Bradley G. Leshnower, MD joins Georgia Heart Institute as a Cardiovascular Grand Rounds speaker during the CME lectures for 2022. Dr. Leshnower is the Director of Thoracic Aortic Surgery, and Associate Professor of Surgery at Emory University School of Medicine in Atlanta, Georgia. Dr. Leshnower discusses cutting edge surgical options for aortic disease. To receive CME credit for this presentation, please visit the survey link. [https://www.surveymonkey.com/r/THPG7QH]
See you are you ready? Good morning and welcome to Georgia Heart grand rounds. This program is provided by Georgia Heart Institute with support from our industry partners. The planners have disclosed no relevant financial relationships with commercial interests. The presenter is on the scientific advisory board for our tv in and as a consultant for endo span inc these relationships do not influence today's presentation to claim cmi credits for today answer the survey evaluation. If you are on zoom the link will be put into the chat. If you have a question for the presenter please type it into the chat section and we will read it at the end for those of you attending in person. You will receive the link at the end of the presentation and now dr samity president of Georgia Heart will introduce Dr Lash now er thank you. Okay let's get these glasses on. Well good morning. Um It's great to see everyone I know we have quite a few people on virtually. So thank you all for joining um Georgia heart grand rounds. Um And um I just want to share with you that today is um the first of probably um well I would say the first but it's I think our fifth cardiovascular grand rounds since we kicked things off. Um And I was just telling dr less now that we've had some amazing speakers Dr Spencer King was here and um Nihal Mehta Jamie Burkle and um many others and so it's with it's a huge honor and privilege to present a great friend and a phenomenal cardiovascular surgeon Dr brad less now Er who's going to talk to us today about cutting edge surgical options for aortic disease. As you can see dr Lessen. Our is currently the director of thoracic aortic surgery and associate professor of surgery at the division of Cardiothoracic surgery at Emory. Um dr less power comes from texas. Um and interestingly he received a bachelor's sickly in music from the University of texas at Austin um The famed university of texas at Austin. Um and subsequently completed residency in general surgery at the University of pennsylvania. Um He then went on to do a two year postdoctoral fellowship and the Harrison department of surgical research studying my cardio scheme every perfusion injury. As a member of the Gorman cardiovascular research group. Following completion of the General surgery training, Dr Leshner completed cardiothoracic surgery residency at Emory under the tutelage of dr robert biden, another giant in the field dr Leshan. Our pursued advanced thoracic aortic surgery training with dr joe bavaria at the University of pennsylvania and endovascular surgery at the Arizona Heart institute. Subsequently dr Fleischmann hour joined the division of cardiothoracic surgery at Emory in 2011 as a cardio aortic surgeon. Um as I mentioned um He currently heads the thoracic aortic surgery program and specializes in cardiac surgery. Open and endovascular therapies I will say in my years at Emory. I've I've had the privilege of working with brad and um referring many patients to him and he is an absolute terrific Clinician and a phenomenal surgeon. Um He's like most cardiac surgeons is built as interventionist out a lot over the years. Um But we we really had an amazing relationship um in addition to leading really the huge aortic program Dr Lesh now er um does incredible research and understanding aortic disease as you understand uh from his talk. He also, remarkably, in the midst of all this has recently gotten NIH funding for R one research in this space which as you know, for busy clinicians is extraordinarily challenging. So, um without further ado, let me ask dr less power to come out and deliver his cardiovascular brian ranch. Thanks Habib. It's a real pleasure to come out to the northeast Georgia Medical Center today and talk to you about some of my passionate work, as I would say. Hopefully this will be an entertaining um talk on cutting edge surgical options for aortic disease here in my disclosures and over the next 45 minutes we'll take a quick tour around the mostly the thoracic aorta uh to see, see what I sort of think is what's going on in the field. That's new. Um you know, we operate mostly for aneurysm or dissection Z as the two main pathologies. And so starting at the root, what would I consider cutting edge route procedures in the year 2022. Um well, most of the audience is familiar with a standard root replacement. Uh Dr Ben Hall originally described the aortic root replacement, which is basically cutting out the pathologic aortic root tissue and then reconstructing it with a valved conduit and then sewing back on the coronary arteries as seen here in the cartoon. And now we have options off the shelf for valved conduit. Actually a dacron graft married to a valve. Either a tissue valve here, a mechanical valve here. This is the full porcine route is actually a pig's true aortic root. And there are the coronary arteries really, I I still consider the most um cutting edge open route procedure. There's a lot of interest in the aortic valve repair these days is a valve sparing root replacement. And there's a number of different techniques. It's named after the famous Canadian surgeon. Um He's actually Brazilian but spent his career in toronto Tyrone. David who's done many, many iterations of this. But basically he described uh operating on patients who have aortic aneurysms. Originally young patients with connective tissue disorders with normal valves and he would cut the aortic tissue out, leave the valve in place, take a dacron grafts seated around the valve apparatus and then so the valve apparatus back into the graph and re implant the coronaries. This really had a huge impact because you could save someone's valve quickly. Young patients, it reduces the risk of endocarditis. You know, avoids a mechanical valve and all the burden of lifelong anti coagulation. And now in the current area, you know, with a tissue valve in um sure you have room for Taber valve and valves but in a young person, how many times can they have that? So if you can save someone's valve similar to the mitral valve space, you know it's highly desirable and here's you know, kind of a few pictures of how it looks. We do this a lot for connective tissue disorder patients you can see an isolated aortic root aneurysm and then a more normal a sending and in a connective tissue disorder patient of Marfan you want to take out that a sending, you can do it under a clamp so they don't have a type a dissection. You take apart the root, here's the head feet and you can see now the valve looks really good. These are the coronary arteries with little catheters that we give cardio, pleasure to protect the heart. Then you see your graft and you can see this valve looks really good. It's nice and competent and here's our final reconstruction, here's the route and a sending aorta and we uh largely the work of my predecessor Ed Chen is now a Duke. But I joined in with building a probably the second or third largest number of valve spring roots in north America. We wrote written a lot of papers about this over the years. We looked at patients who had real severe ai coming into the operation and they did well freedom from residual ai and freedom from valve replacement at five and 10 years is upwards of 98%. We also do it in the setting of type A dissection patients come in and their aorta is destroyed but their valve is clean and um it can up the ante in a in a High mortality type of operation. But if you can do it um you really gain a lot of benefit from it as um as we can see and the results are good. The freedom from really modern Ai and valve replacement is over 90% approaching 10 years. So that's from an open standpoint, what's the cutting edge solutions really going on in the end of vaster space? And the question is could we replicate a root replacement without opening the patient's chest? And this is kind of crazy. But um it's definitely on the horizon. What what the what the solution would be would be to marry trans catheter valve technology with thoracic stent graft technology with branched or finished rated and the vascular technology that's usually uh used in the abdominal aortic space. Get all these techniques and could you do it well first think about the ascending aorta. This is what I consider high priced real estate. The aortic root has the valve, the coronaries in this little space here. So when you talk about landing stent grafts, you think about proximal and distal landing zones. If you look go below the sino tubular junction, you can obstruct the coronary arteries or you know, interfere with the aortic valve. If you land a stent distantly, you might cover the nominal artery and get a stroke. Or certainly putting a stent graft in an aorta puts a risk, particularly in descending order for dissection. So this Ben Tall would now become an endo mental or myth. So is this you see this topic a lot on conferences? Is this myth or reality? Well, I'm happy to say it's reality and I it's not my work at all. We thought about this, but haven't quite found the right procedure and you would have to get a true heart team. You know, you need, I believe a cardiac surgeon, I'll explain why an interventional cardiologist who has either um coronary expertise and structural or get a structural guy and and very well would include a vascular surgeon who does a lot of demonstrated branch work. That's the kind of team I've thought of if we ever did this. So this report, many of you have probably seen it was put out in joy back now over a year or two ago, of the first true inhuman Endo Ben Tall. So let me take you through their case. This is their work. This is a 64 year old lady who came to the emergency room. And this is from a Brazilian group with two years of intermittent bleeding from the neck, she had a prior aortic valve replacement with pericardial valve. And so when they did the ct scan, they saw this huge pseudo aneurysm from her aorta. That's what this is up here. And um it had fish socialized to her super sternal notch. I have not seen this complication and I hope I don't, her aorta, as you can see, looks very heavily calcified. This is all this white wasn't true porcelain but it's close. Her echo showed that her previous valve now had a gradient of almost 30 millimeters of mercury. So she had moderate A. S. The heart team met And based on her euro score of almost 30% plus this near porcelain aorta. They said there's no way she'll survive open surgery, which is probably true. You can't get into this chest without getting into the aneurysm. So she would have to go under cirque arrest before you open the chest. They initially tried to include it with amplats acc Luders and that's what all this what we would say endo trash is here, you can see that. So so could they do it And they did it and here's how they did it. They had the their industry create a customized valve and the graft. And the design is really remarkable. So they took an expanding, self expanding thoracic stent graft. They married it to a trans catheter valve right there. Um So it's all in one and it was the valves pre mounted on the balloon. Then they had um branches already put into the graph for the coronary arteries that had both internal and external components. Um And they were up high that these would sit above the sign of tuber junction so that the operators would have space to work and the coronaries would beep refused. As you can see it's a tapered diameter. So this part is going to go in the distillation in order to obtain your distal seal. And the trans catheter valve would then seal at the aortic valve annuals. So here's some of the videos of their case. Again, not my work, they gained femoral and a pickle access. The coronaries were pre wired. You can't really see it too well but for guidance and then they put their valved conduit in um an unsheathed the stent graft portion first with the valve is sitting there. Now they inflate a balloon and blow up their trans catheter valve. Now at this point they are using peripheral V. A. ECMO for him. Oh dynamic stability to give them plenty of time to start the coronary work which is the most time consuming work. So next after being on V. A. ECMO they had the wires, they went through their branch, they can relate the right coronary artery and then deployed a self expanding stent which this bullet which is this video here and then they shoot their angiogram and have a nice result there. Now they move on to the left um here they used a balloon expandable stent calculated left coronary expand the stent. There videos are a little slow and you could see they had a nice result with this. Again, the V. A. ECMO was key in providing them time and stability. Their total procedure time 400 minutes long, zero and a league. The pseudo aneurysm was thrown boast fistula closed at nine months is short follow up and no M. I stroke patient was doing well on dual anti platelet therapy. So you know, this case was it was really an interesting one for the field. I think Endo Ben tall, so to speak, is an evolving reality. They hit on this ideal device, a stent graft married to a trans catheter valve. Already with pre made administrations or branches for the coronary. These will all I think be customized initially but industry is already onto this and hopefully an off the shelf configuration will be available in the future. I point out there was a second case that hasn't been published or is in press. This was for an aortic dissection and the people simply took a stent graft and put large holes in the stent graft. They burned them for the coronaries just to make large holes. This wouldn't work for aneurysm pathology but to seal a dissection. Um it very well would and I think it's key to be able to use peripheral V A ECMO so that you have time. It provides stability and maintains coronary perfusion. So that's the route. Let's move up a little bit to management of ascending aorta and arch aneurysms really. Open surgery remains the gold standard. Um What is probably novel is just how we protect the brain in the last five years. So briefly aortic arts repair. The outcomes depend not only on your surgical technique but you have to think of organ protection. And first and foremost though we're heart surgeons is it doesn't matter if you have a beating heart, if the brain is dead. So we think about brain protection a lot obviously heart protection and then the lower body profusion almost in that order. So there's multiple strategies of how we manage to search circulation. It depends on where we can relate the aorta or it's arterial branches, We conduct hypothermic circulatory arrest, which I'll explain that term in a second and then the addition of, can we give blood flow to the brain during while we work on the arch essentially. So, a brief history dr randy grief from new york was the first to describe the successful series of arch replacements in the late seventies. And basically what you do for patients with arch aneurysms, you put them on pump, Cool them down for 45 minutes or so, get their brain temperature to 18 or actually less. Sometimes he would go to 14°, turn off the pump and start working as fast as he could cut out the arch. He saved the great vessels in an island technique here. So on a graft and then reattach this great vessels and start the pump up. And he was only using hypothermia. The theory here is when you cool something down, it slows cellular metabolism. So you're on the clock, you got to be moving. So this hypothermia obviously provides cerebral and visceral organ protection by slowing metabolism down so That we have fortunately evolved since the 70s and have gotten better results. So mostly these operations were done with a large accumulation and as I said, hypothermia alone fast forward today we do these operations by calculating a number of different areas depending on the strategies and we've added actually blood flow to the head either in a retrograde fashion or an a grade, giving blood directly up the carrots. Here's kind of our go to method at Emory um we sew a graft onto the right axillary artery in the delta petrol groove. Here we go on bypass there. And then when we're ready to work on the arch and do circulatory rest, we've shifted the paradigm. So now it's really just the lower body that is without blood, we don't have to cool as hard because we're giving blood through the carrots the whole time. So we put clamps on the phenomenon and left common carotid artery and you can see the blood then flows down and up. And usually we just do unilateral one side. It keeps our operative field clean and it is sufficient for excellent results. Here's what a hemi arch looks like. This is the most common operation really performed for the risk aortic aneurysms and a sending aneurysm usually involves some period of circulatory rest. You can get that distal a sending an art so that all the approximately aortic work is done. And we studied in a number of different ways. Our standard hemi arch replacement. Now we cool the patient to a bladder temperature of 29 28. You're usually on pump for about 20 minutes, cooling before it's time to circ arrest. Go cut the arch out. And we've shown in a various number of compare is that compared to colder temperatures. Um There was no difference in our mortality stroke, delirium renal failure. And so we've proven to ourselves that really an elective hemi arts can be done safely with a bladder temperature of 28 or 29. That is the bladder temperature. If you're measuring the brain, it's colder at that time actually. So you do get hypothermia to the area where it's the most important and these can be done in general with a 20 minute circle rest time, 25 minutes. Um And done safely. We also looked at this technique for more extended arch replacements when we're doing the whole thing and really you do need an a grade cerebral perfusion for these. And again we showed this is an older paper in about 150 total arches, both an elective and emergent That you could use. This integrates perfusion, cooling the bladder a little colder. If we're going to do a total art, we want that bladder temperature around 24, Again the brain gets to about 19, your cooling more for about 30 minutes before you circ arrest. If you're going to do more than just a hemi arch. So that's the cutting edge open techniques. What's going on in the end of astro space? Well, you can look at a number of reports throughout the literature of these. One offs of treating a sending aortic pathology with stent grafts. We've published a couple ourselves. Um This was a pseudo aneurysm as you can see down here and we took stent graft which is too long for the a sending aorta, measured it, cut it, repackaged it and deployed it here and got a nice result. Um that was for a pseudo aneurysm. This was for a Taipei sent to us. It was a retrograde type, a dissection. So the tear was distal to the left subclavian and the dissection flat went retrograde into the ascending order. In a Jehovah's witness that I couldn't convince to take blood. So there was no way we were going to do open surgery. And that gave us some opportunity to think and create a solution. And we did um cervical de branching, which is a karate karate, Karadzic libyan bypass whenever I do thoracic stent graft work. It's a combined program with our vascular surgeons which we've really worked well for the patients and us so we have them involved. Doctor will Jordan help me with this case, he did the cervical de branching. Then we stent it across the art and he put a snorkel type chimney stent into the phenomenon arteries you can see here and that fixed the dissection um and got an excellent result. So there's case reports but there's no real devices approved for stenting stenting the ascending aorta for aneurysms sort of the sections. And we're going to move into the arch here too. So what I'm going to talk about in the next few slides is what's going on in the space. So there is currently efforts to develop stent grafts or the extending aorta. This is from gore uh they have a trial called the arise trial and there we are not part of that unfortunately and it's a short stent graph, very flexible and can formidable that they're using for type a dissection. The early feasibility trial is almost complete. We hope to join is a pivotal sites so that when we have these, you know 80 90 year olds or people with comorbidities, maybe they would do better with a stent and and it's not the panacea I've heard and seen some of the results. Um but it is an option, it's I don't think it's ever going to replace open surgery, particularly in the young person that can um that that can tolerate an open operation. But it would be a good tool to have. Um This is the A. M. D. S. Dissection stent that was now under the cryo life which is now called RTV in um portfolio. And we are a part of this trial we haven't put one in but this is for the arch. So it's basically a bare metal stent that you can see here goes across the dissected arch and it's relatively easy at least it looks like of course like all of these products to put in. Um I have not put one in yet. But what you do is you in a type a dissection, the indications for distal malp profusion. So they comment with a type A disk section and maybe their leg is cold too due to malpractice fusion. And you want to open up that true lumen and not have to do some extended arch with a stent graft. And this fancy work that's gonna take forever in this high risk. And they've developed this bare metal stent that goes across the arch vessels. So you've replaced the ascending aorta which is what's going to kill you. But the malp perfusion distantly still maybe um present because the true lumen isn't open. Well this stent helps it so you circ arrest you deploy the stent across the arch and then it has it comes with a nice dacron soft felt collar here, which is a sewing ring for you too. So to, and you actually cannot do a hemi arts. You have to cut your aorta, it's almost an open distal. Um, and and then you deploy the stent in and so your graft on and that trial is starting now, the early work has been done in Canada and europe and it's promising and I think this is gonna be actually a tool that a lot of us use. Um, it's very, I think straight forward what's going on for the arch. So there are two designs, their single branch under graphs and dual branch. So this is the gore thoracic branch and a prosthesis. It has a branch for a single arch vessel and you could put this in the left subclavian or carrot or a nominee on. Um, it's, we've done about five or six cases were part of the trial and it's a good device. It's very easy to use. It's all done transfer morally with a wire out the arm. Um, it's currently in trial for aneurysms and chronic dissection. The pivotal trial is almost complete. I bet this will be available off the shelf, year and a half or two and this is a good solution. This will probably eliminate the need for caracas, a craving bypasses for a number of either dissection or it will, it will make it a historical operation I feel. Um Now moving in a little bit more fancy are the true um uh graphs that are designed for arch pathology. So this is the nexus device the company has to span and it basically has a single branch that goes into the phenomenon. So you have to do a karate, karate, karate subclavian bypass to revascularization, head vessels first, then this can all be done. Transfer family. Again, you have to have a wire out the arm, you deploy this first piece and there's only a very brief period, maybe 15, 20 seconds where that a nomination may be getting reduced blood flow but then it's open and and then you add this second piece. The blood flow is coming out the order and feeding everything once this first main body is deployed. Then you add the second to get your seal and approximately or to um We have had the, the clinical trial going on, it's called the triumph trial. It's a pivotal trial currently enrolling for both chronic sections, aneurysms and then penetrating ultra aortic ulcers and intramural hematoma. I've not done one of these cases yet but we do have to accepted that are, we're going to do it and it's promising. So the other one, the other design is then a dual branch pathology and the real discerning factor of which design is going to work. It's going to be stroke data pure and simple. This is from tara mo aortic. It's called the relay branch. There's a branch for your break is a phallic one for the left carotid. You have to revascularization subclavian artery because you're covering that requires bilateral created cut downs. Um And basically you deploy this initial draft. It's got to inner tunnels which you then Kanye late and put stents in. And I'm gonna show you how this works as we have done one of these cases. So this is the ideal type of case that you don't want to do open surgery on for the stent grafts will be really a game changer. This is a 69 year old female. She had an expanding 5.9 centimeter arch aneurysm. Easy to see here. Bad lungs, crying kidney disease, bad peripheral vascular disease. Smoker. We've all seen these patients. She lives alone. She's not going to do well with an open surgery. This would require a left or economy circ arrest probably because I don't think you could get to it from the front and she would likely have betrayed and maybe on dialysis. So we enrolled her, got her accepted in the trial. And again um it's a two stage approach. We did an aorta them bypass with a large dacron graft to tackle her aorta iliac disease because the device wouldn't pass. And now we have a nice conduit which we can deliver these large boy For 22 French devices. She also got a cracked screen bypass. We did that center home two weeks later brought her back and put the stent graft in. Now when so again when you put this main body stent graft across the arts, this area is open. So you're refusing the brain the whole time. There is no rush risk etcetera. You then why are these two inner cannula as that are in here? There's an inner um components. And then you put bridging steps up to the carrots and it gives you your your brain profusion. So here's a few and those from the case this is us deploying the stent graft across the arts. It's just crazy how long and sort of bulky this is but very smooth, very easy. Next we shoot our aorta graham with our stent graft in place. You can see the large arch aneurysm. And the other thing that was pretty interesting is you didn't have to be that completely accurate and I'm gonna show you why there's these little dots here which is where this rectangle of profusion to the head occurs. So now we're deploying the graft here. We use rapid ventricular pacing, you just unsheath the thing and it opens. And as you can see over here there's these radio opaque markers around this rectangle that provides your brain profusion and here they are. It's a little hard to see but here they are right here and that's your area where you're going to Kanye late for your breakup phallic and carrots. So now we've we start working on the right carotid at first. Now it's all network. Um And our vascular surgeons were doing this with me, they can related the tunnel, this inner tunnel for the break yourself alec. And you can see a stent now deployed here, that's one of them. Then we moved to the left side. It's complete here. So the seal for the aneurysm is high up in the break yourself alec and left charity. You have the stent graft here and we've got a nice result. Here's the completion angiograms. You can see um no feeling of the aneurysm sac, the cervical vessels and great vessels all filled and there's the bypass. Um So this worked out well in our first one, here's the post op ct scans which is really the gold standard. You can see both tunnels are patent and the aneurysm is thrown boast. So this is a very interesting device. There's a one month crazy how it looks. A lot of metal in there. But she did well. So that's what's going on in the arch. Let's move down now to the distal aorta, the descending thoracic abdominal aorta. We still do about 25 open descending or historical abdominal aneurisms a year for mostly chronic dissection but they're mostly young patients because anyone really as you get to 65 70. It's a big hit as we all know to do open surgery on these patients and can we make progress with more minimally invasive endovascular approaches. Certainly for acute type B dissection that is complicated by malp fusion and rupture in the last 10 years. Really stent grafting those patients is the gold standard. And we've written several papers basically showing how you can take a dissected aorta and remodel it, convert that to lumens into one with a stent graft. Um We've shown that it's safe to stand all the way from the left subclavian down to the celiac in the initial procedure. And then the real question in the acute Type B dissection spaces, what about the patients that come in have a Type B dissection but they don't have my profusion of rupture. And this is where dr Sami alluded to. I have some NIH research funding. We're looking at those patients because yes, you could stent them all but not all of them will need a stent. So which ones need a stent because if if they need a stent they're going to dilate into an aneurysm in five years. They're better off stinted right up front. But there's risk to that there's stroke. There's paraplegia even as low, there's the car cost of the device. You know, it's it's not a it's not a freebie in fact where there's a whole new avenue of research going on in terms of what the adverse effects on the heart is when you stick a stent graft in the aorta when you do that, putting a stent graft in the aorta? It turns the order into a lead pipe instantly and therefore the after load on the heart is really increased and you can have some adverse cardiac model. But for a complicated type B no doubt should be getting a stent graft. And here's kind of what I was talking about. The remodel. So you put a stent from the left subclavian all the way down to the celiac, usually two stents. And you can see here in this cartoon here, here's pre op this is the mid descending aorta. That small loom in here is the true lumen. This is what it looks like at one month. The stent is now slowly starting to expand at six months. It's bigger. And look at a year, the false lumen is gone and you can really eliminate the entire false lumen in the chest. In most of these patients. After a year, then you're just following a dissected abdominal Aorta and I in my 10, 11 years um after training, it's rare if you fix their chest that their abdominal aorta is ever going to need anything. So the real question then is what to do for these patients who didn't get a stent initially and now have a chronic dissection. They've developed an aneurysm. And now they have traditionally they're only they're only therapy is open descending north oracle abdominal via large incisions. Um So what are we doing in the end of vascular space. Well chronic this T bar for chronic deceptions, it's feasible. You can do it with really reasonable morbidity mortality if you have a limited dissection that ends above this celiac and you can get the primary entry and exit tears. The stent graft will cure it. So, but those are rare really most of them. The dissection goes all the way down whether this is a residual type A or a true de novo type B. We know you should cover all the falsehood administrations. But the real thing that defeats stent graft therapy currently is retrograde false bloom in profusion. And this is what we're talking about. So you lay your stent in in the chronic type ease. The dissection flap is much thicker and rigid so it doesn't move over like like I showed you in the remodeling with an acute be. So the blood flow goes down here but there's tears throughout the abdominal aorta distal to your stent and the blood flow crosses over and goes back up. Retrograde in the false lumen and feeds this aneurysm. And so the stent alone doesn't defeat that. So how can we tackle this? Well, you can symbolize the false lumen which I'll show you or try and create a single loom in a uni loom in ization for lack of a better word to create a true distal landing zone for your stent. So I'm gonna show you a couple strategies here. You can put coils. This is this is not my case is courtesy of frank arco of bachelor surgeon in charlotte. Um you put coils and and no trash to try and slow down the flow in there or devices have been created. This is called a candy plug which is a stent graft that actually you go in the false limit. So the concept is you want to funnel all that retrograde false bloom in profusion into a small channel and then put a plug in it. So what these guys did here is they took a short stent graft. They cut it, put a collar in so they created their funnel, so to speak. They named it a candy plug like a tootsie roll. Although it's a reverse tootsie roll. Never quite got that. They then put this this candy plug in the false lumen creating their funnel and put a little plug in and you can see here it's worked well for various people. We've done it. I'll take you through this case briefly. This is a lady who came in with uh an acute type that was ruptured. So all that's blood in her left chest. These are emergent cases. We actually take them emergency to the O. R. And sent them and don't put them to sleep because unfortunately I had one that was rock solid stable talking to me with induction of anesthesia. I went to wash my hands. I come back, there's no blood pressure, no one even knew she was done. So we now with tavern being done awake. We've mimicked that protocol and it's worked out well. Um and we published it. But basically for ruptured type B's. You want a stent from the left carotid covering left subclavian all the way to the celiac. And so we did that with her and we got her out of the hospital. But this is her one month scan and there was a lot of profusion of the false lumen and you can see it best on these static images. She was having a lot of back pain. Now they all have back pain after a stent graft. But this was a little bit more right between the scapula is what you want to pay attention to. And I looked at the ct scan. I said wow that aorta is big. In fact it's over six centimeters in a month and it was all due to flow coming retrograde back up. The green is thrombosis but this is a jet of blood coming back up, feeding this six centimeter angelus. So you know what to do here. I was pretty convinced this was not an A. Grade filling. It was all retrograde. I could have done a left or economy. Um taking the stent graft out and we've done it or try a false lumen embolization which is what we chose. You gained true luminant access. I nicknamed this the gemini procedure because I thought it looked like one of these nasa space capsules but basically this this is all abdominal stent graph technology. Um This is a aorta iliac converter. Um For abdominal aneurysm work you take this, you deploy it, flip it around, repackage it so you're putting this narrow end up towards the head in the false looming. Then you take this plug and put a plug in it again creating a funnel creating a blind pouch and putting a plug in it. So here's the angiograms basically the case first we went in and we confirmed that this was not an agreed filling in the false lumen and this pig tails in the in the true lumen distal to our stent. You can see this blood flow right here. Start creeping up late. It's it's slow filling. It's but it's it's creating aneurysm all degeneration. So now we've deployed our stent graft you can see here in the false lumen, we've put our plug in and really what you want to do is put your sheath or catheter in the false lumen and shoot a picture. And what you can see here is the contrast goes up and stops where plug is. So we felt pretty good about this and it worked. Here's the C. T. Scan the false lumens thrombosis, it's much smaller. There's the stent graft um in the false lumen right here just to the distal and you could see pre false lumen embolization. You got the huge jet. Now it's all gone thrombosis. Oh it's a good technique to use. So the other strategy and I'm gonna finish with this case in the next 5, 10 minutes is creating this single lumen so that the stent graft can get a seal. Um And there's a number of ways to do it. There's what we call balloon fracture defenestration, the knickerbocker technique. Or can you do what we would do open which is create a connection between the true and false woman by cutting out the flat. Can you do that in the vascular? And there have been a number of ways that have been described. I'm going to show you are kind of novel technique. So the first is basically just fracturing the stent, the dissection flat. And it's a great technique, the guy who invented it, uh Hilo Coble called it the knickerbocker. Because you thought that somehow it looked like a pair of knickers. What you do is you put your stent graft in the chronic dissection, the true lumen. Then you take a balloon, you blow it up and you intentionally disrupt or fracture that flat so that the covered stent graft opposes the aortic wall. And the false lumen that way when retrograde blood flow goes back up the aorta, it stops where you meet the wall. And it's a it's a very good technique and it's safe. It's a little harrowing when you first do it because as you can see all of a sudden boom, the balloon goes out and you've ruptured the flat and you're thinking oh my God, I just ruptured the aorta. Um So you have to prepare everybody in the room. But eventually you get used to it, it's a cool kind of picture and the dynamics are completely stable the whole time. So this technique does have its limitations though. Um Because you cannot control how much of that flap you're going to rupture. And does that lead to problems? Yeah it does. And I'm gonna show you one of our cases here, you can see here we're ballooning. You don't want the distal stent to expand because if you do you'll create a new entry tear into that false lumen distantly. And that's what happened in this case. The the whole thing starts to expand here and now when we shoot a picture you have this just explosion of blood flow into the false lumen. So it's not outside the aorta. But now you've you've created new and a great feeling of the false lumen to to an already weak um wall. This patient after the procedure had severe pain. We kept him in the hospital, we scanned him two or three times his aorta grew a centimeter in about two weeks and we had to do open operations an open operation for him. So this is clearly a failure of the technique. So can we improve precision and control with an endovascular methods. The michigan guys really tuned me onto this. They're very smart, great group up there. They started doing uh ministrations of the flap to try and control where you rupture the flap. And they did it with laser uh endovascular laser cept Autumn E where they burn across the flat with the laser create a hole or a cheese wire technique. They get a whole they get catheters on both sides of the dissection flat and pull down. Well I don't use lasers. I'm not a cheese wire guy. So could we do something else? Well I'm a member of our structural heart team at Emory and several years ago we learned how to do trans cable techniques and I'm sure it's done here too. But basically it falls under this umbrella of trans catheter electro surgery which is being used and evolving in the structural space. It's a fancy term to say. You're going to apply external source of electrical current outside the body to electrify a small guide wiser inside the body to perforate live or prosthetic tissue as you may know, it's being used to split prosthetic valve leaflets to split mitral valve leaflets in the trans catheter space. And for those who aren't familiar it's kind of crazy the trans cable technique but it's really been revolutionary and I was definitely a nay Sayer and yet I went and learned the technique and Detroit. We brought it back and I'm a true believer now. So what you do for for trans cable access for Taber for people who don't have good trans femoral access is you take a catheter with a small coronary wire. You burn a cross the I. V. C. Using this electric Kateri create a small hole between the I. V. C. The wire goes into the aorta. It's snared brought up and then you convert to a stiffer bigger larger board wire. You then take your delivery system and you actually make a larger hole in the I. V. C. Area or to deliver your tavern and then on the way out you close it with a little plug. Sounds crazy, sounds dangerous. It's very safe. I mean it's shocking how well it works. So could we use this hotwire technique is what I called it to improve our focal dissection flat administration so we have more control. The answer is yes is I'm gonna show you. So this case and this is how I'm gonna finish the talk is a 52 year old morbidly obese truck driver. He had a type a a DeBakey one he got fixed was lost to follow up. Now he needed his D. O. T. Card re upped so he shows back up in clinic five ft 7 £343 and a 7.5 centimeter descending and we can't let this guy drive. He's going to rupture and kill somebody besides himself. Terrible operative candidate based on his body habits. This one kidney. This guy is going to be tricked on dialysis. We've all seen it. So we wanted to do a stent for him. So we did a crowd subclavian bypass to optimize approximate landing zone. Then we finished rated him with this hot wire technique, which I'll show you put our stent graft in and then fractured it. Where we did this fin astray shin and got a nice result that was more control. So on the cT scan you're gonna look for an area and it's generally right near the diaphragm where the aorta is, has to be about less than 40 millimeters. And you use your vertebral bodies landmarks. You get catheters and wires in the true and false lumen. So this is our steerable catheter um with a micro catheter system ready to perforate. The dissection flap is right here and we have this target this hoop right here, the snare and the true lumen. So you line up, you got to use bipolar, which is for me as a cardiac surgeon. My brain doesn't work that way. But fortunately I've learned a few things. So this is how you're looking into your posterior and that looks pretty good. But you have to use the biplane because you may be completely missing your hoop, you can go outside the aorta etcetera. So when you're lined up in the lateral camera this, you know that you've got your orientation correct, then once you do that, you tell your person, alright, three seconds they put they press the electric artery and you carefully just advance that wire and it goes through like butter and it is safe even when we've missed and we've gone outside the US once or twice with that little coronary wire you don't see any bleeding. So next then once you cross you then tighten your snare advance it up the aorta. Then you're gonna confirm that you actually have this this is intravascular ultrasound. You can see this wire here crossing from the false limb into the true there's this nice administration you've made you switch to a stiffer wire and now you're going to create your your administration with a balloon. So this is a 28 millimeter balloon. It's across the dissection. You see a neck and then bam it opens up. Now you've created a nice hole in that dissection flat and this is what it looks like on ivy's real time. You just see this balloon blow up and rupture that flat. Now you lay your stent in after that work and then you do your knickerbocker, you balloon it and now it is a focal expansion of that stent. It doesn't just rip the entire way. Um We did our false women angiogram. You can see the contrast goes up to where the stent graft opposes the wall and stops and we got a nice result. Here's the arterial phase of the C. T. Scan this is calcium really. But there's dramas. And right there you can see the stent graft opposed the wall. And we did a delayed venus to show there was no late filling as well. So in summary cutting edge solutions for aortic disease is really the endo approach is what's really going on. That's going to move the field forward. Stent grafts have crept up from the abdominal aorta where it's easiest straight pipe and started into the branch, abdominal descending. It's making its way over to the arch and the a sending you know my crystal ball. I do think the endo Bente will become more of a reality in the in the next 3 to 5 years it's going to be hard. That is hard stuff. You got to have a team to avoid coronary ischemia. As I mentioned you gotta use V. A. ECMO. I think stent grafts will play a role for inoperable Taipei's. The industry needs to provide larger diameters. Currently the largest diameter stent grafts are 46 millimeters. We really need 50 to really tackle a lot of that and it's not gonna work. Arch pathology. These stent grafts I think in another 18 months certainly I think the gore is gonna be the first one to hit the shelf first. The the true success will be based on stroke outcomes is being heavily scrutinized when you put wires and catheters in the carrots. You're gonna knock stuff loose. The real question is in those trials is how we define a stroke because if you M. R. I. Everyone they're gonna have little hits. But what does that mean? A lot of these are silent strokes and as I showed you a chronic distal dissection is going to depend on some novel devices for the false lumen and techniques. So I'm gonna stop there, entertain any questions. I really appreciate the invitation for coming to talk today. Thank you. Take the microphone. Well, that was an amazing tour of course talk. Um let me see if there are any questions from the audience and I know Suzanne, we've probably got some virtual questions coming in as well, so feel free to chime in. This piece is broken. Hey brad, thank you for coming, enjoyed your talk for sure. I got a three questions basically. We kind of are in the uh dissection belt, as I call it up here. We do a lot of dissections. We've made an informal policy of trying our very best not to operate on someone 80 years of age and older, kinda wanted your opinion on that. Number one. Number two over the last year or two, we have been trying our best to do a lot of valve repairs. Aortic valve repairs were utilizing the heart ring, what do you all experience with that? And then number three with all this new technology, all those devices are very expensive. As you and I both know you add on um V A ECMO, you gotta be, you know, you're spending a lot of money, I just want to know your thoughts on that and the future there. Thanks. The the octogenarian with the Taipei is always tough. Um It's cliche to say but I look at everyone individual um you know I've had partners turned down 86 year olds that I went and saw and got through um surgery. So I think you can't write them off as we've learned with cadaver. Everyone's different. So I would I would look at anybody octogenarians for Taipei's individually. I think the stent grafts could help in that population. The valve repairs I think is absolutely key. So I applaud the use of the harding. I haven't used it. It's intriguing. I just haven't um I got to make the commitment to do it. Um It looks straightforward but most of the valves in a type a dissection are normal as you know and just narrowing the sign a tubular junction down. You don't have to do a route usually. And those patients, even if they leave with mild or or sometimes modern ai depending on their age, that's better than putting a prosthetic valve in there. Um And then as far as the device is the price the ECMO totally agree. It's a tour de force. Um And you know I've I've uh particularly in the setting of a type a dissection. It feels like a lot of people want to put stent grafts down the arch and descending and you know I don't that stuff usually hasn't been necessary in the previous decades of work. Most people got by with just fixing the a sending and hemi arch. And only about 20 to 25% of those patients need um need further operations in their lifetime adding the stent is just burning 15 grand now. But as far as that other fancy stuff. Yeah I think that that that that's a real challenge. Uh It's it seems cool you could you could offer it to somebody but the reality is it's probably you know the cost may be prohibitive for a 85 or 90 year old who whose lifespan even with this procedure they're gonna stay in the hospital for a couple of weeks and probably never will be the same. So I think that you have to be selective just like that. Uh Very good. Great talk. Thank you very much. A lot of great work that y'all are doing their when it comes to the type B dissections and this may tie into some of your research with the uh grant that you're getting. How do we know which of the type B's uh need to be grafted and extended. They come in we control their blood pressure and there asymptomatic. We leave them alone. But if they continue to have symptoms we have a tendency to go ahead and try to graft those. Do you have an algorithm or thoughts on which ones we graft and which ones may be high risk for future problems that if we fix them early on would be much much more simpler. So obviously the ones that have malp er fusion and rupture, it's no brainer. They should get stunted. But you're talking about the uncomplicated type ease. And there is data as some of you know that quote intractable pain refractory hypertension has been shown to be a risk factor for more mortality compared to those who don't have that. And uh so those I've tended to stent and be aggressive um there's an argument to be made to stent every single type B. Um And and this and I've been frankly on that end of the spectrum and I've had to rein it back actually for my NIH grant to really study it because you can do these type B's and and really it's safe and low risk. Um and if they're going to follow up, you can really follow them and the stent graft will reduce their pain as you know. So getting back to the real world scenario, an uncomplicated type B comes in. We they get their initial scan at time 0 48 hours later I re image if there's any significant change in the false lumen size perfusion. If there's a new lake of contrast that from an atomic morphology standpoint, they buy a stent it takes, you know, takes all week now to ramp up their blood pressure medicine safely. And they're still having pain? They may get a third scan. You know, these these are the ones as you know, about 10 o'clock at night. You get to call, hey man, he's having chest pain and like, oh did he convert to a type A or something? You know, they get another scan and you see there and so I would say refractory pain and hypertension. I buy into that and I spent those people they'll still leave with pain but I think you'll reduce it. Um Unfortunately, so that my grant, as you alluded to, we're going to come up with a risk score based on an atomic criteria from the ct scans, how large their primary into multi areas, how large their false lumen is. Um We're gonna use some of the tissue we take from surgery, biomechanical testing and then we have this fancy computational fluid dynamics which I understand about that much of right now pile all this stuff in with our Georgia tech engineers and create a risk score and hopefully that will give us guidance. But that is the question of what what to do with those patients. We have a question. We also have a question on the chat as well. After this. Thanks for a great talk. I was just wondering if you looked into your crystal ball, how the training of the future. Um fellows in training from interventional cardiology cardiac surgery, vascular surgery will evolve to sub sub specialize in these techniques because this is advanced work. And you talked about having a structuralist uh coronary interventional ist vascular surgery, cardiac surgery all in one procedure which uh is a huge amount of resources especially at a smaller institution than emery. Um so how are we going to train future surgeons in the field to really have these interventional techniques and then how are we gonna keep surgeons with the bread and butter operative uh expertise as well because it's hard to have both definitely. So I'm gonna start backwards the front that A. M. D. S. Stent graph that I showed you, I think is going to be a valuable tool that every cardiac surgeon will be able to do it straight forward some of this branch to arch technology. Um I think that a cardiac surgeon interested in this would need to do advanced kendo training uh and do an aortic fellowship, dedicated time or dedicated end of work like I had to do after my training to tackle that. I think trying to pick it up on the fly is a tough ask when you're gonna hopefully be busy doing open surgery. Certainly. Um My vascular colleagues have moved forward doing feminist rated bars and I don't do that. I don't pretend to do it. They've asked me to scrub and frankly my interests, you know, I wanted to be doing trans catheter work about 30% of the time and still maintain a very robust open practice. So for a cardiac surgeon to develop this, I think they they're going to have to really spend time after training and then dedicate their time and they may not in the future be doing uh you know, off pump coronary bypass, that it's going to become more super specialized. Uh and so how does that work in an area that uh then when you don't have that, I think you're gonna have to have teams um to team up with vascular surgeon, vascular surgery has gone the other way. Um It's more challenging to find now young vascular surgeons who can actually come out as we all know and do open big, big surgery because they're so skilled and most of the vascular training has gone endo. But but that's the beauty of my relationship with the vascular eyes. They keep me fresh and up to date and allow me to, to to maintain my endo skills, um, cannula in various branches of the aorta. I think cardiology is a huge, is going to be a huge person to rope into the space. Um be it from a vascular surgeon standpoint or a cardiac surgeon standpoint, um particularly as you move more proximal into the aorta. So, I think, dedicated train to answer the question. I think after your bread and butter, dedicated training, certainly Tavern is now becoming a rotation within our cardiac surgery training. Every one of our trainees has Tavern. So that gives them the basic wire skills, but certainly it's not enough to do this stuff any more questions on the floor. We do have one in the chat brad. You hear me? Um Honestly fantastic work. And it's amazing that you're bringing together all these different sort of disciplines to try to answer questions. So where does um sort of individualized care for this complex anatomy come in with technologies like three D. Printing? Um You know I know that I think the vascular surgeons do have devices that are designed for their procedures. What about the art space? Um It seems like uh some of the devices were sort of makeshift devices to try to fit an anatomy but with three D. Printing techniques now, are there not the possibilities to design and devices that are dedicated? And then the second part of it is you mentioned the effect of metallic stents in the aorta. Um and their impact. Or is there any interest in any biodegradable materials and three D. Printed in the space? So um certainly the 31 of these stent grafts, the nexus device. Uh I have, I'm one of the P. I. S. On the trial. They will actually take your case and make a model of it to see if it's gonna work. And surprisingly it must not cost them that much. They do it a lot. So they'll do a feasibility and say this to the best of our knowledge will work through a polymer model. So that is going on to create individual devices. I know that for instance, my partner in the structural heart space, Vasilis Babayaro gets all these weird congenital cases and he I think has done an occasional three D. Printing. Um I don't know how widespread it is, but it's starting to uh to to come online. Um The second part of your question, the adverse remodeling. I think you're gonna hear a lot more about this, particularly as we put stent grafts into uh into younger patients. So there's an interesting paper in a trauma, in the trauma literature about putting stent grafts in transactions. So you have these young otherwise healthy patients with no corn more biddies. And they saw that over a five year uh period their blood pressures went up and their their pulse pressure uh narrowed. So uh there is it's not without a price to put a stent graft and make that aorta noncompliant with respect to the heart and young patients. So I got on this line of research and I'm starting to get into it. And I've thought about the biodegradable stent graft. I think the the guy that was one of the first people to do abdominal stent graft is probably from what I hear is leading the field juan Perotti has interest in this biodegradable stent graft or something that's more compliant bottom line I know of no none that exists, but I think there's some intellectual property already starting in that field. Um And it's been a thought of mine but it's I think it's far off so far. But yeah, you're on to it for sure. Suzanne, what do we have virtually questions? Well you may have answered this already, but um Dr Syed says great talk, can you speak about three d printed models, utility in this field? So I know that. Yeah, I don't know a ton about it, but as I just mentioned, I think it's it's becoming reality. It's helping for sure. That's all we have on a chat. You know, there's six after eight. Well any other questions? Okay, well fantastic. For many of you will know that brad and I will walk over and do an interview, formal interview that will be posted on our website uh with some more in depth questions. So please look out for that um in Robbie's studio, but thank you all for coming. And dr Leshner, thank you so much for a fabulous car shoot. Yeah. Little plastic piece on that side. I think it's that, it was there. This has to clip onto the switch. I just dropped it. I'm a butterfingers this morning, I think. So the little clip there will go on the button and that's how it will go off and on. I had it working. But there's yeah, I'm so sorry, I am happy to pay for that. Pay for a microphone PS is totally my fault really
