Thoracic Endovascular Repair for Aortic Arch Pathologies with Surgeon Modified Fenestrated Stent Grafts: A Multicentre Retrospective Study

Outcomes of Zone 1 Thoracic Endovascular Aortic Repair With Fenestrated Surgeon-Modified Stent-Graft for Aortic Arch Pathologies

OBJECTIVES

This study evaluated the feasibility and safety of zone 1 thoracic endovascular aortic repair (TEVAR) with fenestrated surgeon-modified stent-graft (SMSG) for aortic arch pathologies.

METHODS

Between March 2016 and November 2020, 34 consecutive patients underwent zone 1 TEVAR with fenestrated SMSG for aortic arch pathologies. Outcomes included technical success, perioperative, and follow-up morbidity and mortality.

RESULTS

During the study period, 34 patients were treated with zone 1 TEVAR with fenestrated SMSG. Twenty-four (70.6%) patients presented with type B aortic dissections, 9 (26.5%) patients presented with aneurysms (7 located on the lesser curvature side of aortic arch), 1 (2.9%) patient presented with type Ia endoleak after previous TEVAR owing to traumatic aortic dissection. The proximal landing zone for all patients were in zone 1, and all supra-aortic trunks were reconstructed, except for one left subclavian artery. Technical success was achieved in all cases. The 30-day estimated survival (±SE) was 90.9% ± 5.0% [95% confidence interval (CI): 77.0%-97.0%]. The 30-day estimated freedom from reintervention (±SE) was 87.9% ± 5.7% (95% CI: 73.4%-95.3%). At a median follow-up of 48 months (range, 12-68 months), 2 patients died, including 1 aortic-related death and 1 non-aortic-related death. One patient had reintervention 13 months after the operation owing to type Ia endoleak. All supra-aortic trunks were patent. The estimated survival (±SE) during follow-up was 85.1% ± 6.2% (95% CI: 69.9%-93.6%). One (2.7%) patient had stroke. The estimated freedom from reintervention (±SE) during follow-up was 84.2% ± 6.5% (95% CI: 69.9%-93.5%).

CONCLUSIONS

Zone 1 TEVAR with fenestrated SMSG is an alternate option for treatment of aortic arch pathologies in experienced centers.

Expert opinion: How to treat type IA endoleakage

Type Ia endoleaks due to failed sealing or loss of landing zone and the adequate management thereof remain crucial for long-term therapeutic success following TEVAR. This expert opinion summarizes our institutional experience with endovascular, open surgical, and hybrid techniques in the context of recent scientific publications. The rapid turnover of technical innovations, but most importantly outcome data demonstrate the requirement for increasingly patient-tailored treatment strategies and the need for specialized aortic centers. The latter should offer a complete range of treatment options, an adequate perioperative management, and the highest level of multidisciplinary expertise.

Meta-analysis and meta-regression of the total endovascular aortic repair in aortic arch

Background: The total endovascular repair of the aortic arch is becoming more and more an acceptable alternative to the open repair in selected patients. The aim of the present study is to perform a meta-analysis of the available data on the outcomes of the various endovascular techniques used to treat the pathologies in this challenging anatomical area. Patients and methods: An extensive electronic search in PubMed/MEDLINE, Science Direct Databases, and the Cochrane Library was conducted. All papers published up to January 2022 on the endovascular techniques in the aortic arch (chimney-thoracic endovascular aortic repair (ChTEVAR), fenestrated/branched grafts as custom made devices (CMD) and surgeon modified TEVAR (SM TEVAR) providing information about at least one of the essential outcomes defined in the inclusion criteria. Results: Out of the 5078 studies found through the search in the databases and registers, 26 studies with a total number of patients of 2327 with 3497 target vessels were included in the analysis. The studies reported a high technical success rate with an estimated proportion of 95.8% (95% CI, 93-97.6%). Moreover, the pooled estimation of the early type Ia/III endoleak was 8.1% (95% CI, 5.4-12.1%). The pooled mortality was 4.6% (95 CI, 3.2-6.6%) with a significant heterogeneity and the stroke had an estimated proportion (major and minor combined) of 4.8% (95% CI, 3.5-6.6%). A meta-regression analysis showed no significant variation between the groups in mortality (P=.324) showed however a significant difference between the therapeutic methods regarding stroke P<.001 (lower rate in ChTEVAR and SM vs. CMD). Conclusions: The present meta-analysis could demonstrate good short- and long-term outcomes of the multiple total endovascular repair methods used in the aortic arch.

Management of an Isolated Left Vertebral Artery on the Arch During Zone 2 Landing Thoracic Endovascular Aortic Repair: A Multicentre Retrospective Study

OBJECTIVE

To compare the early and midterm outcomes of three different strategies for an isolated left vertebral artery on the arch (LVoA) revascularisation during thoracic endovascular aortic repair (TEVAR) with a proximal zone 2 landing.

METHODS

Between January 2016 and December 2021, 67 patients with LVoA and aortic arch pathologies who underwent zone 2 landing TEVAR at four medical centres were enrolled. These patients were divided into three groups for comparison: the novel chimney (group A, n = 28) with the right brachial-left brachial through and through (RLT) procedure; in vitro fenestration (group B, n = 24); and transposition (group C, n = 15). The flow direction and velocity of the LVoA was examined by Doppler ultrasound in the pre-, intra-, and post-operative periods. Primary outcomes were all cause mortality and new neurological symptoms.

RESULTS

No deaths or new neurological symptoms occurred within 30 days. Early type Ia endoleak rates were 18% (n = 5), 17% (n = 4), and 0% in groups A, B, and C, respectively (p = .22). All patients had antegrade flow of the LVoA. The mean ± standard deviation duration of follow up was 63.6 ± 4.0 months. No deaths were observed during follow up. The rates of new neurological symptoms were 0%, 8%, and 33% in groups A, B, and C, respectively. The rates of midterm type Ia endoleak were 7%, 12%, and 0% in groups A, B, and C, respectively (p = .35). Bidirectional flow rates in the LVoA were 0%, 21%, and 27% in groups A, B, and C, respectively (p = .021). Two (8%) and three (20%) patients in groups B and C underwent a secondary procedure because of mild dizziness, but this was not necessary in group A (p = .058).

CONCLUSION

The novel chimney technique of the RLT procedure may be feasible for patients with a LVoA requiring zone 2 anchoring. Accurate determination of the safety and feasibility of this novel technique requires larger sample sizes and longer follow up.

Physician-modified fenestration or in situ fenestration for preservation of isolated left vertebral artery in thoracic endovascular aortic repair

Objective

To present our experience of preserving the isolated left vertebral artery (ILVA) with physician-modified fenestration (PM-F) or in situ fenestration (ISF) during thoracic endovascular aortic repair (TEVAR) for aortic pathologies involving aortic arch.

Methods

This is a single-center, retrospective, observational cohort study. Between June 2016 and December 2021, 9 patients (8 men; median age 60.0 years old) underwent TEVAR with ILVA reconstruction (PM-F, n = 6; ISF, n = 3) were identified and analyzed.

Results

The technical success rate was 100%. No early (<30 days) death occurred. No aortic rupture, major stroke or spinal cord injury was observed. The median follow up was 38.0 (rang: 1.0-66.0) months. One death occurred at 56 months, while the reason cannot be identified. No aortic rupture, major stroke or spinal cord injury was observed during follow up. No patient required reintervention. Out of the 22 successfully revascularized target vessels, 2 ILVAs were found occluded in 2 patients at 6 months and 7 months, respectively. However, these two patients were asymptomatic.

Conclusions

Our initial experience reveals that PM-F or ISF for ILVA preservation was feasible, safe, and effective during TEVAR for complex thoracic aortic pathologies. However, the patency of preserved ILVA should be improved.

Risk factors for target vessel endoleaks after physician-modified fenestrated or branched endovascular aortic arch repair: A retrospective study

Objective

Fenestrated or branched endovascular aortic arch repair (fb-arch repair) is an effective option for treating complex aortic arch lesions, including thoracic aortic aneurysms and aortic dissections. However, the relatively high rate of re-intervention due to target vessel (TV)-related endoleaks have raised concerns. This study aimed to determine risk factors for TV-related endoleaks after fb-arch repair.

Methods

This was a retrospective analysis of all patients undergoing fb-arch repair between 2017 and 2021in nanjing drum tower hospital of China. All the patients underwent computed tomography angiography (CTA) before surgery; at discharge; and at 3 months, 6 months, and yearly post-discharge. All procedures are performed with physician modified grafts. Two experienced vascular surgeons used CTA and vascular angiography data to assess endoleaks. The study endpoints were mortality, aneurysm rupture, and emergence of and re-intervention for TV-related endoleaks.

Results

During the follow-up period, 218 patients underwent fb-arch repair. There were seven perioperative deaths and four deaths during follow-up (two myocardial infarctions and two malignancies). There were nine additional patients who were excluded from the study (two strokes, three with abnormal aortic arch anatomy, and four with insufficient clinical data). Among the 198 patients considered (mean age, 59 ± 13.3 years; 85% male), 309 branch arteries were revascularized. A total of 35 TV-related endoleaks were identified in 28 patients during a mean follow-up of 23 ± 14 months (median 23, IQR 26.3): six type Ic, 4 type IIIb, and 20 type IIIc endoleaks. Patients in the endoleak group had greater aortic arch segment diameters (43.1 ± 5.1 vs. 40.3 ± 4.7; P = 0.004) and a greater number of TVs revascularized (2.0 ± 0.8 vs. 1.5 ± 0.8; P = 0.004) than those in the non-endoleak group. However, the morphological classification of the aortic arch did not seem to affect the occurrence of TV endoleaks (13%, 14%, and 15% for type І, II, and III aortic arches, respectively; P = 0.957). Pre-sewing branch stents in the fenestration position reduced the risk of TV endoleaks (5% vs. 14%; P = 0.037). Additionally, in TVs affected by aortic aneurysm or dissection, the risk of endoleaks increased after reconstruction (17% vs. 8%; P = 0.018). The incidence of secondary TV-related endoleaks after fb-arch repair was 14.1%.

Conclusion

The data from this study showed that the incidence of secondary target vessel related endoleaks after fb-arch repair is approximately 14.1%. Additionally, patients with a larger aortic arch diameter or more revascularized arteries during surgery were at increased risk TV-related endoleaks. The target vessels originating from the false lumen or aneurysm sac are more prone to endoleaks after reconstruction. Finally, prefabricated branch stents reduced risk of TV-related endoleaks.

Covered stent treatment for arterial complications after pancreatic surgery: risk assessment for recurrence and peri-stent implantation management

OBJECTIVES

To explore the risk factors for recurrence of arterial complications after pancreatectomy during the period of covered stent implantation and to provide some opinions on peri-stent implantation management.

METHODS

Data on patients implanted with covered stents due to arterial complications after pancreatectomy between January 2017 and December 2021 were analyzed retrospectively. Technical success, clinical success, recurrence, and survival were evaluated to elucidate the practicability of covered stents. Wilson score, Random Forest, logistic regression, and Pearson's chi-square test with bootstrap aggregation were performed for determining the perioperative risk factors for recurrence.

RESULTS

Among all fifty-five patients, success stent implantation (technical success) was achieved 100%. Patients who were hemodynamically stabilized without further treatment for artery complications in situ (clinical success) accounted for 89.1%. Based on statistical analysis, pre-stent implantation pancreatic fistula was identified as a robust recurrence-related risk factor for preoperative assessment (p = 0.02, OR = 4.5, 95% CI [1.2, 16.9]; p_bootstrap = 0.02). Post-stent implantation pancreatic fistula (p = 0.01, OR 4.5, 95% CI [1.4, 14.6]; p_bootstrap < 0.05) and SMA branches or GDA stumps (p = 0.02, OR 3.4, 95% CI [1.1, 10.3]) were relevant to recurrence. The survival rate during hospitalization was 87.3%. All survivors were free from recurrence during the subsequent follow-up. Vasospasm and stent occlusion were observed as short-term and long-term complications, respectively.

CONCLUSION

A covered stent implantation is a feasible and effective treatment option for post-pancreatectomy arterial complications. Rigorous management of pancreatic fistula, timely detection of problems, sensible strategies during stent implantation, and reasonable anticoagulation therapy are necessary for a better prognosis.

KEY POINTS

• A covered stent is feasible for various artery-related complications after pancreatectomy and has an ideal therapeutic effect. • Pancreatic fistula during the perioperative period of the covered stent is an independent risk factor for recurrent arterial complications and SMA branches or GDA stumps are prone to be recurrent offending arteries. • Rigorous management of pancreatic fistula, timely detection of problems, sensible strategies during stent implantation, and reasonable anticoagulation therapy are necessary for a better prognosis.

Systematic Review on Customized and Non-customized Device Techniques for the Endovascular Repair of the Aortic Arch

PURPOSE

Open repair remains the standard of care for aortic arch pathologies. However, endovascular management became an attractive alternative for high-risk patients. This study aimed to assess the outcomes of the available endovascular techniques for aortic arch pathology management.

MATERIALS AND METHODS

A search of the English literature (2000-2022) using PubMed, EMBASE, via Ovid, and CENTRAL databases (February 1, 2022) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies reporting on patients with aortic arch pathologies managed with custom-made devices ([CMDs] fenestrated or branched thoracic endovascular aortic repair [F/BTEVAR]) and non-CMDs (parallel graft or surgeon-modified FTEVAR) were eligible. Studies reporting on hybrid or open repair were excluded. Studies' quality was assessed using the Newcastle-Ottawa Scale. Primary outcomes were technical success, 30 day mortality, and cerebrovascular events (CVEs). Secondary outcomes were re-intervention and mortality during follow-up.

RESULTS

Thirty studies (2135 patients) were included. Treatment indications were mainly dissections (652 cases [48.0%, 652/1358]; 90 type A, 506 type B; 364 acute, 163 chronic) and aneurysms (46.9%, 582/1239). Five studies (211 patients) reported on FTEVAR and 10 (388 patients) on BTEVAR. For FTEVAR, technical success rate was 98.3%. Thirty-day mortality was 3.8% and CVE rate was 12.3%. Ten deaths (9.7%) and 19 re-interventions (9%) were recorded during follow-up (24 months). Regarding BTEVAR, technical success rate was 98.7%, and 30 day mortality and CVE rates were 5.4% and 11.0%, respectively. During follow-up (27 months), 64 deaths (18.7%) and 33 re-interventions (9.6%) were recorded. Parallel graft technique was reported in 11 studies (901 patients). Technical success rate was 76.4%. Thirty-day mortality was 3.9% and 32 (4.3%) CVEs were recorded. Thirty-five deaths (4.4%) and 43 re-interventions (5.5%) were reported during follow-up (27 months). Surgeon-modified FTEVAR was described in 5 studies (635 patients). Technical success rate was 91.6%. At 30 days, 15 deaths (2.3%) and 22 CVEs (3.5%) were recorded. During follow-up (19 months), 26 deaths (4.2%) and 21 re-interventions (3.6%) were detected.

CONCLUSIONS

Endovascular arch repair presented a variable technical success; >95% for F/BTEVAR; ≤90% for non-CMDs. Acceptable 30 day mortality rates were reported. Cerebrovascular event rates ranged up to 10%. These findings, adjacent to the estimated midterm mortality and re-interventions, set the need for further improvement.

CLINICAL IMPACT

Endovascular arch repair gains popularity as a valuable alternative, especially in patients considered unfit for open repair. According the available literature, any endovascular technique, including custom-made or off-the-shelf solutions, may be applied successfully, with acceptable early mortality. However, the perio-operative cerebrovascular event rate is still an issue, indicating the need for further advancements.

Preclinical Evaluation of a Non-Customized Modular Inner Branched Stent Graft for Total Endovascular Aortic Arch Repair in a Porcine Model

OBJECTIVES

The aim of this study was to evaluate the feasibility and safety of a non-customized modular inner branched stent graft for total endovascular aortic arch repair in a porcine model.

METHODS

The modular inner branched stent graft system with a split main body design included 1 proximal main component, 1 distal main component, and 1 branched covered stent. The gutter in the proximal main component was sealed with sutured membrane. Fatigue testing was performed to evaluate the durability of the stent graft. Fifteen pigs were used in this study. In each pig, a stent graft was delivered and deployed to the aortic arch through the femoral arterial access and right carotid arterial access. Angiography and computed tomography angiography were used to evaluate the morphological features before euthanasia. After euthanasia, the implanted device, surrounding tissue, and major organs were harvested for gross and histological examination.

RESULTS

There were no collapses and no stent graft fractures detected after fatigue testing. The technical success rate was 14/15, and the incidence of major adverse cardiovascular events was 2/15. Angiography performed at the end of follow-up revealed no endoleaks and no device migration. Histological examination demonstrated excellent biocompatibility of the stent graft.

CONCLUSIONS

The non-customized modular inner branched stent graft system is safe and feasible for the endovascular reconstruction of the aortic arch in a porcine model.