MasterClass discusses the management of thoracic aortic disease

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Vascular News attended the recent MasterClass VI: Management Of Complex Thoracic Aortic Disease, at Guy’s Hospital, London, UK, in September 2006. The MasterClass meeting aims to bring together all those with an interest in endovascular treatment of thoracic aortic disease and to focus on areas of current interest with time for discussion and debate. The event was again organised by Peter Taylor and John Reidy of Guy’s and St Thomas’ NHS Foundation Trust, London, UK.

This year’s meeting saw an increased attendance with an audience from North America, Europe and the UK. MasterClass VI focused on hybrid procedures of both the aortic arch and the thoraco-abdominal aorta, as well as aortic dissection. This year’s faculty included Mike Dake, Krassi Ivancev, Christoph Nienaber and Jean-Pierre Becquemin.

The meeting began with a presentation by Dr Richard Couldon, Leicester, UK, who assessed the merits of Computed Tomography Angiography (CTA) vs. Magnetic Resonance Angiography (MRA) in relation to aneurysms. He said that CTA allowed a quick and simple investigation, provided excellent spatial resolution and coverage, was widely available and available out of hours. In constrast, he added that MRA utilised gadolinium-based contrast agents are non-ionising and do not cause nephrotoxicity. On the other hand, MRA examination times are longer than those typically required for CTA, and therefore MRA is less suited to examinations of acute conditions.

Next, Professor Jean-Pierre Becquemin, Paris, France, discussed aortic branch surgery and stent grafting. He stated that arch assessment should examine thrombus/calcification, diameter, angulation, branch patency, vertebrobasilar system and the adequate length of the healthy segment. Citing data from his centre’s study, Becquemin concluded that the current technologies do not meet all the needs and that the aortic arch remains very challenging for endovascular repair. However, he added that acceptable results could be achieved especially in high-risk patients.

Following Becquemin, Dr Matthias Karck, Hanover, Germany, presented an overview of the hybrid graft with the ‘frozen’ elephant technique. The hybrid graft (developed by Jomed) allows a single stage treatment of extensive thoracic aneurysms that would otherwise require a two separate operations. He added that the antegrade selective cold blood brain perfusion covers the additional time of circulatory arrest necessary for stent graft delivery in the descending aorta.

In a series of results from his own hospital, mortality was 12% (not all technical/procedure related and the stroke rate was 12%. However, the survival rate at one year was 88% and at three years 86%. In the subsequent question and answer session, he was asked by Krassi Ivancev about the rate of paraplegia, to which he answered there were no cases. He added that the system was limited to 10cm in the descending aorta, although this was long enough for the majority of patients. He said that the progressive thrombus formation in the perigraft space around the stented segment of the graft supports the therapeutic concept of the hybrid prosthetic.

Next, Krassi Ivancev, Malmo, Sweden, discussed the role of the branched/fenestrated devices in the aortic arch. He began by stating that such devices were necessary when a proximal landing zone for EVAR is short or non-existent in the arch of the aorta. He commented that it was important not to expect too much of a device that is still very much in its infancy, with improvements and additional stent-graft developments anticipated. However, the current devices are beginning to offer the possibility treating aneurysms in the aortic arch. He added that a limitation was the lack of practice, as these are custom made devices. In addition, Matt Thompson, London, UK, commented that the event of stroke is becoming the real risk with the aortic arch.

John Wolfe, London, UK, then presented the pros and cons of hybrid repair of thoracoabdominal aneurysms. He said that an advantage of such a procedure was reduced blood loss, no cardiac bypass, no thoracotomy and no supra renal aortic cross clamp, and reduced visceral ischemia time. However, the disadvantages were stent graft patency/failure and endoleaks as well as distal deployment and true lumen flow.

The sponsors of the MasterClass included Medtronic, Gore, Cook and Bolton Medical (BVM) and they each made short presentations on current product developments. Highlights included an update from Gore, who revealed the creation of several new studies and product release over the next 12 months. In Europe, the company recently launched the 45mm GORE TAG endoprosthesis as well as establishing the ADSORB study for thoracic Type B dissection. In early 2007, Gore will be introducing a small trauma device and a long/tapered TAG device for dissection in 2008.

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