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Nana P, Spanos K, Panuccio G, Rohlffs F, Detter C, von Kodolitsch Y, Torrealba JI, Kölbel T. Branched and fenestrated endovascular aortic arch repair in patients with native proximal aortic landing zone. J Vasc Surg 2024; 80:621-629.e3. [PMID: 38580160 DOI: 10.1016/j.jvs.2024.03.444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/15/2024] [Accepted: 03/28/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Fenestrated and branched thoracic endovascular repair (f/bTEVAR) have been successfully applied in patients with diverse aortic arch pathologies. The aim of this study is to present the early and mid-term outcomes of patients with native proximal aortic landing (NPAL) managed with f/bTEVAR. METHODS A single-center retrospective analysis of patients with NPAL, managed with f/bTEVAR, between September 1, 2011, and June 30, 2022, was conducted. All patients were treated with custom-made devices (Cook Medical) with landing within Ishimaru zones 0 to 2. Primary outcomes were technical success, mortality, stroke, and retrograde type A dissection at 30 days. Follow-up outcomes were considered secondary. RESULTS A total of 126 patients were included (69.8% males; mean age, 70.8 ± 4.2 years; 18.3% urgent). The main indications (60.4%) for repair were aortic arch (29.4%) and thoracoabdominal aortic aneurysms (31.0%). Seventy-two patients (57.1%) were managed with fTEVAR. Proximal landing in zone 0 and 1 was chosen in 97.6%. Technical success was 94.4%, and 30-day mortality was 11.9%. Strokes were diagnosed in 13.5% of patients and major strokes were identified in 7.9% cases. Retrograde type A dissection rate was 3.9%. The multivariate analysis confirmed landing in Ishimaru zone 0 as an independently related factor for stroke (P = .005), whereas stroke (P < .001), pericardial effusion (P < .001), and acute kidney injury (P < .001) were independently related to 30-day mortality. Mean follow-up was 17.5 ± 9.3 months. The estimated survival rate and the freedom from reintervention rate were 72.6% (standard error, 4.4%) and 46.4% (standard error, 6.0%) at 24-month follow-up, respectively. CONCLUSIONS Stroke rate after endovascular arch repair was alarming among patients with NPAL. Proximal landing to zone 0 was related to higher risk of stroke. Reinterventions were common within the 24-month follow-up.
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Affiliation(s)
- Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany.
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Christian Detter
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - José I Torrealba
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
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Cho T, Uchida K, Yasuda S, Izubuchi R, Kaneko S, Minami T, Saito A. What is the Optimal Proximal Landing Zone of the Stent Graft in Treatment of Aortic Type B Dissection? Cardiovasc Intervent Radiol 2024; 47:1037-1044. [PMID: 38944660 DOI: 10.1007/s00270-024-03791-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 06/14/2024] [Indexed: 07/01/2024]
Abstract
PURPOSE Retrograde type A aortic dissection (RTAD) represents a serious complication of endovascular treatment for type B aortic dissection (TBAD). To avoid RTAD, it is recommended to land the proximal end of the stent graft in a non-dissected aortic segment. In this study, we investigated whether landing in the dissection area increased the number of events at the proximal site. METHODS We conducted a retrospective review of endovascular treatments for TBAD at a single institution between 2009 and 2022. Patients were divided into two groups: group A, with a proximal landing zone entirely within the dissected area, and group B, with the proximal extent of the seal zone in the non-dissected area. We evaluated the occurrence of proximal events, including RTAD, and examined long-term outcomes to assess the validity of landing in the dissection area. RESULTS The study included eighty-nine patients who underwent endovascular treatment for TBAD. New intimal tears in the proximal landing site occurred in 3 cases (3.4%), with 1 case (2%) in group A and 2 cases (5.1%) in group B, showing no significant difference. Among the three cases, one (1.1%) in group B with zone 2 landing resulted in RTAD. At 60 months, the overall survival was 85%, and freedom from aorta-related mortality was 88%, with no significant difference between the groups. CONCLUSION Even if the proximal landing is in a dissected area, a treatment strategy performed in zone 3 without proximal landing in zone 2, seeking a non-dissected area, can still provide sufficient therapeutic effects. Level of Evidence 3 Retrospective single-center cohort analysis.
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Affiliation(s)
- Tomoki Cho
- Cardiovascular Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan.
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Shota Yasuda
- Cardiovascular Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Ryo Izubuchi
- Cardiovascular Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Shotaro Kaneko
- Cardiovascular Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Tomoyuki Minami
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Aya Saito
- Department of Surgery, Yokohama City University, Yokohama, Japan
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Leone N, Bieliauskas G, Ohrlander T, Resch T. Total Percutaneous Endovascular Aortic Arch Repair With a Triple Inner-Branch Device (the Innominate Approach). J Endovasc Ther 2024; 31:541-547. [PMID: 36382877 DOI: 10.1177/15266028221134892] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE To describe a completely percutaneous approach for endovascular arch repair (arch-percutaneous endovascular aortic repair [PEVAR]) with a triple inner-branch device: the "Innominate Approach." TECHNIQUE After right axillary and single common femoral arteries percutaneous access, the arch stent-graft is introduced and deployed transfemorally using fusion overlay. The brachiocephalic artery (BCA) and the corresponding inner branch are cannulated from the axillary access. Through this access, a steerable-sheath guides antegrade cannulation of the left common carotid artery (LCCA) through its inner branch. Optionally, a wire preloaded through the left subclavian artery (LSA) and the LCCA branch, is snared from the BCA access providing LCCA through and through access. A 10 Fr sheath is then positioned from the BCA branch in the LCCA branch and a second, trans-axillary wire through the same sheath is used to catheterize the LCCA. The LCCA is then stented antegradely (regardless of approach). Finally, the BCA and LSA are bridged to complete the procedure. An additional novelty described is the use of VBX (W. L. Gore) as a bridging stent for the BCA. CONCLUSION Arch-PEVAR is feasible with the use of adjuncts that are well-known for physicians performing complex endovascular repair. The "Innominate Approach" avoids access and exposure of the carotid arteries. CLINICAL IMPACT We aim to describe the feasibility of the axillary artery as the main route to perform the brachiocephalic artery (BCA) and the left common carotid artery bridging stenting in case of arch endovascular repair (arch-EVAR) with a triple Inner-Branch Device. According to the present "Innominate Approach", percutaneous arch-EVAR is feasible using either a steerable sheath or a preloaded through-&-through wire. The Innominate approach, including a VBX bridging stent for the BCA, avoids carotid access and exposure, reduces the number of vascular accesses, and allows the downsizing of the trans-axillary devices.
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Affiliation(s)
- Nicola Leone
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gintautas Bieliauskas
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tomas Ohrlander
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Timothy Resch
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
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Dabravolskaite V, Makaloski V, Hakovirta H, Kotelis D, Schoenhoff FS, Lescan M. Evaluation of custom-made Relay® stent-grafts for aortic arch landing zones 0 and I: experience from two high-volume aortic centres. Eur J Cardiothorac Surg 2024; 66:ezae241. [PMID: 38991832 DOI: 10.1093/ejcts/ezae241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/28/2024] [Accepted: 07/10/2024] [Indexed: 07/13/2024] Open
Abstract
OBJECTIVES To report experience with a Relay® stent-graft custom-made platform in treating different aortic arch pathology in 2 high-volume aortic centres. METHODS A retrospective analysis of all patients treated between July 2016 and July 2023 with custom-made Relay® stent-graft (custom-made device). Underlying aortic arch pathology was an aneurysm, penetrating aortic ulcer, and dissection. Three custom-made device designs were used: proximal scallop, fenestrations, and inner branches. The endpoints were technical success, perioperative stroke, death, and reintervention rate. RESULTS Thirty-five patients (89% males) with a mean age of 70 ± 11 years were treated.Indication for treatment was penetrating aortic ulcer in 14 patients (40%), aneurysm in 11 patients (31%) and aortic dissection in 10 patients (29%). The technical success rate was 100%. Twenty-eight patients (80%) had proximal sealing in zone 0, and 7 (20%) had proximal sealing in zone 1. Nine patients (25.6%) had proximal scallops, 9 (25.6%) had 1 big fenestration and 17 (48.8%) had a branched device; 1 with single branch, 15 with double branches and 1 with triple branches. Thirty patients (86%) had previous or simultaneous left subclavian artery revascularization. No patient died during 30 days. Two patients (5.7%) had stroke postoperatively; both recovered without disabling deficits. The mean follow-up was 35 ± 26 months. Six patients (17.1%) died during follow-up. One patient required reinforcement of the bridging stent in the left common carotid artery and one additional vascular plugging of the left subclavian artery. Three patients received distal extension. CONCLUSIONS The Relay® stent-graft custom-made platform showed a good performance in our study with a high technical success rate, low perioperative stroke and mortality, and low reintervention rates during the follow-up.
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Affiliation(s)
- Vaiva Dabravolskaite
- Department of Vascular Surgery, University Hospital of Bern, Bern, Switzerland
- Department of Vascular Surgery, University Hospital of Turku, Turku, Finland
- Department of Vascular Surgery, Satakunnan keskussairaala, Pori, Finland
| | - Vladimir Makaloski
- Department of Vascular Surgery, University Hospital of Bern, Bern, Switzerland
| | - Harri Hakovirta
- Department of Vascular Surgery, University Hospital of Turku, Turku, Finland
- Department of Vascular Surgery, Satakunnan keskussairaala, Pori, Finland
| | - Drosos Kotelis
- Department of Vascular Surgery, University Hospital of Bern, Bern, Switzerland
| | | | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Center, Tübingen, Germany
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Ghorayeb G, Palmier M, Le Guillou V, Doguet F, Plissonnier D. Deep Circulatory Arrest and Left Thoracotomy Approach Allow Open Repair of Chronic IIIb Dissection Associated to a Large Aortic Arch: A Case Series. Ann Vasc Surg 2024; 108:92-97. [PMID: 38944192 DOI: 10.1016/j.avsg.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/26/2024] [Accepted: 04/27/2024] [Indexed: 07/01/2024]
Abstract
Thoracic aortic aneurysms evolving within a type IIIb chronic aortic dissection are mostly treated with the deployment of an endograft. However, several cases of dissecting aneurysms are associated with a significant dilatation of the aortic arch. These cases are usually managed in 2 steps: arch reconstruction or supra-aortic trunk debranching at first and a secondary graft deployment for the descending thoracic aorta. We present through this case series an alternative approach for this severe condition which consists in the replacement of the thoracic aorta from its hemi-arch to the distal thoracic or visceral aorta using a left thoracotomy. We deliberately neglected the remaining dissecting aorta if its diameter was below 45 mm, hypothesizing its nonevolution after repair. From 2012 to 2021, 9 patients have been treated for a thoracic aneurysm evolving after a IIIb chronic aortic dissection using a left thoracotomy and a 19°C circulatory arrest. Immediate postoperative results show no mortality or neurological disorders, and the 7 years follow-up for all of these 9 cases enlightened the absence of aneurysmal evolution especially for the distal anastomosis and the remaining dissected aorta. This work suggests that this direct approach strategy can definitively treat a thoracic dissecting aneurysm unsuitable for a simple endovascular treatment.
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Affiliation(s)
- Georges Ghorayeb
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Mickael Palmier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | | | - Fabien Doguet
- Institut chirurgie cardiaque, Hôpital Jacques Cartier, Massy, France
| | - Didier Plissonnier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France.
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Becker D, Tsilimparis N, Ali A, Stana J, Mihály Z, Pichlmaier M, Peterss S, Prendes CF. Sex Related Anatomical Differences in Patients With Aortic Arch Pathology and Their Impact on the Feasibility of Double and Triple Branched Endografts. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00485-4. [PMID: 38879148 DOI: 10.1016/j.ejvs.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 05/20/2024] [Accepted: 06/07/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVE To evaluate sex based differences in ascending aorta and arch anatomy in patients with underlying proximal aortic disease and to evaluate their impact on feasibility for total endovascular repair with custom made, branched arch devices. METHODS This was a retrospective cross sectional review of all patients undergoing open and or total endovascular arch repair due to distal ascending aorta and or aortic arch pathologies in a single high volume aortic centre between 2012 and 2022. Anatomical ascending aorta and aortic arch parameters were analysed on a flow centreline on a dedicated 3D workstation. Sex related differences of the ascending aorta, aortic arch, and supra-aortic vessels were evaluated. Subsequently, four endovascular devices were assessed for feasibility: double and triple branched devices both for the Zenith (Cook Medical) and Relay (Terumo Aortic) platforms, first in accordance with the instructions for use and then considering the possibility of adjunctive cervical debranching. The primary endpoints were sex specific differences in aortic anatomy, while secondary endpoints included sex based feasibility of branched endograft devices. RESULTS During the study period, 395 patients underwent total aortic arch repair, of whom 152 (51 female, 33.5%) had high quality computed tomography angiograms available and were included in the study. Female patients had a shorter proximal landing zone than males (22 mm vs. 47 mm; p < .001). Left subclavian artery dissection was more frequent in men (24.8% vs. 3.9%; p < .001). Other anatomical parameters showed a similar distribution between sexes. Female patients presented a lower feasibility for double branched devices (35.3% vs. 58.4%; p = .015) as well as a tendency for lower feasibility rates for triple branched devices (31.4% vs. 47.5%; p = .081). CONCLUSION Although most ascending aortic and arch parameters showed similar trends in both sexes, the availability of a suitable proximal landing zone was lower in female patients. Consequently, female patients had lower feasibility rates for double arch branched endografts and, to lesser extent, for triple arch branched endografts.
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Affiliation(s)
- Daniel Becker
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Nikolaos Tsilimparis
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Ahmed Ali
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Jan Stana
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Zsuzsanna Mihály
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Maximilian Pichlmaier
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Sven Peterss
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Carlota F Prendes
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany.
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Takayama H, Hohri Y, Brinster DR, Chen EP, El-Hamamsy I, Elmously A, Derose JJ, Hisamoto K, Lau C, Okita Y, Peterson MD, Spielvogel D, Youdelman BA, Pacini D. Open, endovascular or hybrid repair of aortic arch disease: narrative review of diverse strategies with diverse options. Eur J Cardiothorac Surg 2024; 65:ezae179. [PMID: 38724247 DOI: 10.1093/ejcts/ezae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 04/03/2024] [Accepted: 04/20/2024] [Indexed: 06/26/2024] Open
Abstract
OBJECTIVES The management of aortic arch disease is complex. Open surgical management continues to evolve, and the introduction of endovascular repair is revolutionizing aortic arch surgery. Although these innovative techniques have generated the opportunity for better outcomes in select patients, they have also introduced confusion and uncertainty regarding best practices. METHODS In New York, we developed a collaborative group, the New York Aortic Consortium, as a means of cross-linking knowledge and working together to better understand and treat aortic disease. In our meeting in May 2023, regional aortic experts and invited international experts discussed the contemporary management of aortic arch disease, differences in interpretation of the available literature and the integration of endovascular technology into disease management. We summarized the current state of aortic arch surgery in this review article. RESULTS Approaches to aortic arch repair have evolved substantially, whether it be methods to reduce cerebral ischaemia, improve haemostasis, simplify future operations or expand options for high-risk patients with endovascular approaches. However, the transverse aortic arch remains challenging to repair. Among our collaborative group of cardiac/aortic surgeons, we discovered a wide disparity in our practice patterns and our management strategies of patients with aortic arch disease. CONCLUSIONS It is important to build unique institutional expertise in the context of complex and evolving management of aortic arch disease with open surgery, endovascular repair and hybrid approaches, tailored to the risk profiles and anatomical specifics of individual patients.
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Affiliation(s)
- Hiroo Takayama
- Division of Cardiac, Vascular, & Thoracic Surgery, Columbia University, New York, NY, USA
| | - Yu Hohri
- Division of Cardiac, Vascular, & Thoracic Surgery, Columbia University, New York, NY, USA
| | - Derek R Brinster
- Department of Cardiothoracic Surgery, Lenox Hill Hospital, Northwell Health System, New York, NY, USA
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Adham Elmously
- Division of Cardiac, Vascular, & Thoracic Surgery, Columbia University, New York, NY, USA
- Department of Cardiovascular Surgery, Houston Methodist, Huston, TX, USA
| | - Joseph J Derose
- Department of Cardiothoracic and Vascular Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Kazuhiro Hisamoto
- Division of Cardiac Surgery, Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki General Hospital, Takatsuki, Japan
| | - Mark D Peterson
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Benjamin A Youdelman
- Division of Cardiothoracic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Davide Pacini
- Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
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Moqaddam M, Bacri C, Hireche K, Alric P, Canaud L. Short-term results of fenestrated physician-modified endografts for type1a endoleak after conventional thoracic endovascular aortic repair. JTCVS Tech 2024; 25:8-18. [PMID: 38899088 PMCID: PMC11184594 DOI: 10.1016/j.xjtc.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/14/2024] [Accepted: 03/04/2024] [Indexed: 06/21/2024] Open
Abstract
Objective This study aims to assess the feasibility and effectiveness of physician-modified fenestrated stent grafts (PMEGs) in treating type 1a endoleak after conventional thoracic endovascular aortic repair (TEVAR) in aortic arch pathologies. Methods Patients who developed a type 1a endoleak after conventional TEVAR were included in the study. They underwent treatment with fenestrated PMEGs, which involved single or double fenestration for the supra-aortic trunks. Results Twenty patients were treated with PMEGs between October 2018 and November 2023. Among them, 25% received single fenestrated PMEGs and 75% received double fenestrated PMEGs. The technical success rate was 100% for both types. Eighty percent of the PMEGs had a landing zone in zone 0, whereas 20% had a landing zone in zone 2. There were no in-hospital deaths. After 30 days, 1 patient died as the result of an aortic-related cause (retrograde dissection). The mean follow-up time was 16.5 months (range, 0-60 months). No major adverse events such as stroke or spinal ischemia were reported. No type 1 or type 3 endoleaks were observed, and one type 2 endoleaks required peripheral endovascular reintervention. Conclusions The treatment of type 1a endoleaks using fenestrated PMEGs after conventional TEVAR for aortic arch pathologies is a viable option. It is associated with acceptable rates of early and midterm major morbidity and mortality.
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Affiliation(s)
- Mathieu Moqaddam
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Christoph Bacri
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Kheira Hireche
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Ludovic Canaud
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
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DiBartolomeo AD, Kazerounim K, Fleischman F, Han SM. The Initial Results of Physician-Modified Fenestrated-Branched Endovascular Repairs of the Aortic Arch and Lessons Learned From the First 21 Cases. J Endovasc Ther 2024:15266028241255539. [PMID: 38778636 DOI: 10.1177/15266028241255539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Physician-modified fenestrated-branched endovascular aortic repair (PM-FBEVAR) for the aortic arch provides a minimally invasive treatment option for patients who are too high-risk for open repair. Improvements in technique are gained with ongoing experience with these complex repairs. This study aims to describe outcomes of arch PM-FBEVAR and technical lessons. MATERIALS AND METHODS A retrospective review of consecutive patients who underwent PM-FBEVAR with zone 0 proximal sealing at a single institution between January 2019 and July 2023 was performed. Cases completed using initial techniques (early technique) were compared with cases using the current techniques (current technique). Modification technique changed to include a self-orienting spine trigger wire and anatomically specific fenestrations or inner branches in the current group. The primary outcome was in-hospital mortality. Secondary outcomes included technical success and 30 day stroke. RESULTS A total of 21 patients underwent arch PM-FBEVAR, with 7 in the early group and 14 in the current group. Severe comorbidities were present in both groups including chronic obstructive pulmonary disease (COPD) (43% vs 36%), prior open ascending aortic repair (57% vs 43%), and prior stroke (86% vs 21%), respectively. Technical success was the same (86% vs 86%, p=1.0). Fluoroscopy time (56 vs 24 min, p=0.012) and in-hospital death (43% vs 0%, p=0.026) were significantly lower in the current group. A 30 day stroke rate (29% vs 7%, p=0.247) was non-significantly decreased in the current group. All-cause mortality was 100% vs 7% during median follow-up of 8 and 6 months (p<0.001). Three deaths in the early group were related to their aortic arch repair including aortic rupture during endograft advancement and 2 postoperative strokes. CONCLUSION There is a significant learning curve associated with aortic arch PM-FBEVAR. This study suggests that gained experience, use of the spine trigger wire technique, and precise creation of fenestrations or inner branches can lead to a shorter procedure time and lower complications. CLINICAL IMPACT Physician modified fenestrated branched endografting is feasible for the aortic arch. The high rate of stroke and perioperative mortality was reduced with incorporation of self-orienting spine trigger wire and anatomically specific inner branch creation.
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Affiliation(s)
- Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Kayvan Kazerounim
- Division of Cardiothoracic Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Fernando Fleischman
- Division of Cardiothoracic Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
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10
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Ferrer C, Tinelli G, D'Oria M. Endovascular reconstruction of the aortic arch with new-generation dual-branch and triple-branch endograft: design, applicability, indications, outcomes, and future directions. Expert Rev Med Devices 2024:1-9. [PMID: 38557199 DOI: 10.1080/17434440.2024.2337920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/28/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Repair of aortic arch pathologies such as degenerative aneurysms and dissections still represents a significant challenge for vascular and cardiac surgeons. We focused on the design, evolution, implementation, and prospects of endovascular dual branch technology for treatment of pathologies in the aortic arch. AREAS COVERED The literature search was conducted in a non-systematic fashion through the PubMed and Scopus databases; articles deemed relevant to the scope of the work and fully published in English language from January 12,000 until December 2023 were considered for inclusion. Two companies so far have developed and launched in market a dedicated arch dual branch platform: Terumo Aortic and Cook Medical. EXPERT OPINION A common limitation to the available technology is represented by the fact that urgent cases (i.e. large or rapidly growing aneurysms, symptomatic patients) cannot be treated because the customization process generally takes between 6 and 8 weeks, and there is an inherent risk for aorta-related adverse events to happen during the waiting time. While the future holds much promise, several technical hurdles still exist and further developments (in device design, operators' skills, patients' selection, and outcomes assessment) are needed to establish the safety and effectiveness of treatment particularly over the long-run.
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Affiliation(s)
- Ciro Ferrer
- Vascular and Endovascular Surgery Unit, San Giovanni - Addolorata Hospital, Roma, Italy
| | - Giovanni Tinelli
- Cardio-Thoracic-Vascular Department, Università Cattolica del Sacro Cuore, Rome, Italy
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
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Okamoto T, Yokoi Y, Sato N, Suzuki S, Enomoto T, Onishi R, Nakamura N, Okubo Y, Nagasawa A, Mishima T, Shiraishi S, Tsuchida M. Outcomes of thoracic endovascular aortic repair using fenestrated stent grafts in patients with thoracic aortic distal arch aneurysms. Eur J Cardiothorac Surg 2024; 65:ezae062. [PMID: 38439540 DOI: 10.1093/ejcts/ezae062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/28/2023] [Accepted: 02/06/2024] [Indexed: 03/06/2024] Open
Abstract
OBJECTIVES Thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is challenging because of anatomical restrictions and the presence of cervical branches. Revascularization of the cervical branch is required when conventional commercial stent grafts are used. TEVAR using fenestrated stent grafts (FSG) often does not require additional procedures to revascularize cervical branches. This study aimed to evaluate the features and initial and midterm outcomes of TEVAR using fenestrated stent grafts. METHODS From April 2007 to December 2016, 101 consecutive patients underwent TEVAR using fenestrated stent grafts for distal aortic arch aneurysms at a single centre. Technical success, complications, freedom from aneurysm-related death, secondary intervention and aneurysm progression were retrospectively investigated. RESULTS All the patients underwent TEVAR using fenestrated stent grafts. The 30-day mortality rate was zero. Cerebral infarction, access route problems and spinal cord injury occurred in 4, 3 and 2 patients, respectively. Each type of endoleak was observed in 38 of the 101 patients during the course of the study; 20/38 patients had minor type 1 endoleaks at the time of discharge. The endoleak disappeared in 2 patients and showed no significant change in 8 patients; however, the aneurysm expanded over time in 10 patients. Additional treatment was performed in 8 of the 10 patients with type 1 endoleaks and dilatation of the aneurysm. The rate of freedom from aneurysm-related death during the observation period was 98%. CONCLUSIONS TEVAR with FSG is a simple procedure, with few complications. Additional treatment has been observed to reduce aneurysm-related deaths, even in patients with endoleaks and enlarged aneurysms. Based on this study, the outcomes of endovascular repair of aortic arch aneurysms using a fenestrated stent graft seem acceptable.
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Affiliation(s)
- Takeshi Okamoto
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yoshihiko Yokoi
- Division of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Noriaki Sato
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Shuhei Suzuki
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takashi Enomoto
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Ryo Onishi
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Norihito Nakamura
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yuka Okubo
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Ayako Nagasawa
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takehito Mishima
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Shuichi Shiraishi
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Masanori Tsuchida
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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12
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Vervoort D, An KR, Deng MX, Elbatarny M, Fremes SE, Ouzounian M, Tarola C. The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch. Can J Cardiol 2024; 40:478-495. [PMID: 38052303 DOI: 10.1016/j.cjca.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
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.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mimi X Deng
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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13
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Canaud L, Chassin-Trubert L, Abouliatim I, Hireche K, Bacri C, Alric P, Gandet T. Total Arch Thoracic Endovascular Aortic Repair Using Double Fenestrated Physician-Modified Stent-Grafts: 100 Patients. J Endovasc Ther 2024; 31:89-97. [PMID: 35927926 DOI: 10.1177/15266028221116747] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim was to evaluate early and medium-term outcomes of double fenestrated physician-modified endovascular grafts for total endovascular aortic arch repair. METHODS This single-center retrospective analysis of prospectively-collected data included 100 patients, from January 2017 to December 2021, undergoing thoracic endovascular aortic repair (TEVAR) for zone 0. The fenestrations were a proximal larger fenestration that incorporated the brach2iocephalic 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 23±6 minutes. Of the 100 patients, 70 were men. The mean patient age was 70±10.5 years. Indications for treatment included degenerative aortic arch aneurysm (n=32), dissecting aortic arch aneurysm after type A dissections (n=23) and (n=19) after type B dissections, acute complicated type B dissection (n=16), and other pathologies (n=10). Technical success rate was 97%. The 30 day mortality was 2% (n=2). Four patients (4%) had minor stroke with full recovery. One patient (1%) had a type IA endoleak, 1 patient (1%) had a type IB endoleak, and 2 patients (2%) have a type II endoleak from the LSA. Eight patients (8%) required reintervention: 1 type IA endoleak, 1 type IB endoleak, 1 retrograde type A dissection, and 5 because of access-related complications. During a mean follow-up of 24±7.2 months, there were no aortic rupture, paraplegia, and all supra-aortic trunks were patent. CONCLUSIONS Double homemade fenestrated TEVAR is both feasible and effective for total endovascular aortic arch repair avoiding the need for anatomical and extra-anatomical surgical revascularization. The long-term durability will need to be assessed in studies with long-term follow-up. CLINICAL IMPACT Double homemade fenestrated TEVAR is effective for total endovascular aortic arch repair avoiding the need for anatomical and extra-anatomical surgical revascularization. The standout feature of this double fenestrated device is its simple handling during operation with the proximal fenestrations being directed to the orifices of the BT and LCCA automatically when the LSA fenestration is catheterized and secured by covered stent placement. The deployment algorithm actively steers the operator away from superfluous manipulations of the device within the arch and avoids guidewire manipulation in carotid arteries. The long-term durability will need to be assessed in studies with long-term follow-up.
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Affiliation(s)
- Ludovic Canaud
- Service de Chirurgie Vasculaire et Thoracique, Hôpital Arnaud de Villeneuve, Montpellier, France
| | - Lucien Chassin-Trubert
- Service de Chirurgie Vasculaire et Thoracique, Hôpital Arnaud de Villeneuve, Montpellier, France
- Servicio de Cirugía Vascular y Endovascular, Clínica Universidad de los Andes, Las Condes, Chile
| | | | - Kheira Hireche
- Service de Chirurgie Vasculaire et Thoracique, Hôpital Arnaud de Villeneuve, Montpellier, France
| | - Christophe Bacri
- Service de Chirurgie Vasculaire et Thoracique, Hôpital Arnaud de Villeneuve, Montpellier, France
| | - Pierre Alric
- Service de Chirurgie Vasculaire et Thoracique, Hôpital Arnaud de Villeneuve, Montpellier, France
| | - Thomas Gandet
- Service de Chirurgie Vasculaire et Thoracique, Hôpital Arnaud de Villeneuve, Montpellier, France
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14
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Leone N, Bartolotti LAM, Baresi GF, Silingardi R, Resch TA, Gennai S. Anatomical suitability for branched endovascular aortic arch repair and balloon-expandable bridging stent grafts in a cohort of patients previously treated with a hybrid approach. J Vasc Surg 2024; 79:198-206.e15. [PMID: 37967588 DOI: 10.1016/j.jvs.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/30/2023] [Accepted: 11/06/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE We assessed the suitability of two triple branch arch devices (aBranch) (Terumo aortic and Cook Medical) and a balloon-expandable covered stent (VBX, W. L. Gore & Associates, Johnson & Johnson) to incorporate the brachiocephalic trunk (BCT) in a cohort previously treated with hybrid thoracic endovascular repair (TEVAR). METHODS This is a single-center, retrospective, all-comers, preclinical suitability study. We conducted an analysis of preoperative computed tomography scans in surgical patients between 1999 and 2022 in a single vascular surgery unit. The primary outcome was the aortic suitability of aBranch devices and VBX as mating stent for BCT in previous hybrid TEVAR. Hybrid repair of the aortic arch included TEVAR, fenestrated or branched TEVAR associated with any surgical debranching of the supra-aortic trunks and chimney TEVAR with proximal landing in zones 0 to 2. Secondary outcomes included (i) suitability assessment when excluding minor instruction for use (IFU) criteria, (ii) a comparison of suitable and nonsuitable patients, (iii) risk factors analysis for nonsuitability, and (iv) a description of the exclusion causes. RESULTS During the study period, 120 patients were treated. Among elective patients (n = 73), the suitability of any aBranch was 82.2% (60/73) and VBX was suitable in 64.4% of BCTs (47/73). The aBranch suitable patients had a significantly longer sinotubular-BCT length (P = .017) and smaller distal ascending aorta (P = .043) as compared with nonsuitable ones. The suitability of Terumo Aortic and Cook Medical devices was 52.1% (38/73) and 46.6% (34/73), respectively. When minor IFU criteria were ignored, suitability increased to 82.2% (60/73) and 63.0% (46/73), respectively. Left common carotid artery diameter and sinotubular-BCT length were significant nonsuitability risk factors for Terumo Aortic aBranch in multivariable analysis. No associations were found for Cook Medical device. The outcomes were tested in the entire cohort demonstrating a global suitability of 82.9%, increasing to 86.3% when ignoring minor IFUs. VBX was anatomically suitable to use in BCT in 73.2% of patient BCTs. CONCLUSIONS aBranch devices are anatomically suitable in a vast majority of patients (86%) undergoing hybrid TEVAR. The innominate artery seems eligible for incorporation with VBX in almost two-thirds of patients. This mating stent may help to overcome some minor IFU restrictions.
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Affiliation(s)
- Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy; Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark.
| | - Luigi Alberto Maria Bartolotti
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Francesco Baresi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Timothy Andrew Resch
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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15
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Spath P, Campana F, Tsilimparis N, Gallitto E, Pini R, Faggioli G, Caputo S, Gargiulo M. Outcomes of Fenestrated and Branched Endografts for Partial and Total Endovascular Repair of the Aortic Arch - A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2024; 67:106-116. [PMID: 37536517 DOI: 10.1016/j.ejvs.2023.07.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 07/01/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE Fenestrated and branched thoracic endovascular aortic repair (F/B-TEVAR) of the aortic arch is a viable approach in patients unsuitable for open repair. The aim was to summarise the published results of manufactured F/B-TEVAR devices for partial and total repair of the aortic arch, and to compare fenestrated with branched configurations. DATA SOURCES PubMed, Scopus and The Cochrane Library were searched for articles (2018 - 2021) about patients with elective, urgent, or emergency aortic requiring a proximal landing zone in the aortic arch (zone 0 - 1 - 2) and treated by F/B-TEVAR. REVIEW METHODS The systematic review and meta-analysis were performed according to the PRISMA guidelines. Open repair, supra-aortic trunk (SAT) debranching + standard TEVAR, and in situ physician modified and parallel grafts were excluded. Primary outcomes were technical success and 30 day mortality rate. Secondary outcomes were 30 day major adverse events, and overall survival and procedure related endpoints during follow up. RESULTS Of 458 articles screened, 18 articles involving 571 patients were selected. Indications for intervention were chronic dissections (50.1%), degenerative aneurysms (39.6%), penetrating aortic ulcers (7.4%), and pseudoaneurysms (2%). F-TEVAR, B-TEVAR, and F+B-TEVAR were used in 38.4%, 54.1%, and 7.5% of patients, respectively. Overall, technical success was 95.9% (95% confidence interval [CI] 0.93 - 0.97; I2 = 0%; p for heterogeneity (Het) = .77) and the 30 day mortality rate was 6.7% (95% CI 0.05 - 0.09; I2 = 0%; p Het = .66). No statistical differences were found comparing fenestrated with branched endografts, except for a higher rate of type I - III endoleaks in F-TEVAR (9.8% vs. 2.6%; p = .034). The overall survival rate and freedom from aortic related death at the one year follow up ranged between 82 - 96.4% and 94 - 94.7%, respectively. Thirteen and five studies were considered at moderate and high risk of bias, respectively. CONCLUSION F/B-TEVAR for the treatment of the aortic arch, according to experience in dedicated centres, now enjoys a satisfactory level of technical success together with a progressively reduced early mortality rate. There are several limitations, and further studies are needed to reach clearer conclusions.
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Affiliation(s)
- Paolo Spath
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy; Department of Vascular Surgery, Hospital "Infermi" Rimini, AUSL Romagna, Rimini, Italy.
| | | | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximillian University Hospital, Munich, Germany
| | - Enrico Gallitto
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy; Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy; Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy; Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
| | - Stefania Caputo
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy; Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
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Derycke L, Tomasi J, Desgranges P, Pesteil F, Plissonier D, Pernot M, Millon A, Martinez R, Chakfe N, Alsac JM. Assessment of Thoracic Endovascular Aortic Repair Using Relay Proximal Scallop: Results of a French Prospective Multicentre Study. Eur J Vasc Endovasc Surg 2023; 66:821-829. [PMID: 37567339 DOI: 10.1016/j.ejvs.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 06/01/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE A proximal scallop design allows aortic arch repair without complex endovascular manipulation in the aortic arch. The aim was to assess the safety and efficacy at one year of the Relay proximal scallop stent graft. METHODS A prospective multicentre study evaluated consecutive patients treated with the Relay proximal scallop stent graft in 10 French aortic centres. All consecutive patients eligible for elective thoracic endovascular repair with proximal scallop in the 10 participating centres between January 2015 and July 2018 were included. Primary endpoints were 30 day mortality, stroke, and spinal cord ischaemia (SCI) rates. Outcomes including safety and efficacy, technical and clinical success, all cause death, neurological events, vessel patency, and device specific complications were analysed. Survival and survival without severe complications were estimated using Kaplan-Meier estimates. RESULTS Ten aortic centres treated 40 patients for thoracic aortic aneurysm (45%), penetrating atherosclerotic aneurysm (30%), and dissection (25%). Half of the procedures (50%) targeted zone 0 of the aortic arch (zone 0 in 17.5% and zones 0/1 in 32.5%), 37.5% targeted zone 2 (35% zone 2 alone; 2.5% zones 1/2), and 15% targeted zone 1 (12.5% zone 1 alone). Median follow up was one year. Thirty day mortality, stroke, and SCI rates were 10%, 5%, and 0% respectively. Primary technical success was 95%. Type Ia, Ib, and III endoleaks rates were 5.4%, 0%, and 0% respectively at one month. The overall mortality rate at one year was 17.5%. Aneurysm expansion was > 5 mm in one case at one year associated with type Ia endoleak (3%). There was no supra-aortic trunk thrombosis, one (2%) graft kink, and no migration. CONCLUSION One year outcomes showed that the Relay proximal scallop stent graft is an acceptable answer to thoracic aortic disease to deal with short proximal landing zones.
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Affiliation(s)
- Lucie Derycke
- Department of Cardio-Vascular and Vascular Surgery, Hôpital Européen Georges Pompidou, Paris, France.
| | - Jacques Tomasi
- Department of Thoracic and Cardiovascular Surgery, University Hospital Centre-INSERM LTSI 1099, Rennes, France
| | - Pascal Desgranges
- Department of Vascular Surgery, Centre Hospitalier Universitaire Henri Mondor, Créteil, France
| | - Francis Pesteil
- Department of Vascular Medicine and Surgery, Dupuytren University Hospital, Limoges, France
| | - Didier Plissonier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Mathieu Pernot
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, Bordeaux University Hospital, Pessac, France
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Robert Martinez
- Department of Cardiovascular Surgery, University Hospital of Tours, Tours, France
| | - Nabil Chakfe
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Jean-Marc Alsac
- Department of Cardio-Vascular and Vascular Surgery, Hôpital Européen Georges Pompidou, Paris, France
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Frola E, Mortola L, Ferrero E, Ferri M, Apostolou D, Quaglino S, Maione M, Gaggiano A. Multicenter Comparison of Aortic Arch Aneurysms and Dissections Zone 0 Hybrid and Total Endovascular Repair. Cardiovasc Intervent Radiol 2023; 46:1674-1683. [PMID: 37978065 DOI: 10.1007/s00270-023-03607-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Abstract
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.
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Affiliation(s)
- Edoardo Frola
- Vascular and Endovascular Surgery Unit, S. Croce e Carle Hospital, Via Coppino 26, 12100, Cuneo, Italy.
| | - Lorenzo Mortola
- Vascular and Endovascular Surgery Unit, S. Croce e Carle Hospital, Via Coppino 26, 12100, Cuneo, Italy
| | - Emanuele Ferrero
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Michelangelo Ferri
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Dimitrios Apostolou
- Vascular and Endovascular Surgery Unit, S. Croce e Carle Hospital, Via Coppino 26, 12100, Cuneo, Italy
| | - Simone Quaglino
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Massimo Maione
- Vascular and Endovascular Surgery Unit, S. Croce e Carle Hospital, Via Coppino 26, 12100, Cuneo, Italy
| | - Andrea Gaggiano
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
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18
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Patel HJ, Preventza O, Roselli EE, Atkins MD, Brinkman W, Coselli J, Desai N, Estrera A, Fleischman F, Taylor BS, Reardon MJ. Emergency and Compassionate Use of a Novel Ascending Endograft for Ascending and Arch Aortic Pathology. J Endovasc Ther 2023:15266028231208644. [PMID: 37933168 DOI: 10.1177/15266028231208644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
PURPOSE Patients with complicated ascending aortic pathology, including patients with acute type A aortic dissection may be at extreme risk for open repair. Thoracic endovascular aortic repair (TEVAR), infrequently used for the ascending aorta, may be considered an alternative in this setting. We describe early results for emergency and compassionate (E&C) use of a novel endograft, specifically designed for use to treat pathology of the ascending aorta. MATERIALS AND METHODS This case series evaluated 19 patients (mean age, 68.84±13.12 years; 57.9% female) treated with ascending TEVAR for acute and chronic acute (4), subacute (1), or chronic (1) aortic dissection or pseudoaneurysm (13). Six of the 19 patients (31.5%) were treated under compassionate use and 13 patients (68.4%) were treated under the emergency use exemption. Ten patients (52.6%) received additional devices to extend treatment into the arch and descending aorta. RESULTS Device delivery was achieved in all patients (100%). Thirty-day mortality and stroke occurred in 3 patients (15.8%) and in 1 patient (5.3%), respectively. In 1 patient (5.3%), with an Unanticipated Adverse Device Event, the aorta ruptured when the endograft eroded into the adventitial portion of dissection site at the posterior aspect of the ascending wall. Devices were explanted in 2 patients (10.5%), 353 and 610 days after the index procedure, respectively. Six patients had endoleaks (31.6%), including type I (n=2, 10.5%), type II endoleaks (n=3, 15.8%), and indeterminate endoleak (n=1, 5.3%). CONCLUSIONS Delivery and deployment of a novel ascending thoracic stent graft with or without an additional branched arch extension is feasible in patients with complex anatomy and pathology, including acute aortic dissection and pseudoaneurysm. Additional experience with this novel device will further refine the patient population most suitable for endovascular ascending aortic repair for these pathologies. CLINICAL IMPACT This study describes a novel stent graft specifically designed for treatment of ascending aortic pathology, including acute type A dissection. The patients described in this series constituted a group outside the formal US FDA sponsored clinical trial, and were those accepted as part of an emergency and compassionate use basis.
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Affiliation(s)
- Himanshu J Patel
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
- Department of Cardiac Surgery, University of Michigan Hospitals, Cardiovascular Network of West Michigan, Ann Arbor, MI, USA
| | | | - Eric E Roselli
- Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | - Nimesh Desai
- University of Pennsylvania, Philadelphia, PA, USA
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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DiBartolomeo AD, Ding L, Weaver FA, Han SM, Magee GA. Risk of Stroke with Thoracic Endovascular Aortic Repair of the Aortic Arch. Ann Vasc Surg 2023; 97:37-48. [PMID: 37121336 DOI: 10.1016/j.avsg.2023.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) involving the aortic arch is increasingly being performed and novel endografts have been developed for this procedure, but the association of stroke and relative risk of procedural techniques remains unclear. This study evaluates the procedural risk factors for stroke and mortality with zone 0-2 TEVAR. METHODS The Society for Vascular Surgery Vascular Quality Initiative registry was queried for patients who underwent TEVAR with proximal landing in zone 0-2 from 2013 to 2022. Emergent and ruptured cases were excluded. Primary exposure variables included proximal seal zone (0-2) and branch vessel revascularization technique: open debranching/bypass, total endovascular incorporation, or combination (at least 1 branch open and 1 branch endovascular). The primary outcome was perioperative inhospital stroke and the secondary outcome was inhospital mortality. Univariable and multivariable regression analyses were performed. RESULTS In total, 4,355 cases were analyzed with 350 in zone 0 (8%), 513 in zone 1 (12%), and 3,492 in zone 2 (80%). For zone 0, 1, and 2, the stroke rates were 11.1%, 5.3% and 4.7% (P < 0.0001) and inhospital mortality rates were 6.9%, 5.3% and 3.5% (P = 0.002), respectively. Branch vessel revascularization technique was associated with stroke in zone 0 with a 3-fold higher stroke rate for total endovascular incorporation of branches compared to combination and open techniques (P = 0.002). On multivariable analysis, zone 0 was independently associated with a greater than 2-fold increased odds of stroke compared to zone 2 (95% CI 1.4-3.2, P = 0.0008). CONCLUSIONS Stroke rate was 2-3 times higher for zone 0 TEVAR compared to zones 1 and 2. Within zone 0, total endovascular branch incorporation was associated with a 3-fold higher stroke rate than open and combination techniques. Future device design modifications and novel endovascular strategies for stroke prevention are required to make total endovascular repair of the aortic arch an acceptable alternative to combination and open debranching/bypass techniques.
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Affiliation(s)
- Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Li Ding
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA.
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21
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Leone N, Andreoli F, Bartolotti LAM, Migliari M, Baresi GF, Saitta G, Silingardi R, Gennai S. Anatomical feasibility of a 'semi-custom' unibody single-branch endograft in previous zone 2 thoracic endovascular aortic repair. Eur J Cardiothorac Surg 2023; 64:ezad290. [PMID: 37603731 DOI: 10.1093/ejcts/ezad290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/12/2023] [Accepted: 08/18/2023] [Indexed: 08/23/2023] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the suitability of a subclavian unibody single-branch endograft among patients treated with thoracic endovascular aortic repair (TEVAR) in landing zone 2 (LZ2). METHODS This is a pre-clinical, single-centre, real-world, all-comers, retrospective cohort study. Patients treated with TEVAR in LZ2 with an available preoperative computed tomography angiography were included. The primary outcome was the anatomical feasibility of the Castor endograft in patients receiving endovascular treatment in LZ2 between 1999 and 2022. Secondary outcomes were: a comparison of feasible and unfeasible patients; frequencies and description of exclusion causes; non-feasibility risk factor analysis; and analysis of the stent graft configurations necessary to treat 75% of the patients. A logistic regression model was used to find associations between baseline morphological data and non-feasibility. RESULTS A total of 473 procedures were performed and 72 patients fulfilling inclusion criteria were included. The mean distance between the left carotid artery and left subclavian artery (or between innominate artery and bovine trunk) was 12.4 ± 5.2 mm and its average diameter was 33.0 ± 10.6 mm. The pre-vertebral left subclavian artery's diameter and length were 11.3 ± 2.5 and 38.7 ± 10.8 mm. Forty-nine (68.1%) patients were suitable for Castor implantation. Twenty-one configurations were required to treat 75% of feasible patients and might be lowered to 12 configurations applying less strict criteria. CONCLUSIONS The Castor endograft was anatomically feasible in several patients requiring TEVAR in LZ2. Three-quarters of feasible patients could be treated with a reasonable number of configurations, paving the path for future off-the-shelf applications.
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Affiliation(s)
- Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Andreoli
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Luigi A M Bartolotti
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Mattia Migliari
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni F Baresi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Saitta
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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22
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Becker D, Stana J, Prendes CF, Konstantinou N, Öz T, Pichlmaier M, Peterss S, Tsilimparis N. Endovascular arch repair of anastomotic aneurysm and pseudoaneurysm in patients after open repair of the ascending aorta and aortic arch: a case series. Eur J Cardiothorac Surg 2023; 64:ezad345. [PMID: 37889250 DOI: 10.1093/ejcts/ezad345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/05/2023] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVES The aim of the study was to investigate the outcomes of branched endovascular arch repair (b-TEVAR) with a custom-made double- or triple-branched arch endograft in patients with distal anastomotic aneurysms after open repair of the ascending aorta or proximal arch replacement. METHODS Retrospective analysis was conducted of all consecutive patients with anastomotic aneurysms after open surgical repair involving the ascending aorta and/or aortic arch treated with b-TEVAR. All patients were treated with a custom-made double or triple inner-branched arch endograft. Study end points were technical success, 30-day and follow-up mortality/morbidity and re-interventions. RESULTS Between 2018 and 2022, 10 patients were treated with custom-made double- or triple-branched thoracic endovascular aortic repair due to anastomotic aneurysms after open ascending aorta and/or proximal aortic arch replacement. Eight patients received a triple and 2 a double arch-branched endograft. Eight cases were performed electively and 2 urgently for contained rupture. Technical success was achieved in 9 cases (90%). All elective patients survived. Two patients treated due to contained ruptures expired. Within 30 postoperative days, 1 transient ischaemic attack occurred. No early endograft-related re-interventions were necessary. The median follow-up was 20 months. One patient died 2 months after discharge due to sepsis caused by pneumonia. No further deaths or endograft-related re-interventions were observed. CONCLUSIONS Endovascular aortic arch repair with double or triple inner-branched arch endograft for anastomotic aneurysms after open ascending and/or proximal arch replacement is technically feasible and a promising alternative in a patient cohort unfit for surgery.
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Affiliation(s)
- Daniel Becker
- University Aortic Center Munich, LMU University Hospital, Munich, Germany
- Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Jan Stana
- University Aortic Center Munich, LMU University Hospital, Munich, Germany
- Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Carlota F Prendes
- University Aortic Center Munich, LMU University Hospital, Munich, Germany
- Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Nikolaos Konstantinou
- University Aortic Center Munich, LMU University Hospital, Munich, Germany
- Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Tugce Öz
- University Aortic Center Munich, LMU University Hospital, Munich, Germany
- Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Maximilian Pichlmaier
- University Aortic Center Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Sven Peterss
- University Aortic Center Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Nikolaos Tsilimparis
- University Aortic Center Munich, LMU University Hospital, Munich, Germany
- Department of Vascular Surgery, LMU University Hospital, Munich, Germany
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23
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Kus N, Robinson JA, Hall MR, Ghoreishi M, Taylor B, Toursavadkohi S. Emergent Total Endovascular Arch Repair for Contained Aortic Arch Rupture: Another Tool in the Box. Vasc Endovascular Surg 2023; 57:771-775. [PMID: 37058450 DOI: 10.1177/15385744231170919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
To date, emergent total endovascular aortic arch repair has not been described in the literature. We present a 67-year-old female with a poorly differentiated posterior mediastinal sarcoma. Imaging obtained was concerning for intravascular extension of the tumor into the thoracic aorta. While awaiting radiation therapy, the patient complained of worsening chest and arm pain, vital signs demonstrating tachypnea and hypoxia. Subsequent imaging revealed an increase in vascular erosion, concerning for a contained rupture, with complete obliteration of the left mainstem bronchus. The patient was emergently taken for percutaneous endovascular repair of her aortic arch. A three-vessel physician modified fenestrated graft was created and deployed with concurrent stenting of the innominate, left carotid, and left subclavian arteries. Interval computed tomography angiography revealed patency in all stented vessels, with no endoleak and no evidence of pseudoaneurysm. The patient was able to undergo chemotherapy with favorable decrease in tumor burden. Total endovascular aortic arch repair, when planned carefully, is an attractive option in high-risk patients who are otherwise not ideally suited for open total arch replacement.
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Affiliation(s)
- Nicole Kus
- Division of General Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Justin A Robinson
- Division of Cardiovascular and Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Michael R Hall
- Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mehrdad Ghoreishi
- Division of Cardiovascular and Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Bradley Taylor
- Division of Cardiovascular and Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD, USA
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24
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Tan SZ, Jubouri M, Bashir M. Endovascular aortic arch repair: A comparison of outcomes and current trends. Asian Cardiovasc Thorac Ann 2023; 31:589-595. [PMID: 36397652 DOI: 10.1177/02184923221140756] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVE Application of thoracic endovascular aortic repair (TEVAR) to the aortic arch has been met with the development of purpose-made endoprostheses for on-label use in the aortic arch. An appraisal of the clinical efficacy of each major device is therefore useful towards informing clinical decision making for patients eligible for endovascular arch repair (EAR) rather than open surgical reconstruction. METHODS A literature review of publications outlining clinical experience with the RELAY™ Branched and Zenith™ devices was undertaken, and the results therefrom analysed to evaluate the clinical efficacies of each device. RESULTS Early- and long-term mortality rates associated with EAR appear favourable, especially compared against open surgical repair. EAR is also associated with good neurological outcomes and target vessel patency rates. However, EAR continues to be associated with substantial reintervention rates. CONCLUSIONS At the present stage, EAR represents a promising alternative option to open surgical reconstruction in patients that meet its eligibility criteria. Though there remains a substantial learning curve associated with EAR, its favourable outcome profile is likely to increase its applicability in the future.
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Affiliation(s)
- Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull-York Medical School, University of York, York, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Health Education and Improvement Wales, Velindre University NHS Trust, Wales, UK
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25
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Kwan KJS, Li HL, Chan YC, Cheng SWK. Safety and Efficacy of Inner Branched Stent-Graft in the Treatment of Aortic Arch Disease: A Systematic Review. J Endovasc Ther 2023:15266028231197395. [PMID: 37646117 DOI: 10.1177/15266028231197395] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
OBJECTIVE To provide a descriptive overview on the contemporary outcomes of thoracic endovascular arch repair with inner branched endoprosthesis (bTEVAR) for the treatment of aortic arch pathologies. METHODS A comprehensive literature search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Pre-defined search terms were used to interrogate PubMed and OVID Medline databases from January 1999 to July 2022. Patient characteristics, indication for treatment, procedural data, mortality rates, postoperative complications, and reintervention rate during follow-up were evaluated. RESULTS Nineteen articles were included, encompassing a total of 618 patients who received bTEVAR, most of which were double-branched (63.9%, n=395). The main indication for treatment was aneurysm secondary to chronic aortic dissection (38.8%, n=240/618) with a mean maximum diameter of 58.3±11.4 mm. Pooled mean technical success rate was 97.4±4.4% (95% confidence interval [CI]=95.1%-99.5%); 2 and 3 patients required conversion to chimney technique and open repair, respectively. Among the pooled rates of early complications, postoperative stroke was the highest (10.5%; 95% CI=6.8%-14.3%). Thirty-day and in-hospital mortality rate was 5.5% (95% CI=2.6%-9.7%). Forty patients (6.5%; 95% CI=2.5%-9.5%) required early reintervention. During a mean follow-up of 20.7±13.5 months, the mortality rate was 18.2% (n=108/593; 95% CI=8.6%-20.6%) where 12 (11.1%) were aortic-related. Pooled late reintervention rate was 9.6% (95% CI=4.8%-14.3%). Comparison of demographics and outcomes found no significant difference between single and double bTEVAR. CONCLUSION Branched thoracic endovascular aortic repair is a promising approach for aortic arch pathologies with a high technical success rate despite a steep learning curve. However, contemporary outcomes reflect that postoperative stroke remains the predominant concern. Further experience and long-term follow-up are required to sufficiently elucidate the safety and durability of bTEVAR in the management of aortic pathologies for high-risk patients. CLINICAL IMPACT This systematic review summarized the contemporary outcomes of thoracic endovascular aortic repair with different inner branched stent-grafts for the management of aortic arch pathologies. Pooled results from nineteen studies with 618 patients demonstrated a high technical success rate and an acceptable mortality rate. However, postoperative stroke remains the major concern. Long-term follow-up is needed to evaluate its durability.
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Affiliation(s)
- Kristine J S Kwan
- International School, Jinan University, Guangzhou, China
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Hai-Lei Li
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yiu Che Chan
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China
| | - Stephen W K Cheng
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China
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Nana P, Houérou TL, Guihaire J, Gaudin A, Fabre D, Haulon S. Early Outcomes on Triple-Branch Arch Device With Retrograde Left Common Carotid Branch: A Case Series. J Endovasc Ther 2023:15266028231195758. [PMID: 37635649 DOI: 10.1177/15266028231195758] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
INTRODUCTION Endovascular aortic arch repair using multibranch devices has been applied in patients considered at high risk for open repair. The aim of this case series was to report the early outcomes in patients managed with a new design 3 branch arch custom-made device, including a retrograde left common carotid artery (LCCA) branch. METHODS The Preferred Reporting Of CaSe Series in Surgery (PROCESS) guidelines were followed. All consecutive patients undergoing endovascular repair of an aortic arch lesion with a custom-made triple-branch device, including a retrograde LCCA branch (Cook Medical, Bloomington, IN, USA), between October 27, 2022, and February 28, 2023, were included. The presence of an arch aneurysm (degenerative or post-dissection) with diameter ≥55 mm and high risk for a conventional open repair set the indication for treatment. The primary outcomes were technical success and mortality at 30 days. Early morbidity and reinterventions were considered as secondary outcomes. RESULTS Eight elective patients (87.5% men, mean age 72.3±27.0 years) were included. Five of them (62.5%) had undergone a previous ascending aorta repair of an acute type A aortic dissection. All patients were asymptomatic, except one, with left recurrent laryngeal nerve compression. The mean maximum aortic diameter was 70.4±21.0 mm. Percutaneous femoral and axillary access was used in all cases except three in which a cut down for right carotid access was performed. Technical success was 100%. Femoral access to the LCCA and implantation of the bridging stent was performed without technical challenges. No death nor cerebrovascular event was recorded during the 30 day follow-up. Five patients (62.5%) presented major complications, 3 related to access needing reintervention and the remaining related to congestive heart failure (CHF), which were managed successfully with medical treatment. Follow-up (range 1-4 month) was uneventful, except for one patient who presented a secondary type Ia endoleak. CONCLUSIONS According to our early experience, the presence of a retrograde branch facilitated the revascularization of the LCCA through femoral access, decreasing the risk of cerebrovascular morbidity. Further analyses with longer follow-up are needed to evaluate the safety and efficacy of the device. CLINICAL IMPACT Data arising mainly from the retrograde branch for the revascularization of the LSA are encouraging from a variety of devices. The premiminary experience with a triple-branched arch device, with a retrograde branche for the LSA but also for the LCCA, was associated with no 30 day mortality and 100% technical success.The device's design allowed swift catheterization and completion of the LCCA revascularization using femoral access exclusively.
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Affiliation(s)
- Petroula Nana
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
| | - Thomas Le Houérou
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
| | - Julien Guihaire
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
| | - Antoine Gaudin
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
| | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
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Lim ET, Ruiz C, Lyons OT, Laing A, Khanafer A. Mechanical aortic valve may no longer be a contraindication to inner branch aortic arch endografts. Vascular 2023:17085381231192727. [PMID: 37493642 DOI: 10.1177/17085381231192727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
OBJECTIVES The presence of a mechanical aortic valve has been a contraindication to the use of an arch branch aortic endograft due to the risk of damaging the valve, resulting in acute aortic regurgitation, or a trapped endograft. METHODS We present a 67-year-old woman, with a background of Marfan's syndrome and a previous Bentall's procedure, who presented with a symptomatic enlarging aortic arch and descending thoracic aortic aneurysm, with a type 1A endoleak. RESULTS Using an inner branch arch endograft (Cook Medical, Bloomington, Indiana), the nose cone of the delivery system was passed laterally through the semi-circular aperture of the mechanical aortic valve to facilitate deployment just distal to the coronary buttons. CONCLUSIONS With advancement of endovascular technology, techniques and experience, endovascular aortic arch repair in the presence of a mechanical aortic valve is feasible.
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Affiliation(s)
- Eric Ta Lim
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
- Department of Surgery, University of Otago Christchurch, Christchurch, New Zealand
| | - Carmen Ruiz
- Department of Vascular Surgery, Nelson Hospital, Nelson, New Zealand
| | - Oliver T Lyons
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
- Department of Surgery, University of Otago Christchurch, Christchurch, New Zealand
| | - Andrew Laing
- Department of Radiology, Christchurch Hospital, Christchurch, New Zealand
| | - Adib Khanafer
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
- Department of Surgery, University of Otago Christchurch, Christchurch, New Zealand
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Cao L, Zhang H, Ge Y, Guo W. Avoiding Stroke in Patients Undergoing Endovascular Aortic Arch Repair: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:265-277. [PMID: 37438011 DOI: 10.1016/j.jacc.2023.04.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 07/14/2023]
Abstract
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.
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Affiliation(s)
- Long Cao
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China; Department of General Surgery, The 983rd Hospital of Joint Logistic Support Force of PLA, Tianjin, China
| | - Hongpeng Zhang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yangyang Ge
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China.
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Abisi S, Elnemr M, Clough R, Alotaibi M, Gkoutzios P, Modarai B, Haulon S. The Development of Totally Percutaneous Aortic Arch Repair With Inner-Branch Endografts: Experience From 2 Centers. J Endovasc Ther 2023:15266028231184687. [PMID: 37401667 DOI: 10.1177/15266028231184687] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
OBJECTIVE The main objective of this study is to present the experience of 2 centers undertaking total percutaneous aortic arch-branched graft endovascular repair using combination of femoral and axillary routes. The report summarizes the procedural steps, outcomes achieved, and the benefits of this approach, which eliminates the need for direct open surgical exposure of the carotid, subclavian, or axillary arteries, thereby reducing the unnecessary associated surgical risks. METHODS Retrospectively collected data of 18 consecutive patients (15M:3F) undergoing aortic arch endovascular repair using a branched device between February 2021 and June 2022 at 2 aortic units. Six patients were treated for a residual aortic arch aneurysm following previous type A dissection with size range of (58-67 mm in diameter), 10 were treated for saccular or fusiform degenerative atheromatous aneurysm with size range of (51.5-80 mm in diameter), and 2 were treated for penetrating aortic ulcer (PAU) with size range of (50-55 mm). Technical success was defined as completion of the procedure and satisfactory placement of the bridging stent grafts (BSGs) in the supra-aortic vessels percutaneously including the brachiocephalic trunk (BCT), left common carotid artery (LCCA), and left subclavian artery (LSA) without the need for carotid, subclavian, or axillary cut down. The primary technical success was examined as primary outcome well as any other related complications and reinterventions as secondary outcomes. RESULTS The primary technical success with our alternative approach was achieved in all 18 cases. There was one access site complication (groin haematoma), which was managed conservatively. There was no incidence of death, stroke, or cases of paraplegia. No other immediate complications were noted. Postoperative imaging confirmed supra-aortic branch patency, with satisfactory position of the BSGs and immediate aneurysm exclusion except in 4 patients who had type 1C endoleak (Innominate: 2, LSA 2) detected on the first postoperative scan. Three of them were treated with relining/extension, and 1 spontaneously resolved after 6 weeks. CONCLUSIONS Total percutaneous aortic arch repair with antegrade and retrograde inner-branch endografts can be performed with promising early results. Dedicated steerable sheaths and appropriate BSG would optimize the percutaneous approach for aortic arch endovascular repairs. CLINICAL IMPACT This article provides an alternative and innovative approach to improve the minimally invasive techniques in the endovascular treatment of the aortic arch conditions.
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Affiliation(s)
- Said Abisi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College London, London, UK
| | | | - Rachel Clough
- Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Mohammed Alotaibi
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
| | | | - Bijan Modarai
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Stephan Haulon
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
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Kapalla M, Busch A, Lutz B, Nebelung H, Wolk S, Reeps C. Single-center initial experience with inner-branch complex EVAR in 44 patients. Front Cardiovasc Med 2023; 10:1188501. [PMID: 37396572 PMCID: PMC10309562 DOI: 10.3389/fcvm.2023.1188501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/16/2023] [Indexed: 07/04/2023] Open
Abstract
Purpose The use of inner-branch aortic stent grafts in the treatment of complex aortic pathologies aims at broad applicability and stable bridging stent sealing compared to other endovascular technologies. The objective of this study was to evaluate the early outcomes with a single manufacturer custom-made and off-the-shelf inner-branched endograft in a mixed patient cohort. Methods This retrospective, monocentric study between 2019 and 2022 included 44 patients treated with inner-branched aortic stent grafts (iBEVAR) as custom-made device (CMD) or off-the-shelf device (E-nside) with at least four inner branches. The primary endpoints were technical and clinical success. Results Overall, 77% (n = 34) and 23% (n = 10) of the patients (mean age 77 ± 6.5 years, n = 36 male) were treated with a custom-made iBEVAR with at least four inner branches and an off-the-shelf graft, respectively. Treatment indications were thoracoabdominal pathologies in 52.2% (n = 23), complex abdominal aneurysms in 25% (n = 11), and type Ia endoleaks in 22.7% (n = 10). Preoperative spinal catheter placement was performed in 27% (n = 12) of patients. Implantation was entirely percutaneous in 75% (n = 33). Technical success was 100%. Target vessel success manifested at 99% (178/180). There was no in-hospital mortality. Permanent paraplegia developed in 6.8% (n = 3) of patients. The mean follow-up was 12 months (range 0-52 months). Three late deaths (6.8%) occurred, one related to an aortic graft infection. Kaplan-Meier estimated 1-year survival manifested at 95% and branch patency at 98% (177/180). Re-intervention was necessary for a total of six patients (13.6%). Conclusions Inner-branch aortic stent grafts provide a feasible option for the treatment of complex aortic pathologies, both elective (custom-made) and urgent (off-the-shelf). The technical success rate is high with acceptable short-term outcomes and moderate re-intervention rates comparable to existing platforms. Further follow-up will evaluate long-term outcomes.
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Affiliation(s)
- Marvin Kapalla
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
| | - Albert Busch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
| | - Brigitta Lutz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
| | - Heiner Nebelung
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
| | - Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
| | - Christian Reeps
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Dresden, Germany
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Rohlffs F, Grandi A, Panuccio G, Detter C, von Kodolitsch Y, Kölbel T. Endovascular Options for the Ascending Aorta and Aortic Arch - A Scoping Review. Ann Vasc Surg 2023:S0890-5096(23)00316-3. [PMID: 37328096 DOI: 10.1016/j.avsg.2023.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/18/2023]
Abstract
The gold standard for aneurysmal repair of the ascending aorta and the aortic arch has been open surgery with an established track record of good results in suitable patients. In recent years, with innovations in the endovascular field alternative endovascular solutions for pathologies of the aortic arch and ascending aorta became available. At first reserved only for highly selected patients unfit for open surgery, endovascular aortic arch repair is now being offered to patients with suitable anatomy in high volume referral centers after discussion in an interdisciplinary team. The present scoping review aims at providing an overview on indications, available devices, technical aspects and feasibility studies of endovascular arch repair both in elective and emergent situations, including also experiences and considerations from our center.
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Affiliation(s)
- Fiona Rohlffs
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
| | - Alessandro Grandi
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Christian Detter
- Cardiothoracic Surgery, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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Tian Y, Wang C, Xie P. Mid-term outcomes of left subclavian artery revascularization with Castor stent graft in treatment of type B aortic dissection in left subclavian artery. J Interv Med 2023; 6:74-80. [PMID: 37409064 PMCID: PMC10318335 DOI: 10.1016/j.jimed.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/07/2023] [Accepted: 04/09/2023] [Indexed: 07/07/2023] Open
Abstract
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.
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Affiliation(s)
- Yu Tian
- Department of Interventional Therapy, Cancer Hospital Chinese Academy of Medical Science, ShenZhen Center, Guangdong Province, China
| | - Chengjie Wang
- Department of Vascular Surgery, Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Peng Xie
- Department of Orthopedics, The 3rd Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, China
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Houérou TL, Nana P, Pernot M, Guihaire J, Gaudin A, Lerisson E, Costanzo A, Fabre D, Haulon S. Systematic Review on In Situ Laser Fenestrated Repair for the Endovascular Management of Aortic Arch Pathologies. J Clin Med 2023; 12:jcm12072496. [PMID: 37048580 PMCID: PMC10095564 DOI: 10.3390/jcm12072496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/12/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Background: In situ laser-fenestrated thoracic aortic endovascular repair (FTEVAR) has emerged as a valuable alternative for aortic arch management. This review assessed the early and follow-up outcomes of in situ laser-FTEVAR in aortic arch pathologies. Methods: The PRISMA statement was followed. The English literature was searched, via Ovid, until 15 October 2022. Observational studies, published after 2000, reporting on early and follow-up outcomes for the in situ laser-FTEVAR were eligible. The Newcastle–Ottawa Scale was used to assess the risk of bias. Primary outcomes were the technical success, stroke, and mortality at 30-days, and the secondary were the mortality and reintervention during follow-up. Results: Six retrospective studies from 591 and 247 patients were included. Fifty-nine (23.9%) patients were managed for aortic arch aneurysms and 146 (59.1%) for dissections; 22.6% of them for type A. Technical success was at 98% (range 90–100%). Eight patients died (3.2%) and 11 cases presented any type of stroke (4.5%) during the 30-day follow-up. The mean follow-up was 15 months (1–40 months). Ten deaths were reported (4.2%); one was aortic-related (10%). Thirteen re-interventions (6.0%) were performed. Conclusions: In situ laser-FTEVAR for aortic arch repair may be performed with high technical success and low 30-day and midterm follow-up mortality, stroke, and re-intervention rates when applied in well selected patients and performed by experienced teams.
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Porto A, Omnes V, Bartoli MA, Azogui R, Resseguier N, De Masi M, Bal L, Imbert L, Jaussaud N, Morera P, Jacquier A, Barral PA, Gariboldi V, Gaudry M. Reintervention of Residual Aortic Dissection after Type A Aortic Repair: Results of a Prospective Follow-Up at 5 Years. J Clin Med 2023; 12:jcm12062363. [PMID: 36983363 PMCID: PMC10054589 DOI: 10.3390/jcm12062363] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
Background After a type A aortic dissection repair, a patent false lumen in the descending aorta is the most common situation encountered, and is a well-known risk factor for aortic growth, reinterventions and mortality. The aim of this study was to analyze the long-term results of residual aortic dissection (RAD) at a high-volume aortic center with prospective follow-up. Methods In this prospective single-center study, all patients operated for type A aortic dissection between January 2017 and December 2022 were included. Patients without postoperative computed tomography scans or during follow-up at our center, and patients without RAD were excluded. The primary endpoint was all-cause mortality during follow-up for patients with RAD. The secondary endpoints were perioperative mortality, rate of distal aneurysmal evolution, location of distal aneurysmal evolution, rate of distal reinterventions, outcomes of distal reinterventions, and aortic-related death during follow-up. Results In total, 200 survivors of RAD comprised the study group. After a mean follow-up of 27.2 months (1-66), eight patients (4.0%) died and 107 (53.5%) had an aneurysmal progression. The rate of distal reintervention was 19.5% (39/200), for malperfusion syndrome in seven cases (3.5%) and aneurysmal evolution in 32 cases (16.0%). Most reinterventions occurred during the first 2 years (82.1%). Twenty-seven patients were treated for an aneurysmal evolution of RAD including aortic arch with hybrid repair in 21 cases and branched aortic arch endoprosthesis in six cases. In the hybrid repair group, there was no death, and the rate of morbidity was 28.6% (6/21) (one minor stroke, one pulmonary complication, one recurrent paralysis with complete recovery and three major bleeding events). In the branched endograft group, there was no death, no stroke, and no paraplegia. There was one case (16.7%) of carotid dissection. Complete aortic remodeling or complete FL thrombosis on the thoracic aorta was found in 18 cases (85.7%) and in five cases (83.3%) in the hybrid and branched endograft groups, respectively. Conclusions: Despite a critical course in most cases of RAD, with a high rate of aneurysmal evolution and reintervention, the long-term mortality rate remains low with a close follow-up and a multidisciplinary management in an expert center.
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Affiliation(s)
- Alizée Porto
- Department of Cardiac Surgery, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Virgile Omnes
- Department of Vascular Surgery, Timone Aortic Center, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Michel A Bartoli
- Department of Vascular Surgery, Timone Aortic Center, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Ron Azogui
- Department of Vascular Surgery, Timone Aortic Center, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Noémie Resseguier
- Department of Epidemiology and Public Health Cost, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Mariangela De Masi
- Department of Vascular Surgery, Timone Aortic Center, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Laurence Bal
- Department of Vascular Surgery, Timone Aortic Center, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Laura Imbert
- Department of Epidemiology and Public Health Cost, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Nicolas Jaussaud
- Department of Cardiac Surgery, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Pierre Morera
- Department of Cardiac Surgery, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Alexis Jacquier
- Department of Radiology, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Pierre-Antoine Barral
- Department of Radiology, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Vlad Gariboldi
- Department of Cardiac Surgery, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Marine Gaudry
- Department of Vascular Surgery, Timone Aortic Center, Timone Hospital, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
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Ahmad W, Wegner M, Dorweiler B. Meta-analysis and meta-regression of the total endovascular aortic repair in aortic arch. VASA 2023; 52:175-185. [PMID: 36891664 DOI: 10.1024/0301-1526/a001061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
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.
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Affiliation(s)
- Wael Ahmad
- Department of Vascular and Endovascular Surgery-University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Moritz Wegner
- Department of Vascular and Endovascular Surgery-University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery-University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
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Wong J, Tenorio ER, Lima G, Dias-Neto M, Baghbani-Oskouei A, Mendes B, Kratzberg J, Ocasio L, Macedo TA, Oderich GS. Early Feasibility of Endovascular Repair of Distal Aortic Arch Aneurysms Using Patient-Specific Single Retrograde Left Subclavian Artery Branch Stent Graft. Cardiovasc Intervent Radiol 2023; 46:249-254. [PMID: 36319711 PMCID: PMC9628377 DOI: 10.1007/s00270-022-03304-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/14/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the feasibility and outcomes of endovascular repair of distal aortic arch aneurysms using a patient-specific stent graft with a pre-loaded single retrograde left subclavian artery (LSA) branch stent graft. METHODS We reviewed the clinical data and outcomes of consecutive patients enrolled in an ongoing prospective, non-randomized physician-sponsored investigational device exemption study to evaluate the outcomes of endovascular aortic arch repair using patient-specific arch branch stent grafts (William Cook Europe, Bjaeverskov, Denmark) between 2019 and 2022. All patients received a design with triple-wide scallop and a single retrograde LSA branch with a pre-loaded catheter. RESULTS There were five male patients with median age of 77 years old (72-80) treated using the single LSA branch stent graft. Technical success was achieved in all patients. Median operating time, fluoroscopy time, and total radiation dose area product were 103 (78-134) minutes, 26 (19-39) minutes, and 123 (71-270) mGy.cm2, respectively. There were no 30-day or in-hospital mortality, neurological or other major adverse events (MAEs). During median follow-up of 21 (20-27) months, all patients were alive with patent LSA branches, except for one who died of COVID-19 complications. There was no branch instability or secondary interventions. CONCLUSION This early feasibility study demonstrates successful endovascular repair of distal aortic arch aneurysms using a patient-specific stent graft with single retrograde LSA branch without technical failures, mortality or neurological events. Larger clinical experience and longer follow-up are needed to determined effectiveness of this approach in patients who need endovascular repair with proximal extension into Zone 2.
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Affiliation(s)
- Joshua Wong
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Emanuel R Tenorio
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Guilherme Lima
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Marina Dias-Neto
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Bernardo Mendes
- Advanced Aortic Research Program, Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jarin Kratzberg
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, Cook Medical Inc., Bloomington, IN, USA
| | - Laura Ocasio
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Thanila A Macedo
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Gustavo S Oderich
- Advanced Aortic Research Program, Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
- Texas Medical Center, McGovern Medical School, University of Texas Health Science Center, 6400 Fannin, Suite 2850, Houston, TX, 77030, USA.
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Tenorio ER, Vacirca A, Mesnard T, Sulzer T, Baghbani-Oskouei A, Mirza AK, Huang Y, Oderich GS. Technical tips and clinical experience with the Cook Triple inner arch branch stent-graft. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:9-17. [PMID: 36598743 DOI: 10.23736/s0021-9509.22.12569-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Open surgical repair remains the gold standard for treatment for aortic arch diseases, but these operations can be associated with wide heterogeneity in outcomes and significant morbidity and mortality, particularly in elderly patients with severe comorbidities or those who had prior arch procedures via median sternotomy. Endovascular repair has been introduced as a less invasive alternative to reduce morbidity and mortality associated with open surgical repair. The technique evolved with new device designs using up to three inner branches for incorporation of the supra-aortic trunks. This manuscript summarizes technical tips and clinical experience with the triple inner arch branch stent graft for total endovascular repair of aortic arch pathologies.
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Affiliation(s)
- Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Andrea Vacirca
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Thomas Mesnard
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Titia Sulzer
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Aleem K Mirza
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Ying Huang
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA -
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NEXUS Arch: A Multicenter Study Evaluating the Initial Experience With a Novel Aortic Arch Stent Graft System. Ann Surg 2023; 277:e460-e466. [PMID: 33714965 DOI: 10.1097/sla.0000000000004843] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the initial clinical experience with a novel endograft system (NEXUS Aortic Arch Stent Graft System) designed to treat aortic arch pathologies and address the morphology and hemodynamic challenges of the aortic arch. SUMMARY BACKGROUND DATA The aortic arch remains the most challenging part of the aorta for both open and endovascular repair. Transcatheter aortic arch repair has the potential to significantly reduce surgical risks. METHODS Patients underwent transcatheter aortic arch repair with a single branch, 2 stent graft system, implanted over a through-and-through guidewire from the brachiocephalic trunk, to the descending aorta with an ascending aorta stent graft. The ascending aorta stent graft is deployed into a designated docking sleeve to connect the 2 stent grafts and isolate the aortic arch pathology. Proximal landing zone in all cases was in Zone 0. Anatomical inclusion criteria included adequate landing zone in the ascending aorta, brachiocephalic trunk, and descending thoracic aorta. Preparatory debranching procedure was performed in all patients with carotid-carotid crossover bypass and left carotid to left subclavian bypass, or parallel graft from descending aorta to left subclavian artery. Safety and performance were evaluated through 1 year. Survival analysis used the Kaplan-Meier method. RESULTS Twenty-eight patients, 79% males, with a mean age of 72.2 ± 6.2 years were treated with 100% procedural success. Isolated aortic arch aneurysm was the principle pathology in 17 (60.7%) of patients, while chronic aortic dissection was the principle pathology in 6 (21.4%) of patients. The remaining 5 (17.8%) had combined or other pathologies. At 1 month, the vascular pathology was excluded in 25 of 26 alive patients (96.1%). The 30 days mortality rate was 7.1%, stroke rate was 3.6% (all nondisabling), and combined mortality/stroke rate was 10.7%. One-year mortality was 10.7%, without device or aneurysm-related death. Two patients (7.1%) reported stroke or transient ischemic attack at 1 year that recovered completely. One year combined mortality/stroke rate was 17.8%. There were 3 patients (10.7%) that had device-related unplanned reinterventions through 1 year. CONCLUSIONS The NEXUS Aortic Arch Stent Graft System, a novel single branch, 2 stent graft system used for endovascular aortic arch repair that requires landing in the ascending aorta, demonstrates a high success rate with excellent 1 year safety and performance.
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Simonte G, Isernia G, Gatta E, Neri E, Parlani G, Candeloro L, Schiavon S, Pagliariccio G, Cini M, Lenti M, Carbonari L, Ricci C. Inner branched complex aortic repair outcomes from a national multicenter registry using the E-xtra design platform. J Vasc Surg 2023; 77:338-346. [PMID: 36070846 DOI: 10.1016/j.jvs.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Complex aortic pathology still represents an open issue in contemporary endovascular management, with continuous technological advancement being introduced in practice over time aiming to improve outcomes. Thus far, the dualism between the fenestrated and branched configuration for visceral artery revascularization is yet unsolved, with each approach having its own pros and cons. The inner branched technology for endovascular aneurysm repair (iBEVAR) aims to take the best out of both strategies, offering wide applicability and stable bridging stent sealing. The objective of this study was to evaluate the early outcomes obtained with a single manufacturer custom-made inner-branched endograft in a multicenter Italian experience. METHODS All patients consecutively treated with E-xtra design devices in three Italian facilities were enrolled. Anatomic characteristics and perioperative data were analyzed. The main objective was to asses technical and clinical success after iBEVAR. Secondary end points were overall survival, aortic-related mortality, target visceral vessel (TVV) patency, and freedom from target vessel instability during follow-up. RESULTS From 2016 to 2021, 45 patients were treated with an E-xtra design device revascularizing at least one visceral vessel through an inner branch. The mean age at the time of the procedure was 71.1 ± 9.3 years and 77.8% were males. The total number of target visceral arteries to be bridged with an inner branch was 159. The extent of aortic repair was thoracoabdominal in 91.1% of the cases. Technical success was achieved in 93.3% of the procedures (42/45) with all failures owing to a type I endoleak at final angiography. Each TVV was successfully connected to the graft's main body as planned without complications. Following their intervention, five patients developed spinal cord ischemia and in three of these cases symptoms persisted after discharge (6.7%). At 30 days clinical success was 93.3% (42/45). No death as well as no TVV thrombosis occurred within 30 days from the primary procedures. The mean follow-up was 22.8 ± 14.2 months. The Kaplan-Meier estimate of overall survival and TVV patency at 36 months were 83.9% and 95.9%, respectively. CONCLUSIONS Inner branches seem to be a promising technology in the complex aortic repair landscape, with an applicability ranging from type II thoracoabdominal aneurysm to type I endoleak repair after infrarenal endografting. Whether iBEVAR could offer results comparable with those provided by fenestrated/branched endovascular aneurysm repair in terms of target vessel patency and stent stability is yet to be established and further studies are, therefore, needed.
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Affiliation(s)
- Gioele Simonte
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy.
| | - Giacomo Isernia
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Emanuele Gatta
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Eugenio Neri
- Cardiac and Great Vessels Surgery Unit, University of Siena, Siena, Italy
| | - Gianbattista Parlani
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Laura Candeloro
- Vascular and Interventional Radiology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Sara Schiavon
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, Ancona, Italy
| | | | - Marco Cini
- Vascular and Interventional Radiology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Massimo Lenti
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Luciano Carbonari
- Vascular and Endovascular Surgery Unit, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Carmelo Ricci
- Vascular and Interventional Radiology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
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Mesnard T, Vacirca A, Oderich GS, Haulon S. Patient selection and anatomical considerations for zone 0 endovascular aneurysm arch repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:3-8. [PMID: 36763068 DOI: 10.23736/s0021-9509.22.12591-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Endovascular aortic arch repair has been widely used in select patients who are considered high risk for open surgical repair and have suitable anatomy. The anatomical challenges of placement of stent-grafts in the ascending aorta are many, including the curved configuration, short landing zone, proximity to the aortic valve and coronary arteries and need to incorporate the supra-aortic trunks. Stent-graft designs with fenestrations and/or directional branches are applicable to patients who have suitable landing zones in the aorta and supra-aortic trunks, adequate access and absence of significant atheromatous debris. These devices include single and multibranch concepts, which are used in combination or not with cervical debranching procedures. This article summarizes the most commonly used anatomical criterion with currently utilized arch branch stent-grafts.
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Affiliation(s)
- Thomas Mesnard
- The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Andrea Vacirca
- The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Gustavo S Oderich
- The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Stephan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University Paris Saclay, Paris, France -
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Preliminary results from an Italian National Registry on the outcomes of the Najuta fenestrated aortic arch endograft. J Vasc Surg 2023; 77:1330-1338.e2. [PMID: 36621617 DOI: 10.1016/j.jvs.2022.12.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Arch pathology represents one of the last frontiers in aortic aneurysm endovascular management. Several companies recently developed dedicated branched and fenestrated endografts specifically designed for the aortic arch, aiming to overcome some of the issues associated with standard thoracic endograft and supra-aortic vessels extra-anatomic debranching. This study aimed to evaluate early outcomes obtained with a custom-made fenestrated endograft approved for thoracic aortic aneurysms exclusion. METHODS All consecutive patients treated with the Najuta endograft (Kawasumi Laboratories, Inc, Tokyo, Japan) in Italy were enrolled prospectively and included in the study population. Anatomic characteristics and perioperative data were analyzed retrospectively. Study end points were technical success, 30-day clinical success, overall survival, supra-aortic vessel patency, endoleak, and need for reintervention or surgical conversion. RESULTS Between 2018 and 2022, 76 patients received a Najuta endograft in Italy and were enrolled in the study. The median patient age was 72 years (interquartile range, 69-76 years) and 80.3% were male. Most of the patients received treatment for atherosclerotic aneurysms (80.3%); others were treated for postdissection aneurysms (7.9%), penetrating aortic ulcer (9.2%), or type I endoleak correction after previous thoracic endovascular repair (2.6%). Overall, 161 supra-aortic vessels were preserved through a dedicated fenestration. Technical success was achieved in 74 of 76 procedure (97.4%); both failures were associated with endoleak detection at final angiography (one type I and one type III endoleak). Two distal migrations occurred during the implanting procedure. Clinical success at 30 days was 94.7%. Two early reinterventions were needed within 30 days after index procedure: in one case, an aortic false lumen coils embolization was performed, because distal re-entry caused enlargement of the postdissection thoracic aneurysm. The other procedure consisted of a femoral pseudoaneurysm repair. The median follow-up was 7 months (interquartile range, 3-15 months); no supra-aortic vessel occlusions occurred and no patients needed surgical conversion. CONCLUSIONS Early results suggest that, in selected patients with aortic arch pathology needing a proximal landing, an endovascular approach with the Najuta system is safe and effective, especially for those at high surgical risk. A strict follow-up with high-quality computed tomography angiography images and eventual evaluation for long-term complications is needed to confirm these initial experience findings.
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Basha AM, Moore RD, Rommens KL, Herget EJ, McClure RS. A Systematic Review of Total Endovascular Aortic Arch Repair: A Promising Technology. Can J Cardiol 2023; 39:49-56. [PMID: 36395997 DOI: 10.1016/j.cjca.2022.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 10/26/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Total endovascular aortic arch repair (TEAAR) represents an emerging alternative for the treatment of aortic arch disease in patients at prohibitive risk for open surgery. A systematic review of TEAAR was performed to delineate early outcomes with this new technology. METHODS All studies (excluding single-patient case reports) of CE-certified "custom made" or "off-the-shelf" zone 0 stent graft deployments were included. The primary search of Medline, Embase, CINAHL, and the Cochrane CENTRAL registry was supplemented with searches of Web of Science, ClinicalTrials.gov, and conference abstracts (within last 3 years), and a hand search of citations within relevant articles. Articles underwent 2-stage screening by 2 independent reviewers before inclusion. RESULTS Fifteen relevant investigations were identified. Indications for TEAAR were chronic arch dissection with degenerative aneurysmal disease (54%, 148/273), pure arch aneurysm (41%, 112/273), penetrating atherosclerotic ulcer (2%, 5/273), and type IA endoleak from a zone 2 thoracic endograft (1%, 3/273). Double-branch (70%, 192/273), triple-branch (19%, 53/273), and single-branch (into innominate artery; 10%, 28/273) devices were used. Adjunct left carotid-subclavian bypass occurred in 90% of double- and single-branch procedures. Procedural success with TEAAR was 93% (95% CI 85.8%-96.3%). The proportion of all-cause mortality was 16% (95% CI 8%-26%), stroke 14% (8%-24%), peripheral vascular events 7% (1%-33%), and myocardial infarction 4% (2%-7%). Endoleaks were identified in 13% (7%-25%) of the study population. CONCLUSIONS TEAAR represents an emerging option for the management of aortic arch disease wth high procedural success rates and acceptable early outcomes in a high-risk patient population.
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Affiliation(s)
- Ameen M Basha
- Division of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Randy D Moore
- Division of Vascular Surgery, Department of Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Kenton L Rommens
- Division of Vascular Surgery, Department of Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Eric J Herget
- Division of Interventional Radiology, Department of Diagnostic Imaging, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - R Scott McClure
- Division of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
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Kamman AV, van Bakel PAJ, Yang B, Williams DM, Kim KM, Khaja MS, Moll FL, van Herwaarden JA, Trimarchi S, Eagle KA, Eliason JL, Patel HJ. Stroke Following Thoracic Endovascular Aortic Repair: Determinants, Short and Long Term Impact. Semin Thorac Cardiovasc Surg 2023; 35:19-30. [PMID: 35091051 DOI: 10.1053/j.semtcvs.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/18/2021] [Indexed: 11/11/2022]
Abstract
We performed a contemporary assessment of clinical and radiographic factors of stroke after thoracic endovascular aortic repair (TEVAR). Patients undergoing TEVAR from 2006 to 2017 were identified. We assessed clinical and radiographic data, including preoperative head and neck computed tomography, Doppler ultrasonography, and intraoperative angiography. Our primary outcome was stroke after TEVAR. Four hundred seventy-nine patients underwent TEVAR, mean age 68.1 ± 19.5 years, 52.6% male. Indications for TEVAR included aneurysms (n = 238, 49.7%) or dissections (n = 152, 31.7%). Ishimaru landing zones were Zone 2 (n = 225, 47.0%), Zone 3 (n = 151, 31.5%), or Zone 4 (n = 103, 21.5%). Stroke occurred in 3.8% (n = 18) of patients, with 1.9% (8) major events (modified Rankin Scale >3). Pathophysiology was predominantly embolic (n = 14), and occurred in posterior (n = 6), anterior (n = 6), or combined circulation (n = 4), and in the left hemisphere (n = 10) or bilateral (n = 6). Univariate analysis suggested use of lumbar drain (33.3% versus 57.2%, P = 0.04), inability to revascularize the left subclavian artery (16.7% vs 5.2%, P = 0.04) and number of implanted components (2.5 ± 1.2 vs 2.0 ± 0.97, P = 0.03) were associated with stroke. Multivariable analysis identified number of implanted components (OR 1.7, 95%CI 1.17-2.67 P = 0.00) and inability to revascularize the left subclavian artery as independent predictors of stroke. Stroke was associated with a higher perioperative mortality (27.8% vs 3.9%, P < 0.01). Stroke after TEVAR is primarily embolic in nature and related to both anatomic and procedural factors. This may have important implications for device development in the era of endovascular arch repair.
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Affiliation(s)
- Arnoud V Kamman
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Italy; Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Pieter A J van Bakel
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Bo Yang
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - David M Williams
- Department of Radiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Karen M Kim
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Minhaj S Khaja
- Department of Radiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Italy
| | - Kim A Eagle
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Jonathan L Eliason
- Department of Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Himanshu J Patel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan.
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Atkins AD, Atkins MD. Branched and Fenestrated Aortic Endovascular Grafts. Methodist Debakey Cardiovasc J 2023; 19:15-23. [PMID: 36910555 PMCID: PMC10000330 DOI: 10.14797/mdcvj.1200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 02/08/2023] [Indexed: 03/09/2023] Open
Abstract
Endovascular repair of abdominal and descending thoracic aortic aneurysms has become the standard of care due to improvements in morbidity and mortality compared to open surgical repair. Late durability, however, remains an issue because persistent endoleaks can lead to continued aneurysm expansion and eventual rupture, sometimes years following the original repair. Branched, fenestrated, and physician-modified endografts in the thoracic arch and thoracoabdominal aorta have extended the seal zone in order to mitigate the risks of proximal and distal endoleaks. This review summarizes the current state of branched, fenestrated, and physician-modified endografts used in complex aortic pathologies.
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Affiliation(s)
- Aidan D Atkins
- Texas A&M University Department of Biomedical Engineering, College Station, Texas, US
| | - Marvin D Atkins
- Houston Methodist DeBakey Cardiovascular Surgery Associates, Houston, Texas, US
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 446] [Impact Index Per Article: 223.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Liang NL, Dake MD, Fischbein MP, Bavaria JE, Desai ND, Oderich GS, Singh MJ, Fillinger M, Suckow BD, Matsumura JS, Patel HJ, Makaroun MS. Midterm Outcomes of Endovascular Repair of Aortic Arch Aneurysms with the Gore Thoracic Branch Endoprosthesis. Eur J Vasc Endovasc Surg 2022; 64:639-645. [PMID: 35970335 DOI: 10.1016/j.ejvs.2022.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 07/17/2022] [Accepted: 08/05/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Aortic aneurysms involving aortic arch vessels are anatomically unsuitable for standard thoracic endovascular repair (TEVAR) without cervical debranching of the arch vessels. Three year outcomes of a single branched thoracic endograft following previous publication of peri-operative and one year outcomes are reported. METHODS This was a multicentre feasibility trial of the GORE TAG Thoracic Branch Endoprosthesis (TBE), a thoracic endovascular graft incorporating a single retrograde branch for aortic arch vessel perfusion. The first study arm enrolled patients with an intact descending thoracic aortic aneurysm extending to the distal arch with left subclavian artery (LSA) incorporation (zone 2). The second arm enrolled patients with arch aneurysms requiring incorporation of the left carotid or innominate artery (zone 0/1) and extra-anatomic surgical revascularisation of the remaining aortic arch vessels. Outcomes at three years are reported. RESULTS The cohort comprised 40 patients (31 zone 2, nine zone 0/1). The majority were male (52%). Mean follow up was 1 408 ± 552 days in the zone 2 and 1 187 ± 766 days in the zone 0/1 cohort. During three year follow up there was no device migration, fracture, or aortic rupture in either arm. In the zone 2 arm, freedom from re-intervention was 97% at one and three years but there were two side branch occlusions. Two patients had aneurysm enlargement > 5 mm without documented endoleak or re-intervention. Freedom from death at one and three years was 90% and 84%. In the zone 0/1 arm there were no re-interventions, loss of branch patency, or aneurysm enlargement at three years. Cerebrovascular events occurred in three patients during follow up: two unrelated to the device or procedure, and one of unknown relationship. Two patients in this arm died during the follow up period, both unrelated to the procedure or the aneurysm. CONCLUSION Initial three year results of the TBE device for endovascular repair of arch aneurysms show favourable patency and durability with low rates of graft related complications.
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Affiliation(s)
- Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA.
| | - Michael D Dake
- Department of Medical Imaging, University of Arizona Health System, Tucson, AZ, USA
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University Hospitals, Palo Alto, CA, USA
| | - Joseph E Bavaria
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nimesh D Desai
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Mark Fillinger
- Section of Vascular of Surgery, Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA
| | - Bjoern D Suckow
- Section of Vascular of Surgery, Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA
| | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison WI, USA
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Centre, Ann Arbor, MI, USA
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
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Hybrid and endovascular approaches to the aortic arch. Curr Opin Cardiol 2022; 37:439-445. [PMID: 36004870 DOI: 10.1097/hco.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The gold standard treatment for aneurysms and dissections involving the aortic arch remains open total arch replacement. High-risk operative candidates may benefit from hybrid or completely endovascular techniques to reduce the risk of perioperative mortality and morbidity. RECENT FINDINGS Numerous endografts are available for investigational use in the aortic arch as part of investigational device exemption (IDE) programs. Some are fenestrated or scalloped, whereas others are branched, ranging from single branch to triple branch stent-grafts. Initial results for completely endovascular repair of the aortic arch are encouraging. Current data estimates that rates of successful deployment of arch endografts ranges from 84.2% to 100%, whereas operative mortality may be as high as 13.2%, with stroke rates being as high as 20% and spinal cord ischemia being as high as 3.1%. SUMMARY More data are necessary to compare hybrid and endovascular stent-grafting of the aortic arch to conventional open total arch replacement. Longitudinal follow-up is also lacking, which will determine the long-term durability of endografts in the aortic arch. However, endovascular repair represents an important opportunity for improving outcomes in high-risk patients with complex aneurysms and dissections of the aortic arch.
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Nana P, Tyrrell MR, Guihaire J, Le Houérou T, Gaudin A, Fabre D, Haulon S. A review: Single and multi-branch devices for the treatment of aortic arch pathologies with proximal sealing in Ishimaru Zone 0. Ann Vasc Surg 2022:S0890-5096(22)00618-5. [PMID: 36309169 DOI: 10.1016/j.avsg.2022.09.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/23/2022] [Accepted: 09/28/2022] [Indexed: 11/27/2022]
Abstract
Recently published experience has shown that endovascular management of the aortic arch, including sealing in the proximal zones, can be a viable option for patients considered unfit for conventional open repair. Endograft designs vary and include single or multibranch devices, with or without the addition of surgical debranching. Initial reports show that both techniques can be performed with high technical success and acceptable perioperative morbidity and mortality rates in high volume centers. Single branch devices, available off-the-shelf, may provide a treatment option for emergent presentations where patients cannot wait for the design and manufacture of a customized endograft. Double or triple branched endografts are now increasingly implanted in high-volume aortic centers. The purpose of this review is to describe the single and multibranched endovascular devices currently available for aortic arch repair, their associated published outcomes, and to discuss their relative advantages and disadvantages.
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Lescan M. [Status of the Inner Branches in Complex Endovascular Aortic Repair]. Zentralbl Chir 2022; 147:447-452. [PMID: 36220065 DOI: 10.1055/a-1938-8269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Complex endovascular therapy of the aorta with fenestrated and branched endografts plays an essential role in modern vascular medicine. Innovative solutions for demanding aortic pathologies are therefore being constantly developed by the medical industry. The aim of this manuscript is to illustrate the growing importance of the inner branches in complex aortic repair and to show the advantages and limits of this technique with an overview of the current literature. The inner branches (iBEVAR) were therefore compared to the standard treatment options (fenestrations; [FEVAR], outer branches [BEVAR]) and the technical advantages of all platforms were evaluated. The widespread use of iBEVAR in the aortic arch stands in contrast to the thoracoabdominal aorta, which is mirrored by the scarce evidence for the thoracoabdominal inner branches. The published experience is based on smaller retrospective studies with a 1-year follow-up. The E-nside (Artivion, Hechingen, Germany) thoracoabdominal off-the-shelf inner-branch-based endograft was released 2 years ago. Its widespread deployment may increase the use of the inner branches in the thoracoabdominal aorta. Moreover, an ongoing industry-funded registry may provide new insights into the long-term durability of this innovative technique.
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Affiliation(s)
- Mario Lescan
- Klinik für Thorax-, Herz- und Gefäßchirurgie, Sektion Gefäßchirurgie, Universitätsklinikum Tübingen, Tübingen, Deutschland
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