Hybrid repair of aortic arch dissections

Midterm results of endovascular stent grafts in the proximal aortic arch (zone 0): an imaging perspective

BACKGROUND

Endovascular options to repair the arch and ascending aorta are rapidly evolving. Little is known about the durability of endovascular devices deployed at this location. This report describes a single-centre experience with the novel application of thoracic endovascular aortic repair (TEVAR) by examining clinical and radiological outcomes.

METHODS

A retrospective review was performed for a cohort of patients undergoing TEVAR of the arch or ascending aorta, or both, at a single centre from November 2008-July 2012.

RESULTS

Sixteen patients were included in the study, with mean imaging follow-up of 38 months (range, 15-72 months). Two complications at the proximal landing zone in the ascending aorta were identified: 1 endoleak and 1 infolding identified at 3 and 24 months postoperatively, respectively. Clinically, both these complications were attributed to the bird-beak configuration at the proximal landing zone site. At up to 72 months of follow-up, there were no cases of retrograde dissection of the native sinus of Valsalva. There were no cases of stent graft migration, graft fracture, open surgical reintervention for aortic pathologic conditions, or late mortality.

CONCLUSIONS

Early outcomes suggest that the current generation of thoracic aortic endografts can be placed in the complex anatomy of the ascending aorta and aortic arch without a high incidence of early graft fracture or migration. Future endeavors will need to focus on techniques to achieve optimal apposition with the curves of the ascending aorta. These findings are important as indications for endovascular aortic therapies expand to address proximal aortic pathologic conditions.

Best surgical option for arch extension of type B dissection: the endovascular approach

Despite advances in surgical techniques and postoperative management, the in-hospital mortality rate for patients undergoing conventional open surgical repair for type B dissections is still significant. In light of this, the less invasive surgical procedure for acute type B aortic dissections, defined as thoracic endovascular aortic repair (TEVAR), was developed. Despite some controversy, the use of TEVAR for the management of type B aortic dissections has become commonplace. Generally, the main entry tear in type B aortic dissection is located in the vicinity of the orifice of the left subclavian artery (LSA). The proximal landing zone in the aortic arch must be secured as long as the aim of TEVAR for type B dissection is primary entry closure. This requires hybrid surgery that includes the use of open surgical procedures, such as debranching for revascularization of cervical branches. Despite the presence of challenging anatomic conditions in the aortic arch, hybrid repair has evolved as an increasingly viable alternative, and promising early and long-term results have been reported. As the next step, fenestrated and branched TEVAR techniques have recently been reported with satisfactory early results. In the coming years, there will be intense competition to develop the devices themselves, improve delivery systems, and supplement devices with auxiliary functions. Thus there is high expectations for the next generation and how they will improve and advance treatment methods of TEVAR for type B aortic dissections.