Hybrid Technique for Total Arch Repair: Aortic Neck Reshaping for Endovascular-Graft Fixation

Hybrid Surgery to Manage Aortic Arch Pathology

Background and Objectives: Aortic arch disease is still a high-risk surgical challenge despite major advances both in surgical and anesthesiological management. A combined surgical and endovascular approach has been proposed for aortic arch disease treatment to avoid hypothermia and circulatory arrest in high-risk patients. Materials and Methods: Between June 2004 and June 2021, 112 patients were referred to our department for aortic arch surgery; 38 (33.9%) patients underwent supra-aortic debranching and endovascular treatment. Of these, 21 (55%) patients underwent type I aortic arch hybrid debranching procedure and in 17 (45%) patients a type II aortic arch hybrid debranching procedure was performed. None of the patients were emergent. Results: No intra-operative deaths were recorded. In the type I aortic arch hybrid debranching patients’ group, one patient died at home waiting the endovascular step, one developed ascending aortic dissection and another one developed a pseudoaneurysm at the site of the debranching at follow-up. In the type II aortic arch hybrid debranching patients’ group, left carotid artery branch closure was detected at follow-up in one patient. Thirty day/in-hospital rates of adverse neurological events for both the surgical and endovascular procedures were 3% for minor stroke, with no permanent neurological deficit and 0% for permanent paraplegia/paraparesis. In 100% of the cases, the endovascular step succeeded and the type Ia endoleak rate was 0%. Conclusions: Hybrid arch surgery is a valuable option for aortic arch aneurysm treatment in patients with high surgical risk. The choice of aortic arch debranching between type I or type II is crucial and depends on anatomic and clinical patient characteristics. Further larger scale studies are needed to better define the advantages of these techniques.

Efficacy of ascending aortic banding technique concomitant with type I hybrid aortic arch repair in high-risk patients

Banding of the ascending aorta has been introduced as a less complex procedure to optimize the proximal landing zone of the stent graft in hybrid aortic arch surgery. However, data about the long-term results and effects of this technique are still limited. We aimed to study the efficacy of banding of the ascending aorta in hybrid aortic arch repair. The study included 11 high-risk patients with dilated ascending aorta (wider than 38 mm in diameter) undergoing ascending aortic banding for hybrid arch repair. Clinical outcomes, including technical success, endoleaks, perioperative mortality and morbidity, and sequential remodeling of the ascending aorta were investigated. The average diameter of the ascending aorta had been reduced (p = 0.02) from 42.1 mm (range = 39.0-46.4) to 37.2 mm (range = 35.6-38.6) after banding procedure. The technical success rate was 100.0%. No type I endoleak occurred, but 2 cases of distal stent graft-induced new entry required re-interventions. The 5-year survival and freedom from aortic events rates both were 81.8%. The ascending aortic diameter remained stable and no proximal migration of the stent graft was observed during the study period. The 5-year results validated the durability of this therapeutic modality, especially in high-risk patients.

A self-adaptive triple-branched stent graft for arch repair during open type A dissection surgery

OBJECTIVE

To make the open placement of the triple-branched stent graft technique suitable for most patients with acute type A aortic dissection to achieve effective individual total arch repair, we developed a self-adaptive triple-branched stent graft and arch open technique. In this study, we report the clinical experience and outcomes of total arch repair using implantation of this self-adaptive triple-branched stent graft with the aid of the arch open technique.

METHODS

Between December 2012 and July 2014, 105 consecutive patients with acute type A aortic dissection with indications of total arch repair underwent total arch repair using implantation of a self-adaptive triple-branched stent graft with the aid of the arch open technique under hypothermic cardiopulmonary bypass and selective cerebral perfusion. Survivors were followed up prospectively by means of computed tomography angiography.

RESULTS

The cardiopulmonary bypass time was 169.37 ± 27.17 minutes, aortic crossclamp time was 60.48 ± 16.72 minutes, and selective cerebral perfusion and lower body arrest time was 28.95 ± 7.23 minutes. The in-hospital mortality was 4.76%. One patient was lost to follow-up. One sudden death of unknown cause occurred 10 months after surgery. On the 3-month postoperative scans, the false lumen closed with complete thrombus formation around the self-adaptive triple-branched stent graft was found in all survivors and at the diaphragmatic level in 71.72% of patients.

CONCLUSIONS

The simple implantation of a self-adaptive triple-branched stent graft with the aid of the arch open technique can be used safely in most patients with acute type A aortic dissection for effective individual total arch repair.

Hybrid repair of aortic arch pathology

The objective was to evaluate a 13-year single-centre experience of arch endovascular aortic repair using the hybrid approach. Between 1999 and 2013, 491 patients were treated with endografts for thoracic aortic pathologies. The aortic arch was involved in 179 (36.5%) patients (128 men; mean age 70.2 ± 10.8 years, range 27-84). A hybrid approach was performed for all Zone 0 and 1 procedures and in nearly half of Zone 2 procedures. Early and mid-term outcomes were reviewed retrospectively. Overall primary technical success (24 h) was achieved in 162 (90.5%) of the 179 cases; 2 deaths and 15 Type 1 endoleaks were observed. Clinical success at 30 days was achieved in 161 (89.9%) of the 179 patients, with a mortality rate of 4.5% (8/179). Short-term clinical success at 6 months was achieved in 169 (94.4%) of the 179 patients; the rates for the different landing zones did not differ significantly. At a mean follow-up of 27.3 ± 15.7 months (range 1-94), the mid-term clinical success was 165 (92.2%) of the 179 patients; the rates among the different proximal zones did not differ significantly. In selected patients, early and mid-term outcomes of arch endovascular aortic repair using the hybrid approach are promising; however, mortality and morbidity are not negligible. Our results may have practical implications for the ongoing evaluation of the hybrid procedure in the aortic arch, as well as for patients fit for traditional surgery.

Total arch repair using supra-aortic debranching technique with banding of the ascending aorta for endovascular stent graft fixation

Endovascular stenting requires a satisfactory landing zone that guarantees fixation and sealing of the proximal part of the endograft. We report total arch repair using supra-aortic debranching technique with banding of the ascending aorta for endovascular graft fixation. An 85-year-old man presented with hoarseness of voice. A fusiform aneurysm with a maximum transverse diameter of 62 mm on the aortic arch was identified by computed tomographic angiography. Supra-aortic arch debranching of the 3 neck vessels using a trifurcated graft and coronary arterial bypass grafting were performed while closely monitoring the regional cerebral oxygen saturation. The ascending aorta was dilated to 41 mm; we successfully reduced this to a mean outer diameter of 36 mm by banding the aorta using an expanded polytetrafluoroethylene surgical membrane. The endovascular procedure was performed 17 days after surgical intervention. The patient was extubated immediately after endovascular stent placement and spent 1 day in intensive care with no signs of transient or permanent neurologic events. A postoperative computed tomographic scan did not reveal any evidence of endoleak. The banding of the ascending aorta for endovascular graft fixation could facilitate endovascular aortic arch repair and provide an alternative treatment for high-risk patients.

Open stent grafting for complex diseases of the thoracic aorta: clinical utility

Open stent grafting is an alternative treatment for extensive thoracic aortic replacement. However, this procedure is associated with a high incidence of spinal cord injury, which has limited its application. Multiple factors have been suggested to explain the risk of spinal cord injury, including deep delivery of the stent graft, history of operation of the downstream aorta, and postoperative low blood pressure. Cerebrospinal fluid drainage or a hybrid operation in combination with trans-femoral thoracic stent grafting is useful for preventing spinal cord injury. Open stent grafting remains an alternative treatment for atherosclerotic aneurysms with dilatation of the ascending aorta. Open stent grafting for acute aortic dissection is effective for remodeling of the false lumen. The graft diameter for aortic dissection should be 90 % of the total diameter of the aorta, and the distal landing zone should be limited to the T7 vertebral level to prevent new intimal tears or spinal cord injury. Open stent grafting seems a feasible bailout strategy for the treatment of retrograde aortic dissection after TEVAR for type B aortic dissection. Newly designed devices for open stent grafts include the Matsui-Kitamura stent graft or branched open stent graft, which is produced in Japan. The effectiveness of open stent grafting in the treatment of Marfan syndrome remains unclear. A commercially available device for open stent grafting would be desired in Japan. In conclusion, an open stent graft remains an alternative treatment for complex thoracic aortic pathologies.

[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.

Endovascular repair of the half aortic arch in pigs with an improved, single-branched stent graft system for the brachiocephalic trunk

The objective of this study was to evaluate the feasibility of endovascular repair of half of the aortic arch in pigs using an improved, integrated, single-branched stent graft for the ascending aorta and brachiocephalic trunk (BCT). We designed an improved stent graft in an integrated fashion and deployed the stent grafts into the ascending aortas and BCT of eight pigs. The feasibility of the stent graft deployments was evaluated three months after the procedures using arteriography, computed tomography angiography (CTA) and animal autopsy. The stent grafts were successfully deployed in eight pigs. All animals survived for at least three months. Arteriography, CTA and animal necropsy revealed good stent fixation in eight cases. Their head CT scans found no evidence of cerebral infarction. In conclusion, endovascular repair of the half aortic arch with the integrated single-branched stent graft system appears to be safe and feasible in pigs.

Initial experience in the treatment of thoracic aortic aneurysmal disease with a thoracic aortic endograft at Baylor University Medical Center

A retrospective review of 27 patients who underwent endovascular repair of thoracic aneurysms and of other thoracic aortic pathology with the thoracic aortic endograft (Gore Medical, Flagstaff, AZ) from June 2005 to July 2007 was performed. The mean follow-up period was 13.5 months (range, 2-25 months). Indications for thoracic endografting included descending thoracic aneurysms (n = 18), thoracoabdominal aneurysms (n = 3), traumatic aortic injuries (n = 3), penetrating aortic ulcers (n = 2), and contained rupture of a type B dissection (n = 1). One patient died during the procedure, for an overall mortality rate of 3.7%. The average length of stay was 8.1 days, with an average stay in the intensive care unit of 4.2 days. If patients with traumatic aortic injuries were excluded, the average overall and intensive care unit length of stay were 5.6 and 1.8 days, respectively. There was one incident of spinal cord ischemia (3.7%). There were five type I or type III endoleaks, three of which required revision (11.1%). In conclusion, thoracic endografting is a safe and viable option for the repair of descending thoracic aneurysms and other aortic pathologies. We have found it to be less invasive, even in conjunction with preoperative debranching procedures, with a shorter recovery time, decreased perioperative morbidity and blood loss, and decreased peri-operative mortality compared with standard open repair.

Combined open and endovascular repair for aortic arch pathology

Background and Objectives

We describe our experience with combined open and endovascular repair in patients who have aortic arch pathology.

Subjects and Methods

This study is a retrospective analysis of 7 patients who underwent combined open and endovascular repair for aortic arch pathology. Medical records and radiographic information were reviewed.

Results

A total of 7 consecutive patients (5 men, 71.4%) underwent thoracic stent graft implantation. The mean age was 59.9±16.7 years. The indication for endovascular repair was aneurysmal degeneration in 5 patients, and rupture or impending rupture in 2 patients. In all 7 cases, supra-aortic transposition of the great vessels was performed successfully. Stent graft implantation was achieved in all cases. Surgical exposure of the access vessel was necessary in 2 patients. A total of 9 stent grafts were implanted (3 stent grafts in one patient). The Seal thoracic and the Valiant endovascular stent graft were implanted in 6 patients and 1 patient, respectively. There were no post-procedure deaths or neurologic complications. In 2 patients, bleeding and injury of access vessel were noted after the procedure. Postoperative endoleak was noted in 1 patient. One patient died at 10 months after the procedure due to a newly developed ascending aortic dissection. No patients required secondary intervention during the follow-up period. The aortic diameter decreased in 4 patients. In 3 patients, including 1 patient with endoleak, there was no change in aortic diameter.

Conclusion

Our experience suggests that combined open and endovascular repair for aortic arch pathology is safe and effective, with few complications.

Long-term results of the frozen elephant trunk technique for the extensive arteriosclerotic aneurysm

OBJECTIVES

The objective of this report is to elucidate the feasibility of the frozen elephant trunk technique as a one-stage operation for extensive arteriosclerotic aneurysms and to investigate the long-term durability and efficacy of this procedure from our 11 years of experience.

METHODS

The subjects were 58 consecutive patients who electively received the frozen elephant trunk technique for arteriosclerotic aneurysms involving the aortic arch and the descending aorta between September 1997 and September 2008. Concomitant procedures included 15 coronary artery bypass grafts, 2 aortic valve replacements, 1 aortic root replacement, and 3 maze procedures. The stent graft was delivered to the seventh thoracic vertebra level (Th7) in 22, Th8 in 26, Th9 in 8, and Th10 in 2 patients. Cerebrospinal fluid drainage was administered preoperatively in 10 (17.2%) patients.

RESULTS

Operative mortality within 30 days was 0 of 58. There was 1 in-hospital death. Perioperative morbidity included strokes and spinal cord injury in 2 (3.4%) patients each. During the mean follow-up period of 54.2 +/- 36.9 months, there were 9 (15.5%) late deaths, and 7 (12.1%) patients required additional intervention. The 8-year survival was 65.5%, the overall 8-year aortic event free survival was 72.8%, and the 8-year event free survival on the site of the stent graft was 94.8%. A follow-up computed tomographic image was available for 86.2% (50/58) of patients who survived longer than 6 months. The size of the aneurysm increased in 1 (2.0%) patient, was not changed in 6 (12.0%) patients, shrank in 34 (68.0%) patients, and was obliterated in 9 (18.0%) patients.

CONCLUSIONS

The frozen elephant trunk for extensive aortic aneurysms had long-term durability and efficacy and might become the alternative treatment for extended aortic replacement.

Stent graft treatment for transverse arch and descending thoracic aorta aneurysms

PURPOSE OF REVIEW

The aim of this article is to review the recent relevant literature on endovascular repair of thoracic aortic aneurismal disease.

RECENT FINDINGS

The introduction of endovascular stent graft technology has ushered in a new era in therapy for diseases of the aortic arch and descending thoracic aorta. The technical challenges of stent graft deployment in the descending thoracic aorta, such as proximity to the great vessels and arch tortuosity, have been and remain a device engineering focus. More recently, repair of aortic arch aneurysms has been accomplished using both 'hybrid' (open and endovascular) and totally endovascular techniques.

SUMMARY

Endovascular stent grafting of aneurismal disease processes of the thoracic aorta is feasible and relatively safe. Exquisite judgment is essential for good results. These results generally rest on a broad knowledge base of thoracic aortic disease processes and experience in both open and endovascular surgery. Careful attention to patient anatomy and device specifications must be maintained. The key to the successful implementation of this technology lies in careful preoperative planning, intraoperative execution with safe device delivery, and prevention of central nervous system injury. Routine follow-up imaging is imperative to better understand the long-term results and indications for these new procedures.