How to Start an Endoarch Program in a Cardiothoracic Department

As complex arch work shifts further into the endovascular realm, the practicalities of building an ‘endoarch’ program from scratch are an important stepwise discussion to be placed front and center.

To that end, delegates in Main Arena 2 will be privy to what that journey really looks like, who needs to be in the room, which facilities are essential, and how to keep patients safe in the learning phase.

Speaking to LINC Today, Tara Mastracci (St Bartholomew’s London, UK) shared a glimpse of her extensive experience shaping a multidisciplinary endoarch service within a cardiothoracic setting.

What is the minimum ‘starter kit’ for an endoarch program in a cardiothoracic department, including staffing, kit, and facilities?

The guidelines are very clear that developing an aortic team means having a multidisciplinary service. Having functional cardiac surgery and a full vascular/endovascular department is ideal, as they will come with the needed colleagues and facilities that make an excellent endoarch center. This means expertise with complex aortic cases, both in the proximal and distal aorta, and the imaging and critical care support that accompanies these services.

Although having mixed-skilled team is an important first step, it is also important that the people involved work as a team, and that often requires time and experience to develop.

Where should an endoarch program sit organizationally, and why?

The answer is very center-specific, and it depends on the governance structure of the hospital. Ideally, all the specialties are geographically co-located and already have a communication structure where cases can be easily discussed in a multidisciplinary forum. It has been very valuable for our team to have multidisciplinary clinics, and to have the ability to meet for emergency team meetings (virtually) when urgent cases arise. Any of the options above can work, with coordination, adequate facilities, and good communication.

In terms of case selection, in the first 10–20 instances, what are the safer anatomies/pathologies to start with, and which should be avoided until the team is mature?

In the first instance, acquiring the skills can be done with simpler cases – using a single branch device for left subclavian branching introduces the team to the concept of arch intervention in a low-stakes territory. Once the early cases with single branched devices are mastered, the entire team will have more confidence with complex intervention in the arch. The safest cases in this territory will be chronic type B dissections, or thoracic aneurysms where the landing zone is well within the instructions for use.

When it’s time to graduate to total arch, then I think the best evidence for repair is in the post-type A dissection cohort. These patients have a lower stroke risk and a better chance of achieving a good proximal seal. Adjudicating the patients who are too high risk for re-do sternotomy at your center, but still adequate risk for any intervention, is then the domain of a well-functioning multidisciplinary team.

What is your recommended pathway for building competency (e.g. simulation, observerships, proctorship) and when should there be a transition from fully proctored to independent?

I think all of the above. Using the resources available to you, both through courses, simulations, and then proctored cases, will improve confidence with a procedure that is new. It is also important to note that bringing the entire team on the learning journey is important. At our center, we enjoyed running simulations prior to our first cases, so that anesthesia and nursing teams were also well-versed in the steps of the procedure before the patient entered the theatre.

What technical features in the hybrid operating room count the most for endoarch success?

I’m a big advocate of fusion imaging and think it is an absolute must-have for any complex endovascular repair. We also take huge advantage of our cardiac physiologists from the cath labs to help with rapid pacing and monitoring during these cases. An anesthesia team that has access to and proficiency with transoesophageal echocardiography is also handy, as is the ability to rapidly mobilize an intravascular ultrasound for large diameter vessels when needed.

Finally, occasionally there is a need for intravascular lithotripsy, which can make difficult access slightly easier.

Neuroprotection is the make-or-break issue in arch work. What protocols do you consider non-negotiable for stroke prevention and neuro-monitoring when launching a program?

For monitoring neurological outcomes, the answer is often very closely related to the austerity of the healthcare system in which you work. Although I would love to avail myself of transcranial Dopplers for every case, a resource-poor system cannot always have such facilities. We rely on near-infrared spectroscopy for monitoring and use it in the cerebral and paraspinal positions. This has served us well so far.

In terms of improving neurovascular outcomes, the evidence shows that the biggest impact on stroke outcomes comes with good patient selection and when CO2 flushing is used. For devices that have the capability, we use three minutes of CO2 flush, followed by 150 ml saline flush immediately prior to use. Being sure to minimize manipulation in the arch is also important in procedure planning.

How do you build a so-called extended team (radiology, neurology, vascular access expertise, cath lab techs, industry reps) so it feels like one service rather than ad-hoc collaboration?

Our training sessions, which sometimes include ex-vivo deployment (simulated cases), have been beneficial. This allows the industry reps to interact directly with the nursing team and allows us to adjust the pace of procedural steps to bring everyone along with us. Anesthesia, perfusion, radiography, radiology, and physiology are all invited and attend, so we get as close to the same team in the room as on the day. It also allows us to sense-check our setup – be sure that tables and trolleys are in the right place to make the workflow as smoothly as possible.

On to governance, what does good oversight look like early on?

We have an institutional requirement to introduce new procedures in a very controlled way, with the first five cases being audited by an external committee before the program is allowed to proceed. This also allows our finance team to examine the procedure before and after introduction, to be sure there are no hidden costs. After that, a robust morbidity and mortality meeting with good reporting is critical in any advanced aortic work. Having a dedicated database to collect cases and outcomes that is part of the pathway is imperative to be sure you’re collecting data on your whole experience.

Which outcomes should new programs track in Year 1 to prove value and safety, and what benchmarks feel realistic?

I think all of these outcomes are important, and the most vital ones largely depend on the values of the institution. A really successful open arch program will be augmented by one that can take on high-risk, slightly more frail patients and also match institutional expectations. Having a ‘control’ population and setting out benchmarks in advance is critical to getting buy-in from all stakeholders as the program progresses.

Similarly, if you had to give one piece of advice to a cardiothoracic chair considering an endoarch program, what would it be?

I think any successful program starts with a functional and foundational team who share good communication and expectations. Having a suitable volume of patients that require this service is also relatively important. Although low volumes are expected early on, it is easier to build a service if the time between cases can be as short as possible, so the entire team can learn from experience.