Heinz Jakob (Essen, Germany) and Tilo Kölbel (Hamburg, Germany) offer their respective cardiac and vascular surgery perspectives on the potential of some new techniques and technologies at the cutting edge of aortic advances. They detail how novel approaches such as rendezvous access for the Endo-Bentall procedure push the boundaries of treatment and how nascent technologies such as Philips’ Fiber Optic RealShape (FORS) technology might transform current practice.
On day two of the CX Aortic Vienna 2022 Digital Edition (24–26 October), Kölbel presented an edited case on the Endo-Bentall procedure using a rendezvous access technique. Kölbel notes that rendezvous access works by creating a through-and-through guidewire access from the transapical to a transfemoral route, or from a transapical to a transcarotid route. “That is why it is called rendezvous,” he explained, “because the devices meet each other, and then you can do what is otherwise very difficult to do.” He stressed that the access has only been used in three cases so far—one in Hamburg and two in Montpellier, France. “It is not a regular access,” he notes.
According to Kölbel, rendezvous access allows the operating physician to make the Endo-Bentall approach a modular procedure. Prior to the introduction of this technique, he explains that all approaches to combine a transcatheter aortic valve implantation (TAVI) valve with an ascending graft usually aimed to suture or connect those devices outside of the body, and then bring it into the body already connected and deployed. With the rendezvous technique, on the other hand, he details that “these two important parts of the device are connected within the body in a short period of time because of the access from two sides”.
Considering the treatment of Ishimaru zone 0 more generally, Jakob underlines the fact that aortic dissection, for example, is a “dramatic disease,” with a 2% death rate per hour in the first 24 hours. “As cardiac surgeons, this puts us under pressure,” he says. According to Jakob, the rendezvous technique is “an ingenious approach,” as it enables the treatment of a patient population that are prohibited from classic open repair. “This is the last boundary, the last challenge we are facing in our field,” he remarks.
Both Jakob and Kölbel agreed that there were lessons to be learned about the importance of collaboration between the cardiac and vascular surgery fields, that had been brought to the fore at the meeting.
“I think we should overcome this old thinking that they are taking business from us,” said Jakob. “The technology is there, and the experience is growing, and Tilo and Stéphan Haulon in Paris are excellent protagonists of this approach. The heart is our field and so it makes sense to combine the efforts.”
“I personally think this is an area where vascular surgery cannot take over,” added Kölbel. “This disease is not well understood by vascular surgeons, but vascular surgeons have, in most centres, developed advanced endovascular skills which are needed if you want to treat this. The reason why collaboration is paramount is that you need understanding of the disease and of intracardiac structures and cardiac function and at the same time you need the skills and experience of advanced endovascular repair.”
Imaging advances
“For me, it is always fascinating to see the progress in the endovascular world,” Jakob notes, describing the leap that has been made even over the past year or so with FORS.
Kölbel follows this by noting that it was “very interesting” to hear experienced speakers discussing the use of CO2 flushing for the de-airing of stent grafts in their own centres. On this front, things were different a few years ago, he added, as this was not a “regular thing” in stent grafts. “But, watching those presentations, it has become almost the standard—in experienced centres,” he notes.
“We have seen a huge number of small tips and tricks, and they all reduce morbidity and mortality a little bit,” Kölbel continues, “but all of them together suddenly make a procedure possible that has not been [previously].”
Here, Jakob also notes that it will be interesting to see how the community now follows Kölbel’s lead as a pioneer in this field and of many other endovascular treatments.
Kölbel himself adds that, while he has been using FORS for two-and-a-half years in his practice, he learned something new during day two of CX Aortic Vienna—namely that you can ‘zoom out’ on one of the panels while using the technology and view all of the wires. “I learned that from this meeting, here, today—some things you just need to see once to include in your practice,” he says.
And, he remains fascinated by future advances with FORS and is eagerly anticipating what is in the pipeline as well, in the hope these will improve clinical results further. Kölbel concludes that the key is to understand what will actually be of clinical use because, if anything, there is “almost too much information” right now, before complimenting the company (Philips) on their work in this space thus far.
