Endovascular Treatment Options for the Aortic Arch

Outcomes of thoracic endovascular aortic repair with physician-manufactured partial micropore stent grafts for aortic arch pathologies

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) has been used extensively in the management of thoracic aortic diseases. Numerous efforts have been made to enhance clinical outcomes through the use of stent grafts. This study aimed to investigate the effectiveness and safety of physician-manufactured partial micropore stent grafts (PSMGs) in TEVAR.

METHODS

Between December 2017 and June 2022, data were collected from 56 patients who underwent TEVAR using physician-manufactured PSMGs. The evaluation encompassed technical success, perioperative and follow-up morbidity and mortality, stroke incidence, and branch artery patency.

RESULTS

In this investigation, 56 patients received treatment with physician-manufactured PSMGs. Of these patients, 46 were male, with a mean age of 62.1 ± 11.2 years. Aortic pathologies comprised aortic dissection (n = 31 [55.4%]), aortic aneurysms (n = 10 [17.9%]), penetrating aortic ulcer (n = 8 [14.3%]), and intramural hematoma (n = 7 [12.5%]). During a median follow-up of 18 months (interquartile range, 13-25 months), the stroke rate, supra-aortic branch patency rate, and endoleak rate were 0%, 100%, and 7.1%, respectively. There were no occurrences of all-cause mortality, stroke, or the necessity for open conversion.

CONCLUSIONS

TEVAR with physician-manufactured PSMGs is a viable alternative for addressing aortic arch pathologies in proficient medical centers. The approach demonstrates favorable branch patency, a low complication rate, and minimal postoperative mortality.

Technical tips and clinical experience with the Terumo Relay®Branch aortic endovascular graft

Advances in thoracic endovascular aortic repair (TEVAR) are enabling the treatment of increasingly proximal pathology. While the practice of vascular surgery has thus far been mostly limited to TEVAR in zone 2 or more distally, there are emerging devices for zone 1 and zone 0 repair that do not require any further arch debranching compared with a zone 2 repair. Moreover, such devices set forth repair options for patients unable to tolerate the insult of open surgery. One zone 0 device under evaluation is the Terumo Relay^®Branch (Terumo, Tokyo, Japan) endovascular graft, which is an off-the-shelf device based on the Relay^®Pro platform (Terumo). This double branch device uniquely features a large gate, facilitating easy cannulation that contains two locking portal stents for the innominate artery (IA) and left common carotid artery (LCCA) branch grafts. Within our institution, we have had excellent technical success with Relay^®Branch (Terumo) device deployments as part of the Early Feasibility Study, and other centers outside of the USA have published results with this device in small patient series. Notably, there is still a concerning stroke rate associated with the Relay^®Branch (Terumo) device, with permanent stroke rates higher than expected but similar to those for open repair. Thus, these interventions must be undertaken with careful patient selection, thorough planning, and with the guidance of a proficient endovascular aortic team. In this article, we will outline the necessary preoperative workup, highlight device features, and detail the operative strategy, with tips for technical success. These guidelines from our experience will help facilitate successful utilization of this device when it becomes widely available in practice.

Protocol for Guo's aortIc Arch recoNstrucTion: a prospective, multicentre and single-arm study to evaluate the safety and efficacy of the WeFlow-Arch modular inner branch stent-graft system for aortic arch lesions (GIANT study)

INTRODUCTION

Endovascular repair of the entire aortic arch provides treatment opportunities for patients with aortic arch lesions who are intolerant to open surgery. However, the complex anatomical configuration, high-speed blood flow and long access from the femoral artery increase the difficulty of endovascular aortic arch repair. On the basis of our earlier studies, a new modular inner branch stent-graft system was developed specifically for lesions located in the aortic arch and part of the ascending aorta. This study aims to evaluate the safety and efficacy of the novel modular branch stent-graft system in patients with aortic arch lesions who are unsuitable for open aortic arch replacement.

METHODS AND ANALYSIS

This prospective, multicentre, single-arm, clinical trial will enrol 80 patients with aortic arch lesions requiring intervention, namely, true aortic arch aneurysms, pseudo-aortic arch aneurysms and penetrating ulcers involving the aortic arch. Clinical information and CT angiography (CTA) images will be collected and analysed to investigate the safety and efficacy of the novel modular branch stent-graft system. Patients will be followed up for 5 years. The primary outcome will be all-cause mortality and severe stroke within 12 months after the procedure. In addition, this trial will evaluate mid-term to long-term clinical and imaging outcomes through the annual clinical and CTA follow-up for 2-5 years postoperatively.

ETHICS AND DISSEMINATION

We have registered the study on a registry website (https://clinicaltrials.gov/ct2/home). The study findings will be disseminated through peer-reviewed journals, physician newsletters, conferences and the mass media.

TRIAL REGISTRATION NUMBER

NCT04765592.

Outcomes of thoracic endovascular aortic repair with chimney technique for aortic arch diseases

Objective

This study aimed to summarize the long-term experience of using the chimney technique in thoracic endovascular aortic repair (TEVAR) for aortic arch diseases.

Methods

From November 2007 to June 2021, a total of 345 consecutive patients (mean age 56 ± 11.3 years, range 28–83, 302 men) with aortic arch pathologies underwent TEVAR combined with chimney technique (cTEVAR). Their medical data and follow-up results were retrospectively reviewed and analyzed.

Results

Among the 345 patients, 278 (80.6%) received single chimneys, 53 (15.4%) received double chimneys, 7 (2%) received triple chimneys, and 7 (2%) underwent cTEVAR accompanied by other techniques (two with extra-anatomical bypass, two with in situ fenestration, and three with physician modified fenestration). A total of 412 chimney stents were used, including 27 in the innominate artery (IA), 113 in the left common carotid artery, 270 in the left subclavian artery, and two in the aberrant right subclavian artery. Early type IA endoleaks were found in 38 (11%) patients, including 12 with the double or triple chimney technique. Early type II endoleak was found in nine (2.6%) patients. Early re-intervention occurred in two patients with double chimney technique, one for chimney stent migration and the other for compression of chimney stent. The 30-day mortality was 1.2% (4 in 345). During a mean follow-up of 42 ± 22 months (range 1–108 months), major stroke occurred in nine (2.6%) patients, chimney occlusion or stenosis occurred in six (1.7%), and retrograde type A aortic dissection occurred in four (1.2%). Fourteen (4.1%) patients received the secondary intervention. The all-cause mortality was 6.7% (23 in 345). Additionally, the total adverse event rate after cTEVAR was 13.9% (48 in 345).

Conclusion

TEVAR with chimney technique provides a minimally invasive alternative with good chimney graft patency and low postoperative mortality during follow-up. However, the double and triple chimney techniques should be used cautiously as they seem to have a higher risk for type IA endoleak and adverse events after the operation.