Fenestrated or branched prostheses in thoracic and abdominal aorta
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Transcript of Fenestrated or branched prostheses in thoracic and abdominal aorta
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Fenestrated and
Branch Devices
Sean P. Lyden, MD FACS
Associate Professor, Cleveland Clinic
College of Medicine at CWRU
Solaci Chile 2011
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Disclosures
• Consultant & speaker for Medtronic and
Cook
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What Can We Look
Forward To?
• Branch and Fenestrated IDE limited at
present in United States
• Biggest Issue
• Lack of coupling stent graft
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What is Happening Now
• Physician off Label
Modification of
Approved Devices
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Chimney Grafts
J ENDOVASC THER 2008;15:427–432
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Modifications to
Commercial Devices
Courtesy J. Ricotta, MD Mayo ClinicPerspect Vasc Surg Endovasc Ther. 2008 Jun;20(2):174-87; discussion 188-9
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Homemade Iliac Branch
Courtesy J. Ricotta, MD Mayo Clinic
Perspect Vasc Surg Endovasc Ther. 2008 Jun;20(2):174-87; discussion 188-9
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Mating devices
• Viabahn
• ICast
• Fluency
• No ideal device
• No device designed for this use
• Most are using ICast
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Fenestrated Devices
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Bifurcated Bifurcated
Device
• Built in
hypogastric
branch
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Hypogastric Devices
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JoMedAtrium
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Helical Hypogastric
Branch
• IDE at CCF
• All helical branch
device
• On HL&B introducer
with preloaded
wire through branch
to allow contra-
lateral snare
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Cook Preloaded
Fenestrated
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Endologix Off the Shelf
Fenestrated
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Medtronic Branch
Device
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Gore Branch Device
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4 Vessel
Branches
• Helical
• Axial
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Proximal Thoracic
Fenestrations
• Frequently aneurysms
encroach upon the arch
vessels
• Tortuous aortic
segment
• Cant cover brain flow
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Branched & Fenestrated AAA
Devices
• Can be modified to treat the arch
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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
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Brachiocephalic Vessel
Orientation
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Evolution of Devices
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Cook Arch Device
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ARCH BRANCHES
ARE BEING DONE
TODAY
ASCENDING GRAFTS
SOON TO COME
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Ascending Devices
• Physician
sponsored IDE
• Australia
• Canada
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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
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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