A Systematic Review of Total Endovascular Aortic Arch Repair: A Promising Technology

Impact of Arch Disease Pathology on Outcomes of Zone 0 Branched Thoracic Endovascular Arch Repair

OBJECTIVE

Zone 0 branched thoracic endovascular arch repair (Z0BTEVAR) has emerged as an alternative to open repair for high-risk patients with aortic arch pathology. However, it is unclear how disease characteristics in this population impacts clinical outcomes. The study aimed to compare Z0BTEVAR according to arch disease pathology and to identify potential predictors of post-operative outcomes.

METHODS

From 2011 to 2023, patients who underwent Z0BTEVAR for chronic aortic dissection (C-AD) or for non-aortic dissection (N-AD) etiology at 3 European centers were included. The primary outcome was a composite of in-hospital mortality and disabling stroke. Multivariable logistic analyses were conducted to identify independent predictors of the outcomes.

RESULTS

Overall, 213 patients underwent Z0BTEVAR, including 111 patients treated for C-AD and 102 patients treated for N-AD. The median age was 72 years old. Overall composite outcome was 10.3%, higher for N-AD patients compared to C-AD patients (15.7% vs. 5.4%; p=0.01). Similarly, N-AD patients had more post-operative strokes (17.7% vs. 4.5%; p<0.01). On multivariable analysis, previous type A aortic dissection was protective for the composite outcome (OR 0.2; C.I. 0.1-0.6), while degenerative aneurysm with zone 0 or 1 involvement was predictive of post-operative stroke (OR 3.7; CI 1.2-11.8). At 4 years, survival for the N-AD group was 71.8±6.6%, and for the C-AD group was 71.5±6.5% (p=0.81).

CONCLUSION

Z0BTEVAR could be performed with satisfactory short- and mid-term outcomes for high-risk patients, particularly those with previous dissection. Patient selection is important, and continued effort should be placed on minimizing post-operative stroke.

Aortic Dissection Following Transcatheter Aortic Valve Replacement

Transcatheter Aortic Valve Replacement (TAVR) continues to grow in popularity and has become the preferred mechanism for the treatment of aortic stenosis in most patients. Despite significant improvements in the safety of TAVR, complications remain inevitable. Aortic dissection, although rare, is a feared complication following TAVR. Aortic dissection after TAVR has been reported to occur in both the ascending and descending thoracic aorta and may occur acutely during valve placement or in a delayed fashion. Bicuspid aortic valve and ascending aortic aneurysm may increase the risk for Type A dissection following TAVR. Given the rarity of aortic dissection in TAVR, a high index of suspicion must be maintained to provide prompt diagnosis and management. Open surgical repair is the preferred treatment modality for type A aortic dissection, however endovascular management and conservative medical therapy can be utilized in select patients and are more commonly employed for type B dissection.

Anatomic feasibility of a novel modular triple-branched endograft for patients with aortic arch pathologies

OBJECTIVES

This study aimed to assess the anatomical feasibility of a novel modular triple-branched endograft for aortic arch diseases.

METHODS

A cross-sectional study was conducted on 314 patients with aortic arch pathologies treated at a single center from January 2018 to December 2023. Preoperative computed tomography angiography images were analyzed with three-dimensional reconstruction to quantify anatomical features. Feasibility was based on endograft anatomical criteria, and logistic regression identified risk factors for unsuitability.

RESULTS

Out of 132 patients included in the study, 67.4% were deemed anatomically suitable for the triple-branched device. A total of 36 (27.3%) patients were deemed inapplicable due to a large diameter of the proximal landing zone, 12 (9%) patients due to a small diameter of the left common carotid artery, and 1 (0.8%) patient due to a small diameter of the left subclavian artery. Logistic regression identified large proximal landing zone diameter and small left common carotid artery diameter were significant factors for unsuitability (p < 0.001 and p = 0.002, respectively).

CONCLUSIONS

The novel triple-branched endograft demonstrated promising anatomical feasibility in two-thirds of patients. However, anatomical constraints limited its applicability. Future device iterations should focus on accommodating a broader range of anatomical variations.

Total endovascular arch repair: Initial experience in Bologna

Objectives

In the last few years, fenestrated, branched, or scalloped custom grafts have become available for aortic arch repair. Open surgery is the gold standard, but arch thoracic endovascular aortic repair (TEVAR) is indicated for high-risk patients. We focused on total endovascular aortic arch replacement with a zone 0 or zone 1 landing zone to describe its short- and long-term outcomes.

Methods

We retrospectively analyzed patients who underwent arch TEVAR with a zone 0 or zone 1 landing zone at our center. We then performed a Kaplan-Meier analysis for survival and freedom from reintervention at follow-up.

Results

From May 2017 to November 2023, 15 patients underwent elective arch TEVAR, having been deemed unfit for open surgery. Mean age was 74.7 ± 7.8 years. The most frequent procedure was fenestrated endovascular aortic repair with a left carotid-subclavian bypass (LCSB) (6; 40%), followed by double-branched graft with LCSB (5; 33.3%) and triple-branched graft (2; 13.3%) and scalloped graft with LCSB (2; 13.3%). There was 1 in-hospital death (6.7%). Perioperative stroke occurred in 2 cases (13.3%). Mean follow-up (FU) time was 16.4 ± 15.1 months. There were 3 deaths at FU, all for noncardiovascular causes, and 1 stroke at FU. One patient required further stenting of the brachiocephalic trunk for a type III endoleak. Survival at 12 months was 87.5% and freedom from reintervention was 85.7%.

Conclusions

Total endovascular aortic arch repair with custom-made prosthesis is a safe and effective procedure in patients with prohibitive surgical risk. Stroke remains the main complication with significant rates.

Anesthetic Considerations for Endovascular Repair of the Thoracic Aorta

Thoracic aorta pathologies, especially those of the ascending aorta and aortic arch, were traditionally approached via open surgical repair. This carries risk of ischemic end-organ damage and other complications. Endovascular repair of ascending aorta and aortic arch pathologies is becoming more successful and widespread, thereby posing numerous challenges to the anesthesiologist. This article reviews the anesthesia-pertinent pathophysiology, repair techniques, preoperative evaluation, intraoperative management, and postoperative care of patients presenting for endovascular repair of thoracic aorta pathologies.

Cerebral Protection Strategies in Aortic Arch Surgery-Past Developments, Current Evidence, and Future Innovation

Surgery of the aortic arch remains a complex procedure, with neurological events such as stroke remaining its most dreaded complications. Changes in surgical technique and the continuous innovation in neuroprotective strategies have led to a significant decrease in cerebral and spinal events. Different modes of cerebral perfusion, varying grades of hypothermia, and a number of pharmacological strategies all aim to reduce hypoxic and ischemic cerebral injury, yet there is no evidence indicating the clear superiority of one method over another. While surgical results continue to improve, novel hybrid and interventional techniques are just entering the stage and the question of optimal neuroprotection remains up to date. Within this perspective statement, we want to shed light on the current evidence and controversies of cerebral protection in aortic arch surgery, as well as what is on the horizon in this fast-evolving field. We further present our institutional approach as a large tertiary aortic reference center.

Outcomes of Total Aortic Arch Replacement in a Canadian Nationwide Registry

BACKGROUND

Accurate benchmarking of outcomes after elective open total arch replacement is important for surgical decision making and for comparisons with emerging endovascular technologies.

METHODS

A multicentre registry of consecutive aortic arch procedures in 9 centres across Canada contained 250 elective total arch replacements from 2010 to 2021. A total of 728 patients undergoing elective hemiarch replacement over the same time period was used as a comparator group. Propensity score matching was used to construct 202 well matched pairs.

RESULTS

Patients undergoing total arch replacement were 63.2 ± 13.6 years old, and 34% were female. These patients were more likely to have connective tissue disorders compared with patients undergoing hemiarch replacement. When under hypothermic circulatory arrest, the total arch group uniformly used antegrade cerebral perfusion with median nadir temperature of 24°C (interquartile range [IQR] 21-25°C), and median duration 33 minutes (IQR 23-51 minutes). Before matching, in-hospital mortality and stroke rates were 5.2% and 10%, respectively, for the total arch group. After matching, the total arch group had in-hospital mortality similar to the hemiarch group (P = 0.58). Rates of stroke were also not statistically different (P = 0.11). The total arch group was more likely to experience delirium, prolonged intubation, increased intensive care unit length of stay, and transfusions.

CONCLUSIONS

Elective total arch replacement is performed with good in-hospital mortality rates that are similar to rates after elective hemiarch repairs. However, total arch replacement was associated with significantly higher rates of other morbidities, including delirium and prolonged intubation.

Novel chimney balloon technique to safeguard cerebral blood flow during total endovascular aortic arch repair

During endovascular total aortic arch repair by in situ fenestration, extra procedures are needed to sustain cerebral blood flow when targeting all three supra-aortic branches. Recently, our group successfully interposed a chimney balloon between the greater curvature of the aortic arch and an aortic stent to safeguard cerebral blood flow during total endovascular aortic arch repair.

The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch

Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.

Use of Iliac Branch Endoprosthesis to Rescue Inadvertent False Lumen Deployment of the Innominate Branch Stent During Physician-Modified Fenestrated-Branched Aortic Arch Repair

A 70-year-old male with a history of 3 prior median sternotomies and on anticoagulation presented with acute chest and back pain associated with a pseudoaneurysm of the ascending and aortic arch in the setting of residual dissection involving the innominate, proximal right carotid, and subclavian arteries. A physician-modified triple vessel fenestrated-branched arch endograft was deployed. The innominate branch stent was deployed from the right carotid cut down, while the left carotid and left subclavian branch stents were placed from a femoral approach. Postoperatively, the innominate branch was found to be deployed in the false lumen of the dissected native innominate artery, leading to continued pressurization of the pseudoaneurysm. This was rescued by placing a Gore Iliac Branch Endoprosthesis (IBE) into the innominate branch through a temporary conduit sewn to the right carotid artery with a right subclavian branch placed via a brachial artery cut down into the internal iliac gate. The use of IBE allowed branch stent extension past the dissected native vessels. The patient had an uneventful recovery without neurologic complications. At 3-month follow-up, the patient remains well with an excluded pseudoaneurysm, and patent bifurcated innominate, bilateral carotid, and subclavian artery branches. A Gore IBE can be utilized in a dissected innominate artery to create an innominate branch device during fenestrated-branched endovascular arch repair.

Aortic arch endovascular branch and fenestrated repair: Initial Canadian experience with novel technology

Objective

The objective is to describe the initial Canadian experience using novel aortic arch branched endograft technologies.

Methods

We performed a retrospective consecutive case series of all patients undergoing aortic arch branched repair with newly available endograft technology since 2020 at our site. We describe the patient characteristics, treatment characteristics, and postoperative outcomes.

Results

Eleven patients received arch branched endografts, indicated for penetrating aortic ulcer in seven patients (64%), arch degeneration after prior aortic dissection repair in three (27%), and acute aortobronchial fistula in one patient (9%). Their average age was 72 ± 7 years. Complete arch repair from zone 0 to 4 was performed in six cases (55%); the remaining repairs landed proximally in zones 1 or 2. Seven repairs used a single retrograde facing inner branch (thoracic branch endoprosthesis; W.L. Gore & Associates), three used double antegrade inner branch (Bolton Relay; Terumo Interventional Systems), and one emergent case used double in situ fenestrations. Seven repairs (64%) used an adjunctive extra-anatomic bypass to complete great vessel perfusion, two of which were created during a prior aortic repair. Inferior vena cava balloon inflow occlusion during deployment was used in all cases. No mortalities, transient or permanent spinal cord paralysis, myocardial infarction, dialysis dependence, venous thromboembolism, or bleeding requiring reintervention occurred. No patient undergoing elective arch branch repair experienced a stroke. The one patient undergoing emergent repair did suffer a stroke. The median length of stay was 5 days (interquartile range, 2-8 days). Two endoleaks developed: a type Ia endoleak successfully treated with a Palmaz stent (Cordis) during the index admission, and a type II endoleak with ongoing sac regression on postoperative follow-up. Postoperatively, one patient suffered a suspected aortic graft infection that was treated with lifelong antibiotics. During a mean radiographic follow-up of 7.2 months, no cases of branch vessel instability (ie, no migration, reintervention, arterial rupture, intraluminal thrombus, occlusion, stenosis, or kinking of the branch grafts) developed. Three patients experienced sac regression of >5 mm, and no patient experienced continued postoperative dilation.

Conclusions

To the best of our knowledge, this is the largest reported Canadian volume of aortic arch repair using novel branched or fenestrated technology. The series demonstrates that a multidisciplinary program and properly selected patients can yield excellent results using endovascular repair for complex aortic arch pathology.

Multicenter Comparison of Aortic Arch Aneurysms and Dissections Zone 0 Hybrid and Total Endovascular Repair

PURPOSE

Comparison of hybrid and total endovascular aortic arch repair at two tertiary vascular surgery centers.

MATERIALS AND METHODS

Consecutive patients undergoing hybrid (HG) or total endovascular (TEG) total aortic arch repair for aneurysms or dissections were included (2008-2022). Primary outcome measure was 30-day mortality. Secondary outcomes were major complications, technical success (defined as absence of surgical conversion/mortality, high-flow endoleaks or branch/limb occlusion), clinical success (defined as absence of disabling clinical sequelae), late and aortic-related mortality/reinterventions, freedom from endoleaks, aortic diameter growth > 5 mm, graft migration and supra-aortic trunks (SAT) patency.

RESULTS

In total, 30 patients were included, 17 in HG and 13 in TEG. TEG presented shorter intervention time (240.5 vs 341 min, p = 0.01), median ICU stay (1 vs 4.5 days, p < 0.01) and median length of stay (8 vs 17.5 days, p < 0.01). No intraoperative deaths occurred. Technical success was 100%; clinical success was 70.6% in HG and 100% in TEG (p = 0.05). Thirty-day mortality was 13.3%, exclusively in HG (p = 0.11). Nine major complications occurred in 8 patients, 5 in HG and 3 in TEG (p = 0.99), among which five strokes, two in HG and three in TEG (p = 0.62). Late mortality was 38.5%, six patients in HG and four in TEG, p = 0.6. Two late aortic-related deaths occurred in HG (p = 0.9). Two aortic-related reinterventions, no graft migration or SAT occlusion was observed.

CONCLUSIONS

Total endovascular repair seems to shorten operative times and provide higher clinical success compared with hybrid solutions, without significant 30-day mortality differences. The most common major complication is stroke.

The Aortic Team Model for the Management of the Distal Arch, Descending Thoracic and Thoracoabdominal Aorta: Appraisal at 3 Years

BACKGROUND

 This study aimed to assess feasibility, logistical challenges, and clinical outcomes associated with the implementation of an Aortic Team model for the management of distal arch, descending thoracic and thoracoabdominal aortic disease.

METHODS

 An Aortic Team care pathway was implemented in November 2019. Working as a unit, two cardiac surgeons, two vascular surgeons, an interventional radiologist, a cardiologist, and an anesthesiologist collectively determined care decisions via multispecialty presence at an Aortic Clinic. Cardiac and vascular surgeons operated in tandem for open procedures. Interventional radiology participated alongside cardiac and vascular for endovascular procedures. Cardiology aided in medical therapies for heritable and degenerative disease, and had a lead role for genetics and high-risk pregnancy referrals. The model spanned three hospitals. Clinical outcomes at 3 years were assessed.

RESULTS

 There were 35 descending thoracic and thoracoabdominal surgeries and 77 thoracic endovascular aortic repairs. Endoarch devices were used in 7 cases (Gore Thoracic Branch Endoprosthesis, 4, Terumo RelayBranch, 3) and an endothoracoabdominal device in 4 cases (Cook Zenith t-branch). The Aortic Clinic acquired 456 patients, with yearly increases (54 patients [year 1], 181 patients [year 2], 221 patients [year 3]). For surgery, mortality was 8.6% (3/35), permanent paralysis 5.7% (2/35), stroke 8.6% (3/35), permanent dialysis 0%, and reinterventions 8.6% (3/35). For endovascular cases, mortality was 3.9% (3/77), permanent paralysis 3.9% (3/77), stroke 5.2% (4/77), permanent dialysis 1.3% (1/77), and reinterventions 16.9% (13/77).

CONCLUSION

 An Aortic Team model is feasible and ensures all treatment options are considered. Conventional open thoracoabdominal procedures showed acceptable outcomes. Endoarch technology shows early promise.

The Aortic Team Model and Collaborative Decision Pathways for the Management of Complex Aortic Disease: Clinical Practice Update From the Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery/Canadian Association for Interventional Radiology

Disease of the aortic arch, descending thoracic, or thoracoabdominal aorta necessitates dedicated expertise across medical, endovascular, and surgical specialties. Cardiologists, cardiac surgeons, vascular surgeons, interventional radiologists, and others have expertise and skills that aid in the management of patients with complex aortic disease. No specialty is uniformly expert in all aspects of required care. Because of this dispersion of expertise across specialties, an aortic team model approach to decision-making and treatment is advocated. A nonhierarchical partnership across specialties within an interdisciplinary aortic clinic ensures that all treatment options are considered and promotes shared decision-making between the patient and all aortic experts. Furthermore, regionalization of care for aortic disease of increased complexity assures that the breadth of treatment options is available and that favourable volume-outcome ratios for high-risk procedures are maintained. An awareness of best practice care pathways for patient referrals for preventative management, acute care scenarios, chronic care scenarios, and pregnancy might facilitate a more organized management schema for aortic disease across Canada and improve lifelong surveillance initiatives.

Outcomes of Castor Single-Branched Stent Graft for Reconstruction of Multiple Supra-Aortic Branches in Aortic Arch Disease

PURPOSE

To report the outcomes of a combination of Castor single-branched stent grafts with other techniques for the reconstruction of multiple supra-aortic branches in aortic arch disease.

MATERIALS AND METHODS

Between December 2019 and December 2021, 20 patients with aortic arch disease underwent thoracic endovascular aortic repair (TEVAR) at our institution using a Castor single-branched stent graft combined with the fenestration, chimney, or bypass techniques. Thoracic endovascular aortic repair is indicated for complicated or acute type B aortic dissection (TBAD), nonruptured aneurysms with a maximum aneurysm diameter >5.5 cm or showing rapidly expanded, ruptured, or threatened aneurysms, and penetrating aortic ulcers (PAUs) with a maximal aortic diameter >5.5 cm or with PAUs >10 mm deep or >20 mm in diameter. Preoperative, intraoperative, and postoperative clinical data were recorded.

RESULTS

The median age of the patients was 56 (range=52-69 years) years, and 19 patients were men. Seven patients underwent the Castor single-branched stent graft and left common carotid artery (LCCA) chimney technique, 8 patients underwent the Castor single-branched stent graft and fenestration technique, and 5 patients underwent the Castor single-branched stent graft and bypass technique. The technical success rate was 100%. Major adverse events included 2 endoleaks, 1 spinal cord ischemia, and 1 early-stage retrograde type A aortic dissection. No cerebral stroke-related complications were observed. The mortality rate was 10% (2/20 patients). One patient with thoracic aortic aneurysm (TAA) died because of a sudden decrease in oxygen saturation and blood pressure after surgery. Relatives declined autopsy, and the cause of death was not determined. Another patient died of a retrograde type A dissection after surgery. The median follow-up period was 6 months (range=3.5-12 months). During follow-up, 1 patient with type I endoleak underwent thoracotomy again after a year. The remaining patients recovered well.

CONCLUSIONS

The combination of a Castor single-branched stent graft with fenestration, chimney, or bypass techniques may be an effective treatment for preserving multiple supra-aortic branches in aortic arch disease.

CLINICAL IMPACT

This study introduced three methods of reconstruction of multiple supra-aortic branches using a Castor single-branched stent graft (Castor single-branched stent graft combined with fenestration, chimney, or bypass technique) and analysed their advantages and shortcomings to provide experience for the future treatment of aortic arch diseases.

Avoiding Stroke in Patients Undergoing Endovascular Aortic Arch Repair: JACC Review Topic of the Week

As the bottleneck of endovascular aortic arch repair, early postoperative stroke remains a devastating complication in high-risk patients and a critical concern for the development of optimal endovascular techniques and devices. The incidence of early postoperative stroke varies widely among currently available endovascular techniques and devices, with reported rates ranging from 0.0% to 42.9%, and is significantly influenced by the severity of the patient's preexisting aortic atherosclerotic burden, air released from the endovascular device, and a variety of factors leading to cerebral perfusion insufficiency. Currently, preidentification of high-risk patients and careful perioperative management appear to play a critical role in reducing stroke incidence. Specific intraoperative prevention methods are still lacking, but embolic protection devices and carbon dioxide or high-volume saline flushing of endovascular devices appear promising. Detailed preoperative stroke risk stratification and screening for optimal endovascular techniques and devices for aortic arch treatment are unmet clinical needs.