:
Total Arch vs. Hemi-Arch &
Frozen Stent Graft vs. Warm Stent Graft

18. CONCLUSIONS:
Early Results with Hybrid Arch Techniques for ATAAD are very encouraging compared to large contemporary registry data
Classification system of Extended Arch Techniques based on
Total Arch vs. Hemi-Arch
Frozen Stent Graft vs. Warm Stent Graft
Hybrid Repairs for treatment of ATAAD now entering Guidelines
2014 European Guidelines
2015 Canadian Guidelines

19. NEXT PHASE:
Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do?
Hemi-arch vs. Extended Arch ± Descending Stent Graft ?
*Recall no RCT ever done for isolated ascending aortic replacement vs. hemi-arch

20. NEXT PHASE:
Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do?
Hemi-arch vs. Extended Arch ± Descending Stent Graft
Frozen Elephant Trunk vs. Warm Stent Graft?

21. NEXT PHASE:
Which Multicentre RCT of Hybrid Arch for ATAAD does Aortic Community wish to do?
Hemi-arch vs. Extended Arch ± Descending Stent Graft
Frozen Elephant Trunk vs. Warm Stent Graft
Hybrid Arch vs. Hybrid Arch + BareMetal Stent Distally?

22. My objectives for past 8 mins:
Introduce new concept of “Warm Stent Graft” vs. Frozen Stented Elephant Trunk
Propose Classification System & Results of Hybrid Arch for ATAAD
Share a case
Provoke thought on what’s next step for Aortic Community

23. Calgary Thoracic Aortic Program, www. aorta. ca,. Jehangir
Calgary Thoracic Aortic Program,