Intentional coverage of the left subclavian artery during endovascular stent graft repair for thoracic aortic disease

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.

Early Outcomes of Left Subclavian Artery Revascularization Using Castor Single-Branched Stent-Graft in the Treatment of Type B Aortic Dissection or Intramural Hematoma

Background: More evidence was required to guide the management of left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR). The present study aimed to compare the outcomes of LSA coverage with LSA revascularization. Another purpose of this study was to share our experience of LSA revascularization with castor single-branched stent-graft.

Methods: From January 2016 to December 2019, 134 patients with type B aortic dissection (TBAD) or intramural hematoma (IMH) were enrolled and divided into two groups, the LSA-covered group (n = 61) and the LSA-revascularized group (with castor single-branched stent-graft, n = 73). The results, such as in-hospital and 30-day mortality, stroke, paraplegia, left arm ischemia, operation time, endoleak, were compared between the two groups.

Results: The incidence of 30-day stroke in the LSA-covered group (8.2%) was significantly higher compared with the LSA-revascularized group (0%, P = 0.018). 30-day ischemia of left arm occurred in more patients in the LSA-covered group (11.5%, P = 0.003). No statistical difference was found in the incidences of paraplegia, endoleak, in-hospital mortality, and 30-day mortality.

Conclusions: LSA should be revascularized during TEVAR to reduce the incidences of stroke and left arm ischemia. Castor single-branched stent-graft was feasible and safe for treating TBAD or IMH.

Endovascular Repair of Aortic Dissection Involving the Left Subclavian Artery by Castor Stent Graft: A Multicentre Prospective Trial

OBJECTIVE

The left subclavian artery (LSA) origin can be intentionally covered by stent grafts, to provide adequate proximal landing zones during thoracic endovascular repair for Stanford type B aortic dissections (TBADs). To preserve the LSA, a novel single branched stent graft, named "Castor" was designed and a clinical trial conducted to investigate its suitability.

METHODS

From April 2013 to March 2015, 73 patients with TBAD were treated by Castor stent grafts at 11 Chinese tertiary hospitals as part of a single arm prospective clinical trial. There were 50 acute (<2 weeks [68.5%]) and 23 chronic aortic dissections (>2 weeks [31.5%]).

RESULTS

The technical success rate was 97% (n = 71/73). The two failures were caused by occlusion of the branch section of the stent graft. There were four intra-operative endoleaks (two type Ia, two type B from the LSA). The endoleak rate was 5% (n = 4/73). There was one in hospital death and no major complications. The median follow up time was 61 months (range 48-72 months). The mortality was 5% (n = 4/73) within one year and 7% within six years (n = 5/73). Two deaths were of unknown cause and three were not related to the aorta. Two new entry tears were found on the proximal or distal edge of the stent graft and were retreated endovascularly. Six occlusions of the branch section of the Castor stent graft were found, and the follow up patency rate of the branch section was 93% (n = 63/68). Two intra-operative endoleaks were left during follow up and eventually disappeared according to the latest computed tomography angiograms.

CONCLUSION

For patients with TBADs needing anchoring proximal to the origin of LSA, the Castor single branched stent graft may provide an easily manipulated, safe, and effective endovascular treatment.

Endovascular Repair of Thoracic Aortic Disease: Early and Midterm Experience

Thoracic aorta disease remains a challenging problem, and despite improvements, open repair techniques are still associated with significant morbidity and mortality. This is a retrospective review of 53 consecutive patients with thoracic aortic pathology who were treated with endovascular repair between September 1998 and December 2004 at a tertiary-care hospital. Endovascular stent graft placement was performed on 23 elective and 30 emergent patients (34 male patients, mean age 66 years, 21 to 85 years). Completion angiography revealed no endoleak in 47 (89%) patients, a type I endoleak in 4 patients, and a type II endoleak in 2 patients. Operative 30-day mortality for elective aneurysms (n = 22), emergent aneurysms (n = 10), dissection (n = 3), penetrating aortic ulcers (n = 7), and trauma (n = 11) was 0%, 40%, 0%, 29%, and 9%, respectively. In total, 46 (87%) patients survived 30 days, and 36 (78.3%) of the survivors were discharged home free of complications. Two patients (4%) experienced paraplegia. Median follow-up was 22 months (1 to 72 months). Intermediate-term results revealed 41 (89%) patients free of endoleak, stent migration, or aneurysmal expansion. Two (4%) patients required reintervention with an additional stent graft. There were 2 (4%) patients with late aortic-related deaths and four (9%) patients with non—aorticrelated late deaths. Endovascular stent graft placement for thoracic aorta disease can be performed successfully and safely with good perioperative and intermediate-term outcomes. Stent graft complication and reintervention rates are low, whereas intermediate survival rates are good. Long-term efficacy still needs to be evaluated.

Application of triple-chimney technique using C-TAG and Viabahn or Excluder iliac extension in TEVAR treatment of aortic arch dilation diseases

Background

To report the experience of a single centre regarding the application of the triple-chimney technique using C-TAG with Viabahn or Excluder iliac extension devices for the endovascular management of aortic arch dilation diseases.

Methods

From July 2016 to August 2017, 7 patients (5 men; mean age 56.1±10.8 years) with aortic arch dilation diseases were treated with the triple-chimney technique. All patients were followed up at 1, 3, and 6 months and every 6 months thereafter.

Results

Six innominate arteries were deployed with Excluder iliac extensions and one with a Viabahn cover-stent. All the left common carotid arteries and left subclavian arteries were placed with Viabahn. Reverse chimney technique was applied in four patients. Three (42.0%) type I endoleaks were found on the final angiogram. Two were apparently reduced, and one disappeared after balloon dilation. The mean follow-up time was 15.7 months (9-20 months). All the type I endoleak was found disappeared within 3 months. One patient died of myocardial infarction at 6 months after discharge. No other complications such as stent-graft migration, occlusion, type II endoleak or neurological stroke occurred.

Conclusions

The use of C-TAG coupled with Viabahn or Excluder iliac extension is feasible and effective for the treatment of aortic arch dilatation diseases. However, more patients and longer follow-up time are required to verify its long-term safety and efficacy.

A simple patient-tailored aortic arch tangential angle measuring method to achieve better clinical results for thoracic endovascular repair of type B aortic dissection

Background

To report a simple individual tailored aortic arch tangential angle (θ-AATA) measuring method and its clinical application efficacy in the endovascular treatment of type B aortic dissection (AD).

Methods

From January 2013 to December 2014, acute type B AD patients were prospectively enrolled and treated with endovascular therapy in our center. Among these patients, a specific method was applied to measure θ-AATA based on the axial images of the CT scan. The length of proximal landing zone (PLZ) of each patient was measured at the routinely applied left-anterior oblique (LAO) 45-degree and θ-AATA. Respective treatment strategies based on the length of the PLZ were planned accordingly, and the stent-graft was deployed under the fluoroscopy at θ-AATA. The occurrence of immediate type I endoleak was recorded during the completion angiogram, while the alignment of the proximal marks was determined under fluoroscopy at θ-AATA and at LAO-45-degree as well.

Results

Totally 76 patients with type B AD were prospectively enrolled. The average value of θ-AATA was 58.3±5.2 degrees, which was significantly larger than the routine 45 degrees (P<0.01). The mean landing zone length measured under θ-AATA (18.4±3.9 mm) was longer than that (15.9±3.1 mm) obtained at the routine LAO-45 degrees (P<0.05). Stent-grafts' deployment strategies were substantially changed accordingly. Alignment of the proximal marks was achieved in 72 patients (93.4%) under θ-AATA and only in two patients (2.7%) at LAO-45 degrees (P<0.01). All stent-grafts' implantation was successfully completed. No major type I endoleak was found in the immediate post-deployment angiography.

Conclusions

It is easy to apply this patient-tailored θ-AATA measuring method in clinical practice. This more precise measurement is benefit for more reasonable treatment strategy planning, more precise deployment, and therefore a better outcome.

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.

Experience of endovascular repair of thoracic aortic dissection after blunt trauma injury in a district general hospital

BACKGROUND

Traumatic thoracic aortic dissection is uncommon in clinical practice; however, it is associated with high morbidity and mortality. Thoracic aortic dissection is usually caused by sudden deceleration resulting from a traffic accident or fall. Aortic injury after blunt trauma is a critical condition. This study reported the outcomes of endovascular repair of acute traumatic aortic dissection in patients at a district general hospital.

METHODS

In this study, we retrospectively reviewed the clinical data of eight patients with acute traumatic aortic dissection after a blunt trauma who had undergone thoracic endovascular aortic repair (TEVAR) between January 2012 and December 2015 at a district general hospital in Taiwan.

RESULTS

The median age of the patients was 49±22 years (range, 20-77 years), and 6 of the 8 (75%) patients were men. Five patients were involved in traffic accidents, and 3 patients had fallen from heights. The injury severity score (ISS) of the patients ranged from 17 to 66. In all patients, the aortic injury was located near the origin of the left subclavian artery (LSA). Four patients had seal ostium of subclavian artery, left. None of the patients developed paraplegia or lower extremity ischemia. Moreover, all patients had concomitant injuries, and no patients died postoperatively.

CONCLUSIONS

Endovascular repair is a rapid and minimally invasive therapy for patients with traumatic aortic injury and is associated with favorable technical results.

Alternative management of the left subclavian artery in thoracic endovascular aortic repair for aortic dissection: a single-center experience

Background

Since the new 2009 guidelines for left subclavian artery (LSA) management using thoracic endovascular aortic repair (TEVAR), a few studies have been published about alternative LSA management. The objective of this study was to present the follow-up results of covered or revascularized LSA during TEVAR.

Methods

From January 2010 to August 2012, 109 consecutive patients were treated with TEVAR at the Department of Vascular Surgery, Changhai Hospital, for aortic dissection extending near the LSA. After evaluating the bilateral vertebral arteries, fifty-two LSAs were covered and not revascularized (covered group), while 57 LSAs were preserved (revascularized group). Complications were stratified according to the time of occurrence after surgery.

Results

Emergency operations were more common (17.3 vs. 3.5 %, P = 0.017) and operation time was shorter (96.9 ± 16.3 vs. 135.3 ± 38.4 min, P < 0.001) in the covered group. Pulselessness and intermittent claudication of the left arm occurred in most patients in the covered group (P < 0.001). Incidence of stroke and cold shoulder feeling were higher in the covered group compared with the revascularized group (P = 0.026 and <0.001, respectively). There were five aorta-related deaths in the covered group and one in the revascularized group. Eight endoleaks were observed in the revascularized group (P = 0.006).

Conclusions

The results of this study suggest that due to occurrence of complications, LSA should be preserved or revascularized to reduce complications and to improve patients’ quality of life.

Hybrid Strategy for Residual Arch and Thoracic Aortic Dissection following Acute Type A Aortic Dissection Repair

Progressive dilatation of the false lumen in the arch and descending aorta has been encountered in one-third of survivors as a late sequelae following repair of ascending aortic dissection. Conventional treatment for the same requiring cardiopulmonary bypass and deep hypothermic circulatory arrest is associated with high morbidity and mortality especially in the elderly cohort of patients. Herein we report a case of symptomatic progressive aneurysmal dilatation of residual arch and descending thoracic aortic dissection following repair of type A aortic dissection, successfully treated by total arch debranching and ascending aortic prosthesis to bicarotid and left subclavian bypass followed by staged retrograde aortic stent-graft deployment. This case report with relevant review of the literature highlights this clinical entity and the present evidence on its appropriate management strategies. Close surveillance is mandatory following surgical repair of type A aortic dissection and hybrid endovascular procedures seem to be the most dependable modality for salvage of patients detected to have progression of residual arch dissection.

Ischemia and functional status of the left arm and quality of life after left subclavian artery coverage during stent grafting of thoracic aortic diseases

BACKGROUND

The objective of this study was to report on the incidence of left arm ischemia, left arm function, and quality of life after thoracic endovascular aortic repair (TEVAR) by stent grafting with and without coverage of the left subclavian artery (LSA).

METHODS

All patients who underwent TEVAR since 1996 in our institution were included. Basic demographic parameters, underlying disease, details of TEVAR, long-term left arm function (Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire), and quality of life (12-Item Short Form Health Survey) were analyzed. End points were left arm ischemia, need for LSA revascularization (before or after TEVAR), long-term functional impairment, and quality of life.

RESULTS

A total of 138 patients underwent TEVAR for degenerative aneurysm (n = 64), traumatic aortic injury (TAI; n = 38), or Stanford type B dissection (n = 36). Seventy-three patients (52.9%) had LSA coverage, which led to partial or complete LSA occlusion in 49 (35.5%). Selectively, nine patients (6.5%) had primary LSA revascularization. After TEVAR, left arm ischemia was observed in only one patient, who consecutively needed a left carotid to subclavian bypass. During a mean follow-up period of 4.1 ± 3.7 years, no additional patient needed secondary LSA revascularization. In comparing patients with occluded vs patent LSA, the Physical Component Summary (PCS) and Mental Component Summary (MCS) health scores (12-Item Short Form Health Survey) as well as DASH scores were similar. However, subgroup analysis showed better PCS scores for TAI patients with patent LSA, whereas MCS and DASH scores were similar in TAI patients, and scores were indifferent within thoracic aortic aneurysm and Stanford type B dissection subgroups. In comparing different subgroups, TAI patients had significantly better PCS, MCS, and DASH scores.

CONCLUSIONS

TEVAR is associated with a low risk of peri-interventional left arm ischemia. During long-term follow-up, secondary LSA revascularization is uncommon. Coverage of the LSA has no impact on left arm function and quality of life, probably with the exception of physical health scores in patients with TAI.

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 repair of an ductus arteriosus aneurysm causing Ortner syndrome

A ductus arteriosus aneurysm (DAA) is a rare but potentially fatal condition in adults. In the past, open surgery was the only available option for treatment. Nowadays, endovascular repair has emerged as a safe and less invasive treatment option for aortic aneurysms. However, there is little experience with DAA and its anatomic location can complicate endovascular repair. Here, we describe the case of a 69-year-old patient who presented with Ortner syndrome caused by DAA, which was successfully treated using a solely endovascular approach and a standard stent graft.

Thoracic aortic aneurysms and dissections: endovascular treatment

The treatment of thoracic aortic disease has changed radically with the advances made in endovascular therapy since the concept of thoracic endovascular aortic repair was first described 15 years ago. Currently, there is a diverse array of endografts that are commercially available to treat the thoracic aorta. Multiple studies, including industry-sponsored and single-institution reports, have demonstrated excellent outcomes of thoracic endovascular aortic repair for the treatment of thoracic aortic aneurysms, with less reported perioperative morbidity and mortality in comparison with conventional open repair. Additionally, similar outcomes have been demonstrated for the treatment of type B dissections. However, the technology remains relatively novel, and larger studies with longer term outcomes are necessary to more fully evaluate the role of endovascular therapy for the treatment of thoracic aortic disease. This review examines the currently available thoracic endografts, preoperative planning for thoracic endovascular aortic repair, and outcomes of thoracic endovascular aortic repair for the treatment of both thoracic aortic aneurysms and type B aortic dissections. Mt Sinai J Med 77:256-269, 2010. (c) 2010 Mount Sinai School of Medicine.

Percutaneous occlusion of the left subclavian and celiac arteries before or during endograft repair of thoracic and thoracoabdominal aortic aneurysms with detachable nitinol vascular plugs

PURPOSE

To review an experience with the Amplatzer vascular plug (AVP) for prevention of type II endoleaks during endovascular aneurysm repair (EVAR) of thoracic and thoracoabdominal aneurysms.

MATERIALS AND METHODS

Retrospective review was undertaken of 14 patients undergoing transcatheter occlusion of the left subclavian (n = 12) or celiac artery (n = 2) with the AVP as part of EVAR of thoracic and thoracoabdominal aneurysms at a single institution. Procedural criteria evaluated were success at target vessel occlusion, the number of AVPs used, use of adjunctive embolization devices, and embolization-related ischemic end-organ events. Follow-up imaging criteria included evaluation of persistent target vessel occlusion, evidence of device migration, and the presence and characterization of endoleak secondary to AVP failure.

RESULTS

Complete target vessel occlusion was documented for all cases. In six cases, more than one AVP was placed, with an average of 1.5 devices per patient. In two cases, adjunctive coils were placed. Computed tomographic or magnetic resonance angiography follow-up was available for all patients (mean follow-up, 419 days; range 28-930 d). No case showed evidence of device migration or type II endoleak resulting from AVP failure. There was a single instance of left subclavian artery recanalization without type II endoleak. There were no embolization-related ischemic end-organ events.

CONCLUSIONS

Transcatheter arterial occlusion of the subclavian and celiac arteries with the AVP is a valuable adjunct to endografting in cases in which side branch embolization is necessary to extend the landing zone.

Incidence of neurological complications following overstenting of the left subclavian artery

OBJECTIVE

Aortic endovascular stent-graft implantation is associated with low morbidity and mortality rates. Overstenting of the left subclavian artery may be necessary to create a satisfactory proximal 'landing zone' for the stent-graft. Few cases have been published reporting adverse neurological events after overstenting of the left subclavian artery. We thus evaluated whether this procedure is associated with a higher rate of neurological complications by focusing on the management of the supra-aortic vessels.

METHODS

Twenty patients suffering from aortic arch aneurysms (n=3), descending aortic aneurysms (n=7), acute (n=6) and chronic (n=4) type-B aortic dissections underwent stent-graft repair with complete (n=14) or partial (n=6) overstenting of the left subclavian artery. Three patients underwent overstenting of the entire aortic arch with ascending aortic-bi-carotid bypass grafting. One patient with right carotid and vertebral artery occlusion underwent initial carotid-to-subclavian bypass. All patients subsequently underwent neurological examination and Doppler ultrasound for detection of neurological and peripheral vascular complications.

RESULTS

Aortic stent-graft repair was successful in all patients without acute neurologic complications. Two patients developed late central adverse neurological events: right-sided vertebral artery occlusion with brainstem infarction (n=1) and impaired binocular vision combined with dizziness (n=1), necessitating secondary subclavian transposition in one patient. Peripheral symptoms related to occlusion of the left subclavian artery were observed in five patients as sensory and motoric deficits of the left hand and arm.

CONCLUSIONS

Overstenting of the left subclavian artery as treatment of aortic pathologies in high-risk patients is feasible but associated with the risk of neurological complications and peripheral symptoms. Side effects were mild or transient in most of our patients. Detailed preoperative exploration of vascular anatomy and pathology via Doppler ultrasound, CT- or MRI scan is mandatory to avoid adverse neurological events. Prior surgical revascularization of the left subclavian artery is essential in patients with high-grade stenoses, occlusions, or anatomic variants of the supra-aortic branches. Delayed surgical revascularization is necessary only in patients with relevant subclavian steal syndrome or severe peripheral vascular symptoms.