Giampiero Esposito MDGiampiero Esposito MD2010-A-2010-A-1010-AATS-AATS

Cardiovascular Surgery UnitCardiovascular Surgery UnitCITTA’ DI LECCE HOSPITALCITTA’ DI LECCE HOSPITAL - ITALY - ITALY

GVM Hospitals of Care and GVM Hospitals of Care and ResearchResearch

Hybrid Approach to Type A acute Hybrid Approach to Type A acute aortic dissection: the Lupiae technique. aortic dissection: the Lupiae technique.

HYBRID TWO-STAGE HYBRID TWO-STAGE “LUPIAE TECHNIQUE”“LUPIAE TECHNIQUE”

Visceral vesselsVisceral vesselsCT & SMACT & SMA

Conception of HYBRID Two-Stage Strategy Conception of HYBRID Two-Stage Strategy ““LUPIAE TECHNIQUE” LUPIAE TECHNIQUE” in Type A A.D.(De in Type A A.D.(De

Bakey I)Bakey I)Intended Intended two stagetwo stage repair repair

of of Type A Aortic Type A Aortic DissectionDissection with with

“complicated” residual “complicated” residual false lumen by combining false lumen by combining ascending aorta, arch ascending aorta, arch

replacement and replacement and debranching debranching

of epiaortic vessels using a of epiaortic vessels using a New Multibranched Dacron New Multibranched Dacron Prosthesis with subsequent Prosthesis with subsequent retrograde transfemoral retrograde transfemoral

Stent graftingStent grafting

HYBRID Two-Stage Strategy HYBRID Two-Stage Strategy ““LUPIAE TECHNIQUE” LUPIAE TECHNIQUE” in Extensive Type A in Extensive Type A

A.D.A.D.

1.1. ““Easy” surgical procedureEasy” surgical procedure• Easy distal OPEN anastomosis Easy distal OPEN anastomosis • Short circulatory arrest timeShort circulatory arrest time• Easy debranching of BCT, LCA, LSAEasy debranching of BCT, LCA, LSA

2.2. ““Ideal” proximal landing zoneIdeal” proximal landing zone• Safe, Long, StableSafe, Long, Stable

3.3. ““Easy” subsequent endovascular Easy” subsequent endovascular procedureprocedure• Optimized sealing Optimized sealing • Minimized risk of Type I endoleakMinimized risk of Type I endoleak• False lume exclusionFalse lume exclusion

OBJECTIVESOBJECTIVES

OPERATIVE METHODSOPERATIVE METHODSin Type A Aortic Dissectionin Type A Aortic Dissection

LUPIAE TechniqueLUPIAE Technique

• Rapid transfer to the operating room after diagnosis (TTE, CT-scan)Rapid transfer to the operating room after diagnosis (TTE, CT-scan)

• Intraoperative TEE to confirm diagnosis and plane type of surgeryIntraoperative TEE to confirm diagnosis and plane type of surgery

• Arterial cannulation by right axillary artery, brachiocephalic trunk Arterial cannulation by right axillary artery, brachiocephalic trunk or left ventricular apex or left ventricular apex

• Cooling at 28°C, ascending aortic clamp, myocardial protection (Custodiol)Cooling at 28°C, ascending aortic clamp, myocardial protection (Custodiol)

• AVA resuspension, proximal aortic reconstructionAVA resuspension, proximal aortic reconstruction

• Circulatory arrest with cerebral anterograde perfusion and distal aortic Circulatory arrest with cerebral anterograde perfusion and distal aortic reconstruction (20-25 min)reconstruction (20-25 min)

• Distal aortic riperfusion, LCA and BCT reimplantation, off-ECC, Distal aortic riperfusion, LCA and BCT reimplantation, off-ECC, LSA reimplantationLSA reimplantation

• LSA debranching and perfusionLSA debranching and perfusion

LUPIAE Technique in TYPE A A.D.LUPIAE Technique in TYPE A A.D.first surgical stage first surgical stage RESULTS RESULTS

May 2005 – April 2009May 2005 – April 2009

• Number of patients:Number of patients: 38 (26 males and 12 females, mean age 64,7 38 (26 males and 12 females, mean age 64,7± 8,9 yrs) ± 8,9 yrs)

• Intraoperative data: Intraoperative data: - ECC 103,2- ECC 103,2 ± 17,0 min± 17,0 min - Xclamp 44,8 ± 9,2 min- Xclamp 44,8 ± 9,2 min - CA 20 ± 2,5 min- CA 20 ± 2,5 min

• Mortality:Mortality: 2/38 2/38

• Morbidity: Morbidity: - 3 temporary neurological dysfunction- 3 temporary neurological dysfunction - 2 temporary renal failure requiring dialysis- 2 temporary renal failure requiring dialysis - 4 temporary respiratory failure (2 requiring tracheo)- 4 temporary respiratory failure (2 requiring tracheo) - 3 reexplorations for bleeding- 3 reexplorations for bleeding

““LUPIAE TECHNIQUE”LUPIAE TECHNIQUE”““Fixed” Elephant TrunkFixed” Elephant Trunk

Ideal Proximal Ideal Proximal Aortic Landing Aortic Landing

ZoneZone

LUPIAE Technique:LUPIAE Technique:Second Endovascular Second Endovascular StageStage

3D3D CT-scan follow-up CT-scan follow-up ininType A Aortic Type A Aortic DissectionDissection

LUPIAE Technique in TYPE A A.D.LUPIAE Technique in TYPE A A.D.hybrid two stage hybrid two stage RESULTS RESULTS

May 2005 – April 2009May 2005 – April 2009

• Number of patients:Number of patients: 27 (19 males and 8 females, mean age 64,7 27 (19 males and 8 females, mean age 64,7± 8,9 ± 8,9 yrs)yrs)

• Approach: Approach: - general/local anesthesia- general/local anesthesia - surgical exposure of femoral artery- surgical exposure of femoral artery

• Mortality:Mortality: 1/27 1/27

• Morbidity: Morbidity: - 1 femoral artery dissection - 1 femoral artery dissection

• Devices:Devices: Vascutek Vascutek®® Lupiae dacron & Medtronic Lupiae dacron & Medtronic®® Valiant Valiant

CONCLUSIONS CONCLUSIONS

The The Lupiae TechniqueLupiae Technique in Type A aortic dissection with in Type A aortic dissection with

complicated false lumen achieves complicated false lumen achieves 2 2 important targets:important targets:

1.1. ““Easy”Easy” replacement of dissected ascending aorta replacement of dissected ascending aorta

and arch with epiaortic vessels debranching using Vascutekand arch with epiaortic vessels debranching using Vascutek®®

““Lupiae graft”Lupiae graft”..2. 2. A A “safe, long and stable”“safe, long and stable” proximal landing zone created by proximal landing zone created by the the “fixed”“fixed” Elephant Trunk is ready to be used for Elephant Trunk is ready to be used for second endovascular stage in which stent graft deployment second endovascular stage in which stent graft deployment is performed in the residual dissected thoracic aorta.is performed in the residual dissected thoracic aorta.