Experimental Assessment of Physician Modified Proximal Scalloped Stent Graft to Extend Proximal Landing Zone in the Aortic Arch

Anatomical Feasibility of the "Canaud Technique" for Physician-Modified Thoracic Endovascular Grafts for the Treatment of Aortic Arch Disease

PURPOSE

Thoracic endovascular aortic repair (TEVAR), originally conceived for deployment distal to the left subclavian artery (LSA), has been recently extended to more proximal landing zones. Among total endovascular solutions, the "Canaud technique" for Physician-Modified Thoracic Endovascular Grafts (C-PMEGs) has gained acceptance with good early results. The aim of this study is to report the proportion of patients with zone 0, 1, and 2 aortic arch lesions that could theoretically be treated with a C-PMEG.

MATERIALS AND METHODS

Computed tomography angiography (CTA) of all consecutive patient candidates to open, hybrid, or endovascular arch repair from January 2009 to July 2023 at our Institution were analyzed. The assessment of feasibility of C-PEMG was conducted following previously extensively described anatomical criteria.

RESULTS

During the study period, 209 consecutive patients were candidates for an open, hybrid, or endovascular aortic arch repair. Of them, 164 patients had a preoperative CTA scan eligible for analysis. One hundred twenty-six patients were male (76.8 %), with a mean age of 67 ± 10.8 years. Ninety-four patients (57.3%) were affected by atherosclerotic aneurysms, 48 post-dissecting aneurysms (29.3%) and 22 penetrating aortic ulcers (PAUs) (13.4%). Twenty patients (12.2%) were suitable for double-fenestrated C-PMEG, and 34 patients (20.7%) for single-fenestrated C-PMEG, totaling 32.9% of the entire cohort. The combination of supra-aortic trunks (SAT) bypass or the use of covered stent in IA or left common carotid artery (LCCA) as adjunctive maneuvers, would extend the C-PMEGs feasibility to 69 patients (42.1%). The use of an iliac graft conduit in 3 (1.8%) patients with inadequate ileo-femoral accesses would increase the C-PMEG suitability to 72 patients (43.9%). The main reason for exclusion was excessive ascending aortic diameter in 78 patients (47.6%).

CONCLUSIONS

The use of C-PMEG was shown to be theoretically feasible in a percentage of patients ranging from 32.9 to 43.9% affected by aortic arch aneurysms, dissections, and PAU. The main reason for exclusion was the dimension of the ascending aorta. The C-PMEG technique is a viable option in aortic arch lesions endovascular treatment. An off-the-shelf device with similar characteristics could also be used in emergency, avoiding the limitations of physician modifications (such as time for back-table procedure, sterility, off-label use).

CLINICAL IMPACT

Thoracic endovascular aortic repair (TEVAR) has been extended to more proximal landing zones for the treatment of aortic arch aneurysm, dissections, penetrating aortic ulcers. Among total endovascular solutions, the "Canaud technique" for Physician-Modified Thoracic Endovascular Grafts (C-PMEGs) has gained acceptance with good early results. The anatomical feasibility in 164 consecutive patients was 69 patients (42.1%), with the combination of supra-aortic trunks (SAT) bypass or the use of covered stent in IA or left common carotid artery (LCCA) as adjunctive maneuvers, showing that the C-PMEG technique is a viable option in aortic arch lesions endovascular treatment.

Outcomes of thoracic endovascular aortic repair with fenestrated surgeon-modified stent-graft for type B aortic dissections involving the aortic arch

Objectives

This retrospective analysis aimed to evaluate the early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) with fenestrated surgeon-modified stent-graft (f-SMSG) for type B aortic dissections (TBAD) involving the aortic arch.

Methods

From March 2016 to April 2021, 47 consecutive patients were treated using TEVAR with f-SMSG. All patients were diagnosed with TBAD involving the aortic arch.

Results

In total, 47 patients with TBAD involving the aortic arch were treated with f-SMSGs. There were 21 zone 1 and 26 zone 2 TEVAR, and 65 arteries were revascularized successfully with fenestrations. Technical success was achieved in 46 patients (97.88%). The 30-day estimated survival (± SE) and reintervention was 93.6 ± 1.0% (95% Confidence Interval [CI], 92.6-94.6%) and 91.5 ± 1.2% (95% CI, 90.3-92.7%), respectively. During a median follow-up of 51 months (range, 16-71 months), 1 patient died of rupture of aortic dissection (AD) and 3 patients died of non-aortic-related reasons. Reintervention was performed for four patients, including two patients of type IA entry flow and two patients of type IB entry flow. No occlusion of the supra-aortic trunk was observed. The estimated survival and reintervention (± SE) at 4 years was 88.7 ± 1.4% (95% CI, 87.3-90.1%) and 84.8 ± 1.5% (95% CI, 83.3-86.3%), respectively.

Conclusion

Thoracic endovascular aortic repair with f-SMSG is an alternative treatment option for TBAD involving the aortic arch in high-volume centers.

Double fenestrated physician-modified stent-grafts for total aortic arch repair in 50 patients

OBJECTIVE

Our aim was to evaluate the early- and medium-term outcomes of using double fenestrated physician-modified endovascular grafts (PMEGs) for total endovascular aortic arch repair.

METHODS

The present single-center retrospective analysis of prospectively collected data included 50 patients from January 2017 through October 2019, who had undergone thoracic endovascular aortic repair (TEVAR). The fenestrations were a proximal larger fenestration that incorporated the brachiocephalic trunk and left common carotid artery and a distal smaller fenestration for the left subclavian artery (LSA). Only the LSA fenestration was stented.

RESULTS

The median duration for stent graft modification was 26 ± 6 minutes. Of the 50 patients, 41 were men. The mean patient age was 68 ± 11.5 years. The indications for treatment included degenerative aortic arch aneurysm (n = 17), dissecting aortic arch aneurysm after type A dissection (n = 13), type B dissection (n = 13), aortic ulcer (n = 3), and other pathologies (n = 4). The technical success rate was 94% (47 of 50) overall, and 100% (28 of 28) after a technical modification incorporating a preloaded guide wire for the LSA fenestration (P < .05). The 30-day mortality was 2% (n = 1). Two patients (4%) had a minor stroke with full recovery. One patient (2%) had a type IB and two patients (4%) had a type II endoleak from the LSA. Four patients (8%) required reintervention: one because of a type IB endoleak and three because of access-related complications. All supra-aortic trunks were patent. During a mean follow-up of 16 ± 8.3 months, no conversions to open surgical repair were required and no aortic rupture, paraplegia, or retrograde dissection occurred.

CONCLUSIONS

Using double fenestrated PMEGs for TEVAR is both feasible and effective for total endovascular aortic arch repair, avoiding the need for anatomic and extra-anatomic surgical revascularization. The absence of brachiocephalic trunk stenting was not associated with endoleaks or treatment failure and resulted in a lower stroke risk than alternative strategies. The midterm results suggest that stenting of the brachiocephalic trunk and right common carotid artery might not be necessary for a large proportion of patients undergoing total endovascular aortic arch repair. The persistence of the seal and ongoing durability require assessment in studies with long-term follow-up data available.

Midterm Follow-up of Fenestrated and Scalloped Physician-Modified Endovascular Grafts for Zone 2 TEVAR

Purpose: To investigate the midterm outcomes of scalloped or fenestrated physician-modified endovascular grafts (PMEGs) for zone 2 thoracic endovascular aortic repairs (TEVAR). Materials and Methods: Between November 2013 and May 2019, 54 consecutive patients (mean age 63 years; 41 men) were treated with thoracic PMEGs modified with 7 scallops or 47 fenestrations for the left subclavian artery (LSA). Indications for aortic repair were acute complicated type B aortic dissection (17, 31%), degenerative aneurysm (13, 24%), acute traumatic rupture of the aortic isthmus (9, 16%), post chronic dissection aneurysmal evolution (8, 15%), penetrating aortic ulcer (3, 6%), intramural hematoma (2, 4%), and floating thrombus (2, 4%). Results: Technical success was 94%; 3 (6%) LSAs were unintentionally covered. An intraoperative type Ia endoleak was treated during the index procedure. One (2%) patient suffered spinal cord ischemia, with irreversible bilateral paraplegia. Three (6%) patients experience postoperative minor strokes with full neurological recovery. Four (7%) patients died in the perioperative period; 2 (2%) were due to aneurysm rupture. Mean follow-up was 26±16 months; 15 (28%) patients had at least 3 years of follow-up. Two (4%) type II endoleaks were identified and successfully treated (4% reintervention rate); no other endoleaks were identified. All the LSAs remained clinically and radiologically patent. There were no conversions to open repair, ruptures, retrograde dissection, stent fracture, migrations, or other aortic complications. Conclusion: Scalloped or single-fenestrated PMEGs for the LSA appear to be durable and safe in the midterm. Combined with low periprocedural morbidity and mortality, these results suggest that this approach can be considered as an off-label alternative to extend proximal seal to zone 2 for TEVAR. Further studies with a larger number of patients and long-term outcomes are needed to fully validate this approach.