Thoracic Endovascular Aortic Repair Combined with Assistant Techniques and Devices for the Treatment of Acute Complicated Stanford Type B Aortic Dissections Involving Aortic Arch

Surgical treatment for right-side aortic arch concomitant with Kommerell's diverticulum: techniques selection and follow-up results

BACKGROUND

Right-side aortic arch concomitant with Kommerell's diverticulum (KD) is a rare and complex ailment, and there is no consensus on the optimal strategy to deal with this congenital anomaly. We retrospectively analyzed and summary of the cases treated in our center with individual treatment methods for different situations.

METHODS

Between September 2018 and December 2021, 10 patients experienced surgical therapy at our institution who presented with a Kommerell's diverticulum arising from an aberrant subclavian artery from the right-side aortic arch. Four main surgical techniques were applied to those patients: 1. total arch replacement with frozen elephant trunk implantation (n = 2); 2. hybrid procedure combining open arch repair and endovascular intervention (n = 1); 3. total endovascular repair using thoracic endovascular aortic repair (TEVAR) with or without left subclavian artery (LSCA) revascularization (n = 6); 4. direct repair underwent endoaneurysmorrhaphy. Clinical characteristics and outcomes were collected.

RESULTS

The mean age of these 10 patients was 56.5 years (range 29-79 years) and only 1 woman. The pathology includes aortic dissection (n = 6) and aneurysm (n = 4). The mean diverticulum size was 41.4 [24.2-56.8] mm. There were no in-hospital deaths, and the median hospital stay was 22 [15-43] days. During the follow-up period (21.4 months, 1-44 months), one died of an unknown cause and one died of esophageal fistula. Two patients underwent second-stage endovascular intervention for distal lesion. And none of the patients had endoleak during the follow-up period.

CONCLUSIONS

Each of the procedures we have mentioned here has its advantages and disadvantages; individualized treatment should meet the appropriate indications. A single-branched stent graft is feasible and effective in the treatment of aortic disease combined with Kommerell's diverticulum.

Chimney Technique and Single-Branched Stent Graft for the Left Subclavian Artery Preservation During Zone 2 Thoracic Endovascular Aortic Repair for Type B Acute Aortic Syndromes

PURPOSE

The purpose of this study was to evaluate the efficacy and safety of zone 2 thoracic endovascular aortic repair assisted by the chimney technique or single-branched stent graft for the preservation of the left subclavian artery, and summarize our single-center experience with the techniques.

MATERIALS AND METHODS

From February 2017 to June 2020, 137 patients who underwent left subclavian artery revascularization during zone 2 thoracic endovascular aortic repair were enrolled. Patients had acute type B aortic dissection and penetrating aortic ulcer associated with intramural hematoma. The chimney technique was performed in 68 patients (group A), and single-branched stent graft was deployed in 69 patients (group B). All procedures were performed during the acute phase. Primary technical success, immediate postoperative endoleak, neurologic complications (stroke or spinal cord ischemia), 30-day mortality, 1-year technical success, all-cause mortality, patency of the left subclavian artery, and reintervention were analyzed. Comparing the occurrence of the Bird-Beak Configuration, defined as a gap between the aortic wall and the sent graft with stent protrusion into the aortic lumen more than 5 mm, was also performed.

RESULTS

Primary technique success was achieved in 66 and 67 patients in groups A and B, respectively. The incidence of immediate postoperative endoleak, neurologic complications (stroke or spinal cord ischemia), and 30-day mortality were 5.9%, 1.5%, and 4.4% in group A, and 2.9%, 2.9%, and 2.9% in group B, respectively. During follow-up, the 1-year technical success rate was similar in both groups. All-cause mortality was similar in both groups (3.1% in group A and 4.5% in group B). The patency of the left subclavian artery was not significantly different between the 2 groups with 2 and 3 occlusions in groups A and B, respectively. The rate of reintervention was higher in group B (3.1% vs 1.6%, p=0.536), with a non-significant difference. Bird-Beak Configuration was more prominent in group B with the incidence of 59.42%.

CONCLUSIONS

Acting as minimally invasive alternatives, both techniques are feasible for left subclavian artery preservation during zone 2 thoracic endovascular aortic repair for type B acute aortic syndromes with encouraging mid-term outcomes. Long-term follow-up is required to confirm these findings.

Mid-term outcomes of left subclavian artery revascularization with Castor stent graft in treatment of type B aortic dissection in left subclavian artery

Background

Here we analyzed mid-term data of thoracic endovascular aneurysm repair (TEVAR) surgery with Castor single-branched stent graft placement for the management of Stanford type B aortic dissection (STBAD) involving the left subclavian artery (LSA).

Methods

Between April 2014 and February 2019, 32 patients with STBAD involving a Castor single-branched stent graft were included. We analyzed their outcomes, including technical success rate (TSR), surgical duration (SD), presence of ischemia, perioperative complications, LSA patency, and survival rate (SR), using computed tomography angiography and clinical evaluation during mid-term follow-up.

Results

The mean patient age was 54.63 ​± ​12.37 years (range, 36-83 years). The TSR was 96.88% (n ​= ​31/32). The mean SD was 87.44 ​± ​10.89 with a mean contrast volume of 125.31 ​± ​19.30 ​mL. No neurological complications or deaths occurred during the study period. The patients had a mean hospital stay of 7.84 ​± ​3.20 days. At a mean follow-up of 68.78 ​± ​11.26 months, four non-aortic deaths (12.5%) were observed. The LSA patency rate was 100% (n ​= ​28/28). There was only one case of type I endoleak immediately after surgery (3.12%) (type I from LSA). However, none of the patients experienced type II endoleaks, and there were no cases of retrograde type A aortic dissection or stent graft-driven new distal entry. Finally, all patients exhibited good LSA patency.

Conclusion

TEVAR using a Castor single-branched stent graft may be a highly feasible and efficient procedure for the management of STBAD involving the LSA.

Update on Trials & Devices for Endovascular Management of the Ascending Aorta and Arch

Thoracic endovascular aortic repair (TEVAR) may treat a variety of acute and chronic aortic diseases as described in several articles in this issue of TVIR. A major challenge to endovascular treatment in the thoracic aorta is disease involving or in close proximity to the aortic valve, coronary arteries, or aortic arch branch vessels. Disease involving the ascending aorta in particular has significant limitations based on its distance from the aortic root. The left subclavian artery (LSA) can be covered in the emergent setting to ensure an adequate landing zone, but patients may require later surgical revascularization, and any coverage of the carotid arteries would require definite pre-endograft revascularization. Open surgical repair continues to have high morbidity and mortality rates in the acute setting, and endovascular therapy is preferred if feasible. Ad hoc modifications of current endografts to maintain arch vessel patency include placement of chimney/snorkel stents or custom fenestrations. However, there is a need for commercially available "off-the-shelf" ascending arch stent-grafts and branched stent-grafts that allow for complete endovascular repair of the aortic arch. This review will focus on devices under investigation for the treatment of pathologies involving the ascending aorta and aortic arch.

Endovascular Repair for Acute Type B Aortic Dissection With Unfavorable Proximal Landing Zone

BACKGROUND

The study aimed to compare the safety and effectiveness between fenestrated technique with or without chimney stent and single-branched stent graft for isolated left subclavian artery revascularization during endovascular repair of acute type B aortic dissection with unfavorable proximal landing zone.

METHODS

From January 2016 to December 2019, 65 acute type B aortic dissection patients with unfavorable proximal landing zone were treated with either the fenestrated technique (n = 34, group A) or single-branched stent graft (n = 31, group B). Type I endoleak, retrograde type A dissection, stroke, left subclavian artery patency, 30-day mortality, and aortic remodeling were systematically recorded and retrospectively analyzed.

RESULTS

Technical success rates for groups A and group B were 94.12% and 100%, respectively. Left subclavian artery primary patency was achieved for all enrolled patients. The incidence of type I endoleak, retrograde type A dissection, stroke, and 30-day mortality was 5.9%, 5.9%, 2.9%, and 2.9% in group A, respectively, but none were encountered in group B. Left subclavian artery occlusion was observed in 3 patients in group A and 2 patients in group B during a mean follow-up of 16.18 ± 2.08 months and 15.19 ± 2.68 months, respectively. After the procedure, significant aortic remodeling was detected in both groups during follow-up.

CONCLUSIONS

Both techniques are feasible and safe for isolated left subclavian artery revascularization during endovascular repair for acute type B aortic dissection. Apart from the associated perioperative risks of complications and mortality for the fenestrated technique, both procedures contributed to favorable aortic remodeling.

Carotid-Axillary Bypass as an Alternative to Carotid-Subclavian Bypass Following Coverage of Left Subclavian Artery During TEVAR

INTRODUCTION

Thoracic Endovascular Aortic Repair (TEVAR) has become the procedure of choice for pathology involving the descending thoracic aorta since its approval by the FDA in 2005. Left subclavian artery (LSA) coverage is commonly required to facilitate an adequate proximal landing zone for the endograft. The traditional revascularization procedure of choice is carotid-subclavian bypass, however recent studies report complication rates as high as 29%-specifically phrenic nerve palsy in 25% of patients undergoing this procedure. Our aim is to present our experience using carotid-axillary bypass as a safe alternative to carotid-subclavian bypass.

METHODS

All patients undergoing carotid-axillary bypass for TEVAR with LSA coverage between June 2016 and September 2019 at a tertiary medical center were retrospectively identified. Short-term and long-term complications were identified and analyzed including: phrenic nerve, recurrent laryngeal nerve, and axillary nerve injuries, as well as local vascular complications requiring re-intervention. All perioperative chest radiographs were reviewed for new hemidiaphragm elevation to assess for phrenic nerve injuries.

RESULTS

35 patients underwent carotid-axillary bypass in conjunction with TEVAR during this time period. The majority of bypasses were performed concurrently with TEVAR (80.0%, 28/35) utilizing GORE PROPATEN 8 mm externally supported vascular graft (91.4%, 32/35). The complication rate specific to carotid-axillary bypass was 14.3% (5/35). We observed a significantly lower (0%, 0/35, P < 0.01) rate of phrenic nerve palsy for carotid-axillary bypass compared to the previously reported 25% (27/107) for carotid-subclavian bypass. For patients with available follow-up imaging (85.7%, 30/35), there was a 100% patency rate at time intervals ranging from 0-1066 days (IQR = 3-37.8).

CONCLUSION

Carotid-axillary bypass can be performed as a safe alternative to carotid-subclavian bypass for LSA coverage during TEVAR involving a more superficial anatomic course of dissection. Phrenic nerve palsy, a well-described complication of the traditional carotid-subclavian bypass, was not observed in this retrospective series.

Outcomes of single physician-modified fenestrated stent grafts for endovascular repair of thoracic aortic lesions involving the distal aortic arch

OBJECTIVES

Our goal was to evaluate the outcomes of fenestrated thoracic endovascular aortic repair of thoracic aortic lesions involving the distal aortic arch using single physician-modified stent grafts.

METHODS

This single-centre, retrospective study included 58 consecutive patients (mean age, 57 ± 14 years; 11 women) who underwent fenestrated thoracic endovascular aortic repair for thoracic aortic pathologies involving the distal aortic arch using single physician-modified stent grafts between November 2015 and December 2018. Indications included complicated acute type B dissection or intramural haematoma with an unfavourable proximal landing zone (n = 49), type Ia endoleak subsequent to thoracic endovascular aortic repair due to acute type B dissection (n = 1) and distal arch degenerative aneurysms <15 mm from the left subclavian artery (n = 8).

RESULTS

The technical success rate was 94.8%. The 30-day mortality was 1.7%, and the perioperative ischaemic stroke rate was 1.7%. The incidence of perioperative complications was 10.3%. At a mean follow-up of 26.3 months (range, 7-44), all target vessels were patent. All-cause mortality was 5.2%. Estimated 1-, 2- and 3-year survival was 98.3 ± 1.7%, 96.4 ± 2.5% and 93.2 ± 3.9%, respectively.

CONCLUSION

The single fenestrated stent graft technique is feasible and effective for endovascular repair of thoracic aortic pathologies involving the distal aortic arch.

Open stented elephant trunk for complicated Stanford type B aortic dissection: a single-center experience

Background

Open stented elephant trunk (SET) or SET with left subclavian artery (LSCA) to left common carotid artery (LCCA) bypass is proven to a potentially alternative treatment for complicated Stanford type B aortic dissection (TBAD). In the current study, we reported our experience with ten consecutive TBAD patients who underwent open SET.

Methods

Patients with complicated TBAD underwent open SET from May 2016 to November 2018 in our institution were included. Patients’ clinical data were obtained from the electronic medical record system, and long-term clinical outcomes were collected by telephone interviews or outpatient interviews.

Results

A total of ten patients with nine males and one female were included, and the average age was 47.3 (31–65) years. Increased D-dimer and fibrinogen degradation products were observed in all patients at admission, and two patients had renal insufficiency. The average postoperative mechanical ventilation time, length of stay in intensive care unit, and postoperative hospital length of stay were 46.9 (6.7–151.2) hours, 7.7 (4–17) days, and 15.7 (10–26) days. No postoperative death occurred. Acute kidney injury and other complications were observed, and they were recovered well when discharge. In long-term follow-up, computed tomography angiography indicated that aortas were completely well remodeled, and blood supply of the brachiocephalic trunks was normal without anastomotic complications. All patients lived well.

Conclusion

SET or SET with subclavian artery correction shows satisfactory clinical outcomes, and it could be considered as an alternative treatment. Well-designed, large-scale studies with long-term follow-up are still needed.

Mid- and Long-Term Effects of Endovascular Surgery and Hybrid Procedures for Complex Aortic Diseases

Objective

To assess the efficacy and short- and mid-term results of endovascular surgery and hybrid surgical procedures in treatment of complex aortic dissection.

Methods

Clinical data of 90 patients with complex aortic dissection admitted from June 2012 to June 2018 were retrospectively analyzed. Among the patients, 60 cases were male and 30 cases were female, and their ages were ranged from 32 to 79, with an average age of 55 years old; different endovascular techniques and/or hybrid procedures were performed in these patients.

Results

Technical success rate was 100% for the entire group of patients. Type I endoleak occurred in 8 patients immediately after stent-graft placement, which in 2 cases disappeared after a proximal Cuff placement, and the other cases received no special treatment. Follow-up was conducted from 1 month to 72 months, with an average of 36.3 months, and no stent-graft migration or organ ischemia was noted. In the follow-up patients, no type I endoleak occurred but type II endoleak was found in 2 cases, which were cured without treatment; no patient had paraplegia.

Conclusion

Endovascular surgery and hybrid procedures have demonstrable mid- and long-term efficacy in treatment of complex aortic diseases. However, this conclusion still requires multicenter, large-sample studies to further confirm.

The strategies and outcomes of left subclavian artery revascularization during thoracic endovascular repair for type B aortic dissection

This study was to analyze the outcomes of left subclavian artery (LSA) revascularization during thoracic endovascular repair (TEVAR) for type B aortic dissections (TBAD). From 2011 to 2017, TBAD patients who underwent LSA revascularization during TEVAR were enrolled. Technical success, endoleaks, mortality, complication, reintervention, and patency of target vessels were analyzed. 38 patients were included, 14 underwent carotid-subclavian bypass (CSB), and 24 underwent chimney graft (CG) implantation. Technical success rates were 92.9% and 100% in CSB and CG group. Eleven immediate type I endoleak (EL-I) was detected, including one from CSB group and ten from CG group. Three immediate type II endoleak (EL-II) was detected in CSB group. Perioperative complications showed no difference, but CSB group had longer intensive care unit (ICU) stay time. Median follow-up time was 26.2 months, and overall mortality was 14.3% and 0% in each group. Three EL-I and one EL-II underwent reintervention. All the LSA showed good patency, except one suffered from CG collapse. Both CSB and CG were feasible strategies to preserve the antegrade blood flow of LSA, and each strategy had its advantages and disadvantages. Based on our current experience, we preferred CG for high-risk patients. However, the evidence was still not strong enough, further well-designed studies are necessary to identify the criteria for LSA revascularization strategy during TEVAR.

Case report of retrograde in situ fenestration of the thoracic stent graft with reentry device in a patient with aortobronchial fistula

RATIONALE

In situ fenestration may be necessary to preserve branch arteries during thoracic endovascular aortic repair (TEVAR) when there is an inadequate landing zone.

PATIENT CONCERNS

We report the case of a 74-year-old man presenting with recurrent hemoptysis.

DIAGNOSES

Based on computed tomography (CT) angiogram and bronchoscopy, diagnosis was aorto-bronchial fistula.

INTERVENTIONS

We performed retrograde in situ fenestration with reentry catheter (Pioneer Plus, Volcano Corporation, San Diego, CA) to preserve the left subclavian artery following TEVAR for aorto-bronchial fistula.

OUTCOMES

Following this procedure, the patient had a patent left subclavian artery and no evidence of endoleak. The patient had no further episodes of hemoptysis.

LESSONS

The retrograde in situ fenestration with reentry catheter strategy is an option for patients when carotid-subclavian bypass is deemed unsafe.

Status of branched endovascular aortic arch repair

Multiple medical device manufacturers are developing branched endografts for thoracic endovascular aortic repair (TEVAR), to provide a minimally invasive alternative for the treatment of aortic arch pathologies in patients who are deemed unfit for open or hybrid arch repair. Different branched endografts have been introduced, with varying number, size and orientation of the branches that redirect flow to the supra-aortic arteries. We present an overview of the currently investigated devices and review their outcomes. The results of branched TEVAR are promising, yet stroke remains the predominant periprocedural concern. For now, these procedures should be limited to select expert centers where the design and deployment procedure of branched endografts can be further developed to reduce the risk of stroke.

Risk factors and early outcomes of acute renal injury after thoracic aortic endograft repair for type B aortic dissection

Background

Thoracic endovascular aortic repair (TEVAR) has become an emerging treatment modality for acute type B aortic dissection (TBAD) patients in recent years. The risk factors and impacts of acute kidney injury (AKI) after percutaneous TEVAR, however, have not been widely established.

Methods

We retrospectively studied the clinical records of 305 consecutive patients who admitted to our institution and had TEVAR for TBAD between December 2009 and June 2013. The patients were routinely monitored for their renal functions preoperatively until 7 days after TEVAR. The Kidney Disease Improving Global Guidelines (KDIGO) criteria were used for AKI.

Results

Of the total 305 consecutive patients, 84 (27.5%) developed AKI after TEVAR, comprising 66 (21.6%) patients in KDIGO stage 1, 6 (2.0%) patients in stage 2 and 12 (3.9%) patients in stage 3. From the logistic regression analysis, systolic blood pressure (SBP) on admission >140 mmHg (odds ratio [OR], 2.288; 95% CI, 1.319–3.969) and supra-aortic branches graft bypass hybrid surgery (OR, 3.228; 95% CI, 1.526–6.831) were independent risk factors for AKI after TEVAR. Local anesthesia tended to be a protective factor (OR, 0.563; 95% CI, 0.316–1.001). The preoperative renal function, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or statin administration, volume of contrast agent, range of TBAD and false lumen involving renal artery were not associated with post-operation AKI. The in-hospital mortality and major adverse events were markedly increased with the occurrence of AKI (7.1% vs 0.9%, P=0.006; 14.3% vs 3.2%, P<0.001, respectively).

Conclusions

TEVAR for TBAD has a high incidence of AKI, which is associated with worse in-hospital outcomes. SBP on admission and supra-aortic branches graft bypass hybrid surgery were the most significant risk factors. Renopreventive measures should be considered in high-risk patients.

Aortic Dissection: Novel Surgical Hybrid Procedures

The management of patients with aortic dissection is challenging and its treatment is an area of development and innovation. Conventional surgical techniques are associated with significant risks in terms of mortality and morbidity in such high-risk patients. As a result of cumulative advances in technology, classical surgical techniques have been improved and enhanced by the newer endovascular approaches, leading to novel surgical hybrid procedures. Impressive early results have been seen with frozen elephant techniques, revascularisation of the supra-aortic branches and branched/fenestrated thoracic endovascular aortic repair-alone procedures. This review describes the techniques involved in the latest hybrid procedures for aortic dissection and their outcomes.