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1 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Invitation 안녕하셨습니까? 강남세브란스병원하이브리드대동맥센터에서는이번심포지움에서 Chronic Type B Aortic Dissection 에대한 Hybrid Treatment에중점을두어 Live Surgery 와더불어, Unsolved Issue들에대한국내외의경험이많으신선생님들을모시고활발한토론의장을마련하고싶습니다. 특히, Aortic Dissection의 Endovascular Management에주안점을두어 Standard Treatment Strategy를정립하고자합니다. 이번행사가우리나라대동맥수술의발전의토대가되는정례학술행사로발전할수있도록많은선생님들의참여와성원을부탁드립니다. 감사합니다. 연세대학교강남세브란스병원하이브리드대동맥센터 흉부외과송석원 / 영상의학과이광훈올림

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3 Registration 사전등록 : ~ 2014년 10월 17일 ( 금 ) 평점 : 대한의사협회 6평점 등록비 회원구분 사전등록 현장등록 의사 ( 전문의 ) 50,000원 80,000원 간호사, 방사선사 20,000원 40,000원 전공의, 학생 무료 무료 기타 20,000원 40,000원 입금계좌 : 우리은행 ( 예금주 : 송석원 ) 유의사항 : 홈페이지에서만등록이가능합니다. 등록하신후등록비는반드시신청자명 ( 개인명 ) 으로입금해주십시오. 입금확인및등록여부는개별메일로알려드립니다. - 마감일이후에는현장등록을이용하여주시기바랍니다. 문의처 : 강남세브란스병원대동맥심포지엄학술대회준비사무국 - 연락처 : 02) , 팩스 : 02) 이메일 : gshybrid@yuhs.ac - Homepage: Venue Grand Auditorium (3F), Gangnam Severance, Yonsei University

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5 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Program 08:00-08:45 Registration 08:45-08:50 Opening Remark Suk-Won Song [Director of Hybrid Aortic Center, Gangnam Severance, Yonsei Univ.] 08:50-08:55 Welcome Address Kyung Jong Yoo [CEO of Cardiovascular Hospital, Yonsei Univ.] 08:55-09:00 Welcome Address Hyung Jung Kim [CEO of Gangnam Severance, Yonsei Univ.] Session I TEVAR Live 1 and Hot Issues Moderator: Hyuk Ahn, Won-Heum Shim Panel: Cheesoon Yoon, Jae-sung Choi, EuySuk Chung, Young Won Yoon, Ho Jong Chun 09:00-09:10 Live Case 1 presentation 09:10-09:30 TEVAR for chronic aortic dissection: Pros vs. Cons Young-Guk Ko [Yonsei Univ.] vs Kiick Sung [Sungkyunkwan Univ.] 3 09:30-09:50 What factors influence favorable aortic remodeling after TEVAR for chronic dissection? Kwang Bo Park [Sungkyunkwan Univ.] 5 09:50-10:10 Aortic remodeling after TEVAR for chronic aortic dissection Chun-Che Shih [Taipei Veterans General Hospital, Taipei, Taiwan] 6 10:10-10:30 Live Case 1 comments and discussion 10:30-11:00 Break Session II Focusing on Technical Issues of TEVAR Moderator: Tilo Kölbel, Young-Guk Ko Panel: Joonkyu Kang, Hyun-chul Joo, Sang-ho Cho, Woong Chol Kang, Jong Yun Won 11:00-11:20 Proximal and distal landing zone: Risk vs. Benefit Ho Jong Chun [Catholic Univ.] 9 11:20-11:40 Device characteristics and proper selection per anatomy and pathology Chun-Che Shih [Taipei Veterans General Hospital, Taipei, Taiwan] 10 11:40-12:00 Unresolved issues of TEVAR for chronic III aneurysm Tae-Hoon Kim [Sejong General Hospital] 11 Session lll Luncheon Presentation at the Auditorium Moderator: Suk Jung Choo, Hwan Jun Jae Panel: Jae Hyun Kim, Keun Her, Sang-Wan Ryu, Young-Guk Ko, Je Hwan Won 12:00-12:20 Demand for TEVAR after open repair for Type A aortic dissection Jae Hyun Kim [Keimyung Univ.] 17 12:20-12:40 TEVAR and Adjunctives for chronic aortic dissection Kwang-Hun Lee [Yonsei Univ.] 18 12:40-13:00 The role of TEVAR for chronic aortic dissection : consensus and controversies Woong Chol Kang [Gachon Univ.] 19 13:00-13:20 TEVAR in chronic aortic dissection: Factors for achieving a more durable repair and what's next? Tilo Kölbel [University of Lund, Sweden and University of Hamburg, Germany] 20 13:20-13:30 10 minutes Refresh Session IV TEVAR Live 2 and Hot Issues Moderator: Kay-Hyun Park, Hyung Jin Shim Panel: Chul-Hyun Park, Kilsoo Yie, Byoung Kwon Lee, Nam Yeol Yim 13:30-13:40 Live Case 2 presentation 13:40-14:00 Novel techniques for chronic aortic dissection Tilo Kölbel [University of Lund, Sweden and University of Hamburg, Germany] 23 14:00-14:20 How to prevent neurologic complications? Joon Hyuk Kong [Sungkyunkwan Univ.] 25 14:20-14:40 Reintervention and its outcome after TEVAR Hwan Jun Jae [Seoul National Univ.] 32 14:40-15:00 Live Case 2 comments and discussion 15:00-15:30 Break Session V Learned from Extreme/ Adhoc Situations/ Morbidity & Mortality Cases Moderator: Suk-Won Song, Kwang-Hun Lee 15:30-15:45 Case 1 Woong Chol Kang [Gachon Univ.] 35 15:45-16:00 Case 2 Je Hwan Won [Ajou Univ.] 37 16:00-16:15 Case 3 Jae-sung Choi [Seoul National Univ.] 38 16:15-16:30 Case 4 Keun Her [Soonchunhyang Univ.] 39 16:30-16:45 Case 5 Sang-Wan Ryu [Chosun Univ.] 40 16:45-17:00 Case 6 Hyun-chul Joo [Yonsei Univ.] 41 17:00-17:15 Case 7 Nam Yeol Yim [Chonnam National Univ.] 42 17:15 - Closing Remark

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7 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Session I TEVAR Live 1 and Hot Issues Moderator: Hyuk Ahn, Won-Heum Shim Panel: Cheesoon Yoon, Jae-sung Choi, EuySuk Chung, Young Won Yoon, Ho Jong Chun

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9 Session I TEVAR Live 1 and Hot Issues TEVAR for chronic aortic dissection: Pros 고영국 연세의대 만성B형대동맥박리증의장기적예후는불량한편으로보전적인치료를하였을경우대동맥의확장및파열로인해 5년생존률이 60~80% 에불과한것으로알려져있다. 현재까지 B형대동맥박리증의치료인약물치료, TEVAR, 또는수술적치료를직접적으로비교한연구들은매우적다. Nienaber 등은 TEVAR로치료한합병증이동반된만성 B형대동맥박리증환자 12명을수술로치료받은환자 12명과비교하였는데수술군에서는 12개월내 33% 가사망하고 42% 가중증의합병증을경험한반면 stent graft 군에서는사망이나주요합병증이발생하지않아 TEVAR 안전하면서도효과적이었다고발표하였다. Fattori 등은 International Registry of Aortic Dissection (IRAD) 데이터를분석한결과, 571명의급성 B형대동맥박리증환자중합병증이동반되지않아약물치료를했던군 (n=390) 에서는 8.7% 의입원중사망률을나타났고, 합병증이동반된환자중수술로치료받은환자군 (n=59) 에서는사망률이 33.9% 로나타난반면, stent graft 로치료를받았던환자군 (n=66) 에서는사망률이 10.6% 로관찰되어 TEVAR 가수술보다더우수한것으로나타났다. 그러나최근에발표된논문들에서는수술후조기사망률이약 8%, 1년과 5년사망률이각각 78% 와 68~92% 정도로보고되고있어 TEVAR 와유사하다고할수있다. 다만일반적으로 TEVAR 후수술에비해합병증으로인한조기발병률이낮은반면, 장기적으로재시술률은더높은편이라하겠다. 합병증이동반되지않은만성 B형대동맥박리증환자에서는 TEVAR와약물치료를비교한 INSTEAD 연구가시행되었다. 이연구는 140명의만성 B형대동맥박리증환자들을약물치료군 (72명) 과 TEVAR군 (68명) 으로무작위배정하어치료하였는데 2년생존률이약물치료군에서 95.5%, stent graft 군에서 88.9% (p=0.15) 로양군간에유의한차이를보여주지못하였다. 그러나 aortic remodeling (true-lumen expansion과 thoracic false-lumen thrombosis) 은TEVAR 군의 91.3% 에비해약물치료군에서는 19.4% 로관찰되어 TEVAR 가더유리할수있음을시사하였다. 그후환자들을 5년추적관찰하여후향적으로분석한결과모든원인에의한사망 (11.1% versus 19.3%; P=0.13), 대동맥관련사망 (6.9% versus 19.3%; P=0.04), 그리고질환악화 (27.0% versus 46.1%; P=0.04) 가 TEVAR군에서약물치료군에비해더낮은것으로나타났다. 그러나아직합병증이없는만성 B형대동맥박리증환자에서 TEVAR 를권고하기에는임상데이터가부족한상태이고, B형대동맥박리증환자에서 TEVAR 후흉부하행대동맥에서목표한 remodeling이나타났다하더라도복부대동맥은오히려점차확장되는경우들이관찰되고있어이에대한적절한대응책도필요한상태라하겠다. 3

10 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 TEVAR for chronic aortic dissection: Cons 성기익 성균관의대 4

11 Session I TEVAR Live 1 and Hot Issues What factors influence favorable aortic remodeling after TEVAR for chronic dissection? 박광보 삼성서울병원영상의학과 Noncomplicated chronic type B dissection은 aorta가 medical treatment 로더이상의직경증가없이 stable할경우추가적 intervention을하지않는다. 그러나, 시간이지나면서 chronic dissection도 false lumen 이더커져서 aortic diameter자체가증가하거나, 다른이차적문제가발생할때 stent graft로치료하게되는데, TEVAR이후 aorta가안정적인 remodelling을거치기위해서는과연어떠한인자들이관여하는지에대해아직까지연구가불충분하다. 보통 TEVAR를시행한 chronic dissection환자의약 30% 전후가나중에어떤형태로든 secondary reintervention을시행받는것으로보고되고있는데 TEVR이후에 false lumen 이 thrombosis를보이는비율은최근보고들에서약 70% 전후에서많게는 90% 까지이며, false lumen 에 flow가남는경우는결국시간이지나다시문제가생긴다고보고있다. Chronic type B dissection 은환자마다 tear된 aorta전체의 anatomy 가아주다양해서, entry tear과 reentry tear가각각하나씩있는경우도있지만, intervening tear가하나또는그이상있는경우도허다하며, entry tear의 seal off가완전한지불완전한지여부와, entry tear의위치와크기, 그리고 reentrey tear의위치와크기에따라 false lumen 으로들어올수있는 inflow source의종류, 크기, 혈류량, 혈류방향등이모두달라진다. 우리가 chronic dissection환자에서 TEVR를시행한다하여도결국막을수있는것은 entry tear의 main inflow 에국한되며, intervening tear나 reentry tear까지모두한번에해결하고그결과를추적한연구가없기때문에 false lumen flow를완전히소멸시켜 thrombus가생길수있게유도하기는어렵다. 또한, dissection 이발생한최초시점에서 aorta직경이가장크게늘어난부분이어느 level에위치하며최대직경이얼마인지도하나의변수가된다. 그러나, 이러한 anatomic factor만으로 aorta의 remodelling이진행되는것은아니므로, 결국은 true lumen flow와 false lumen 의잔존혈류사이에이루어지는 hemodynamic balance가어떤상황에서붕괴되는지가중요하며, 어느정도역치를기준으로 false lumen flow가 stable해지는지에대해서는아직까지정확은분석이없다. 지금까지알려진바로는, upper thoracic aorta의 false lumen직경이크거나, entry tear가완전히 stent graft로 cover 되지않았거나, entry tear가작아서 jet flow가들어오는경우, dissection이 diaphragm이하로내려갈수록, 및그리고고령일수록, aorta가 TEVAR 에도불구하고더늘어나거나향후이차적문제가생기는경우가많다고보고된다. 결국 TEVAR이후 false lumen flow가남느냐남지않느냐, 그리고 false flow가어느정도많은양이어느 level에남느냐에따라서 aorta의 positive remodelling이크게영향을받는다고볼수있다. 5

12 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Aortic remodeling after TEVAR for chronic aortic dissection Chun-Che Shih Taipei Veterans General Hospital, Taipei, Taiwan 6

13 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Session II Focusing on Technical Issues of TEVAR Moderator: Tilo Kölbel, Young-Guk Ko Panel: Joonkyu Kang, Hyun-chul Joo, Sang-ho Cho, Woong Chol Kang, Jong Yun Won

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15 Session II Focusing on Technical Issues of TEVAR Proximal and Distal Landing Zones: Risk vs Benefit Ho Jong Chun, M.D., Ph.D. Seoul St. Mary s Hospital, The Catholic University of Korea Thoracic endovascular aneurysmal repair (TEVAR) with stent-graft is now widely accepted as a first-line treatment of the thoracic aorta pathology involving the aortic arch, since conventional open surgical repair is associated with significant morbidity and mortality. TEVAR is generally indicated when the landing zone is sufficient, usually more than 15 mm in length distal to the left subclavian and proximal to the celiac trunk, but a strategy that incorporates TEVAR into open surgical/endovascular hybrid arch procedures may allow for endovascular repair in patients with insufficient landing zones. Despite the potential advantages of less invasive hybrid arch procedures, outcomes after hybrid arch repair remain unclear. It is because that the mortality rates from the open surgical hybrid arch procedures are reported with a wide variety, whereas the longer proximal landing zone may minimize the proximal endoleak more. If the circle of Willis and both vertebral arteries are favorably patent, the left subclavian artery may be simply covered by stent-graft in order to increase the length of the proximal landing zone, and it is well tolerated by more than 90% of the patients. A carotid-subclavian bypass as a second stage procedure is necessary in a few patients. Open surgical hybrid arch procedures consist of bypasses to the left subclavian artery alone, to both left subclavian and left common carotid arteries or to all three of the supra-aortic vessels. It is followed by TEVAR of the aortic arch or descending thoracic aorta pathology via transfemoral arterial approach, as a second stage procedure. However, these procedures may lead to an increase in the procedure-related mortality or morbidity rate. For the distal landing zone, hybrid procedures consisting of surgical bypasses to the visceral arteries, followed by TEVAR with stent-graft, are associated with a persistently high mortality. The mortality associated with branched endografts appears to be lower with an acceptable patency of the target vessels. Considering the procedure-related morbidity and mortality, the benefits of invasive therapy at both ends of the descending thoracic aorta should be carefully weighed against the untreated risk of aneurysm rupture. 9

16 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Device characteristics and proper selection per anatomy and pathology Chun-Che Shih Taipei Veterans General Hospital, Taipei, Taiwan 10

17 Session II Focusing on Technical Issues of TEVAR Unresolved issues of TEVAR for chronic III aneurysm Tae-Hoon Kim, M.D., Ph.D. Sejong General Hospital, Division of Cardiology Modified Crawford Classification of TAAA Timing of TEVAR is very important for the patients who have chronic thoraco-abdominal aneurysm, because aortic size is a very strong predictor of rupture, dissection and mortality. For aneurysms greater than 6 cm in diameter, rupture occurred at 3.7% per year, rupture or dissection at 6.9% per year, death at 11.8%, and death, rupture, or dissection at 15.6% per year 1. However, it is hard for physician to change the strategy as invasive treatment especially for the patients having unfavorable anatomy for simple TEVAR or EVAR. Usually long segment thoracic aneurysm which required extensive coverage of descending aorta has great risk of death or morbidity during repair. Peri-operative comorbidity including mortality of open surgical repair for thoraco-abdominal aortic aneurysm (TAAA) is reported as high as 36% in previous outcome study 2. However, ongoing progress in endovascular techniques has altered previous approach to TAAA repair for patients who are bad candidates for open repair. Hybrid approaches that combine open visceral bypass with endovascular TAAA exclusion have been introduced and are rapidly accumulating. During hybrid operation, usually two to four visceral vessels (celiac axis, superior mesenteric artery and renal arteries) required re-vascularisation and they have been attached to the previous vascular graft or the native aorta 3. However, in previous outcome study from Europe reported that a mean perioperative mortality of 15.6%, the rate of primary endoleaks was 17.9%, paraplegia/paraparesis 7.2% and renal failure 9.9%, with other major 11

18 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 perioperative complications reported in the 50.6% of cases. At the follow-up period visceral graft occlusion rate was 5.1% 3. Indeed, with the 13 to 89 patients of each center experiences report that overall mortalities were 0% to 38.5% and paraplegia or paraparesis rates were 0 to 15% with this technique 4-9. Finally, fenestrated stent grafts have made TAAA aortic repair totally by endovascular technique. Increasing evidence supports the feasibility of TAAA repair with a total endovascular procedure, as shown by the study of Clough et al (Crawford type I, II, III, n=15; IV, n=4). In this report, thirty-day mortality was 9.7% (3/31) and only one patient (3.1%) presented late-onset paraparesis and a second (3.1%) developed acute renal failure after 8 months. In 32.7% of patients, deterioration of renal function was detected after treatment. There were no conversions to open repair and, of the overall three endoleaks, only one was type III originating from a celiac bridging stent and requiring re-intervention 10. Recently, a novel navigation system has been developed and helps to reduces radiation exposure, contrast use, and overall procedural time in endografting 11 and along with devices, new concepts of exclusion of aneurysm are introduced diversely 12. In conclusion, various devices and techniques breaking the outcome record in a classically challenging TAAA repair. Very promising mortality and morbidity rates are lately reported consecutively. However, careful morphologic and clinical patient selections as well as pre-procedural planning including surgical Plan B are required for the treatment. References 1. Davies RR, Goldstein LJ, Coady MA, et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. The Annals of thoracic surgery 2002;73:17-27; discussion Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. The Annals of thoracic surgery 2007;83:S ; discussion S Chiesa R, Tshomba Y, Melissano G, Logaldo D. Is hybrid procedure the best treatment option for thoraco-abdominal aortic aneurysm? European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 2009;38: Black SA, Wolfe JH, Clark M, Hamady M, Cheshire NJ, Jenkins MP. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. Journal of vascular surgery 2006;43: ; discussion Wolf O, Heider P, Hanke M, et al. WITHDRAWN: Immediate and mid-term results following hybrid procedures for the treatment of thoracoabdominal aneurysms (TAAA) and secondary expanding aortic dissections (SED). Annals of vascular surgery Resch TA, Greenberg RK, Lyden SP, et al. Combined staged procedures for the treatment of thoracoabdominal aneurysms. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists 2006;13: Lee WA, Brown MP, Martin TD, Seeger JM, Huber TS. Early results after staged hybrid repair of thoracoabdominal aortic aneurysms. Journal of the American College of Surgeons 2007;205: Zhou W, Reardon M, Peden EK, Lin PH, Lumsden AB. Hybrid approach to complex thoracic aortic aneurysms in high-risk patients: surgical challenges and clinical outcomes. Journal of vascular surgery 2006;44: Bockler D, Kotelis D, Kohlhof P, et al. Spinal cord ischemia after endovascular repair of the descending thoracic 12

19 Session II Focusing on Technical Issues of TEVAR aorta in a sheep model. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 2007;34: Clough RE, Modarai B, Bell RE, et al. Total endovascular repair of thoracoabdominal aortic aneurysms. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery 2012;43: McNally MM, Scali ST, Feezor RJ, Neal D, Huber TS, Beck AW. Three-dimensional fusion computed tomography decreases radiation exposure, procedure time, and contrast use during fenestrated endovascular aortic repair. Journal of vascular surgery Anderson J, Nykamp M, Danielson L, Remund T, Kelly PW. A novel endovascular debranching technique using physician-assembled endografts for repair of thoracoabdominal aneurysms. Journal of vascular surgery

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21 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Session III Luncheon Presentation at the Auditorium Moderator: Suk Jung Choo, Hwan Jun Jae Panel: Jae Hyun Kim, Keun Her, Sang-Wan Ryu, Young-Guk Ko, Je Hwan Won

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23 Session lll Luncheon Presentation at the Auditorium Demand for TEVAR after open repair for Type A aortic dissection 김재현 계명대학교흉부외과 1994년처음으로 Thoracic endovascular aortic repair (TEVAR) 가시행된이후지난 20년간흉부대동맥류및대동맥박리증환자에서 TEVAR는중요한치료 modality로자리를잡아가고있고치료영역을확장하고있는상황이다. 특히 complicated acute type B aortic dissection (ABAD) 에서는전통적인수술보다는 TEVAR 가우수한치료성적을보임으로써수술에우선하여 TEVAR가권장되고있다. 또한 Best medical treatment (BMT) 가우선이되던 uncomplicated ABAD 에서도 randomized prospective study인 ADSORB trial의결과가최근발표됨으로써 TEVAR 시행의이론적근거를마련하였으나, long-term 결과를좀더지켜봐야될것이다. Chronic type B aortic dissection (CBAD) 에서 TEVAR 의결과는처음우려했던것보다는양호하나, TEVAR 시술의적응증과적절한시술시기에대한 consensus가형성되기까지는시간이좀더필요할것으로생각된다. 최근발표된 INSTEAD trial 5년결과에서 uncomplicated CBAD에서 BMT보다 TEVAR후환자들의대동맥관련생존률이더우수하고대동맥질환진행이지연되는효과를보여향후이런환자군에서치료 paradigm의변화를예고하고있다. 하지만순수한 CBAD와는달리 Acute Type A aortic dissection 수술후에남게되는 CBAD에서는 TEVAR 시술이용이하지않는경우가많다. 우선이전수술의범위에따라서마땅한 proximal landing zone이없거나 dissection 되어있을수있으며, 복부대동맥을함께침범한경우가많아서흉부대동맥에국한된 TEVAR만으로는해결할수없는경우가많다. 또한대동맥박리후상당히오랜기간이지난후에 aneurysm이발생한경우가많아서 intimal flap의 fibrotic stiffness가심하고 true lumen이매우작을수있으며 false lumen에서중요장기로의 perfusion 이유지되는경우도흔히있어 TEVAR시술을더어렵게할수있다. 보고된바는많지않지만 Acute Type A aortic dissection 수술후 Residual CBAD의치료및 TEVAR 의 role에대해서살펴보기로하겠다. 17

24 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 TEVAR and Adjunctives for Chronic Aortic Dissection Kwang-Hun Lee, M.D., Ph.D. Associate Professor Interventional Radiology & Cardiovascular Surgery Gangnam Severance Hospital, Yonsei University College of Medicine There are several principles that we should carry out during the TEVAR procedure to achieve favorable aortic remodeling. Beyond those basic principles, especially in chronic aortic dissection, to achieve favorable aortic remodeling after the TEVAR, adjunctive procedures might be necessary before and after the main procedure of TEVAR. Since the Hybrid Operating Room has been set up at Gangnam Severance Hospital, from June 2012 to September 2014, a total of 163 patients were treated by TEVAR: 54 patients with thoracic aneurysm, 43 chronic aortic dissection, 21 acute aortic dissection, 20 traumatic aortic transection, 11 PAU, 7 IMH and 7 combined PAU and IMH. Except for simple routine AVP embolization of LSA right after the bypass surgery for hybrid TEVAR, for the endograft treatment of chronic aortic dissection, several interesting endovascular adjunctive procedures should be emphasized. - Arch vessel re-entry tear of both TL and FL embolization with coil and/or AVP: LSA, LVA off aortic arch - Viabahn stent-graft insertion to seal up re-entry tear: renal artery, iliac artery - AVP embolization into celiac trunk when TEVAR extension to supra-sma region - Entry tear embolization with AVP - NBCA (Glue) embolization of the FL - DTA FL obliteration with AVP - Iliac FL embolization with AVP - Abdominal tube stent-graft 18

25 Session lll Luncheon Presentation at the Auditorium The role of TEVAR for chronic aortic dissection : consensus and controversies Woong Chol Kang Cardiology, Gil Hospital, Gachon University Chronic Aortic Dissection (CAD) is defined as the persistence of the dissection flap and false lumen more than 2 weeks after the initial event. The definition of 2 weeks is arbitrary and historical. The most significant difference between acute and CADs is the capacity to remodel. The mobility of the aortic dissection (AD) flap decreases as the dissection matures, reducing the ability of the aorta to remodel. This renders the patient vulnerable to aneurysmal dilatation and eventual aortic rupture. Chronic complications after AD are related to the persistence of blood flow through a patent false lumen with resultant aortic expansion estimated to be mm per year with the attendant risk of rupture. It is estimated that 20 40% of patients who survive the acute phase of aortic dissection will develop significant aneurysmal dilatation of the descending thoracic or thoracoabdominal aorta. Decreased pressure and thrombosis of the false lumen predict good long-term outcome. Conversely, false lumen flow is a predictor of aortic expansion. The risk of aortic rupture is reported to be greater in women than in men, and once the aorta reaches 6 cm, it is estimated to be 30%. Identifying which patients with CAD are at risk of developing complications is difficult. The key methodological difference when treating CAD compared to AAD is the length of aorta that should be stented. In AAD, short stents are adequate to close the entry tear and promote false lumen thrombosis; however, in CAD, aortic coverage from the dissection flap to the distal thoracic aorta is necessary to preserve the integrity of the endovascular repair. There is little place for bare stents because they do not exclude dissection fenestrations and are less likely to achieve aortic remodeling in the chronic setting. Extensive aortic coverage may increase the incidence of paraplegia in this population. Type B dissections often start within 1 cm of the left subclavian artery (LSA), necessitating coverage of this artery. There is evidence (level C) that in this setting, preoperative revascularization of LSA by bypass will reduce the risk of death, stroke, and paraplegia. Debranching procedures can be performed in single or combined staged procedures. They can only be staged in the management of chronic dissection; there is no benefit from revascularization after stent deployment. The risk of paraplegia after endovascular stent deployment is approximately 3%. In the event of postdeployment paraplegia, immediate insertion of a cerebrospinal fluid drain and maintenance of mean arterial pressure of >100 mmhg can be an effective way of recovering spinal cord function. Patients at increased risk of paraplegia seem to be those with long aortic coverage, women, and those with aneurysmal disease. Stent graft collapse has been described after endovascular repair. Risk factors include small aortic lumen and a small radius of aortic arch curvature. This potentially fatal complication is reduced by modern devices that conform better to the arch. If endograft collapse occurs, implantation of additional stents or surgery is required. 19

26 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 TEVAR in chronic aortic dissection: Factors for achieving a more durable repair and what's next? Tilo Kölbel University of Lund, Sweden and University of Hamburg, Germany Chronic aortic dissection includes different previous histories such as residual dissection after surgical repair of a DeBakey type I aortic dissection, dissection after ascending aortic repair for other pathologies, and chronic type B aortic dissection. Despite the different background, the risk for future complications in chronic aortic dissection is mainly related to false-lumen aneurysmal dilatation and rupture. The aim of therapy in chronic aortic dissection therefore is to prevent false lumen dilatation and aortic related death. Endovascular stent-graft therapy aims to reduce or abolish flow in the false lumen. Since the introduction of thoracic endovascular aortic repair (TEVAR) for the treatment of aortic dissection type B in the 1990 s, it has become the mainstay of operative treatment for acute complicated type B aortic dissection, offering a clear benefit with lower mortality and morbidity rates compared to open surgical repair. TEVAR in aortic dissection is based on the implantation of thoracic tubular stent-grafts to cover the proximal entry tear and thereby redirect flow into the true lumen. This strategy intends to depressurize and thrombose the false lumen, and promote aortic remodeling in a majority of patients with acute aortic dissection. Response to this treatment strategy is limited in patients with chronic dissections with a reduced capacity for aortic remodeling due to the thickened and fibrotic degenerated intimal flap. A significant proportion of patients have persistent and significant false lumen flow despite placement of a thoracic stent-graft even where long lengths of the thoracic aorta are covered. Large re-entry tears at the level of the visceral aorta or further distally are particularly responsible for persistent false lumen flow. This limited response to endovascular treatment in chronic aortic dissection is caused by the continued pressurization from persistent retrograde false-lumen flow to intercostal and bronchial arteries from downstream entry-tears. Retrograde filling and pressurization leads to late aortic expansion in 35% of patients treated by TEVAR for chronic type B aortic dissection. The lack of aortic remodeling and false lumen aneurysmal dilatation caused by continued perfusion of the false lumen causes late aortic death. In patients with ruptured chronic false lumen aneurysm after type A and B aortic dissection the persisting retrograde filling may lead to continued bleeding despite TEVAR down to the celiac artery to cover the descending aortic entry-tears. Factors that influence treatment success include the extend of the dissection, involvement of branch-vessels, the size of the true lumen. The presentation will focus on current indications and treatment strategies. 20

27 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Session IV TEVAR Live 2 and Hot Issues Moderator: Kay-Hyun Park, Hyung Jin Shim Panel: Chul-Hyun Park, Kilsoo Yie, Byoung Kwon Lee, Nam Yeol Yim

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29 Session IV TEVAR Live 2 and Hot Issues Novel techniques for chronic aortic dissection Tilo Kölbel University of Lund, Sweden and University of Hamburg, Germany Aortic dissection is a severe disease affecting all segments of the aorta and it is associated with a high mortality rate if left untreated. Thoracic endovascular aortic repair (TEVAR) was introduced for the treatment of acute and chronic type B aortic dissection in the 1990 s. Since then TEVAR has become the mainstay of operative treatment for complicated acute type B aortic dissection, offering a clear benefit with lower mortality and morbidity rates compared to open surgical repair. Common practice for TEVAR in aortic dissection is the implantation of thoracic tubular stent-grafts to cover the proximal entry tear and redirect flow into the true lumen. This successful strategy results in false lumen thrombosis and aortic remodeling in a majority of patients with acute type B aortic dissection. Response to this endovascular treatment strategy is limited in patients with chronic dissections with a reduced capacity for aortic remodeling due to the fibrotic tissues. While proximal sealing is possible in most cases of chronic Type B aortic dissection due to the presence of a landing zone in non-dissected aortic wall with or without the use of debranching techniques and/or fenestrated and branched endografts, distal sealing remains an unresolved issue in most patients due to the double-barrel anatomy of dissectons extending throughout the visceral aorta. False lumen aneurysms in untreated chronic type B aortic dissection and in residual dissection are most often located in the proximal descending aorta. In cases of ruptured false lumen aneurysms it may not be possible to seal off the distal false lumen backflow into the aneurysm leading to continued bleeding despite TEVAR down to the celiac artery. Open surgical techniques have been proposed to enable distal sealing in this type of anatomy, such as open fenestration followed by TEVAR. Furthermore complex endovascular techniques have been introduced including fenestrated and branched endografts covering a longer segment of the aorta into the infrarenalaorta and the iliacs to occlude more distal entries and reduce pressure- and flow-transmission into the true lumen. These techniques require advanced endovascular skills and access to custom-made products, which are not available in most countries. We present two newly developed techniques to seal off the distal false lumen in patients with proximal descending false-lumen aneurysms in chronic aortic dissection. The Candy-plug technique utilizes a double-tapered thoracic endo-graft that can be used in combination with commercially available nitinol-mesh plugs to create a giant plug up to 46mm. The candy-plug is introduced into the false-lume in the distal descending thoracic aorta to block off false lumen backflow into more proximal false-lumen 23

30 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 aneurysms. The Knickerbocker technique involves relining of the true lumen in the descending aorta with an oversized thoracic tubular endograft, followed by controlled rupture of the dissection membrane, using a large compliant balloon within the graft s mid-section, to allow expansion of the stent-graft s mid-section into the false lumen. Both strategies have been developed in order to occlude the large false lumen distally and thus prevent continued false lumen perfusion through distal abdominal entry-tears. 24

31 Session IV TEVAR Live 2 and Hot Issues How to prevent neurologic complications? 공준혁 성균관대학교강북삼성병원흉부외과 스텐트그라프트의개발과치료기술이발전함에따라기존에높은사망률과이환울을보였던대동맥궁의질환과흉복부대동맥류등의치료에도사용이증가하게되었다. 특히대동맥궁의질환과흉복부대동맥질환의외과적치료는광범위한외과적절개를필요로하고, 장시간이소요될뿐만아니라신경학적손상의위험이크다. 그래서, 기존에개발된스텐트그라프트를주된병변안대동맥에삽입하고주병의주요가지혈관들에대하여혈류를유지하도록수술적요법을겸하는이른바하이브리드술식 (hydrid operation) 이가능하게되었다. 아직은초기및중기결과를토대로문헌을점포하고그유용성을평가해야하므로단정적인결론을지을수는없으며, 최근보고되는흉복부대동맥질환에대한하이브리드술식의결과는술후사망률과이환율에있어실망스러운부분또한많이존재하므로선택된환자에서이러한술식이적절히적용될수있어야할것이다. 1. 뇌보호 (cerebral protection) 대동맥궁질환의고식적치료는체외순환과더불어저체온순환정지상태에서대동맥궁과주요가지혈관을치환하는과정이다. 수술적기법과마취및술후관리기법이향상되었지만사망률이 7-17% 로보고되며, 신경학적합병증이 4-12% 정도로유발되는데, 고령환자에게서주로발생하고술후치명적인결과를초래하게된다 1). 1) Frozen Elephant Trunk Technique (FET) 1983년 Borst등에의해소개된 Frozen Elephant Trunk Technique(FET) 은이후여러의사들의노력에의해이러한광범위한대동맥질환을해결할수있는하나의방법으로대두되었다. 고식적인정중흉골절개술로상행대동맥과대동맥궁을치환한후하행대동맥방향으로스텐트그라프트를밀어넣은방식이다 (Fig. 1). 현재까지보고된결과를종합해보면지난몇년간결과의향상을보여준것으로평가된다 (Table 2). 평균사망률을추정하면약 7.7% 이며, 대뇌손상및척추손상은각각 4.3%, 2.5% 정도로나타나비교적만족할만한결과를보이고있다. 그러나술전복부대동맥률치료했던환자에서원위부 landing zone을 T7이상의부위로스텐트그라프트를삽입할경우하지신경손상의빈도가증가하므로주의를요한다. FET와연관된또다른합병증들은좌측되돌이후두신경 (left recurrent laryngeal nerve) 의손상, 투석을요하는신부전, 장기간에걸친인공호흡기사용등이있다. 25

32 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Figure 1. Frozen Elephant Trunk Table 2. Overall early outcomes of Frozen Elephant Trunk 26

33 Session IV TEVAR Live 2 and Hot Issues 이후이차적으로시행되는좌측개흉술하에서하행대동맥원위부의병변에대한문합술을시행하는경우에는사망률이 9.6% 로보고되고있다 2). 이러한고식적 2차수술을대체하여대퇴동맥을통해스텐트그라프트를병변이있는하행대동맥에삽입하여치환을완성하는방법이시도되었고, 제한된보고이지만이러한방법의경우사망률이 0-8.3% 로비교적만족할만한결과를보이며, 아직까지는영구적인사지마비를보고한경우는거의없는실정이다 3,4). 2) Revaularization of Supra-aortic Branches Prior to Stent-Grafting Therapy 이와같은성공적인스텐트그라프트삽입의결과를바탕으로점차대동맥근위부까지적용범위가확대되었다. 그러나, 대동맥에스텐트그라프트를성공적으로삽입하기위해서는근위부에최소한 20mm이상의공간이필요하다. 이러한제한점을극복하고자대동맥궁의가지혈관에대한수술적방법과함께스텐트그라프트를순차적으로또는동시에삽입하는방법이대두되었다. 또한 2002년국제적인논의를거쳐병변이있는대동맥의위치에따른스탠트그라프트의삽입범위를통일하여명명하도록하는이른바 Ishimaru zone 이확립되었고, 이러한일련의과정을통해병병의부위데따른적합한하이브리드술깃의적용이이루어지게되었다 (Fig. 2). Figure 2. Ishimaru zone Landing zone 에따흔다양한하이브리드술식적용이있다 (Fig. 3) 27

34 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Figure 3. Debranching techniques according to Ishimaru zone 28

35 Session IV TEVAR Live 2 and Hot Issues 또다른분류법으로는 Szeto 등 5) 이주장한방법으로치환된수술의부위에따라분류하는방법도있다 (Fig. 4) Figure 4. Classification of hybrid aortic arch repair by Szeto WY. 3) Revascularization of Left Subclavian Artery(LSCA) 시술초기일부에서좌총경동맥 (LCCA; left common carotid artery) 와좌쇄골하동맥 (LSCA; left subclavian artery) 의문합술없이스텐트그라프트가 LSCA에걸쳐삽입한경우에도신경학적문제를포함한다른합병증의빈도가많지않다고보고하였으나논란의여지가많은부분이다. Morasch 등 6) 은 16개의문헌에서보고된 218명의환자를 LSCA가재관류된 114명과그렇지않은 104명으로구분하여비교분석한결과술후합병증의빈도가 LSCA 가재관류된군에서 3% 로나타나, 그렇지않은군에서의 23% 에비해현저히낮음을증명하며재관류의중요성을강조하였다. 이러한논란이있음을참고하여환자에따라재관류의필요성의차이를인식하는것이매우중요하리라사료되며, 이에대해 Reece등 7) 은재관류를반드시시행하거나또는고려해야하는경우를제시하였다 (Table3). 그리고, 2009년 The Society for Vascular Surgery Practice Guidelines; Management of the left subclavian artery with thoracic endovascular aortic repair에도명시되어있다 (Table 4). 29

36 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Table 3. Indications and considerations for left subclavian artery revascularization with endograft exclusion of its origin. Table 4. Recommedations of The Society for Vascular Surgery Practice Guidelines: Management of the left subclavian artery with thoracic endovascular aortic repair. 2. 척수보호 (spinal protection) 뇌조직과마찬가지로관류압이 mmHg 범위내에있는경우에는척수로가는관류량은일정하게유지되는자동조절기전이있다고밝혀져있다. 척수, 특히운동신경영역이존재하는앞쪽 2/3의혈류공급의주통로는척수를딸라종으로주행하는 anterior spinal artery(asa) 인테이는양쪽척수동맥 (vertebral artery:va) 들에서시작한다. ASA 이외에하행대동맥의늑간동맥 (intercostal artery) 과요추동맥 (lumbar artery) 들에서나오는 radicular artery들이 ASA와만나서척수관류에일조하면그중에서가장큰분지가 greater radicular artery ( 혹은 arteria 30

37 Session IV TEVAR Live 2 and Hot Issues radicularis Magana, artery of Adamkiewicz, ARM) 로일컬어진다. 흉부대동맥수술에대한척수보호수단들은이미많이기술되었다. Nobuyoshi Kawaharada 등 8) 은 TEVAR에있어서 ARM의 coverage의유무도중요하나흉부대동맥의 coverage length가척수손상과의미있는관계가있었다고발표하였고, Manish Metha 9) 등은 TEVAR시선택된환자에서 CSF drainage유뮤에따른척수손상예방의긍정성을증명하였다. 그래서, 최근에는 multifactorial causes 에의해서척수손상의가능성이확실해지고있다. 수술이나시술직후뿐아니라수술후수일이경과한이후에도척수허혈에대한하지마비가발생할수있으며이는수술후발생하는하지마비의약 1/3을차지한다고알려져있다 10). 따라서술이나시술후에도면밀한감시가필요하며만약발생하는경우에는혈압상승, 뇌척수액배액, 항응고제, mannitol과같은 free radical scavenger, steroid 투여등으로호전을기대할수있다. References 1. Bachet J, Guilmet D, Goudot B, Dreyfus GD, Delentdecker P, Brodaty D, Dubois C. Antegrade cerebral perfusion with cold blood: a 13-year experience. Ann Thorac Surg. 1999;67: Safi HJ, Miller CC 3rd, Estrera AL, Villa MA, Goodrick JS, Porat E, Azizzadeh A. Optimization of aortic arch replacement: two-stage approach. Ann Thorac Surg. 2007;83:S Greenberg RK, Haddad F, Svensson L, O'Neill S, Walker E, Lyden SP, Clair D, Lytle B. Hybrid approaches to thoracic aortic aneurysms: the role of endovascular elephant trunk completion. Circulation. 2005;112: Carroccio A, Spielvogel D, Ellozy SH, Lookstein RA, Chin IY, Minor ME, Sheahan CM, Teodorescu VJ, Griepp RB, Marin ML. Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage "elephant trunk" repair. Vascular. 2005;13: Milewski RK, Szeto WY, Pochettino A, Moser GW, Moeller P, Bavaria JE. Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction. J Thorac Cardiovasc Surg 2010;140: Morasch MD, Peterson B. Subclavian artery transposition and bypass techniques for use with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg. 2006;43S:73A-77A. 7. Reece TB, Gazoni LM, Cherry KJ, Peeler BB, Dake M, Matsumoto AH, Angle J, Kron IL, Tribble CG, Kern JA. Reevaluating the need for left subclavian artery revascularization with thoracic endovascular aortic repair. Ann Thorac Surg. 2007;84: Kawaharada N, Morishita K, Kurimoto Y, Hyodoh H, Ito T, Harada R, Kuwaki K, Higami T. Spinal cord ischemia after elective endovascular stent-graft repair of the thoracic aorta. Eur J Cardiothorac Surg. 2007;31: Nobuyoshi Kawaharada, et al. Spinal cord ischemia after elective endovascular stent-graft repair of the thoracic aorta. European Journal of Cardio-thoracic Surgery. 2007; 31: Metha M, Hnath JC. Cerebrospinal Fluid Drainage During TEVAR Endovascular today 2008;Sep; Huynh TT, Miller CC 3 rd, Safi HJ. Delayed onset of neurologic deficit: significance and management. Semin Vasc Surg 200;13:

38 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Reintervention and its outcome after TEVAR Hwan Jun Jae, M.D. Seoul National University Hospital Since the first report of TEVAR repair in 1994 by Dake et al, indications for TEVAR have broadened. At present, due to lower perioperative mortality and morbidity compared with conventional open repair, the use of TEVAR is not limited to treating degenerating aneurysms but is also used for complicated acute or chronic aortic dissection. TEVAR has reduced perioperative mortality by more than two-thirds in the setting of aortic dissection but is associated with higher reintervention rates than open repair and TEVAR for degenerative thoracic aneurysms. Long-term durability for this specific disease remains unknown. Current published reports suggest that reintervention rates at up to 5 years seem to be higher for TEVAR for complicated aortic dissection (acute and chronic) than TEVAR for thoracic degenerative aneurysm. Parsa et al. (J Thorac Cardiovasc Surg. 2011;141:322 7) reported rates of 23%, whereas Böckler et al. (J Thorac Cardiovasc Surg. 2006; 132:361 8) reported rates of 32% in the setting of complicated aortic dissection, increasing to 46% at 5 years when TEVAR is performed for acute dissection. This compares to reintervention rates of 15% to 17% after TEVAR for thoracic aneurysm. Patterson et al. (Circulation. 2013;127:24 32) recently reported a lower mortality rate after TEVAR for patients with chronic dissection (3%) than for patients with aneurysmal disease (5%). The sample group reported higher reintervention rates for chronic (29%) or acute aortic dissection (54%) at 6 years compared with TEVAR for thoracic aortic aneurysm (16%). These results may be related to the higher comorbidity rates in patients with thoracic aortic aneurysm than in patients treated for aortic dissection and confirm that outcomes should be analyzed for specific pathologies rather than for the type of procedure with the aim of improving the durability of this technique. Recently, Faure EM and colleagues (J Vasc Surg. 2014;59(2):327-33) performed TEVAR for a complicated aortic dissection involving the descending thoracic aorta in 41 patients. Fourteen secondary procedures were performed in 13 patients (32%) for indications of device migration in 2, proximal type I endoleak in 5, distal type I endoleak in 2, type II endoleak in 1, aneurysmal evolution of the descending thoracic aorta in 2, aneurysmal expansion of the dissected abdominal aorta in 1, and retrograde dissection in 1. Multivariate analysis demonstrated that oversizing 20%, bare-spring stent in the proximal landing zone of the stent graft, and anticoagulant therapy were significant factors for reintervention. On univariate analysis, large aneurysm was a risk factor for reintervention, whereas complete false lumen thrombosis at the stent graft level was protective. Anticipating these modifiable risk factors for reintervention appears essential for the long-term durability of TEVAR. 32

39 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Session V Learned from Extreme/ Adhoc Situations/ Morbidity & Mortality Cases Moderator: Suk-Won Song, Kwang-Hun Lee

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41 Session V Learned from Extreme/ Adhoc Situations/ Morbidity & Mortality Cases Case 1. Hybrid approach to thoracic aortic aneurysm with confined rupture Woong Chol Kang Cardiology, Gil Hospital, Gachon University A 71 year-old male patient presented with chest pain 5 days ago. He had a history of hypertension. Simple chest radiography showed mass opacity in left perihilar area, suspecting lung cancer or aneurysm of descending thoracic aorta. Chest computed tomography (CT) demonstrated irregular aneurysmal dilatation and multiple ulcerative plaques in aortic arch and proximal descending thoracic aorta with periaortic hematoma and left pleural effusion, indicating thoracic aortic aneurysm and penetrating aortic ulcer with confined rupture. Intravenous beta blocker and calcium channel blocker were prescribed for control of blood pressure and heart rate. We were planning to perform endovascular aortic repair with bypass surgery of supra-aortic vessels. However, femoral CT angiography revealed total occlusion of right external iliac artery and severe calcification at left common and external iliac artery, which could preclude vascular access and delivery of stent-graft for endovascular repair. Thus, construction of open iliofemoral bypass conduit to facilitate device navigation was considered. Bypass surgery between supra-aortic vessels and right iliofemoral bypass were concurrently performed. Left subclavian artery was bypassed to left common carotid artery with a 7 mm diameter Gore-Tex vascular graft to create a landing zone at zone 2 of aortic arch. And, right iliofemoral bypass with Gore-Tex vascular graft was performed and open bypass conduit was constructed as a Y graft. Then, he was transferred to the catheterization laboratory. Initial aortography was done via left femoral artery, showing aneurysmal dilatation of aortic arch. Left brachial artery was punctured and a 6 Fr Ansel 1 sheath (Cook Inc, Bloomington, IN, USA) was inserted into ostium of left subclavian artery. And embolization of left subclavian artery was performed using a 14 mm diameter Amplatzer Vascular Plug II (AGA Medical, Golden Valley, MN, USA). Then, a 10 Fr vascular sheath was inserted into right common iliac artery via open bypass conduit and a inch Lunderquist guidewire (Cook Inc) was placed into ascending aorta. A stent-graft (38 mm x 208 mm; Zenith TX2, Cook Inc) was deployed at aortic arch just distal to left common carotid artery. And an additional stent-graft (34 mm x 152 mm; Zenith TX2, Cook Inc) was implanted at descending thoracic aorta in an overlapping manner. After the deployment of stent-grafts, aortography showed complete exclusion of aneurysmal sac. However, type III endoleak was found at the overlapping site, even after balloon dilatation with a 40 mm diameter balloon catheter (Coda, Cook Inc) to assure optimal sealing between stent-grafts. Then, a stent-graft (42 mm x 81 mm; Zenith TX2, Cook Inc) was additionally implanted at the proximal overlapping segment. After post-deployment balloon dilatation was performed, final aortography revealed no evidence of endoleak. After endovascular procedure, open bypass conduit was removed. Follow-up CT angiography after 1 week of 35

42 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 endovascular repair showed good patency of stent-grafts without evidence of endoleak In summary, hybrid approach to thoracic aortic aneurysm with confined rupture was successfully performed via open iliofemoral bypass conduit and the patient recovered uneventfully. 36

43 Session V Learned from Extreme/ Adhoc Situations/ Morbidity & Mortality Cases Case 2. Kink of stent-graft during TEVAR for complicated intramural hematoma Je Hwan Won Ajou University Hospital 본 49세남자환자는 chest pain을조소로내원하여시행한 CT상 intramural hematoma with multiple intramural blood pool이관찰되었음. 1주간격으로추적 CT검사상 intramural hematoma의두께가증가하고 ulcer like projection 및 intramural blood pool의 size가증가하여 stent-graft를설치하기로하였음. 병변의범위가길어서아래쪽 descending thoracic aorta에 Æ 42mm-38mmx150mm stent-graft (Capivia, medtromics) 를먼저설치한후 proximal descending thoracic aorta에 Æ44-40mmx150mm stent-graft를설치하고자하였음. 두번째 stent-graft를 deployment하는과정에서 proximal part가혈압을낮추었음에도불구하고혈류에의해꺾임. 이후혈관조영술상 stent-graft 의 kinking으로인해 flow 장애가관찰되었음. Reliant balloon을 stent-graft의 angulation된부위에위치시키고천천히 inflation시켜서 stent-graft를펴주었음. 이후 post-op angiography상 perforation같은합병증없이병변은모두 exclusion되었음. 추적 CT검사상 intramural hematoma 의 thickness 는감소하고 intramural blood pool 및 ulcer like projection은모두 exclusion 되었음. 37

44 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Case 3. Three-year follow-up of an old patient suffering endoleak developed after endovascular management of complicated acute type B aortic dissection Jae-Sung Choi, MD, PhD SMG-SNU Boramae Medical Center Case summary A 84 year-old male patient was transferred to ER. A sudden back pain radiating to posterior neck developed 3 hours ago. The ECG and cardiac enzyme checked at ER did not show MI findings. The outside chest contrast CT revealed acute type III aortic dissection with proximal transaortic diameter of 45mm without pleural effusion or hematoma. The dissection extended from right distal to left subclavian artery to both common iliac arteries. All the major visceral branches of thoracoabdominal aorta were supplied by true lumen but a perfusion to right kidney decreased without increased creatinine level. From the review of CT and subsequently performed FDG PET, malignancies of left upper lung and prostate were strongly suspicious. At first, we decided to treat him medically but the patient developed progressive renal failure with medicallyuncontrollable hypertension and ultimately underwent successful renal stenting. However, the uncontrollable hypertension persisted and short-term follow-up CT revealed newly appeared periaortic effusion and hematoma. Because these findings were taken as an ominous sign of impending rupture, an urgent TEVAR covering proximal entry tear was performed (10 days after symptom-onset). In spite of additional more proximal deployment with larger stent graft and endo-ballooning, an weak type I endoleak remained. Considering his old age and combined potential malignancies, a further intervention was avoided. Afterwards, he showed well controlled blood pressure and underwent bronchoscopic and prostate needle biopsies and discharged uneventfully. A serial CT angiography showed completely thrombosed false lumen at 3-month follow-up and disappeared false lumen at both 1-year and 3-year follow-up. Moreover and fortunately, the pathologic report for the biopsies elucidated no-malignancy. This case shows that TEVAR can be a good option for old aged patients with co-morbidities presenting complicated acute type B dissection. 38

45 Session V Learned from Extreme/ Adhoc Situations/ Morbidity & Mortality Cases Case 4. Learned from Extreme/Adhoc Situation/Morbidity & Mortality Cases 허균 순천향대학교부천병원흉부외과 대동맥질환에혈관내치료가도입된이후약 20여년이지나고있는현재혈관내치료의가장중요한이슈는혈관내치료와수술적치료가접목된하이브리드치료라할수있다. 그러나이러한하이브리드치료의수술적부분은시간이지나면서최소화되고있으며하이브리드치료의혈관내치료부분이최소화된수술적부분을보완해주면서더욱폭넓게사용되고있다. 따라서대동맥질환에있어서하이브리드치료는결국최종적으로모든대동맥질환을단일혈관내치료로만완성하기위한일종의과도기적치료라할수있겠다. 이에저자들은본병원에서최근까지치료하였던대동맥질환중수술적부분이거의없거나아주최소화된혈관내치료및하이브리드치료들중몇가지의증례들을보고하고자한다. Case 1 - Suprarenal mycotic aneurysm contained rupture: TEVAR scollped Case 2 Saccular aortic arch aneurysm: TEVAR scalloped Case 3 Saccular aortic arch aneurysm: TEVAR fenestrated Case 4 - Large saccular aneurysmal dilatation with mural thrombus on ascending aorta: hybrid TEVAR 상기의증례들이대동맥질환의치료에있어하이브리드치료에서단일혈관내치료로전환하는데도움이되었으면한다. 39

46 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Case 5. Hybrid TEVAR for residual CTBAD following Acute type A aortic dissection repair Ryu Sang-Wan, M.D. 1, Kim Kwan-Sik, M.D. 2, Seo Hong-Ju, M.D. 1 Department of Thoracic and Cardiovascular Surgery, Chosun University Hospital 1 St. Carollo General Hospital 2 A 44 year old male was transferred to our emergency center for sustained chest and back pain from several hours ago. He had no history of hypertension, but he was recommended regular check-up about his hepatic status at 2years ago. On preoperative examination, he was diagnosed as Child Grade B liver cirrhosis. He was underwent emergency operation in aortic replacement on ascending and hemiarch aorta, and discharged at postoperative 27 th days without any sequela despite suffering from small, multiple cerebral infarction and minor complications of liver cirrhosis during postoperative periods. By serial follow-up CT, the true lumen of residual dissecting flap was compressed by partial thrombosed and dilated false lumen. He was underwent staged debranching operation for arch vessel following TEVAR from just beyond of the origin of Lt CCA to just proximal of celiac axis at 12months after first operation. Just after ascending aorta replacement At 10months after ascending aorta replacement Just after TEVAR At 18months after TEVAR 40

47 Session V Learned from Extreme/ Adhoc Situations/ Morbidity & Mortality Cases Case 6. Hybird treatment for complication after EVAR and Open Hyun-chul Joo Division of Cardiovascular Surgery, Severance Cardiovascular Hospital Yonsei University College of Medicine 58세남환은 2011년 NSTEI, CAOD (3VD) 로 PTCA 시행받은과거력있는환자로내원 1시간전 Rt, knee-foot pain을주소로 ER 내원하였다. Lower extrimites CT angio 상 Rt popliteal artery 에 acute embolism 및 infrarenal AAA 87mm 발견되어입원하였다. Rt popliteal artery embolism 에대해 thrombus apiration시행하여 distal flow 재개통하였다. 이틀뒤 infareal AAA 에대해 EVAR 시행하였고시술중 wire 와 shuttle sheath 가 main body에걸려 fracture 된채로제거되지않아 emergency 수술로 conversion 하였다. Emergency AAA 수술준비중 TEE 상 retrograde aortic dissection 발견되어 AAA 에대한수술을미루고 ascending & hemiarch replacement 먼저시행하였다. 2주뒤 TAAA approach 하여 fracture 된채로걸려있는 wire 와 sheath 제거하고 EVAR 제거후 graft replacement 하였다. 수술후회복하던중 retroperitoneal space 로 bleeding 있어 angiography 시행하였고 inferior epigastric artery에 bleeding focus 있어 embolization 시행후 hematoma에대해 pigtail 삽입후 procedure 를종료하였다. 환자는회복하여퇴원하여현재외래 follow up 중이다. 41

48 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Case 7. Fatal effect of delayed diagnosis of Standford type B aortic dissection Nam Yeol Yim MD., Jae Kyu Kim MD. Department of Radiology. Chonnam National University Hospital A 44 year old male patient with Stanford type B aortic dissection has visited our hospital. He complained sustained severe, diffuse abdominal pain, which were developed 1 day before. On computed tomography (CT), aortic dissection (descending thoracic aorta ~ bilateral common iliac artery level) was diagnosed. Emergency TEVAR were performed, and intimal flap were sealed. However, just after TEVAR, cardiac arrest was developed. Although 40min cardiac massage, the patient cannot survive. On medical record review, after event, we have found prior medical records and CT exams taken from 2 different outside hospitals, which were done about 20 days, and 10 days before. At his 1 st visiting, intramural hematoma along thoracic aorta was overlooked and reported as simple atherosclerotic change. And 2 nd visiting, entry tear was misdiagnosed as an ulcerated atheroma. Learning points from this case were as follows. 1) Stanford type B aortic dissection is not a stable disease, 2) Precise diagnosis and clinical suspicion is crucial factor for early detection and successful treatment for aortic dissection. 42

49 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Domestic Faculty Young-Guk Ko Woong Chol Kang Tae-Hoon Kim Kiick Sung Jae Hyun Kim Yonsei University Gachon University Sejong General Hospital Sungkyunkwan University Keimyung University Joon Hyuk Kong Ho Jong Chun Kwang Bo Park Hwan Jun Jae Kwang-Hun Lee Sungkyunkwan University Catholic University Sungkyunkwan University Seoul National University Yonsei University Je Hwan Won Jae-sung Choi Keun Her Sang-Wan Ryu Hyun-chul Joo Ajou University Seoul National University Soonchunhyang University Chosun University Yonsei University Nam Yeol Yim Won-Heum Shim Byoung Kwon Lee Young Won Yoon Hyuk Ahn Chonnam National University Sejong General Hospital Yonsei University Yonsei University Seoul National University 43

50 2 nd Gangnam Severance Hybrid Aortic Surgery 2014 Kay-Hyun Park Suk Jung Choo EuySuk Chung Cheesoon Yoon Kilsoo Yie Seoul National University Ulsan University Inje University Catholic university Sejong General Hospital Sang-ho Cho Joonkyu Kang Kyung Jong Yoo Suk-Won Song Hyung Jin Shim Kyung-Hee University Catholic University Yonsei University Yonsei University Chung-Ang University Jong Yun Won Chul-Hyun Park Hyung Jung Kim Yonsei University Gachon University Yonsei University International Faculty Chun-Che Shih Taipei Veterans General Hospital, Taipei, Taiwan Tilo Kölbel University of Lund, Sweden and University of Hamburg, Germany 44