O-097 - INFERIOR VENA CAVA - BALLOON OCCLUSION AND ITS EFFECT ON THE MYOCARDIUM DURING ENDOGRAFT DEPLOYMENT IN THE ARCH

TOPIC:
New vascular techniques and devices
AUTHORS:
Karelis A. (Vascular Center, Department of Thoracic surgery and vascular diseases, Skåne University hospital, Malmö, Sweden ~ Malmö ~ Sweden) , Dias N. (Vascular Center, Department of Thoracic surgery and vascular diseases, Skåne University hospital, Malmö, Sweden ~ Malmö ~ Sweden) , Holmström A. (Department of Intensive and Perioperative Care, Skåne University Hospital Malmö, Sweden ~ Malmö ~ Sweden) , Kölbel T. (German Aortic Centre Hamburg, Department of Vascular Medicine, Hamburg, Germany ~ Hamburg ~ Germany) , Sonesson B. (Vascular Center, Department of Thoracic surgery and vascular diseases, Skåne University hospital, Malmö, Sweden ~ Malmö ~ Sweden)
Introduction:
Thoracic endovascular repair (TEVAR) of aortic arch and thoracic aortic aneurysms has become a valid alternative to open surgical repair and should be considered in patients unfit for open surgery and with a suitable anatomy (1). Precise positioning of the thoracic stent-graft is crucial during TEVAR. To avoid inaccurate stent-graft deployment caused by the systolic jet, methods to reduce cardiac output (CO) have been developed including pharmacologically induced systemic hypotension, rapid ventricular pacing, and recently the Munich Valsalva Implantation Technique (MuVIT) (2-4). The technique of inferior vena cava (IVC)-balloon occlusion is an alternative technique for CO reduction in TEVAR used for many years. (5-7) Partial inflow occlusion from IVC to the right atrium with a compliance balloon at the IVC-atrial junction (ICAJ) leads to a reduction in stroke volume (SV) and CO due to reduced venous return and consequently reduced preload. However, information about the impact of IVC-balloon occlusion on the myocardium and the overall cardiac function is lacking. The impact of this drastic reduction of CO on the myocardium may include an imbalance between oxygen supply and oxygen demand and has not been previously investigated. The aim of this study is to report the results of a prospective cohort study with focus on the cardiac stress of partial occlusion of right atrial inflow and the impact on myocardium.
Methods:
A prospective observational cohort study of 21 patients who underwent endovascular repair of aortic arch and thoracic aorta in a single tertiary referral center with use of inferior vena cava (IVC) balloon occlusion as a method of intraoperative cardiac output reduction, Figure 1. Pre-, intra- and post-operative measurements of heart rate, blood pressure, stroke volume index and central venous oxygen saturation were noted. High-sensitive serum troponin levels were also analyzed according to a pre-established protocol. Endpoints were cardiac troponin T levels after induced hypotension and left ventricular ejection fraction during follow-up. Secondary endpoints were procedure technical success and overall survival.
Results:
21 patients (18 male, median age 69, (62 - 75, IQR)) enrolled in the study between May 2015 and January 2019. Indication for endovascular treatment was an aortic arch aneurysm (n=10), descending aortic aneurysm (n=8), lusorian aneurysm (n=2) and thoracoabdominal aortic aneurysm (n=1), baseline characteristics demonstrates on Table 1. Median time to reach half mean arterial pressure was 60 sec while median recovery time of blood pressure was 135 s, overall peri- and post-operative measurements of cardiac stress demonstrates on Table 2. In 5 (24%) cases we observed a > 50% change of Troponin T on the reference level, Figure 2. Technical success was achieved in all cases. Two (10%) patients developed new and persistent atrial fibrillation and one (5%) suffered a peri-operative ST-elevation myocardial Infarction.
Conclusion:
IVC-balloon occlusion during aortic arch and descending thoracic TEVAR is a feasible technique with no documented procedure-related complications but is associated with cardiac compromise documented by a significant Troponin T leakage. Further studies are needed to study in depth the cardiac stress caused by cava balloon occlusion and to compare to alternative techniques of CO reduction.
References:
1. Czerny M, Schmidli J, Adler S, van den Berg JC, Bertoglio L, Carrel T, et al. Editor's Choice - Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019;57(2):165-98. 2. Nienaber CA, Kische S, Rehders TC, Schneider H, Chatterjee T, Bunger CM, et al. Rapid pacing for better placing: comparison of techniques for precise deployment of endografts in the thoracic aorta. J Endovasc Ther. 2007;14(4):506-12. 3. Qu L, Raithel D. Techniques for precise thoracic endograft placement. J Vasc Surg. 2009;49(4):1069-72; discussion 72. 4. Tsilimparis N, Abicht JM, Stana J, Konstantinou N, Rantner B, Banafsche R, et al. The Munich Valsalva Implantation Technique (MuVIT) for Cardiac Output Reduction During TEVAR: Vena Cava Occlusion With the Valsalva Maneuver. J Endovasc Ther. 2021;28(1):7-13. 5. Lee WA, Martin TD, Gravenstein N. Partial right atrial inflow occlusion for controlled systemic hypotension during thoracic endovascular aortic repair. J Vasc Surg. 2008;48(2):494-8. 6. Marty B, Morales CC, Tozzi P, Ruchat P, Chassot PG, von Segesser LK. Partial inflow occlusion facilitates accurate deployment of thoracic aortic endografts. J Endovasc Ther. 2004;11(2):175-9. 7. Pietersen LC, van der Meer RW, Alders DJC, van Schaik J, Eefting D, van Rijswijk CSP. Partial Right Atrial Inflow Occlusion for Transient Systemic Hypotension During Deployment of Thoracic Stentgrafts. Cardiovasc Intervent Radiol. 2021;44(7):1116-20.
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