Cerebral embolic protection in thoracic endovascular aortic repair

Grover, Gagandeep Singh; Perera, Anisha H.; Hamady, Mohamad; Rudarakanchana, Nung; Barras, Christen; Singh, Abhinav; Davies, Alun H.; Gibbs, Richard

doi:10.1016/j.jvs.2017.11.098

Cited by 36 publications

(36 citation statements)

References 30 publications

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“…6 These filters do not protect against gaseous embolism, and even with bilateral use in the carotid arteries, the posterior cerebral circulation remains unprotected and prone to embolization. 15 Clearly, effective, procedure-specific techniques that provide global CEP during TEVAR are required; our endeavor in the present case was to fill this void and improve the safety of such procedures in patients at high-risk for embolization. Being an unfamiliar and complex procedure requiring multidisciplinary collaboration, we had to proceed in an unhurried and methodical manner, using multiple neuromonitoring modalities, which resulted in a fairly long procedure.…”

Section: Discussionmentioning

confidence: 99%

Cerebral Protection Using Percutaneous Normothermic Bilateral Antegrade Cerebral Perfusion During Total Arch TEVAR in a Patient With Shaggy Aorta

et al. 2020

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Purpose: To report a technique of global cerebral embolic protection (CEP) designed for use during thoracic endovascular aortic repair (TEVAR). Technique: Arterial cannulas are inserted percutaneously in the right axillary artery (12-F) and left common carotid artery (LCCA; 10-F) to provide normothermic antegrade cerebral perfusion during TEVAR with neuromonitoring. Inferior vena cava blood is drawn using a 19-F femoral cannula, filtered, oxygenated, and delivered through independent roller pumps to the arterial cannulas. Static CEP is obtained by balloon occlusion of the 3 aortic arch branches proximally, resulting in complete separation of aortic and cerebral blood flow; static CEP is used during aortic endograft delivery and deployment. Dynamic CEP, obtained by creating flow reversal in the innominate artery and proximal LCCA, is used at all other times. Successful use of this CEP technique is illustrated in a patient with shaggy aorta undergoing fenestrated total arch TEVAR. Conclusion: Percutaneous normothermic bilateral antegrade cerebral perfusion provides effective CEP during TEVAR.

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Section: Discussionmentioning

confidence: 99%

Cerebral Protection Using Percutaneous Normothermic Bilateral Antegrade Cerebral Perfusion During Total Arch TEVAR in a Patient With Shaggy Aorta

et al. 2020

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“…6 Recent in vitro studies demonstrated air release from angiographic catheters and during deployment of different TEVAR devices, with a potential risk for air embolization in the supra-aortic arteries. [7][8][9] Grover et al 10 showed in vivo that 90% of MES in MCA during TEVAR are caused by air emboli, and the highest number was measured during stentgraft deployment.…”

Section: Introductionmentioning

confidence: 99%

Distribution of Air Embolization During TEVAR Depends on Landing Zone: Insights From a Pulsatile Flow Model

et al. 2019

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Purpose: To analyze the distribution of air bubbles in the supra-aortic vessels during thoracic stent-graft deployment in zones 2 and 3 in an aortic flow model. Materials and Methods: Ten identical, investigational, tubular, thoracic stent-grafts were deployed in a glass aortic flow model with a type I arch: 5 in zone 2 and 5 in zone 3. A pulsatile pump generated a flow of 5 L/min with systolic and diastolic pressures (±5%) of 105 and 70 mm Hg, respectively. The flow rates (±5%) were 300 mL/min in the subclavian arteries, 220 mL/min in the vertebral arteries, and 400 mL/min in the common carotid arteries (CCAs). The total amounts of air released in each supra-aortic branch and in the aorta were recorded. Results: The mean amounts of air measured were 0.82±0.23 mL in the zone-2 group and 0.94±0.28 mL in the zone-3 group (p=0.49). In the zone-2 group compared with zone 3, the amounts of released air were greater in the right subclavian artery (0.07±0.02 vs 0.02±0.02 mL, p<0.01) and right CCA (0.30±0.8 vs 0.18±07 mL, p=0.04). There were no differences between the groups concerning the mean amounts of air measured in the right vertebral and all left-side supra-aortic branches. The amount of air released in the descending aorta was significantly higher in the zone-3 group vs the zone-2 group (0.48±0.12 vs 0.13±0.08 mL, p<0.01). Small bubbles were observed continuously during deployment, whereas large bubbles appeared more commonly during deployment of the proximal stent-graft end and after proximal release of the stent-graft. Conclusion: Air is released into all supra-aortic branches and the descending aorta during deployment of tubular thoracic stent-grafts in zones 2 and 3 in an aortic flow model. Higher amounts of air were observed in right-side supra-aortic branches during deployment in zone 2, whereas significantly greater amounts of air were observed in the descending aorta during deployment in zone 3.

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“…Increasingly widespread application of transcatheter aortic valve replacement (TAVR) has encouraged the development and implementation of cerebral protection devices for prevention of intra-operative stroke. The Sentinel Cerebral Protection System (Claret Medical, Santa Rosa, CA) is currently the only FDA-approved cerebral protection device for TAVR, and preliminary data regarding its efficacy in both TAVR [4] and TEVAR of the descending aorta [5] have been promising. Here we present the first published report of cerebral protection device utilization during TEVAR for an ascending aortic aneurysm.…”

Section: Introductionmentioning

confidence: 99%

Novel Implementation of a Cerebral Protection System During Ascending Thoracic Endovascular Aortic Repair (TEVAR)

Kossar

Takayama

Patel

et al. 2019

Seminars in Thoracic and Cardiovascular Surgery

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Cerebral embolic protection in thoracic endovascular aortic repair

Abstract: The use of a CEPD with TEVAR appeared to be safe and feasible in this first pilot study and could serve as a useful adjunct to reduce cerebral injury. The significance of gaseous embolization and its role in cerebral injury in TEVAR warrants further investigation.

Cited by 36 publications

References 30 publications

Cerebral Protection Using Percutaneous Normothermic Bilateral Antegrade Cerebral Perfusion During Total Arch TEVAR in a Patient With Shaggy Aorta

Cerebral Protection Using Percutaneous Normothermic Bilateral Antegrade Cerebral Perfusion During Total Arch TEVAR in a Patient With Shaggy Aorta

Distribution of Air Embolization During TEVAR Depends on Landing Zone: Insights From a Pulsatile Flow Model

Novel Implementation of a Cerebral Protection System During Ascending Thoracic Endovascular Aortic Repair (TEVAR)

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