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Aortic dissection: current percutaneous options

Aortic dissection: current percutaneous options. Advanced Angioplasty BSET Jan 2008. MY CONFLICTS OF INTEREST ARE Preceptor for complex endografts for Cook. Multidisciplinary. Radiology Vascular Surgery Cardiology Anaesthesia Cardiothoracic surgery. Imaging.

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Aortic dissection: current percutaneous options

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  1. Aortic dissection: current percutaneous options Advanced Angioplasty BSET Jan 2008

  2. MY CONFLICTS OF INTEREST ARE Preceptor for complex endografts for Cook

  3. Multidisciplinary • Radiology • Vascular Surgery • Cardiology • Anaesthesia • Cardiothoracic surgery

  4. Imaging • Pre-operative CT and workstation review • Intra-operative angiography • TOE • IVUS

  5. Acute type B aortic dissection • Endovascular intervention for: • 1. Failure of medical therapy • Malperfusion • Rupture • Rapid enlargement

  6. Haemodynamics • True lumen collapse • Depends on ratio of inflow capacity to outflow capacity in true and false lumina • Reduce FL inflow - endografts • Increase FL outflow - fenestration

  7. Primary treatment aim • Cover the primary tear • Stent grafts: • PTFE, Dacron • Nitinol, stainless steel • Bare metal? • Barbs proximally?

  8. Hybrid theatre

  9. Arch angiogram

  10. Length of stent graft?

  11. Distal bare metal scaffolding • PETTICOAT concept • Provisional extension to induce complete attachment after stent graft placement in acute type B dissection C Nienaber JEVT 2006; 13:738-746

  12. PETTICOAT • 12 patients • Primary tear covered • Persistent distal true lumen collapse and perfused abdominal false lumen • Adjunctive or staged • Uncovered stents: Sinus, Fortress, Z-stents • 120-230mm • True lumen increase 4 – 21mm

  13. Fenestration techniques • Via natural fenestrations • Punctured with guidewires, TIPS needles, re-entry devices • Guided by angiography, snares, balloons, IVUS • Enlarged by balloons, or guidewires - push cuts (scissor technique) or pulled

  14. Fenestration: natural

  15. Percutaneous recanalisation devices

  16. Percutaneous recanalisation devices Courtesy of Roy Greenberg

  17. Outback catheter

  18. Outback catheter

  19. Outback catheter

  20. Other techniques: TIPS needle

  21. Hartnell, Radiographics 2005

  22. Chronic dissections?

  23. Conclusions • Challenging and complex multidisciplinary area • Evolving role and understanding of percutaneous options • Stent grafts, visceral stents • Fenestration • Uncovered stents - scaffolding

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