Coverage of the left subclavian artery during thoracic endovascular aortic repair

Atypical presentation of subclavian steal syndrome with left sided sensorineural deafness

We present a rare manifestation of a common pathology: left sided sensorineural hearing loss secondary to subclavian steal syndrome after thoracic endovascular aortic repair for complicated acute aortic dissection. We describe the vascular physiology that can result in unilateral hearing loss and provide a brief review of subclavian steal syndrome. This case report highlights the importance of avid clinical recognition of an atypical presentation of a common vascular disease.

Left subclavian artery revascularization is associated with less neurologic injury after endovascular repair of acute type B aortic dissection

OBJECTIVE

The aim of this study was to analyze patients with acute type B aortic dissection (aTBAD) requiring thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) coverage to determine whether LSA revascularization decreased the risk of neurologic complications.

METHODS

The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with aortic aneurysms or aortic ruptures were excluded from the analysis. Patients were divided into two groups according to whether their LSA was revascularized (prior to or during TEVAR) or not. Univariate followed by multivariate analysis was used to account for possible confounders and evaluate the association of LSA revascularization with the primary outcome of neurologic injury (stroke or spinal cord ischemia).

RESULTS

Among patients who had TEVAR for aTBAD, 501 patients had the LSA covered. The LSA was revascularized prior to or concomitant with TEVAR in 28% of these patients (n = 139). Average age was 57 years, and 73% (n = 366) were male. Neurologic injury developed in 88 patients (18%). On univariate analysis, patients who had their LSA revascularized were significantly less likely to develop neurologic injury (10% vs 20%; P < .01). This association persisted after accounting for potential confounders (odds ratio, 0.4; P = .02). No significant difference was seen when comparing 30-day or 1-year mortality between patients who had LSA revascularization and those who did not. Follow-up averaged 1.9 years (range, 0-8.1 years). Long-term survival did not differ between the two groups on Kaplan-Meier analysis.

CONCLUSIONS

In this study of patients with aTBAD who underwent LSA coverage during TEVAR, the addition of a LSA revascularization procedure was associated with a significantly lower incidence of neurological injury including spinal cord ischemia and/or stroke.

Evaluation and Management of Complications of Endovascular Aneurysm Repair of the Thoracic Aorta

Thoracic endovascular aortic repair (TEVAR) has become the standard of care for descending thoracic aortic pathology as the procedure has a historically low rate of reintervention and a high rate of success. However, TEVAR can be associated with complications such as endoleak, upper extremity limb ischemia, cerebrovascular ischemia, spinal cord ischemia, and post-implantation syndrome. An 80-year-old man with a history of complex thoracic aortic aneurysms underwent repair of a large thoracic aneurysm with a frozen elephant trunk procedure in 2019 at an outside institution. The proximal aortic graft extended to the arch and the innominate and left carotid artery were implanted into the distal portion of the graft. The endograft, extending from the proximal graft to the descending thoracic aorta, was fenestrated to maintain left subclavian artery flow. In an attempt to gain a seal at the fenestration, a Viabahn graft (Gore, Flagstaff, AZ, USA) was inserted. A type III endoleak was identified postoperatively at the fenestration, and a second Viabahn graft was required to gain a seal during the initial hospitalization. In 2020, an endoleak persisted at the fenestration on follow-up imaging, but the aneurysmal sac was stable. No intervention was recommended. The patient later presented to our institution with three days of chest pain. A type III endoleak at the level of the subclavian fenestration persisted with significant enlargement of the aneurysm sac. The patient underwent an urgent repair of the endoleak. This consisted of covering the fenestration with an endograft and left carotid to subclavian bypass. Subsequently, the patient developed a transient ischemic attack (TIA) due to kinking and extrinsic compression by the large aneurysm sac of the proximal left common carotid artery, requiring a right carotid to left carotid-axillary graft bypass. This report with a literature review discusses TEVAR complications and outlines methods to approach them. TEVAR complications and their management should be firmly understood to improve overall treatment outcomes.

Emergency Endovascular Interventions on Descending Thoracic Aorta: A Single-Center Experience

Background

Implementation of emergency endovascular aortic repair provides an attractive opportunity in the treatment of complicated acute aortic syndromes involving descending aorta.

Aim

The aim of this study was to analyze the effectiveness of thoracic endovascular aortic repair (TEVAR) for the treatment of acute surgical emergencies involving the descending thoracic aorta.

Methods

A retrospective review of the medical records of all patients undergoing TEVAR in a single center since 2007 was undertaken. Patients with the aortic disease treated on emergency inclusion criteria were complicated spontaneous acute aortic syndrome (csAAS), traumatic aortic acute injuries (TAIs), and other indications requiring emergent intervention. Technical and clinical success with patient mortality, survival, and reoperation rate was evaluated according to Society for Vascular Surgery reporting standards for thoracic endovascular aortic repair (TEVAR).

Results

The emergency interventions were necessary in 74 cases (51.0%), including patients with the complicated spontaneous acute aortic syndrome (csAAS) (64.8%; n = 48) and traumatic aortic acute injuries (TAIs) (31.1%). In addition, in one case aortic iatrogenic dissection (AID) and in 2 other fistulas after the previous stent graft, implantations were diagnosed. All procedures were done through surgically exposed femoral arteries while 2 hybrid procedures required additional approaches. The primary technical success rate was 95.9%, in 3 cases endoleak was reported. The primary clinical success occurred in 94.5%. All patients survived the endovascular interventions, whereas during in-hospital stay one of them died due to multiorgan failure (early mortality 1.3%). During the follow-up period, lasting 6 through 164 months (median 67), 11 patients died. Annual, five- and ten-year probability of survival was 86.4 ± 0.04%, 80.0 ± 0.05%, and 76.6 ± 0.06%, respectively. However, the rate of 5-year survivors was significantly higher after TAI (95.2%) than scAAS (63.4%) (p=0.008). Early after the procedure, one individual developed transient paraparesis (1.3%). No other serious stent-graft-related adverse events were noted within the postdischarge follow-up period.

Conclusions

Descending aortic pathologies requiring emergent interventions can be treated by endovascular techniques with optimal results and low morbidity and mortality in an experienced and dedicated team.

Endovascular Repair of Descending Thoracic Aortic Aneurysms

Descending thoracic aortic aneurysms (DTAAs) are an important cause of morbidity and mortality in the elderly. Once diagnosed, they should be surveilled and then repaired at a diameter of 5.5 to 6 cm, depending on the individual patient's physiologic and anatomic risk of repair. Thoracic endovascular aortic repair (TEVAR) is the preferred approach for repair and there are multiple procedural adjuncts that can expand indications for and use of TEVAR. Spinal cord injuries are an important and highly morbid complication after TEVAR and it is imperative to mitigate this risk.

Effects of different bypass surgeries on LSA revascularization in patients with left subclavian occlusion

INTRO

Left subclavian artery bypass surgery is mainly carried out for patients with severe left subclavian occlusion. This paper aimed to evaluate the hemodynamic effects of different surgical bypass modes on left subclavian artery revascularization.

METHODS

Three-dimensional models of the aorta were reconstructed from CTA images of a patient with left subclavian artery occlusion, a patient with type B aortic dissection with left subclavian artery coverage during thoracic endovascular aortic repair, and a healthy 74 year-old man, resulting in six modes for each person: healthy left subclavian artery mode, left subclavian artery occlusion mode and four bypass modes. Hemodynamic parameters, including flow field, flow distribution, pressure gradient, and wall shear stress, were calculated using computational fluid dynamics.

RESULTS

After left subclavian artery bypass surgery, distal left subclavian artery blood flow resulting from left common carotid artery to distal left subclavian artery bypass was 100% of that in the healthy mode, while the other modes yielded flows at least 91%. Moreover, reversed flow only completely disappeared with left common carotid artery to distal left subclavian artery bypass, whereas reverse flow was observed in the other three modes in early systole.

CONCLUSION

Left common carotid artery to distal left subclavian artery bypass can effectively reduce reverse blood flow in the left vertebral artery, and it is a feasible, effective, and safe option for left subclavian artery revascularization in patients with left subclavian occlusion.

Stroke, spinal cord ischemia and upper limb ischemia in patients undergoing TEVAR with coverage of the left subclavian artery: a case series study

Background

We performed routine spinal fluid drainage for patients who underwent TEVAR for thoracic aortic pathology together with left subclavian artery coverage, which was needed for achievement of a safe proximal sealing zone. We assessed the occurrence of spinal cord ischemia as well the rate of occurrence of other complications such as stroke, and upper limb ischemia.

Results

This was a case series study done between July 2014 and April 2020, in them all the left subclavian artery was covered to ensure a proximal safe seal zone. Routine spinal fluid drainage was done, keeping the spinal fluid pressure < 10–15 mmHg with catheter in place for 48 h. Data was obtained from twenty-three patients who underwent TEVAR for thoracic aortic dissection (73.91%), thoracic aortic aneurysm (21.74%), or ulcer (4.35%). Planning was based upon multi-slice computed tomographic angiography and covering the left subclavian was mandatory to achieve a proximal sealing zone. Technical success was achieved in 100% of cases. 4.35% of patients had three endograft, 56.52% had two endografts, 39.13% had one endograft. All patients lost their radial pulsations immediately after implantation, 8.70% developed post implantation syndrome(fever) that was managed conservatively, 4.35% developed stroke related to the anterior circulation, 4.35% developed signs of spinal cord ischemia. During the follow up, one patient died within 6 h after the procedure due to extensive myocardial infarction (patient was scheduled for CABG after our procedure). 17.40% developed upper limb symptoms that were tolerable and were managed conservatively.

Conclusion

By adopting routine spinal cord drainage and pressure monitoring, we can consider not to revascularize the left subclavian artery prior to TEVAR if it will be covered.

CT of Postoperative Repair of the Ascending Aorta and Aortic Arch

While many of the classic open surgical repairs are still used to repair the ascending aorta, management of the aortic arch has become more complex via implementation of newer open surgical and endovascular techniques. Furthermore, techniques are often combined in novel repairs or to allow extended anatomic coverage. As such, a framework that rests on understanding the expected postoperative appearance is necessary for the diagnostic radiologist to best interpret CT studies in these patients. After reviewing the imaging appearances of the common components used in proximal aortic repair, the authors present a structured approach that focuses on the key relevant questions that diagnostic radiologists should consider when interpreting CT studies in these patients. For repair of the ascending aorta, this includes determining whether the aortic valve has been repaired, whether the sinuses of Valsalva have been repaired, and how the coronary arteries were managed, when necessary. In repairs that involve the aortic arch, the relevant considerations relate to management of the arch vessels and the distal extent of the repair. In focusing on these questions, the diagnostic radiologist will be able to identify and describe the vast majority of repairs. Understanding these questions will also facilitate improved understanding of novel repairs, which often use these basic building blocks. Finally, complications-which typically involve infection, noninfectious repair breakdown, hemorrhage, problems with endografts, or disease of the remaining adjacent aorta-will be identifiable as deviations from the expected postoperative appearance. Online supplemental material is available for this article. ^©RSNA, 2021.

Partial subclavian artery coverage in TEVAR patients for acute type B aortic dissections: an alternative solution

BACKGROUND

Acute type B aortic dissection with origin of the left subclavian artery (LSA) is generally managed with endovascular therapy for acute coverage of the LSA with: 1) no revascularization; 2) revascularization with open methods; or 3) endovascular revascularization. To identify an alternative solution, we critically evaluated a small cohort of patients who had partial coverage of their LSA.

METHODS

Three thoracic endovascular repairs were performed from January-March 2015. Patients were deemed eligible for endovascular repair after they had failed conservative management. Indications included acute type B dissection with lower extremity ischemia, ruptured dissection, and persistent symptoms of dissection after medical therapy.

RESULTS

Technical success was achieved in all three patients, and all procedures were performed percutaneously. The mean distance between the ostium of the LSA and the entry point of dissection was 11.1±3.4 mm. Within the 30-day postoperative period, there were no deaths, aortic ruptures, myocardial infarctions, or conversions to open repair. Freedom from re-intervention was noted in all 3 patients. There was no spinal cord ischemia.

CONCLUSIONS

There is no strong evidence to support the current optimal approach for treatment of the thoracic aorta. Partial coverage of LSA in patients with <2 cm seal zones may be considered as an alternative. However, due to our small sample size, limited follow-up, and lack of comparison cohort, further investigation is necessary.

Management of acute type B aortic dissection

BACKGROUND

The best management of acute uncomplicated type B aortic dissection is currently a controversial area. Recent advances in endovascular intervention have begun to establish pre-emptive thoracic endovascular aortic repair as a potential strategy. A review about the management for type B aortic dissection has been conducted.

METHODS

A narrative review consisting of 157 original articles, meta-analyses and guidelines was conducted. The findings were synthesized and summarized using 70 articles.

RESULTS

There are clear guidelines directing surgical management of acute complicated type B aortic dissection. However, the best management of acute uncomplicated disease is more ambiguous, which is especially concerning in a condition which is associated with significant morbidity and mortality. Medical management alone is generally favoured. Endovascular intervention is now being considered by some surgeons, but it can be technically difficult, while exposing the patient to potential surgical risks.

CONCLUSIONS

Clinical and anatomical risk factors have been identified to help vascular surgeons make decisions about treatment in acute uncomplicated type B aortic dissection. New endovascular strategies are being developed to reduce surgical risk and address technical challenges. Registry data should be used to support future best management.

Die traumatische Aortenruptur

Verkehrsunfälle sind für den größten Teil der traumatischen Aortenrupturen verantwortlich, meist zusammen mit weiteren schweren Begleitverletzungen. Die prähospitale Sterblichkeit ist hoch. Bei Verdacht auf eine beteiligte Aortenverletzung, aufgrund eines hohen traumatic aortic injury scores, ist eine Computertomographie durchzuführen. Es erfolgt eine Triage der Verletzungen, und die Versorgungspriorität der Aorta richtet sich nach dem Schweregrad der Aorten- und Begleitverletzungen sowie dem Zustand des Patienten. Bis zur definitiven Versorgung der aortalen Läsion muss der Blutdruck konsequent gesenkt werden. Grad I und II können in Einzelfällen unter enger Kontrolle inital konservativ gemanagt werden. Grad III (gedeckte Ruptur) und Grad IV (freie Ruptur) benötigen eine raschestmögliche Versorgung (interventionell, chirurgisch). In ausgesuchten Fällen kann auch eine verzögerte Versorgung günstig sein.

Als bevorzugte Versorgungsform hat sich die interventionelle Stentgrafttherapie etabliert.

Isolated left vertebral artery and its consequences for aortic arch repair

A left vertebral artery (LVA) originating directly from the aortic arch is the second most common supra-aortic branching anomaly. This isolated LVA can also terminate in the posterior inferior cerebellar artery without contributing to the circle of Willis, limiting treatment options, especially in cases with an incomplete circle. Here, we describe our consideration of the treatment options for a 79-year-old patient with a large distal aortic arch aneurysm combined with an isolated LVA and incomplete circle of Willis that may endanger adequate (intraoperative) cerebral perfusion.

Off pump hybrid extra-anatomic techniques for aortic arch repair-own experience

Background

Treatment of the aortic arch pathologies is technically challenging. In this study we assess early and late outcomes of hybrid aortic arch repairs that comprise extra-anatomic surgical procedures completed by thoracic endovascular interventions [thoracic endovascular aortic repair (TEVAR)].

Methods

Since 2007, 21 patients (8 women and 13 men) with a median age of 48 years have undergone hybrid procedures for aortic arch pathologies. All of them were treated without cardio-pulmonary bypass. All survivors were followed up regularly and imaging examination were performed. A technical success, procedural complications as well as the early and late mortality and morbidity rates were evaluated.

Results

All patients survived surgery and TEVAR was technically successful in all of them. However, 2 individuals died (in-hospital mortality rate 9.5%) during in-hospital stay, both due to multi-organ failure (MOF). Additionally, one patient developed symptoms of cerebral stroke, another one of spinal cord ischemia. During the follow-up that ranged from 6 to 118 months and was completed by 100% of the survivors, one patient died 3 years after procedure because of sepsis (aorto-oesophageal fistula prior to intervention) and late vascular graft occlusions were noted in three cases.

Conclusions

Hybrid procedures on the aortic arch that comprise surgical and endovascular interventions has become an attractive and safe therapeutic option with acceptable mortality and morbidity rate. They may be considered as a method of choice in treatment of the elderly and high-risk patients.

A Primary Computational Fluid Dynamics Study of Pre- and Post-TEVAR With Intentional Left Subclavian Artery Coverage in a Type B Aortic Dissection

The impact of left subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR) on the circulatory system is not fully understood. Here, we coupled a single-phase non-Newtonian model with fluid–structure interaction (FSI) technique to simulate blood flow in an acute type B aortic dissection. Three-element Windkessel model was implemented to reproduce physiological pressure waves, where a new workflow was designed to determine model parameters with the absence of measured data. Simulations were carried out in three geometric models to demonstrate the consequence of TEVAR with the LSA coverage; case A: pre-TEVAR aorta; case B: post-TEVAR aorta with the disappearance of LSA; case C: post-TEVAR aorta with virtually adding LSA. Results show that the blood flow through the compressed true lumen is only 8.43%, which may lead to ischemia in related organs. After TEVAR, the wall pressure on the stented segment increases and blood flow in the supra-aortic branches and true lumen is improved. Meantime, the average deformation of the aorta is obviously reduced due to the implantation of the stent graft. After virtually adding LSA, significant changes in the distribution of blood flow and two indices based on wall shear stress are observed. Moreover, the movement of residual false lumen becomes stable, which could contribute to patient recovery. Overall, this study quantitatively evaluates the efficacy of TEVAR for acute type B aortic dissection and demonstrates that the coverage of LSA has a considerable impact on the important hemodynamic parameters.

Endovascular treatment of complex diseases of the thoracic aorta-10 years single centre experience

BACKGROUND

Introduction of invasive endovascular techniques constituted a real a breakthrough in the treatment of aortic aneurysm dissection and rupture. We assessed the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) in patients with thoracic aortic pathologies.

METHODS

Between 2007 and 2017, 118 patients with thoracic aortic pathology underwent TEVAR. Among them, 20 (16.9%) patients required hybrid procedures. Stent grafts indication were thoracic aortic aneurysm in 46 (39.0%) patients, type B dissection in 68 (57.6%) patients and other indications in 4 (3.3%). Procedural success rate, in-hospital and late mortality and morbidity were evaluated.

RESULTS

The patients were followed-up for a mean of 55 months (range, 6-118 months). The technical success rate was 96%. Five patients died during the first 30 days after procedure (mortality 4.2%), four due to ischemic stroke followed by multi-organ failure and another one hemodynamically significant type I endoleak. Most of them were noted in the first years of our study. Five others died during post-discharged period. Four patients developed neurological complications, including stroke (n=2; 1.7%) and paraparesis (n=2; 1.7%). There were 6 (5.1%) primary (5 type I and 1 type II) and 3 (2.5%) secondary endoleaks (1 type I and 2 type III). Secondary interventions were required in 8 subjects. There was one case of stent collapse and two retrograde aortic dissection.

CONCLUSIONS

Treatment of descending aortic diseases by using stent graft implantation has become the method of choice, decreasing the risk of open surgery, especially in patients with severe clinical state and comorbidities. However, effectiveness and safety may be achieved by experience team.

Two Wire System and Modified Olive Tip to Facilitate Implantation of Fenestrated TEVAR in Patient with Proximal Descending Aortic Pathology: First Two Cases

Introduction

Although Fenestrated TEVAR (F-TEVAR) has been considered to be a more physiologic approach to treat proximal descending aortic pathology, its application is still limited due to availability, cost and technical difficulties. We introduce a new design of fenestrated stent graft with a new delivery system and successfully performed first in human implantation in two patients, one with an aortic aneurysm and one with an acute aortic dissection.

Materials and Methods

The design of these two wires fenestrated stent graft include creation of an additional lumen at the side of the olive tip during manufacture, from which an additional wire can be introduced for a side branch passing into the fenestration, running inside the stent graft and exit the delivery sheath through additional hub. The two wires will facilitate delivery and deployment of the stent graft. One patient with descending aortic aneurysm and another with Stanford B aortic dissection is included in this first in human study.

Results

The aneurysm and dissection were completely excluded immediately after the TEVAR. Six month follow up CT showed good position of the stent graft and patent LSA in both patients. In the patient with aortic dissection, expansion of the true lumen and partial thrombosis of the false lumen was seen.

Conclusions

This is a report of a two wire system in 2 patients with distal aortic arch pathology demonstrating a good technical and clinical success using pre-cannulated fenestrations through a modified nose cone olive.

Level of Evidence

Level 4, report of two cases.

Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management

In recent decades, endovascular aneurysm repair or endovascular aortic repair (EVAR) has become an acceptable alternative to open surgery for the treatment of thoracic and abdominal aortic aneurysms and other aortic pathologies such as the acute aortic syndromes (e.g., penetrating aortic ulcer, intramural hematoma, dissection). Available data suggest that endovascular repair is associated with lower perioperative 30-day all-cause mortality as well as a significant reduction in perioperative morbidity when compared to open surgery. Additionally, EVAR leads to decreased blood loss, eliminates the need for cross-clamping the aorta and has shorter recovery periods than traditional surgery. It is currently the preferred mode of treatment of thoracic and abdominal aortic aneurysms in a subset of patients who meet certain anatomic criteria conducive to endovascular repair. The main disadvantage of EVAR procedures is the high rate of post-procedural complications that often require secondary re-intervention. As a result, most authorities recommend lifelong imaging surveillance following repair. Available surveillance modalities include conventional radiography, computed tomography, magnetic resonance angiography, ultrasonography, nuclear imaging and conventional angiography, with computed tomography currently considered to be the gold standard for surveillance by most experts. Following endovascular abdominal aortic aneurysm (AAA) repair, the rate of complications is estimated to range between 16% and 30%. The complication rate is higher following thoracic EVAR (TEVAR) and is estimated to be as high as 38%. Common complications include both those related to the endograft device and systemic complications. Device-related complications include endoleaks, endograft migration or collapse, kinking and/or stenosis of an endograft limb and graft infection. Post-procedural systemic complications include end-organ ischemia, cerebrovascular and cardiovascular events and post-implantation syndrome. Secondary re-interventions are required in approximately 19% to 24% of cases following endovascular abdominal and thoracic aortic aneurysm repair respectively. Typically, most secondary reinterventions involve the use of percutaneous techniques such as placement of cuff extension devices, additional endograft components or stents, enhancement of endograft fixation, treatment of certain endoleaks using various embolization techniques and embolic agents and thrombolysis of occluded endograft components. Less commonly, surgical conversion and/or open surgical modification are required. In this article, we provide an overview of the most common complications that may occur following endovascular repair of thoracic and AAAs. We also summarize the current surveillance recommendations for detecting and evaluating these complications and discuss various current secondary re-intervention approaches that may typically be employed for treatment.

Post-traumatic acute thoracic aortic injury (TAI)-a single center experience

Background

We assess the effectiveness and our experience in emergency thoracic endovascular aortic repair (TEVAR) in patients with post-traumatic acute thoracic aortic injury (TAI) and associated multiorgan trauma. TAI is a life-threatening condition. It usually results from a sudden deceleration caused by vehicle accident, a fall or some other misfortune. Techniques of endovascular aortic repair have become promising methods to treat emergent TAI.

Methods

Since 2007, 114 patients with thoracic aorta pathologies have been treated by TEVAR. Our study involved 15 (incl. 14 men) of them (13%) who underwent stent graft implantation for post-traumatic either aortic rupture or pseudoaneurysm. The procedural access was limited to small skin incision in one groin and percutaneous puncture of the contralateral femoral artery. We evaluated technical success, early and long-term mortality, complication rate of procedure and throughout clinical and instrumental follow-up.

Results

Technical success rate was 100%. All patients survived the endovascular interventions. No additional procedures or conversions to open surgery were necessary. After the operation, none of the patients had symptoms of stroke or spinal cord ischemia (SCI). No serious stent-graft-related adverse events such as endoleak, infection or migration were noted during follow-up period that ranged from 6 to 108 months.

Conclusions

In our department, techniques of TEVAR with stentgraft implantation have become methods of choice in treatment of traumatic TAIs since they have enabled to minimize operational risk, particularly in unstable multitrauma patients in severe clinical status. TEVAR for TAI performed in emergency settings provide favorable long-term results.

Association of left subclavian artery coverage without revascularization and spinal cord ischemia in patients undergoing thoracic endovascular aortic repair: A Vascular Quality Initiative® analysis

Objectives

Investigate the impact of left subclavian artery coverage without revascularization on spinal cord ischemia development in patients undergoing thoracic endovascular aortic repair.

Methods

The Vascular Quality Initiative thoracic endovascular aortic repair module (April 2011–July 2014) was analyzed. Patients undergoing left subclavian artery coverage were divided into two groups according to revascularization status. The association between left subclavian artery revascularization with the primary outcome of spinal cord ischemia and the secondary outcome of stroke was assessed with multivariable analysis adjusting for between-group baseline differences.

Results

The left subclavian artery was covered in 508 (24.6%) of the 2063 thoracic endovascular aortic repairs performed. Among patients with left subclavian artery coverage, 58.9% underwent revascularization. Spinal cord ischemia incidence was 12.1% in the group without revascularization compared to 8.5% in the group undergoing left subclavian artery revascularization (odds ratio (95%CI): 1.48(0.82–2.68), P = 0.189). Multivariable analysis adjustment identified an independent association between left subclavian artery coverage without revascularization and the incidence of spinal cord ischemia (adjusted odds ratio (95%CI): 2.29(1.03–5.14), P = 0.043). Although the incidence of stroke was also higher for the group with a covered and nonrevascularized left subclavian artery (12.1% versus 8.5%), this difference was not statistically significant after multivariable analysis (adjusted odds ratio (95%CI): 1.55(0.74–3.26), P = 0.244).

Conclusion

For patients undergoing left subclavian artery coverage during thoracic endovascular aortic repair, the addition of a revascularization procedure was associated with a significantly lower incidence of spinal cord ischemia.

Type II Endoleaks, Left-Arm Complications, and Need of Revascularization after Left Subclavian Artery Coverage for Thoracic Aortic Aneurysms Endovascular Repair: A Systematic Review

BACKGROUND

The status of the left arm, the need of revascularization, and the occurrence of type II endoleakes from de left subclavian artery (LSA) after intention LSA coverage for thoracic aortic aneurysm endovascular repair need to be better understood. This systematic review was developed for contributing with such issue.

METHODS

Systematic literature review of studies published from January 2000 through December 2015 identified 7 studies comprising 201 patients submitted to elective endovascular repair for thoracic aortic aneurysms requiring intentional LSA coverage. Outcomes of interest included left-arm complications (ischemia, symptoms of claudication, and subclavian steal syndrome [SSS]) requiring postoperative revascularization of LSA, as well as endoleaks from the subclavian artery requiring postoperative embolization of LSA.

RESULTS

Left-arm complication rate was 4.5% (9 patients), requiring postoperative revascularization of LSA in 1 case (0.5%) of SSS. Type II endoleaks from the subclavian artery requiring postoperative embolization of LSA were reported in 2 cases (1.0%).

CONCLUSIONS

Low-quality evidence suggests very low rates of arm complications with need of LSA revascularization and of type II endoleaks requiring embolization in elective endovascular treatment of thoracic aortic aneurysms with intentional coverage of LSA without prophylactic revascularization of LSA.

A Rare Entity: Traumatic Thoracic Aortic Injury in a Patient with Aberrant Right Subclavian Artery

BACKGROUND

Aberrant right subclavian artery is an uncommon entity incidence ranging from 0.5 to 2.5%. Management of thoracic aortic injury in the presence of such anomalies can be a challenge. We present here a case of traumatic aortic injury, which was incidentally found to have an asymptomatic aberrant right subclavian artery. The patient was managed by an endovascular repair of thoracic aortic injury with an endograft and a right carotid to subclavian artery bypass as a hybrid procedure.

METHODS

A 40-year male patient was brought to the emergency in shock with an alleged history of road traffic accident an hour back. After initial resuscitation as per advance trauma life support protocol, imaging revealed thoracic aortic injury with aberrant right subclavian artery with multiple rib and bilateral humerus fracture. After primary stabilization of arm fractures, the patient was shifted to a hybrid operation room. As the aortic injury was within 10 mm of the origin of both subclavian arteries, it was decided to cover the origin of both subclavian arteries and land the endograft distal to the left carotid artery origin. Since there was a right dominant vertebral artery on imaging, right carotid to right subclavian artery bypass was done with expanded polytetrafluoroethylene graft to prevent posterior circulatory stroke along with thoracic endovascular aortic repair to seal the thoracic aortic injury.

RESULTS

After endovascular repair of thoracic aortic injury, left subclavian artery perfusion was maintained through left vertebral artery; and hence, revascularization of left subclavian artery was deferred. After management of all fractures, the patient was discharged 3 weeks after the date of admission without any complications. At 6 months follow-up, patient was stable and images showed patent bypass graft and sealed aortic injury.

CONCLUSIONS

In a trauma setting with multiple injuries, hybrid procedure with a thoracic endograft is associated with low mortality and morbidity; hence, it is the treatment of choice for thoracic aortic injury over open surgical repair. A hybrid suite can be life and time saving in situations which mandate simultaneous endovascular repair along with surgical revascularization when indicated, especially in cases with aberrant aortic arch anatomy.

Analysis of Risk Factors for Early Type I Endoleaks After Thoracic Endovascular Aneurysm Repair

Purpose: To evaluate risk factors for early (<30 days) type I endoleak following thoracic endovascular aortic repair (TEVAR). Methods: A retrospective study was conducted of 439 consecutive patients (mean age 74.0±10.0 years; 333 men) who underwent TEVAR at a single center between June 2006 and June 2013. Pathologies included 237 aortic arch aneurysms and 202 descending thoracic aortic aneurysms (dTAA). Maximum TAA diameter was 63.6±13.7 mm. Among the distal aortic arch aneurysms, 124 required coverage of the left subclavian artery (LSA), while the remaining 113 arch aneurysms had debranching (n=40), the chimney technique (n=52), and a branched stent-graft (n=13). Eight patients with dilatation of the ascending aorta underwent arch replacement with elephant trunk prior to TEVAR. Predictive factors for type I endoleak were explored in univariate analysis and examined for each outcome using logistic regression models; results are given as the odds ratio (OR) and 95% confidence interval (CI). Results: Among 439 TEVAR cases, 37 (8.4%) had type I endoleaks on imaging at 1 month; 31 were in the 237 arch cases (13.1%). Endoleak investigation by site indicated a low incidence (3.0%) for dTAAs and markedly low (1.4%) in zone 4. Significantly more endoleaks were observed in zones 0–2 than in zone 4 (p<0.001). On univariate analysis, significant associations were found between endoleak and LSA coverage (OR 5.8, 95% CI 2.4 to 14.4, p<0.001), operative time ≥240 minutes (OR 3.7, 95% CI 1.5 to 6.2, p=0.002), and ≥270 mL of contrast (OR 2.8, 95% CI 1.4 to 5.8, p=0.004). Among the aortic branch reconstruction procedures, the chimney technique was the only maneuver associated with a significant risk of endoleak (OR 5.3, 95% CI 2.3 to 11.2, p<0.001). Arch state was not correlated with endoleaks, but ≥38-mm proximal neck diameter (OR 3.6, 95% CI 1.2 to 10.8, p=0.023), stent-graft diameter ≥40 mm (OR 9.9, 95% CI 1.4 to 30.5, p=0.015), and excessively oversized (≥14%) stent-grafts (OR 3.5, 95% CI 1.2 to 10.3, p=0.020) were; the proximal neck length was not correlated with endoleaks if a proximal neck length >10 mm can be secured. Conclusion: Risks for early type I endoleaks after TEVAR for aneurysm were landing zone 0–2, LSA coverage, large proximal neck and stent-graft diameters, excessive oversizing, and the use of the chimney technique.

Long-Term Experience of Endovascular Repair for Thoracic Aortic Aneurysms and Dissections

Purpose:

To report the long-term results of thoracic endovascular aortic repair (TEVAR) in both elective and emergency cases of thoracic aortic aneurysm (TAA) and type B dissection.

Material and Methods:

A prospective single-center study of 78 TEVAR patients treated between February 1998 and February 2013. Stent-graft implantation was performed in 51 (65%) patients for TAA (43 elective and 8 emergency cases) and in 27 (35%) patients for type B dissection (11 elective and 16 emergency cases). Short- and long-term results were evaluated, and a subgroup of patients with left subclavian artery (LSA) coverage was also analyzed.

Results:

The patients were followed for a mean of 55 months (1-160 months). The technical success rate was 81% and 30-day mortality 6.4% (n = 5). The stroke rate was 7.7% (n = 6) and permanent paraparesis 2.6% ( n = 2). In follow-up, there were 28 (36%) primary (15 type I and 13 type II) and 10 secondary endoleaks (8 type I and 2 type II). Multivariate analysis showed no significant predictive factors for developing a type I endoleak. Secondary interventions were required in 24% of the patients. There was 1 late thoracic aortic rupture and 1 late conversion (1.3%). Patients with LSA coverage had a higher incidence of stroke (12.5% vs 4.3%, P = .18) and paraparesis (3.1% vs 2.2%, P = .79) compared to those without LSA coverage, although this difference was not statistically significant. Stroke rates were significantly higher in patients treated in an emergency setting ( P = .048).

Conclusion:

Thoracic endovascular aortic repair is a relatively safe and effective therapy for different aortic pathologies with good long-term success. The risk of stroke and paraparesis is notable whether the LSA is covered, and strokes clearly accumulate in the emergency setting. A type I endoleak is the most common complication, but there are no predictive factors for its development.

Upper Extremity Runoff: Pearls and Pitfalls in Computed Tomography Angiography and Magnetic Resonance Angiography

Upper extremity vasculature can be affected by various traumatic and nontraumatic pathologies; however, the evaluation of these arteries can be challenging for the radiologists as well as for the clinicians. After an accurate history and clinical examination, imaging plays a vital role in the diagnosis and treatment planning of these patients. Depending on the urgency and the indication, upper extremity arteries may be evaluated by ultrasonography with color Doppler, computed tomography (CT), magnetic resonance imaging (MRI), or digital subtraction angiography. This review article discusses relevant imaging anatomy of the upper extremity arteries, presents CT and MRI protocols, briefly describes the state-of-the-art CT and MRI of various pathologies affecting the upper extremity arteries, and summarizes the important pearls needed for busy practicing radiologist.

TEVAR: Endovascular Repair of the Thoracic Aorta

The development of thoracic endovascular aortic repair (TEVAR) has allowed a minimally invasive approach for management of an array of thoracic aortic pathologies. Initially developed specifically for exclusion of thoracic aortic aneurysms, TEVAR is now used as an alternative to open surgery for a variety of disease pathologies due to the lower morbidity of this approach. Advances in endograft technology continue to broaden the applications of this technique.

Extensive Operation as One of the Solution for Patients with the Insufficient Proximal Landing Zone for TEVAR in Aortic Dissection - short term results

OBJECTIVE

In our study we wanted to showed the safety, feasibility, efficacy and way how to solve the problems of endovascular repair for aortic dissection with insufficient proximal Landing Zone.

METHODS

The clinical data of all the patients with insufficient proximal Landing Zone (PLZ) for endovascular repair for aortic aneurism and dissection Stanford type B for the period from October 2013 to June 2014 was prospectively reviewed. According to the classification proposed by Mitchell et al, aortic Zone 0 was involved in 3 cases, Zone 1 in 1 case, Zone 2 in 9 cases and Zone 3 in 6 cases (19 patients in total). A hybrid surgical procedure of supraortic debranching and revascularization, with direct anastomosed truncus brachiocephalicus and left common carotid artery, were performed to obtain an adequate aortic PLZ. Revascularization of the left subclavian artery was carried out on the patient with dissection Stanford type B and short PLZ 2.

RESULTS

There was no significant difference of risk factors between Zone 0, Zone 1, and Zone 2 (Table 1.), but the length of the PLZ significantly differed between groups (p<0.01) and there is no significant difference in technical and clinical success rate among the groups.

CONCLUSION

The procedure of extending insufficient PLZ for endovascular repair for aortic arch pathology is feasible and relatively safe. The TEVAR applicability in such aortic disorders could be extended.

Thoracic endovascular aortic repair with left subclavian artery coverage without prophylactic revascularisation-early and midterm results

Background

The management of the left subclavian artery when coverage is necessary during thoracic aorta endografting remains a matter of debate.

Materials and methods

A retrospective analysis of a single-centre experience with thoracic endovascular aorta repair (TEVAR) was performed. Between April 2004 and October 2012, 125 cases of TEVAR were performed. The analysis focused on patients who required coverage of the left subclavian artery (LSA). We analysed mortality and morbidity with special attention to the rates of cerebrovascular accidents (CVAs) and spinal cord ischaemia (SCI) in the early and midterm.

Results

Of the 125 patients, 53 (42 %, group A) required an intentional coverage of the LSA to obtain an adequate proximal seal for the endograft; the remaining patients constituted group B. None of the patients in group A had protective LSA revascularisation prior to TEVAR. The primary technical success rate was 79.2 vs. 90.3 % (group A vs. group B, p = 0.08), and the primary clinical success rate was 77.4 vs. 82 % (group A vs. group B, p = 0.53). The 30-day mortality rate was 11.3 vs. 11.1 % (group A vs. group B, p = 0.97). The 30-day morbidity was 7.5 vs. 13.9 % (group A vs. group B, p = 0.4). CVA occurred in 1.9 % of group A patients, compared to 1.4 % of patients from group B (p = 0.82). The SCI incidence rate was 0 vs. 1.4 % (p = 0.39). The mean follow-up of group A was 24.1 months (range 2–64.6 months, SD = 19). Additionally, the 1-year estimated survival was 85.5 %, and the 3-year estimated survival was 78 %. There were no midterm CVAs; one event of SCI occurred in the seventh post-operative month in group A.

Conclusion

Our analysis, although retrospective and based on one institution experience, shows a realistic population of TEVAR patients. We prove that TEVAR with coverage of LSA origin can be accomplished with minimal neurological morbidity in this patient population. The study shows that LSA revascularisation is not mandatory before endograft deployment, especially in emergency settings. We also prove that although zone 2 TEVAR extends the proximal landing zone, it does not prevent type IA endoleaks from appearing. A multicentre randomised control trial with higher number of patients is necessary for proper, robust conclusion to be established.

External carotid-to-subclavian artery bypass in stent grafting of thoracic aorta

BACKGROUND

A bypass between the left common carotid artery and the left subclavian artery has been made in some patients undergoing thoracic endovascular aortic repair that covers the orifice of the left subclavian artery. However, complications associated with temporary occlusion of the left common carotid artery are reportedly not uncommon.

METHODS

Between January 2009 and September 2011, left external carotid-to-left subclavian artery bypass was made using a polytetrafluoroethylene graft in 15 patients undergoing a thoracic endovascular aortic repair that covered the orifice of the left subclavian artery. Adverse effects associated with the procedure were assessed, and patency of the bypass graft was determined by contrast-enhanced computed tomography before discharge and at least once during follow-up.

RESULTS

All patients were discharged without any brain complications. All 15 bypass grafts were patent prior to discharge and during the follow-up period. One patient suffered temporary left recurrent laryngeal nerve palsy postoperatively. No other sequelae were associated with left external carotid-to-left subclavian artery bypass.

CONCLUSION

Left external carotid-to-left subclavian artery bypass is a promising procedure in patients undergoing thoracic endovascular aortic repair that covers the orifice of the left subclavian artery.

[Endovascular treatment of thoracic aneurisms: indications, techniques and results]

CLINICAL ISSUE OF THORACIC ANEURYSMS: Aneurysms are among the most common diseases affecting the thoracic aorta, with a continuous increase in incidence over the recent decades. The main cause of thoracic aneurysms is atherosclerosis, which, due to the frequent lack of major symptoms and the potentially lethal complications such as ruptured aortic aneurysm, remains a challenge in clinical practice.

STANDARD RADIOLOGICAL METHODS

CT angiography remains the imaging method of choice for acute aortic aneurysms, with MR angiography being increasingly used for follow-up imaging. THRESHOLD FOR TREATMENT: In the ascending aorta a diameter larger than 5-5.5 cm (descending aorta 6.5 cm) is regarded as the threshold for treatment. THORACIC ENDOVASCULAR AORTIC REPAIR: The continuous evolution of aortic stent grafting (i.e., thoracic endovascular aortic repair [TEVAR]) since Parodi, Palmaz and Dake has led to a steep rise in stent grafting procedures in recent years.

PRACTICAL RECOMMENDATIONS

Particularly in elderly patients with multiple comorbidities, TEVAR is a valuable, less invasive option compared to open surgical repair.

Hybrid arch debranching and proximal endograft extension to repair a type I endoleak after endovascular thoracic aneurysm repair

Endovascular repair of complex aortic disease has emerged over the past decade as an alternative to traditional open repair, especially for patients with significant medical comorbidities and/or anatomic challenges, such as reoperative fields. However, the possibility of graft migration and endoleak mandates long-term follow-up of these grafts. We present a patient who underwent hybrid repair after stent graft migration and proximal type I endoleak after thoracic endovascular aneurysm repair. This approach allowed us to avoid extensive surgery that would also necessitate circulatory arrest.

Coverage of the left subclavian artery without revascularization during thoracic endovascular repair is feasible: a prospective study

BACKGROUND

To effectively isolate thoracic aortic lesions in thoracic endovascular aortic repair (TEVAR), an adequate proximal landing zone length is required. The left subclavian artery (LSCA) and other branches of the aortic arch commonly impose limitations on proximal landing zone length, restricting the use of TEVAR. In this study, we investigated the outcomes of LSCA coverage during TEVAR.

METHODS

Between March 2009 and February 2010, we recruited patients with thoracic dissection, aneurysm or trauma from a single center for TEVAR. We categorized patients into 3 groups: full coverage, partial coverage, or noncoverage of the LSCA. We measured pre- and postoperative blood pressures and evaluated complications during follow-up.

RESULTS

We recruited 111 patients for our study: 55 (50%) and 25 (23%) patients had full and partial LSCA coverage, respectively. The upper left arm blood pressures before and after the operations were significantly different between the full-coverage group and the other groups (P < 0.0001). Follow-up occurred between 6 and 20 months, and the mean follow-up time was 10.4 months. Thirteen patients (24%) in the full-coverage group and 2 patients (8%) in the partial-coverage group suffered from simple vertebrobasilar ischemia (VBI). Eleven of the patients with VBI (20%) in the full-coverage group and 2 (8%) patients with VBI in the partial-coverage group had left subclavian steal syndrome at follow-up. No paraplegia or stroke was observed.

CONCLUSIONS

Intentional coverage of the LSCA to obtain an adequate proximal landing zone for TEVAR can be a treatment option for thoracic aortic lesions, although some patients experienced mil complications.

Further consideration for subclavian revascularization with TEVAR

Management of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) continues to be controversial, despite recent guidelines submitted by the Society for Vascular Surgery recommending routine revascularization of the LSA in most circumstances. Up to one third of patients require coverage of the LSA during TEVAR. The LSA provides extensive circulation to the upper extremity, spinal cord, and brain, consequently, sacrifice of this great vessel might not be physiologically tolerated. Studies supporting routine preoperative revascularization of the LSA note increased rates of spinal cord ischemia, strokes, and upper extremity ischemia when the LSA is sacrificed. Other studies supporting a selective revascularization strategy note no difference in neurologic outcomes and recommend expectant management of upper extremity ischemia. In addition, LSA revascularization has associated complications that are avoided by selective revascularization. The purpose of this article is to review and focus the available data in support of routine versus selective LSA revascularization.

Surgery for type B dissection using a short-stented elephant trunk procedure

BACKGROUND

Stent grafting is a very important treatment for type B dissection. Some patients are unsuitable for endograft repair because of inadequate proximal and/or distal fixation zones. We reviewed our experience of proximal descending thoracic replacement combined with short-stented elephant trunk implantation for type B dissection for patients without adequate fixation zones for endografts.

METHODS

Twenty-one patients with type B dissection (10 acute, 11 chronic) underwent this procedure between August 2003 and December 2007. After replacement of the proximal descending thoracic aorta, a short-stented elephant trunk was implanted into the residual descending thoracic aorta. The residual false lumen was evaluated post-operatively using computed tomography (CT) scans.

RESULTS

There were no in-hospital deaths. One death was observed during a mean follow-up of 69 ± 15 months. One patient with preoperative shock suffered paraparesis but recovered postoperatively. One patient had paraplegia and was lost to follow-up. Cerebral hemorrhage was observed in 1 patient, but he recovered. Thrombus obliteration of the false lumen around the stented elephant trunk was observed in 19 patients (95%) and at the diaphragmatic level in 17 patients (85%) during follow-up.

CONCLUSION

Replacement of the proximal descending thoracic aorta combined with short-stented elephant trunk implantation was a suitable alternative for type B dissection for patients without adequate fixation zones for endografts (particularly for young subjects). This procedure allowed enlargement of the true lumen, re-establishment of the true lumen, induction of thrombosis of the false lumen, and shrinkage of the aorta. Injury to the spinal cord, however, was an intractable problem.

[Treatment of thoracic aortic disease using endovascular stent-grafts: from therapeutic indications to possible complications]

Thoracic endovascular aortic repair (TEVAR) is a minimally invasive technique which is increasingly used in different thoracic aortic pathologies such as aortic aneurysm, complicated type B aortic dissection, aortic trauma, intramural hematoma and penetrating aortic ulcer. In this paper we discuss the main indications for endovascular stent-grafts in the treatment of thoracic aortic disease, based on three cases in which this procedure was used for three different conditions: degenerative aneurysm, complicated type B dissection and post-traumatic injury. These case reports add to the evidence that TEVAR is a safe and feasible therapeutic alternative in selected patients with thoracic aortic disease, improving aortic remodeling, with relatively low morbidity and mortality. The main complications and difficulties related to the procedure are also discussed.

Neurological complications of thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) has decreased the morbidity and mortality associated with open surgical repair of descending thoracic aortic diseases, but important complications unique to the procedure remain. Spinal cord ischemia and infarction is a recognized complication caused by endovascular coverage or injury to spinal cord collateral vessels. Stroke is a consequence of thromboembolism or coverage of aortic arch branch vessels with insufficient collateral circulation. Understanding the risk factors and the pathophysiology of neurological complications of TEVAR are important for the successful anesthetic and surgical management and treatment of patients undergoing endovascular procedures involving the thoracic aorta.