Nuremberg, May 2023
 
Tara MASTRACCI shares her perspective on a range of sessions.

Update on a RCT trial to reduce paraplegia in Thoracoabdominal Aortic Aneurysm (TAAA)Speakers: Christian Etz

Christian Etz discussed the progress of the PAPIARTIS trial, which is randomising patients expected to have open or endovascular thoracoabdominal repair to either early coil embolization of the intercostals, or standard treatment.  He reviewed the background and significant evidence to date that has set the basis for the trial.  Despite the spinal ischemic risk of this strategy, the initial Leipzig experience had no cases of spinal ischemia.

The trial was designed to be a 5-year duration with 500 participants, however recruitment slowed during COVID pandemic.  There are 17 centres currently enrolling patients, of which 193 patients have been randomised.  86 are randomised to the treatment arm and 107 in the control arm, with 120 patients who have reached the final repair stage.  The first analysis is not yet done but should be done in the next few months.  

The entire thoracoabdominal community looks forward to results of this trial for future treatment guidance to possibly decrease risk of this challenging complication.

Multidisciplinary session on arch/ascendingSpeakers: Piotr Szopinski, KakKhee Yeung, Michele Antonello, Stephan Haulon

The arch session at the Critical Issues Meeting was a showcase of devices available for proximal aortic work.  The presenters reviewed the available offerings including devices from Bolton, Cook and Castor, and some composite bespoke constructs.  The group pointed out that cardiac movement and the boundary of the aortic valve present some of the challenges for implanting devices in this area.  

The stroke rate has been reported to be as high as 20% in early publications, but most modern iterations of devices now quote a stroke rate of 4-7%.

Perhaps one of the more exciting areas of endovascular expansion was in the work being done in Endo-Bentall procedures, which was presented by Stephan Haulon.  He emphasises the importance of these cases being done at the highest volume aortic centres because of the multidisciplinary skill required for the cases, and as compassionate use only, because of the early developmental stage.  

Given the success with arch repair, the natural next step for arch repair is including the valve — and he described several different Endo-Bentall procedures where valve incorporation was possible.  A device custom constructed with two branches for coronary arteries was demonstrated — with significant learning about the directional consequences of the coronary arteries.  By crossing the valve and using a rendezvous technique for transcatheter aortic valve replacement (TAVR), he demonstrated that the entire construction of the valve/ascending complex can completed in 1 minute.  The coronary arteries, which maintained perfusion using helical branches, were then connected in sequence.  

There is certainly great hope that these early devices will lead to a more standardised, and commercially available minimally invasive option for ascending pathology.

False Lumen Occlusion in DissectionSpeakers: Tilo Koelbel, Germano Mellisano

The use of false lumen excluders was debated in this session at Critical Issues.  Various techniques for false lumen occlusion were presented and discussed. The candy plug has been reinvented with three different iterations. The pros and cons of this technique was explored by both Tilo Koelbel and Germano Melisano. Although both agree the technique would be useful, they were honest about limitations and have refined indications for use. 

One insight provided is that its best used as a single stage procedure – to decrease the risk of thrombus formation and allow for circumferential intimal apposition in the false lumen.  This obstructive technique was compared with other embolization techniques, which may have a limited role of complete occlusion does not occur.  

Both experts agreed that a registry is needed to document cases in which success is seen, and those in which further treatment is needed, to help guide use for the future.