The SPIDER-Graft for Thoracoabdominal

Aortic Repair – a feasability study in pigs

Wipper S, Kölbel T, Manzoni D, Duprée A,

Sandhu H, Nelis V, Debus ES

University Heart Center HamburgUniversity Heart Center HamburgGerman Aortic Center

DisclosuresDisclosures

The experimental study was supported by VASCUTEK

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BackgroundBackground

Solely endovascular treatment is not possible in all

patients (e.g. connective tissue disease, difficultpatients (e.g. connective tissue disease, difficult

anatomy with kinked or atherosclerotic access

vessels, no landing zone, accessory renal arteries, …)

Risk of spinal cord ischemia (no reimplantation of

radicular arteries)radicular arteries)

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Courtacy Prof. Oderich

BackgroundBackground

Open thoracoabdominal aortic repair using

Crawford access and extracorporeal

circulation is still challenging

ECC related complications ECC related complications

Thoracotomy required

Reimplantation of thoracic/ lumbar arteries Reimplantation of thoracic/ lumbar arteries

to reduce spinal cord ischemia possible

Hybrid repair with endovascular treatment

of the thoracic aorta and open repair of the

abdominal aorta might reduce

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abdominal aorta might reduce

perioperative risk

Idea of the studyIdea of the study

Frozen elefant trunk in aortic arch repair to provide

landing zone in the descending aorta for futurelanding zone in the descending aorta for future

endovascular treatment

Reversed modified frozen elefant trunc for hybrid repair

of thoracoabdominal aortic aneurysm ???

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Idea of the studyIdea of the study

Modification of a frozen elefant trunk for

retrograde delivery to descending thoracic aorta

Developed of a six-branched hybrid graft for

thoracoabdominal aortic replacement

Avoiding thoracotomy by endovascular treatment of theAvoiding thoracotomy by endovascular treatment of the

thoracic part

Avoiding extracorporeal circulation by perfusion of the

visceral branches via transient distal aortic anastomosis

Retrograde delivery into the descending thoracic aorta

Save fixation in the proximal landing zone

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Save fixation in the proximal landing zone

Side armes for reimplantation of renal and visceral arteries

Aim of the studyAim of the study

Experimental evaluation in a pig model:

Six-branched hybrid graft for thoracoabdominal aortic replacement withSix-branched hybrid graft for thoracoabdominal aortic replacement with

endovascular treatment of the thoracic aorta avoiding thoracotomy and

extracorporal circulation and

open repair of the abdominal aorta including visceral reimplantationopen repair of the abdominal aorta including visceral reimplantation

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Study protocolStudy protocol

6 domestic pigs (75-85kg)

Technical feasibilityTechnical feasibility

Hemodynamic parameters (HD)

Blood-flow (Transit-Time flow measurement)

Ischemic time of related organsIschemic time of related organs

Angiography

Post Mortem CT angiography

Swan-Ganz Catheter:CVP, PAP, LAP, PVR, BGA

PiCCO:PiCCO:MAP, HR, CO, SVR,GEDV, BGA

Transit-Time flow measurement (TTFM):Coeliac trunc, superior mesenteric artery, left renalartery, Iliac arteries

SPIDER graft deploymentSPIDER graft deployment

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Anastomosis of iliac sidebranchAnastomosis of iliac sidebranch

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Insertion of thoracic stentgraftInsertion of thoracic stentgraft

In-flow occlusion

Aortic clamp distal to CT

Clamp on CT

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Retraction of sheathRetraction of sheath

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Stentgraft deployedStentgraft deployed

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Release of proximal fixation wireRelease of proximal fixation wire

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Release of introducer systemRelease of introducer system

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DeDe--airing of the SPIDER graftairing of the SPIDER graft

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Release of iliac clamp andRelease of iliac clamp andperfusion of visceral arteriesperfusion of visceral arteriesperfusion of visceral arteriesperfusion of visceral arteries

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Stepwise reStepwise re--implantation ofimplantation ofvisceral and iliac carteriesvisceral and iliac carteriesvisceral and iliac carteriesvisceral and iliac carteries

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Surgical ProcedureSurgical Procedure

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ResultsResults

Successful graft deployment in all 6 animals

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ResultsResults

Successful fixation of graft in proximal landing zone

Modificatoin of Delivery System for easier retraction necessary

Thoracic graft implantation 4.2±1min

Ischemic time(min)

TTFM Base(ml/min)

TTFM post(ml/min)

TC 11.5±2.3 585±65 534±110TC 11.5±2.3 585±65 534±110

SMA 9.0±2.1 492±113 722±115

RRA 13.4±3.8

LRA 21.2±4.0 246±97 163±97

RIA 9.0±3.3 565±192 326±67

LRA 15.6±6.5 592±156 400±127LRA 15.6±6.5 592±156 400±127

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SummarySummary

Hybrid graft implantation is technically feasable in pigs

Crossclamping time and visceral and renal ischemia can be kept in

a short limita short limit

Extracorporeal circulation can be avoided

Thoracotomy can be avoided

Prothesis has to be further modified

Further experimental studies are necessary

Hybrid graft might be a useful treatment option for selective cases

Future perspectiveFuture perspective

Modification of nose cone for delivery system difficult to extract Modification of nose cone for delivery system difficult to extract

Over the wire implantation

Modification of the graft for reimplantation for thoracic or lumbar arteries for

spinal cord perfusion

Better orientation of side arms for retroperitoneal access

Actual experimental studies for evaluation of

Organ perfusion

Comparision to conservative prothesisComparision to conservative prothesis

Evaluation of spinal cord perfusion

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Future perspectiveFuture perspective

E.S. Debus, MD

3rd generation2nd Generation

Thank you for yourThank you for your

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