Total endovascular treatment of the aortic arch after type A dissection with chimney and sandwich technique

This is a very advanced case of a total endovascular repair of a post-type A dissection aneurysm of the aortic arch with chimney endografts for the brachiocephalic trunk and the LCCA and a periscope in Sandwich technique for the LSA. See the procedure in chapters for the different steps under:


    Very impressive work Theo! Endovascular medicine at its Limits.

    A question from my side. What is your indication for a CMD-arch prothesis? Where are the limits? Can you give a short description or overview about your algorithm ?
    Thank you and warm regards from Dorsten…

    Dr. Theodosios Bisdas
    June 11, 2018

    Thank you Özgün for your question. This was not a custom-made device, but an off-the-shelf treatment with chimney and sandwich technique. A custom-made device was not indicated in that case due to the short length of the replaced ascending aorta. There are strict inclusion and exclusion criteria for those cases. We decided to go forward with an endovascular approach due to the comorbidity of the patient and the redo operation.

    Thank you for your answer Theo! My question was not precise, sorry. It is obvious, that you’ve done a great case with this chimney/periscope exclusion and not with a CMD. I am sure the planning was complex. My question is your general opinion about CM-branched-devices for the arch if indicated. You answered my question why it was not possible in this particular case. Maybe it is possible in the future to see a CMD-case for the arch at Vascupedia. Your opinion about the indication and characteristics would be valuable for the vascular public.

    Again, great job!

    Mr Arne Stachmann
    June 11, 2018

    Hello Theo,
    great and challenging case.
    3 questions:
    1. Would it make sense in this case to implant 3 Chimneys?
    2. Would it be possible to implant an aortic arch prosthesis?
    3. What about anticoagulation after discharge?


    Dr. Theodosios Bisdas
    June 11, 2018

    Thank you Arne for your questions.
    1. We decided against a 3 chimney for 2 reasons: (a) to avoid a bigger gutter and (b) to have the option for an antegrade (transbrachial) access to the descending aorta (e.g. further endovascular repair with fenestrated or branched endograft)
    2. See my comment to Dr. Sensebat
    3. The patient will receive dual antiplatelet treatment for 3 months and afterwards only ASA. However, I cannot support this with any kind of evidence. The advantage is that we have large bridging stent-grafts (12 mm for the brachiocephalic trunk and 10mm for LCCA and LSA).

    MD Michel Bosiers
    June 12, 2018

    Amazing and very difficult case Theo! Congrats!
    I have 2 questions, why use an IBD for the Brachiocephalic trunc, and not a limb? And why not perform a carotid-subclavian Bypass, since you already made the incisions for it to implant your chimney/ sandwich?

    Dr. Theodosios Bisdas
    June 15, 2018

    Hi Michel! Thank you for your question.
    Regarding your first question. I did not use for example the Endurant limb because of the length (82mm) and the difference of the materials compared to the cTAG (Dacron vs PTFE). I think the gutter could be an issue. The IIA-branch of the IBD device is tapered (16 to 12mm) and shorter (70mm).
    Regarding your second question, the downwards orientated branch for the LSA allows access for a branched endograft and principally for a transbrachial approach.

    June 15, 2018

    Amazing case Theo! Great tutorial from many points of view. Great discussion. Meticulous planning is the key to success in these cases! That’s why they didn’t use C-S bypass, Michael even so it would make sense, but this would have closed the door for further interventions distally if needed. Theo, can you comment on your CSI protective measures in complex TEVAR cases and what’s the incidence of stroke and how to minimize it? Thanks

    Dr. Theodosios Bisdas
    June 15, 2018

    Thank you, Martin! Well, we are far away from a well-established protocol for CSI protection. Especially, in that case, you have to be very quick after deploying the thoracic endograft over the aortic arch. There are some new filters for the brachiocephalic trunk and the LCCA but these are applicable only in TEVAR cases. When you have to get access for the supraaortic vessels you have no option to protect the brain. My measures are:
    1. Remove very carefully the air from the devices
    2. Check multiple times your angiographic catheters to avoid air embolisation
    3. Avoid a lot of manipulations with your thoracic endograft
    4. Introduce the large-bore sheaths (12F), when you really need them and not from the beginning of the procedure
    5. Check the quality of your arch at the angio-CT before planning your procedure.

    September 18, 2018

    Aortic Disease Awareness Day – Please comment

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