Post on 01-Nov-2014
description
Fenestrated and
Branch Devices
Sean P. Lyden, MD FACS
Associate Professor, Cleveland Clinic
College of Medicine at CWRU
Solaci Chile 2011
Disclosures
• Consultant & speaker for Medtronic and
Cook
What Can We Look
Forward To?
• Branch and Fenestrated IDE limited at
present in United States
• Biggest Issue
• Lack of coupling stent graft
What is Happening Now
• Physician off Label
Modification of
Approved Devices
Chimney Grafts
J ENDOVASC THER 2008;15:427–432
Modifications to
Commercial Devices
Courtesy J. Ricotta, MD Mayo ClinicPerspect Vasc Surg Endovasc Ther. 2008 Jun;20(2):174-87; discussion 188-9
Homemade Iliac Branch
Courtesy J. Ricotta, MD Mayo Clinic
Perspect Vasc Surg Endovasc Ther. 2008 Jun;20(2):174-87; discussion 188-9
Mating devices
• Viabahn
• ICast
• Fluency
• No ideal device
• No device designed for this use
• Most are using ICast
Fenestrated Devices
Bifurcated Bifurcated
Device
• Built in
hypogastric
branch
Hypogastric Devices
JoMedAtrium
Helical Hypogastric
Branch
• IDE at CCF
• All helical branch
device
• On HL&B introducer
with preloaded
wire through branch
to allow contra-
lateral snare
Cook Preloaded
Fenestrated
Endologix Off the Shelf
Fenestrated
Medtronic Branch
Device
Gore Branch Device
4 Vessel
Branches
• Helical
• Axial
Proximal Thoracic
Fenestrations
• Frequently aneurysms
encroach upon the arch
vessels
• Tortuous aortic
segment
• Cant cover brain flow
Branched & Fenestrated AAA
Devices
• Can be modified to treat the arch
Problems Unique to the
Arch
• Increased pressure and
migration forces
• Coronary Arteries
• Largest Vessels
• 3D spacial relationships
of the arch vessels
• Imaging difficulty
• Dealing with the aortic
valve
• Delivery system
problems
Brachiocephalic Vessel
Orientation
Evolution of Devices
Cook Arch Device
ARCH BRANCHES
ARE BEING DONE
TODAY
ASCENDING GRAFTS
SOON TO COME
Ascending Devices
• Physician
sponsored IDE
• Australia
• Canada
What is the biggest
limitation?
• Merging TEVAR
devices with
Percutaneous
Valve Technology
will be necessary
to treat the entire
ascending aorta
and provide
proximal fixation
Conclusions
• Branch and fenestrated devices are
needed
• Lack of coupling branch device has
delayed development
• Use in IDE and outside US
• ? When in US
• Multiple Companies working on it