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Chen W, Liu D, Chen T, Liu J, Guo Y, Ye B. Treatment for Stanford type B aortic dissection with insufficient anchoring region using castor integrated branched aortic stent graft. Front Cardiovasc Med 2024; 11:1351342. [PMID: 38601044 PMCID: PMC11006418 DOI: 10.3389/fcvm.2024.1351342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/20/2024] [Indexed: 04/12/2024] Open
Abstract
Background To investigate the clinical efficacy of Castor integrated branched aortic stent graft for the treatment of Stanford type B aortic dissection with insufficient anchoring area. Methods Retrospective analysis of clinical data of 26 patients with Stanford type B aortic dissection with insufficient anchoring region (<15 mm) treated by Castor branched aortic stent graft from September 2018 to June 2022 at Ganzhou People's Hospital, including 23 acute cases and 3 chronic cases. Results Surgical procedures were successfully performed in all 26 patients, and during the perioperative period no complications occurred, such as cerebrovascular accident, stenosis or occlusion of left subclavian artery, progression of reverse avulsion of aortic dissection, and paraplegia. During the operation 2 patients had a small amount of type I endoleak, which disappeared during the postoperative follow-up. The other patients had good postoperative follow-up results. Review of the aortic CTA indicated good stent morphology with patency of the left subclavian artery. Conclusions The Castor integrated branched aortic stent graft expanded the indications for endoluminal treatment for Stanford type B aortic dissection, which can avoid open surgery and has good clinical outcomes.
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Affiliation(s)
- Weiqing Chen
- Department of Vascular Surgery, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Dabing Liu
- Department of General Surgery, The People’s Hospital of Ganxian District, Ganzhou, Jiangxi, China
| | - Tao Chen
- Department of Vascular Surgery, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Jian Liu
- Department of Vascular Surgery, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Yi Guo
- Department of Vascular Surgery, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Bo Ye
- Department of Vascular Surgery, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
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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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Zhao Y, Zeng Z, Bao X, Wu M, Feng J, Jing Z, Feng R. TEVAR for aortic arch lesions combining physician-modified endograft and in-situ fenestration. INT ANGIOL 2023; 42:412-419. [PMID: 37962899 DOI: 10.23736/s0392-9590.23.05063-0] [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: 11/15/2023]
Abstract
BACKGROUND The aim of this retrospective study was to investigate the outcomes of combining physician-modified endograft (PMEG) and in-situ fenestration (ISF) for aortic arch repair. METHODS A retrospective analysis was performed in 12 patients with aortic arch pathologies who underwent thoracic endovascular aortic repair with PMEG and ISF between June 2019 and February 2020. RESULTS Revascularizations of supra-aortic arteries were successfully performed in 91.7% patients (11/12). One patient with aberrant right subclavian artery was unsuccessful because of tortuosity and sharp angle. One patient received endovascular exclusion by Viabahn due to artery injury of the femoral access. During the follow-up (mean 22.7 months), one patient underwent Bentall surgery because of retrograde type A aortic dissection, and one patient received coils embolization due to occurrence of a type I endoleak. In addition, one patient died of myocardial infarction 13 months after surgery. Results obtained after computed tomography angiography confirmed patency of all the supra-aortic arteries. CONCLUSIONS Combining PMEG and ISF could be a feasible option for aortic arch lesions in selected patients. Long-term durability concerns require further evaluation.
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Affiliation(s)
- Yuxi Zhao
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Zhaoxiang Zeng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Xianhao Bao
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Mingwei Wu
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Jiaxuan Feng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Rui Feng
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China -
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Wu X, Li Y, Zhao Y, Zhu Y, Wang S, Ma Q, Liu D, Gao B, Wei S, Wang W. Efficacy of left subclavian artery revascularization strategies during thoracic endovascular aortic repair in patients with type B dissection: A single-center experience of 105 patients. Front Cardiovasc Med 2023; 10:1084851. [PMID: 37077745 PMCID: PMC10106686 DOI: 10.3389/fcvm.2023.1084851] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/15/2023] [Indexed: 04/05/2023] Open
Abstract
BackgroundLeft subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) is necessary to reduce postoperative complications in patients with Stanford type B aortic dissection and an insufficient proximal anchoring area. However, the efficacy and safety of different LSA revascularization strategies remain unclear. Here, we compared these strategies to provide a clinical basis for selecting an appropriate LSA revascularization method.MethodsIn this study, we included 105 patients with type B aortic dissection who were treated using TEVAR combined with LSA reconstruction in the Second Hospital of Lanzhou University from March 2013 to 2020. They were divided into four groups according to the method used for LSA reconstruction, namely, carotid subclavian bypass (CSB; n = 41), chimney graft (CG; n = 29), single-branched stent graft (SBSG; n = 21), and physician-made fenestration (PMF; n = 14) groups. Finally, we collected and analyzed the baseline, perioperative, operative, postoperative, and follow-up data of the patients.ResultsThe treatment success rate was 100% in all the groups, and CSB + TEVAR was the most commonly used procedure in emergency settings compared with the other three procedures (P < 0.05). The estimated blood loss, contrast agent volume, fluoroscopic time, operation time, and limb ischemia symptoms during the follow-up were significantly different in the four groups (P < 0.05). Pairwise comparison among groups indicated that the estimated blood loss and operation time in the CSB group were the highest (adjusted P < 0.0083; P < 0.05). The contrast agent volume and fluoroscopy duration were the highest in the SBSG groups, followed by PMF, CG, and CSB groups. The incidence of limb ischemia symptoms was the highest in the PMF group (28.6%) during the follow-up. The incidence of complications (except limb ischemia symptoms) during the perioperative and follow-up periods was similar among the four groups (P > 0.05) The median follow-up time of CSB, CG, SBSG, and PMF groups was significantly different (P < 0.05), and the CSB group had the longest follow-up.ConclusionOur single-center experience suggested that the PMF technique increased the risk of limb ischemia symptoms. The other three strategies effectively and safely restored LSA perfusion in patients with type B aortic dissection and had comparable complications. Overall, different LSA revascularization techniques have their advantages and disadvantages.
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Affiliation(s)
- Xiangyang Wu
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Yinglu Zhao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Yilin Zhu
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Shixiong Wang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Qi Ma
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Debin Liu
- Department of Cardiac Surgery, Hainan General Hospital, Hainan, China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Shilin Wei
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Correspondence: Weifan Wang Shilin Wei
| | - Weifan Wang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Correspondence: Weifan Wang Shilin Wei
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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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Yao S, Chen X, Liao Y, Ding G, Li D, Qin G, Qiao R, Sun X, Zheng Q. Systematic review and meta-analysis of type B aortic dissection involving the left subclavian artery with a Castor stent graft. Front Cardiovasc Med 2022; 9:1052094. [PMID: 36523362 PMCID: PMC9745178 DOI: 10.3389/fcvm.2022.1052094] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/07/2022] [Indexed: 09/05/2023] Open
Abstract
OBJECTIVE Despite the rapid development of thoracic endovascular aortic repair (TEVAR), it is still a challenge to maintain the blood flow of the branch arteries above the aortic arch in Stanford type B aortic dissection involving the left subclavian artery (LSA). The Castor stent graft is an integrated, customized, single-branch stent that enables reconstruction of the LSA. The purpose of this systematic review and meta-analysis was to assess the efficacy of the Castor stent graft for type B aortic dissection. MATERIALS AND METHODS An extensive electronic literature search (PROSPERO registration number: CRD42022322146) was undertaken to identify all articles published up to August 2022 that described thoracic aortic repair with branch stents in the treatment of type B aortic dissection involving the LSA. The quality of the included studies was analyzed using the MINORS criteria. The primary outcome measures were the technical success rate, early mortality rate, endoleak rate, and 1-year survival rate. The secondary outcome measures were the stroke rate, left upper extremity ischemia rate, and target vessel patency rate. RESULTS Eleven studies involving 415 patients were eligible for this meta-analysis. The LSA was successfully preserved in all procedures. The technical success rate was 97.5% (95% CI: 0.953-0.991); the intraoperative endoleak rate was 0.1% (95% CI: 0.000-0.012); the intraoperative LSA patency rate was 99.52%; the intraoperative LSA stent deformation and stenosis rate was 0.15% (95% CI: 0.000-0.051); the early type I endoleak rate was 1.6% (95% CI: 0.003-0.035); the 30-day mortality rate was 0.96%; the early reintervention rate was 0.9% (95% CI: 0.000-0.040); and the perioperative stroke rate was 0% (95% CI: 0.000-0.005). The 1-year survival rate was 99.7% (95% CI: 0.976-1.000). The half-year LSA patency rate was 99.3%, the 1-year LSA patency rate was 97.58%, and the 2-year LSA patency rate was 95.23%. During the follow-up period, the leakage rate was 0.3% (95% CI: 0.000-0.017), the incidence of left upper extremity ischemia rate was 0.5% (95% CI: 0.000-0.035), and the deformation and stenosis rate of the LSA stent was 2.2% (95% CI: 0.06-0.046). CONCLUSION This meta-analysis shows that endovascular repair of type B aortic dissection using the Castor stent-graft may be technically feasible and effective. However, this conclusion needs to be interpreted with caution, as the quality of evidence for all outcomes is between low and very low. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022322146].
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Affiliation(s)
- Shihua Yao
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Xu Chen
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Yalin Liao
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Gangbing Ding
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Dagang Li
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Gengliang Qin
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Ruiguo Qiao
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Xin Sun
- Department of Cardiovascular Medicine, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Qijun Zheng
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
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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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Wu M, Zhao Y, Zeng Z, Bao X, Li T, Feng R, Feng J, Jing Z. Mid-term Comparison of One-Piece Branched Stent-Graft and Chimney Technique Treating Aortic Arch Pathologies. Cardiovasc Intervent Radiol 2022; 45:733-743. [PMID: 35355095 DOI: 10.1007/s00270-022-03063-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 01/22/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE We compared the mid-term outcomes of a one-piece branched stent-graft with the chimney technique in the treatment of aortic arch pathologies. METHODS Between August 2012 and December 2017, a retrospective analysis of 279 patients with thoracic aortic dissection (TAD) or aneurysm (TAA) who underwent thoracic endovascular aortic repair with b-TEVAR (n = 69, 58 TAD and 11 TAA) or c-TEVAR (n = 210, 151 TAD and 59 TAA) was performed. RESULTS Forty-five double-chimney for the left subclavian artery (LSA) and left common carotid artery LCCA and 165 single-chimney for the LSA were performed in chimney-TEVAR (c-TEVAR) and 69 branched-TEVAR (b-TEVAR) with 36 single-branched stent-grafts and 33 branched stent-grafts combined with fenestration technique. The c-TEVAR group experienced more in-hospital complications than the b-TEVAR group (19.5 vs. 7.2%, p = 0.017), primarily because the c-TEVAR group experienced more in-hospital cerebral ischemia events (6.2 vs. 0%, p = 0.043) and intra-operative type I endoleaks (31.9 vs. 5.8%, p < 0.01). There were significantly more follow-up type I endoleaks (21.9 vs. 4.3%, p = 0.002), cerebral ischemia events (11.0 vs. 2.9%, p = 0.042), and re-interventions (12.9 vs. 4.3%, p = 0.048) in the c-TEVAR group than in the b-TEVAR group. However, follow-up mortality was not significantly different between the c-TEVAR and b-TEVAR groups (5.2 vs. 2.9%, p = 0.638). CONCLUSION In patients with aortic pathologies involving the arch branches, customized b-TEVAR may result in fewer cerebral ischemia events and endoleaks than c-TEVAR. However, c-TEVAR should be considered an off-the-shelf treatment option for patients in need of emergency treatment. LEVEL OF EVIDENCE Level 4, Case Series.
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Affiliation(s)
- Mingwei Wu
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Yuxi Zhao
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Zhaoxiang Zeng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Xianhao Bao
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Tao Li
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Rui Feng
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiaotong University, 650 New Song Jiang Road, Shanghai, 201600, People's Republic of China.
| | - Jiaxuan Feng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China.
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China.
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Li Y, Li Z, Feng J, Feng R, Zhou J, Jing Z. A Novel Solution for Distal Dilation of Chronic Dissection After Repair Involving Visceral Branches: The Road Block Strategy. Front Cardiovasc Med 2022; 9:821260. [PMID: 35355962 PMCID: PMC8959700 DOI: 10.3389/fcvm.2022.821260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/31/2022] [Indexed: 12/02/2022] Open
Abstract
Aim Notwithstanding that unprecedented endovascular progress has been achieved in recent years, it remains unclear what is the best strategy to preserve the blood perfusion of abdominal visceral arteries and promote positive aortic remodeling in patients with distal dilatation of chronic aortic dissection in abdominal visceral part (CADAV) after aortic repair. The present study developed a Road Block Strategy (RBS) to solve this conundrum. Methods and Results This prospective single-center clinical study included patients suffering from symptomatic distal dilatation of CADAV after aortic repair treated with RBS from January 2015 to December 2019 and followed up regularly for at least 2 years. Stent grafts were implanted first to cover distal tears and expand the true lumen. Device embolization was performed to induce proximal and distal segmental false lumen thrombosis (FLT) apart from the level of the ostia of vital branches. Successful RBS was performed in 13 patients. Significant differences were found in maximum true lumen diameter (p < 0.05), blood flow area in false lumen (FL) (p < 0.001), and the ratio of blood lumen to FL area (p < 0.05) between the pre-procedure and the latest follow-up results. No aortic rupture, vital branches occlusion, thoracic and abdominal pain, or death occurred during hospitalization and follow-up. Conclusions Our findings suggest that RBS is feasible in treating distal dilatation of chronic aortic dissection after prior proximal repair, inducing false lumen thrombosis, preventing deterioration of aortic dissection, and maintaining the patency of abdominal visceral arteries.
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Affiliation(s)
- Yiming Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Zhenjiang Li
- Department of Vascular Surgery, The First Affiliated Hospital of the Medical School of Zhejiang University, Hangzhou, China
| | - Jiaxuan Feng
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Rui Feng
- Department of Vascular Surgery, Shanghai General Hospital, Affiliated to Shanghai Jiaotong University, Shanghai, China
| | - Jian Zhou
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
- *Correspondence: Zaiping Jing
| | - Zaiping Jing
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
- Jian Zhou
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Juan S, Liangtao X, Ligang L, Xiang W, Mingjia M. Application of different types of hybrid aortic arch repair:Toward to solve dissection involving the aortic arch. Ann Vasc Surg 2021; 83:222-230. [PMID: 34954031 DOI: 10.1016/j.avsg.2021.11.023] [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: 05/10/2021] [Revised: 11/14/2021] [Accepted: 11/28/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the outcomes and effectiveness of different types of hybrid aortic arch repair for aortic dissection involving the aortic arch. METHODS From 2013 to 2020, 168 patients underwent hybrid aortic arch repair for dissection involving the aortic arch. We collected data from our electronic medical records, including the presenting pathology, perioperative details, and postoperative outcomes. We included the following types of hybrid aortic arch repair: classic type I, type II, and type III hybrid aortic arch repair, as well as the new type IV hybrid aortic repair. We defined type IV hybrid aortic arch repair as revascularization of supra-aortic branches through extra-anatomy bypass without sternotomy, followed by stent-graft placement. RESULTS There were 23, 82, and 63 patients who underwent type I, type II, and type IV hybrid aortic arch repair, respectively. There were no type III hybrid aortic repairs performed. Forty-nine cases were performed urgently. The technical success rate was 99.4%. The early mortality rates of the total group, type I group, type II group, and type IV group were 6.5%, 4.3%, 8.5%, and 4.8%, respectively. Postoperative complications mainly included tracheotomy (8.9%), stroke (6%), wound infection (4.2%), renal insufficiency (8.9%), and endoleak (7.7%). With a mean follow-up of 45.1±28.5 months, the total 1-year and 5-year actual survival rates were 93.5% and 89.0%, respectively. At 6 months, the aortic diameter at the level of the diaphragm decreased significantly (30.8±4.9 mm vs 28.5±6.3 mm, p=0.012), and the rate of thrombosis of the false lumen at the level of pulmonary bifurcation and diaphragm were 95.7% and 83.1%. Ten patients underwent reintervention of the aorta, including 7 endovascular reinterventions, 2 total thoracoabdominal aortic aneurysm repairs, and 1 open total arch replacement. For the total group, the free from aorta reintervention rate at 5 years was 91.4%. CONCLUSION Our results with hybrid aortic arch repair for aortic dissection involving the aortic arch are acceptable. The hybrid aortic arch repair could promote thrombosis of the distal false lumen while excluding intimal tears in the aortic arch.
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Affiliation(s)
- Shi Juan
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Xia Liangtao
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Liu Ligang
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Wei Xiang
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology.
| | - Ma Mingjia
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology.
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Banathy AK, Khaja MS, Williams DM. Update on Trials & Devices for Endovascular Management of the Ascending Aorta and Arch. Tech Vasc Interv Radiol 2021; 24:100756. [PMID: 34602266 DOI: 10.1016/j.tvir.2021.100756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) may treat a variety of acute and chronic aortic diseases as described in several articles in this issue of TVIR. A major challenge to endovascular treatment in the thoracic aorta is disease involving or in close proximity to the aortic valve, coronary arteries, or aortic arch branch vessels. Disease involving the ascending aorta in particular has significant limitations based on its distance from the aortic root. The left subclavian artery (LSA) can be covered in the emergent setting to ensure an adequate landing zone, but patients may require later surgical revascularization, and any coverage of the carotid arteries would require definite pre-endograft revascularization. Open surgical repair continues to have high morbidity and mortality rates in the acute setting, and endovascular therapy is preferred if feasible. Ad hoc modifications of current endografts to maintain arch vessel patency include placement of chimney/snorkel stents or custom fenestrations. However, there is a need for commercially available "off-the-shelf" ascending arch stent-grafts and branched stent-grafts that allow for complete endovascular repair of the aortic arch. This review will focus on devices under investigation for the treatment of pathologies involving the ascending aorta and aortic arch.
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Affiliation(s)
- Alex K Banathy
- Department of Radiology & Medical Imaging; University of Virginia Health, Charlottesville, VA
| | - Minhaj S Khaja
- Department of Radiology & Medical Imaging; University of Virginia Health, Charlottesville, VA; Department of Radiology, University of Michigan-Michigan Medicine, Ann Arbor, MI.
| | - David M Williams
- Department of Radiology, University of Michigan-Michigan Medicine, Ann Arbor, MI
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12
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Imaev TÉ, Salichkin DV, Komlev AE, Kolegaev AS, Kuchin IV, Lepilin PM, Tripoten' MI, Fedotenkov IS, Balakhonova TV, Akchurin RS. Endovascular repair of the aorti arch. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:34-45. [PMID: 34528587 DOI: 10.33529/angiq2021303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM The study was aimed at assessing the in-hospital results of aortic arch endoprosthetic repair using different variants of endovascular supraaortic debranching. PATIENTS AND METHODS The analysis included 27 patients subjected within the framework of aortic arch endoprosthetic repair to various types of supraaortic endobranching, including the technique of parallel prostheses and implantation of fenestrated stent grafts. We analysed the clinical and morphological status of patients prior to operation, peculiarities of the intervention (type of debranching and Ishimaru's classification zones in which the reconstruction was performed) and in-hospital results of treatment. RESULTS The patients' mean age amounted to 66 years. The main nosology (70%) was an aortic aneurysm. Nearly in 30% of cases, the operation was performed emergently for acute aortic syndrome. The main causes of refusal from the traditional prosthetic repair included chronic kidney disease (22.5%), chronic obstructive pulmonary disease (11%), acute cerebral ischaemia within the previous 6 months (15%). The technical success rate of the operation was achieved in 100% of cases. The average duration of the intervention amounted to 226 min, with the mean blood loss equalling 355 ml. The majority of reconstructions were performed in zones 1 and 2 according to Ishimaru (59 and 33%, respectively), in 2 (7%) patients prosthetic repair was performed in zone 0. The total number of the aortic branches involved into reconstruction amounted to 45. Intervention-related complications included 3 (11%) cases of acute cerebral circulation impairment, 2 (7.4%) aortic branch occlusions, and 1 (3.7%) type II endoleak. The in-hospital and 30-day mortality rates amounted to 3.7 and 7.4%, respectively. CONCLUSION Aortic arch endoprosthetic repair using supraaortic endobranching is considered to be an effective alternative method of treatment for patients with various pathology of the aortic arch and contraindications to traditional prosthetic repair involving artificial blood circulation.
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Affiliation(s)
- T É Imaev
- Department of Cardiovascular Surgery, National Medical Research Center of Cardiology of the RF Ministry of Public Health, Moscow, Russia
| | - D V Salichkin
- Department of Cardiovascular Surgery, National Medical Research Center of Cardiology of the RF Ministry of Public Health, Moscow, Russia
| | - A E Komlev
- Department of Cardiovascular Surgery, National Medical Research Center of Cardiology of the RF Ministry of Public Health, Moscow, Russia
| | - A S Kolegaev
- Department of Cardiovascular Surgery, National Medical Research Center of Cardiology of the RF Ministry of Public Health, Moscow, Russia
| | - I V Kuchin
- Department of Cardiovascular Surgery, National Medical Research Center of Cardiology of the RF Ministry of Public Health, Moscow, Russia
| | - P M Lepilin
- Department of Cardiovascular Surgery, National Medical Research Center of Cardiology of the RF Ministry of Public Health, Moscow, Russia
| | - M I Tripoten'
- Department of Ultrasound Diagnosis, National Medical Research Center of Cardiology of the RF Ministry of Public Health, Moscow, Russia
| | - I S Fedotenkov
- Department of Tomography, National Medical Research Center of Cardiology of the RF Ministry of Public Health, Moscow, Russia
| | - T V Balakhonova
- Department of Ultrasound Diagnosis, National Medical Research Center of Cardiology of the RF Ministry of Public Health, Moscow, Russia
| | - R S Akchurin
- Department of Cardiovascular Surgery, National Medical Research Center of Cardiology of the RF Ministry of Public Health, Moscow, Russia
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13
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Brown JA, Arnaoutakis GJ, Szeto WY, Serna-Gallegos D, Sultan I. Endovascular repair of the aortic arch: State of the art. J Card Surg 2021; 36:4292-4300. [PMID: 34405439 DOI: 10.1111/jocs.15920] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Open total arch replacement remains the gold standard treatment for aneurysms and dissections involving the aortic arch. However, high-risk surgical candidates may benefit from endovascular techniques to reduce the risk of perioperative mortality and morbidity, especially neurologic complications. Numerous endografts are available for investigational use in the aortic arch as part of investigational device exemption (IDE) programs. Some devices are fenestrated or scalloped, while others are branched, ranging from single branch to triple branch stent-grafts. Furthermore, chimney techniques and in situ fenestration may be utilized in bailout or emergent situations. RESULTS Initial results describing outcomes of complete endovascular repair of the aortic arch are encouraging, with current data estimating that technical success ranges from 84.2% to 100%. Moreover, operative mortality may be as high as 13.2%, while neurologic complications also remain common, with stroke rates being as high as 20% and spinal cord ischemia being as high as 3.1%. However, more data are necessary to determine the comparative treatment effect of endovascular stent-grafting of the aortic arch, compared with conventional open and hybrid repairs. Longitudinal follow-up is also lacking, which will determine the long-term durability of endografts in the aortic arch. Nevertheless, endovascular repair represents an important opportunity for improving outcomes in patients with complex and potentially devastating pathologies of the aortic arch.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - George J Arnaoutakis
- Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Derek Serna-Gallegos
- UPMC Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,UPMC Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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14
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Branch stent-grafting for endovascular repair of chronic aortic arch dissection. J Thorac Cardiovasc Surg 2021; 162:12-22.e1. [DOI: 10.1016/j.jtcvs.2019.10.184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 12/27/2022]
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15
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Shi J, Liu L, Wei X, Ma M. Back-Table Modified Stent-Graft for Endovascular Repair of Ascending Aorta. J Endovasc Ther 2021; 28:888-896. [PMID: 34190632 DOI: 10.1177/15266028211028201] [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: 11/16/2022]
Abstract
OBJECTIVES To investigate the effectiveness of modified stent-grafts (SGs) for the management of ascending aortic pathologies. MATERIALS AND METHODS From January 2015 to December 2019, 31 individuals were treated by ascending aortic endovascular repair with a back-table modified SG for acute (n=4) or chronic (n=1) type A aortic dissections, penetrating aortic ulcers (n=18), pseudoaneurysms (n=2), anastomotic fistula (n=1), and endoleaks after thoracic endovascular aortic repair (TEVAR) (n=5). The commercially available thoracic aortic SGs were modified with a fenestration or truncation technique on the back-table according to aortography during the operation. RESULTS The 30-day mortality and aorta-related mortality rates were 12.9% and 6.5%, respectively. There were 2 strokes, 3 respiratory insufficiencies, and 6 endoleaks during hospitalization. During a mean follow-up of 28.8±16.6 months, the overall survival rates at 1 year and 3 years were both 80.6%. Free from adverse event rates at 1 year and 3 years were 88.9% and 84.7%, respectively. There were 2 deaths during follow-up: One patient died of cachexia 1 month after discharge, and the other patient died of acute myocardial infarction 3 months after discharge. One patient with a pseudoaneurysm underwent open ascending aorta replacement 3 months after discharge for a type Ia endoleak. Another patient suffered from cerebellar infarction 17 months after discharge. CONCLUSION The modified SG for endovascular repair of the ascending aorta is a practicable alternative and presents acceptable outcomes in high-risk patients.
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Affiliation(s)
- Juan Shi
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ligang Liu
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiang Wei
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Mingjia Ma
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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16
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Li X, Zhang L, Song C, Zhang H, Xia S, Li H, Jing Z, Lu Q. Long-Term Outcomes of Thoracic Endovascular Repair for Aortic Arch Dissection Using Customized Single-Branched Fenestrated Stent-Graft. Vasc Endovascular Surg 2021; 55:577-585. [PMID: 34036846 DOI: 10.1177/15385744211010446] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To report outcomes of thoracic endovascular repair using customized single-branched fenestrated stent-grafts in treatment of aortic arch dissections. MATERIALS AND METHODS Between November 2009 and November 2011, 16 patients with aortic arch dissections underwent thoracic endovascular aortic repair utilizing customized unibody single-branched fenestrated stent-graft (UBFSG) in our institution. RESULTS All 16 patients were male with mean age of 54.50 ± 11.33. The technical success rate was 100%. 30-day mortality rate was 6.25% (n = 1). The median follow-up period was 98 months (range, 0-119). During follow-up, 4 nonaorta-related deaths were recorded. Two (2) cases of left subclavian artery occlusion were observed 12 and 14 months after the operation. Two (2) patients had another successful endovascular repair in time, including one case of type Ib endoleak occurred 100 months after the operation and one case of stent-graft induced new entry tear 38 months after the operation. No stroke and migration of stent-grafts were observed. CONCLUSIONS The branched fenestrated stent-graft may be an effective alternative treatment for aortic arch dissections unfit for open surgery.
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Affiliation(s)
- Xiaoye Li
- Department of Vascular Surgery, 12520Changhai Hospital, Naval Medical University, Shanghai, China.,Basic Medical School, Naval Medical University, Shanghai, China
| | - Lei Zhang
- Department of Vascular Surgery, 12520Changhai Hospital, Naval Medical University, Shanghai, China
| | - Chao Song
- Department of Vascular Surgery, 12520Changhai Hospital, Naval Medical University, Shanghai, China
| | - Hao Zhang
- Department of Vascular Surgery, 12520Changhai Hospital, Naval Medical University, Shanghai, China
| | - Shibo Xia
- Department of Vascular Surgery, 12520Changhai Hospital, Naval Medical University, Shanghai, China
| | - Haiyan Li
- Department of Vascular Surgery, 12520Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zaiping Jing
- Department of Vascular Surgery, 12520Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qingsheng Lu
- Department of Vascular Surgery, 12520Changhai Hospital, Naval Medical University, Shanghai, China
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17
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Endovascular Treatment of Post Type A Chronic Aortic Arch Dissection With a Branched Endograft: Early Results From a Retrospective International Multicenter Study. Ann Surg 2021; 273:997-1003. [PMID: 30973389 DOI: 10.1097/sla.0000000000003310] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the outcome of endovascular aortic arch repair for chronic dissection with a custom-made branched endograft. BACKGROUND Acute type A aortic dissections are often treated with prosthetic replacement of the ascending aorta. During follow-up, repair of an aneurysmal evolution of the false lumen distal to the ascending prosthesis can be a challenge both for the surgeon and the patient. METHODS We conducted a multicenter, retrospective study of consecutive patients from 14 vascular units treated with a custom-made, inner-branched device (Cook Medical, Bloomington, IN) for chronic aortic arch dissection. Rates of in-hospital mortality and stroke, technical success, early and late complications, reinterventions, and mortality during follow-up were evaluated. RESULTS Seventy consecutive patients were treated between 2011 and 2018. All patients were considered unfit for conventional surgery. In-hospital combined mortality and stroke rate was 4% (n = 3), including 1 minor stroke, 1 major stroke causing death, and 1 death following multiorgan failure. Technical success rate was 94.3%. Twelve (17.1%) patients required early reinterventions: 8 for vascular access complication, 2 for endoleak correction, and 2 for pericardial effusion drainage. Median follow-up was 301 (138-642) days. During follow-up, 20 (29%) patients underwent secondary interventions: 9 endoleak corrections, 1 open repair for prosthetic kink, and 10 distal extensions of the graft to the thoracic or thoracoabdominal aorta. Eight patients (11%) died during follow-up because of nonaortic-related cause in 7 cases. CONCLUSIONS Endovascular treatment of aortic arch chronic dissections with a branched endograft is associated with low mortality and stroke rates but has a high reintervention rate. Further follow-up is required to confirm the benefits of this novel approach.
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Gordeev ML, Uspenskiĭ VE, Rubinchik VE, Kotin AN, Skripnik AI, Zverev DA. [Removal of ascending aortic dissection and residual blood flow after transcatheter isolation of descending aortic dissection]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:65-71. [PMID: 33825730 DOI: 10.33529/angio2021111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Presented herein is a clinical case report concerning successful simultaneous surgical treatment of a female patient with a complication after transcatheter treatment for chronic dissection of the descending portion of the thoracic aorta. The woman was subjected to elective transcatheter isolation of chronic dissection of the descending thoracic aorta using a stent graft with complete coverage of the zone of the origin of the left subclavian artery. Repeat control imaging studies several months after the intervention revealed residual blood flow through the false channel, directed retrogradely from the distal edge of the stent graft to the left subclavian artery. Besides, the patient was also found to have local dissection of the distal part of the ascending aorta (zone 0). An operative intervention was performed: sternotomy, prosthetic repair of the ascending portion of the aorta and part of the aortic arch, as well as transposition of the left subclavian artery to the left common carotid artery. The control imaging studies confirmed radical removal of the false aneurysm of the ascending aorta and the presence of total thrombosis of the false channel at the level of the stent graft.
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Affiliation(s)
- M L Gordeev
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - V E Uspenskiĭ
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - V E Rubinchik
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - A N Kotin
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - A Iu Skripnik
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - D A Zverev
- Scientific Research Laboratory of Surgery for Cardiac Defects and Ischaemic Heart Disease, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
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19
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De Freitas S, Rossi MJ, Abramowitz SD, Fatima J, Kiguchi MM, Vallabhaneni R, Walsh SR, Woo EY. Systematic review and meta-analysis of endovascular interventions for Stanford type A aortic dissection. J Vasc Surg 2021; 74:1721-1731.e4. [PMID: 33592292 DOI: 10.1016/j.jvs.2021.01.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The standard surgical approach to Stanford type A aortic dissection is open repair. However, up to one in four patients will be declined surgery because of prohibitive risk. Patients who are treated nonoperatively have an unacceptably high mortality. Endovascular repair of the ascending aorta is emerging as an alternative treatment for a select group of patients. The reported rates of technical success, mortality, stroke, and reintervention have varied. The objective of the study was to systematically report outcomes for acute type A dissections repaired using an endovascular approach. METHODS The systematic review and meta-analysis was conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. We performed online literature database searches through April 2020. The demographic and procedural characteristics of the individual studies were tabulated. Data on technical success, short-term mortality, stroke, and reintervention were extracted and underwent meta-analysis using a random effects model. RESULTS Fourteen studies with 80 cases of aortic dissection (55 acute and 25 subacute) were included in the final analysis. A wide variation was found in technique and device design across the studies. The outcomes rates were estimated at 17% (95% confidence interval [CI], 10%-26%) for mortality, 15% (95% CI, 8%-23%) for technical failure, 11% (95% CI, 6%-19%) for stroke and 18% (95% CI, 9%-31%) for reintervention. The mean Downs and Black quality assessment score was 13.9 ± 3.2. CONCLUSION The technique for endovascular repair of type A aortic dissection is feasible and reproducible. The results of our meta-analysis demonstrate an acceptable safety profile for inoperable patients who otherwise would have an extremely poor prognosis. Data from clinical trials are required before the technique can be introduced into routine clinical practice.
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Affiliation(s)
- Simon De Freitas
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC.
| | - Matthew J Rossi
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Steven D Abramowitz
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Javairiah Fatima
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Misaki M Kiguchi
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | | | - Stewart R Walsh
- Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland
| | - Edward Y Woo
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
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Natsis K, Piagkou M, Lazaridis N, Kalamatianos T, Chytas D, Manatakis D, Anastasopoulos N, Loukas M. A systematic classification of the left-sided aortic arch variants based on cadaveric studies' prevalence. Surg Radiol Anat 2021; 43:327-345. [PMID: 33386933 DOI: 10.1007/s00276-020-02625-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Typical branching pattern of the left-sided aortic arch consists of the brachiocephalic trunk (BCT), the left common carotid artery (LCCA) and the left subclavian artery (LSA). Variant patterns have been associated with a broad spectrum of pathologies. The meticulous knowledge of potential aortic arch variants is of utmost importance to radiologists, interventional cardiologists, vascular and thoracic surgeons. The current systematic review collects all aortic arch branching patterns and their frequency as published by various cadaveric studies, calculates prevalence taking into account the gender and the different people background, as well. All extracted variant patterns are classified into types and subtypes according to the number of emerging (major and minor) branches (1, 2, 3, 4 and 5) and to the prevalence they appear. In cases of similar prevalence, total cases were taken into consideration; otherwise the variants were classified under the title "other rare variants". METHODS A systematic online search of PubMed and Google books databases was performed only in cadaveric studies. RESULTS Twenty studies with typical (78% prevalence) and variable (22%) branching patterns were included. Types 3b, 2b, 4b, 1b and 5b had a prevalence of 81%, of 13%, of 5%, 0% and of 0%, respectively. Common variants were the brachiocephalico-carotid trunk (BCCT, 49% prevalence), the aberrant left vertebral artery (LVA, 41%) and the aberrant right subclavian artery (ARSA, 8%). LVA of aortic origin was detected in 32%, the bicarotid trunk (biCT) in 5% and the bi-BCT trunk in 3%. Thyroidea ima artery, a minor branch emerging from the aortic arch was found in 2%. Coexisted variants were detected in 4% (ARSA with a distinct RCCA and LCCA origin), in 3% (BCCT with a LVA of aortic origin), in 2% (ARSA with a biCT and a vertebrosubclavian trunk). CONCLUSION No significant gender or ethnic differences exist among the 5 branching types. The proposed classification scheme aims to become a valuable and easy to use tool in the hands of all physicians involved in diagnosis and treatment of aortic arch pathology. It could be also useful in anatomical education, as well.
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Affiliation(s)
- K Natsis
- Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, P.O. Box 300, 54124, Thessaloníki, Greece.
| | - M Piagkou
- Department of Anatomy, Faculty of Health Sciences, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - N Lazaridis
- Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, P.O. Box 300, 54124, Thessaloníki, Greece
| | - T Kalamatianos
- Hellenic Center for Neurosurgical Research "Petros Kokkalis", Athens, Greece
| | - D Chytas
- Medical School, European University of Cyprus, 6, Diogenous Str, 2404, Nicosia, Cyprus
| | - D Manatakis
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, 14233, Athens, Greece
| | - N Anastasopoulos
- Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, P.O. Box 300, 54124, Thessaloníki, Greece
| | - M Loukas
- Department of Anatomical Sciences, School of Medicine, St George's University, Saint George's, Grenada
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Zhang YJ, Bai L, Wang L, Shi HR, Liu JL, Ma FZ, Guo SP, Li XD. Pre-fenestration endovascular repair of aortic diseases in patients with zone 2 segment: A single-center experience. Vascular 2020; 29:637-643. [PMID: 33308107 DOI: 10.1177/1708538120979874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The present study aims to analyze the outcomes of three cases of pre-fenestration and branch stent-graft endovascular repair of aortic disease with zone 2 aortic lesions. METHODS From August 2017 to June 2018, three patients with zone 2 aortic lesions underwent thoracic endovascular repair with innominate artery, left common carotid artery, and left subclavian artery recannulation using pre-fenestration and branched stent-grafts to preserve the patency of the aortic arch branches. RESULTS The technical success rate was 100%. One patient had a proximal type I endoleak with no need for additional treatment. The overall mortality was 0%. All branches were patent. The follow-up period lasted for 2-15 months, with one patient lost to follow-up. There were no conversions to open surgical repair, aortic rupture, paraplegia, or retrograde type A aortic dissection. CONCLUSION The use of a pre-fenestration and branch stent-graft for the thoracic endovascular repair of zone 2 aortic lesions is a feasible and effective method for aortic arch branch revascularization. The risk of this surgical procedure is high, requiring significant expertise. The procedure should be conducted only in experienced centers. Durability concerns should be assessed in future studies with long-term follow-up.
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Affiliation(s)
- Yu-Jing Zhang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Lei Bai
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Liang Wang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Hong-Rui Shi
- Angiography and Interventional Therapy Center, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Jiang-Long Liu
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Fu-Zhen Ma
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Shu-Ping Guo
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xiao-Dong Li
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
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22
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Jing Z, Lu Q, Feng J, Zhou J, Feng R, Zhao Z, Bao J, Jiang W, Zhang X, Shu C, Fu W, Liu C, Guo W, Zhang X, Chen Z, Liu C, Han X. Endovascular Repair of Aortic Dissection Involving the Left Subclavian Artery by Castor Stent Graft: A Multicentre Prospective Trial. Eur J Vasc Endovasc Surg 2020; 60:854-861. [PMID: 33183920 DOI: 10.1016/j.ejvs.2020.08.022] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 07/20/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The left subclavian artery (LSA) origin can be intentionally covered by stent grafts, to provide adequate proximal landing zones during thoracic endovascular repair for Stanford type B aortic dissections (TBADs). To preserve the LSA, a novel single branched stent graft, named "Castor" was designed and a clinical trial conducted to investigate its suitability. METHODS From April 2013 to March 2015, 73 patients with TBAD were treated by Castor stent grafts at 11 Chinese tertiary hospitals as part of a single arm prospective clinical trial. There were 50 acute (<2 weeks [68.5%]) and 23 chronic aortic dissections (>2 weeks [31.5%]). RESULTS The technical success rate was 97% (n = 71/73). The two failures were caused by occlusion of the branch section of the stent graft. There were four intra-operative endoleaks (two type Ia, two type B from the LSA). The endoleak rate was 5% (n = 4/73). There was one in hospital death and no major complications. The median follow up time was 61 months (range 48-72 months). The mortality was 5% (n = 4/73) within one year and 7% within six years (n = 5/73). Two deaths were of unknown cause and three were not related to the aorta. Two new entry tears were found on the proximal or distal edge of the stent graft and were retreated endovascularly. Six occlusions of the branch section of the Castor stent graft were found, and the follow up patency rate of the branch section was 93% (n = 63/68). Two intra-operative endoleaks were left during follow up and eventually disappeared according to the latest computed tomography angiograms. CONCLUSION For patients with TBADs needing anchoring proximal to the origin of LSA, the Castor single branched stent graft may provide an easily manipulated, safe, and effective endovascular treatment.
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Affiliation(s)
- Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
| | - Qingsheng Lu
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
| | - Jiaxuan Feng
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jian Zhou
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Rui Feng
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhiqing Zhao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Junmin Bao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Weiliang Jiang
- Department of Vascular Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xiwei Zhang
- Department of Vascular Surgery, People's Hospital of Jiangsu Province, Jiangsu, China
| | - Chang Shu
- Department of Vascular Surgery, Second Xiangya Hospital of Central South University, Hunan, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Affiliated Hospital of Fudan University, Shanghai, China
| | - Changjian Liu
- Department of Vascular Surgery, Gulou Affiliated Hospital of Nanjing University, Jiangsu, China
| | - Wei Guo
- Department of Vascular Surgery, General Hospital of the People's Liberation Army, Beijing, China
| | - Xiaoming Zhang
- Department of Vascular Surgery, People's Affiliated Hospital of Peking University, Beijing, China
| | - Zhong Chen
- Department of Vascular Surgery, Anzhen Affiliated Hospital of Capital Medical University, Beijing, China
| | - Changwei Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Xinwei Han
- Department of Vascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China
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Pepe A, Li J, Rolf-Pissarczyk M, Gsaxner C, Chen X, Holzapfel GA, Egger J. Detection, segmentation, simulation and visualization of aortic dissections: A review. Med Image Anal 2020; 65:101773. [DOI: 10.1016/j.media.2020.101773] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 06/01/2020] [Accepted: 07/06/2020] [Indexed: 12/16/2022]
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An Innovative Customized Stent Graft Manufacture System Assisted by Three-Dimensional Printing Technology. Ann Thorac Surg 2020; 112:308-314. [PMID: 32950488 DOI: 10.1016/j.athoracsur.2020.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/06/2020] [Accepted: 07/06/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Commercially available thoracic aortic stent grafts rarely match the geometric characteristics of the aorta perfectly, which can lead to complications. Customization maybe a solution for this problem, but the delay inherent in the current manufacturing process makes it unable to meet the urgent requirement of acute aortic events. We established and optimized a rapid design and manufacture system for a customized aortic stent graft assisted by 3-dimensional (3D) printing technology. We also evaluated the preliminary feasibility and capability of this customized stent graft. METHODS Seven essential production steps comprised the rapid design and manufacture process for the customized stent graft system assisted by 3D printing technology. Optimization of the manufacture process was refined over time in 3 stages. Bench test and in vivo experiments were used to verify the feasibility of this system and evaluate the preliminary usability of the customized stent graft. RESULTS After optimization, the theoretical production time of the customized stent graft was reduced to approximately 12 hours. Bench test showed radial forces against the aorta wall were better distributed in the customized stent graft than in the control stent graft. In vivo experimental results showed that the customized stent graft system worked effectively. CONCLUSIONS It was feasible to rapidly design and manufacture a customized aortic stent graft assisted by 3D printing technology, which demonstrated better geometric compliance and physical characters in the bench test and in in vivo experimentation. The manufacturing process could be accelerated to approximately 12 hours, which might be optimized further to meet urgent clinic requirements.
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25
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Wang L, Bai L, Zhang Y, Liu J, Li X. Application of an extracorporeal prefenestrated stent graft in endovascular repair of ascending aorta and aortic arch lesions. Vascular 2020; 29:323-329. [PMID: 32921291 DOI: 10.1177/1708538120950876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Aortic dissection involving the ascending aorta and aortic arch is a serious condition. Treatment using traditional surgical methods has certain disadvantages. This study investigated the effectiveness of thoracic endovascular repair of aortic dissection using an external prefenestrated stent. METHODS We present a series of aortic dissection cases involving the ascending aorta and aortic arch treated with an external prefenestrated stent. RESULTS Postoperative follow-up of the patients showed that all stents were released at the proper position and that branch vessels were not occluded, and there were no instances of type I endoleak. One patient died suddenly one week after surgery; another experienced retrograde type A aortic dissection in the second week; and type I endoleak occurred in one patient in the first week, although this resolved within six months. No serious complications such as cerebrovascular events, acute spinal cord ischemia, and paraplegia occurred during the perioperative period. All patients had false lumen thrombosis in the ascending aorta and aortic arch. CONCLUSION Prefenestrated stent grafting is a feasible treatment option for repairing an entry tear in the ascending aorta.
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Affiliation(s)
- Liang Wang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Lei Bai
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yujing Zhang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Jianglong Liu
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xiaodong Li
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
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26
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Kuo HS, Huang JH, Chen JS. Handmade fenestrated stent grafts to preserve all supra-aortic branches in thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2020; 160:629-639.e1. [DOI: 10.1016/j.jtcvs.2019.07.096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 11/16/2022]
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27
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Bellamkonda KS, Yousef S, Nassiri N, Dardik A, Guzman RJ, Geirsson A, Ochoa Chaar CI. Trends and outcomes of thoracic endovascular aortic repair with open concomitant cervical debranching. J Vasc Surg 2020; 73:1205-1212.e3. [PMID: 32861861 DOI: 10.1016/j.jvs.2020.07.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) has become the most common surgical procedure for treatment of descending thoracic aortic pathology. Cervical debranching in the form of carotid-subclavian bypass or transposition (CSBT) and carotid-carotid bypass (CCB) has enabled the use of TEVAR for the treatment of more complex anatomy involving the arch. The present study examined the effects of concomitant cervical bypass on the perioperative outcomes of TEVAR. METHODS The American College of Surgeons National Surgical Quality Improvement Program files (2005-2017) were reviewed. Using the Current Procedural Terminology codes, all patients who had undergone TEVAR were identified and were divided into three groups: TEVAR, TEVAR with one bypass (CSBT or CCB), and TEVAR with two bypasses (CSBT and CCB). The patient characteristics and perioperative outcomes of the three groups were compared. Multivariable analysis was performed to determine the factors associated with mortality. RESULTS A total of 3281 patients had undergone TEVAR and 10% had also undergone one or more debranching procedure (one bypass, 9%; two bypasses, 1%). The frequency of debranching had increased from 3.4% to 10.9% (P = .01) during the study period. Significant differences were found among the three groups in age, sex, smoking history, urgency of surgery, and anesthesia technique. The patients who had undergone TEVAR with cervical debranching had had significantly greater morbidity, longer operating times, and longer hospital stays compared with those who had undergone TEVAR alone. The mortality of TEVAR with two bypasses (22.6%) was significantly greater than that of TEVAR alone (7.5%) and TEVAR with one bypass (6.8%; P < .01). The total morbidity (30.9% vs 35.1% vs 67.7%; P < .001) and stroke rate (3% vs 7.5% vs 12.9%; P < .0001) increased with the increasing number of bypasses. A subgroup analysis of patients who had undergone TEVAR with one bypass showed no significant differences in mortality between TEVAR plus CSBT (6.6%) vs TEVAR plus CCB (8.8%; P = .63). Multivariable analysis showed that TEVAR with two bypasses was associated with significantly increased mortality compared with TEVAR alone (odds ratio [OR], 4.33; 95% confidence interval [CI], 1.75-10.73) and TEVAR with one bypass (OR, 3.44; 95% CI, 1.24-9.51). Older age (OR, 1.74; 95% CI, 1.42-2.13), dependent functional status (OR, 1.48; 1.00-2.19), dialysis (OR, 2.61; 95% CI, 1.57-4.33), and emergent status (OR, 3.66; 95% CI, 2.73-4.90) were also associated with mortality. CONCLUSIONS TEVAR with concomitant cervical debranching has been increasingly used to treat complex aortic pathology but is associated with significantly worse outcomes than TEVAR alone. As advanced endovascular technology to treat the aortic arch emerges, the outcomes of open surgical debranching in the present study constitute an important benchmark for comparison.
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Affiliation(s)
| | - Sameh Yousef
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Naiem Nassiri
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Alan Dardik
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Raul J Guzman
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Cassius I Ochoa Chaar
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn.
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Preventza O. Commentary: Keep working: Current endovascular arch-repair technology still has a way to go. JTCVS Tech 2020; 3:11-12. [PMID: 34317798 PMCID: PMC8302920 DOI: 10.1016/j.xjtc.2020.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Ourania Preventza
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.,Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
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29
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Milligan JM, Dayama A, El Sayed HF, Panneton JM. Current technology for endovascular repair of the aortic arch. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01451-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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30
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Mougin J, Charbonneau P, Guihaire J, Schwein A, Tyrrell MR, Maurel B, Fabre D, Haulon S. Endovascular management of chronic post-dissection aneurysms of the aortic arch. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:402-415. [PMID: 32337939 DOI: 10.23736/s0021-9509.20.11395-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.
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Affiliation(s)
- Justine Mougin
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Philippe Charbonneau
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Julien Guihaire
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Adeline Schwein
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | | | - Blandine Maurel
- Service of Vascular Surgery, Thorax Institute, Nantes University Hospital, Nantes, France
| | - Dominique Fabre
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Stéphan Haulon
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France -
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31
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Kim J, Kim JB. Commentary: Branches of life. J Thorac Cardiovasc Surg 2020; 162:24-25. [PMID: 31928829 DOI: 10.1016/j.jtcvs.2019.10.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Jihoon Kim
- Department of Thoracic and Cardiovascular Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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32
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Bozinovski J. Commentary: Delayed stenting for arch dissection. J Thorac Cardiovasc Surg 2019; 162:23-24. [PMID: 31831197 DOI: 10.1016/j.jtcvs.2019.10.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 10/25/2019] [Accepted: 10/26/2019] [Indexed: 10/25/2022]
Affiliation(s)
- John Bozinovski
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Zhang L, Wu MT, Zhu GL, Feng JX, Song C, Li HY, Jing ZP, Yeung KK, Lu QS. Off-the-Shelf Devices for Treatment of Thoracic Aortic Diseases: Midterm Follow-up of TEVAR With Chimneys or Physician-Made Fenestrations. J Endovasc Ther 2019; 27:132-142. [PMID: 31789078 DOI: 10.1177/1526602819890107] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To evaluate the midterm outcomes of thoracic endovascular aortic repair (TEVAR) using chimney grafts (ch-TEVAR) or thoracic stent-grafts with fenestrations made on the back table (f-TEVAR) to treat thoracic aortic dissection (TAD) and thoracic aortic aneurysm (TAA). Materials and Methods: A retrospective analysis was conducted of 474 consecutive patients (mean age 62.3±10.7 years; 346 men) treated with either f-TEVAR (n=110) or ch-TEVAR (n=364) for 352 TADs (81 f-TEVAR and 271 ch-TEVAR) or 122 TAAs (29 f-TEVAR and 93 ch-TEVAR) from 2008 to 2016. The primary endpoints at 30 days and during follow-up were overall mortality, aorta-related mortality, and major complications. The secondary endpoints were endoleak and reintervention. The patency of the target branches, cost of hospitalization, and the use of antiplatelet drugs were also analyzed. Results: Intraoperative type I endoleaks were treated in 69 (14.6%) cases (4 f-TEVAR and 65 ch-TEVAR, p<0.01) to achieve 100% technical success. Four (0.8%) patients died within 30 days [1 (0.9%) f-TEVAR and 3 (0.8%) ch-TEVAR]. Perioperative cerebral ischemia (1 fatal stroke) occurred in 9 (1.9%) patients: (1 f-TEVAR and 8 ch-TEVAR, p=0.39). During the mean follow-up of 50.6±20.0 months (49.5±18.3 months in f-TEVAR and 50.9±20.6 months in ch-TEVAR), 11 (2.3%) patients died of an aorta-related event. Type I endoleak was present in 40 (8.4%) patients (1 f-TEVAR and 39 ch-TEVAR, p<0.01). Eleven (2.3%) patients experienced stent-graft migration and 13 (2.7%) had a retrograde dissection. One hundred (16.9%) of the 593 branch stents occluded (4/75 in the f-TEVAR group and 96/518 in the ch-TEVAR group, p<0.01). The branch reintervention rate was 7.2% (34/474). The f-TEVAR group had a significantly higher probability of freedom from branch occlusion (92%) than the ch-TEVAR group (83%, p=0.007). Conclusion: Off-the-shelf techniques employing chimney grafts and homemade fenestrations are both suitable options for TAD and TAA involving the supra-aortic branches, with a low incidence of reintervention. Fenestrated TEVAR seems to have more favorable short- and midterm outcomes. Further study of these off-the-shelf techniques for aortic arch repair is warranted.
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Affiliation(s)
- Lei Zhang
- Department of Vascular Surgery, Changhai Hospital, Navy (Second) Military Medical University, Shanghai, China
| | - Meng-tao Wu
- Department of Vascular Surgery, the Second Hospital of Shandong University, Ji’nan, Shandong Province, China
| | - Guang-lang Zhu
- Department of Vascular Surgery, Changhai Hospital, Navy (Second) Military Medical University, Shanghai, China
| | - Jia-xuan Feng
- Department of Vascular Surgery, Changhai Hospital, Navy (Second) Military Medical University, Shanghai, China
| | - Chao Song
- Department of Vascular Surgery, Changhai Hospital, Navy (Second) Military Medical University, Shanghai, China
| | - Hai-yan Li
- Department of Vascular Surgery, Changhai Hospital, Navy (Second) Military Medical University, Shanghai, China
| | - Zai-ping Jing
- Department of Vascular Surgery, Changhai Hospital, Navy (Second) Military Medical University, Shanghai, China
| | - Kak Khee Yeung
- Department of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | - Qing-sheng Lu
- Department of Vascular Surgery, Changhai Hospital, Navy (Second) Military Medical University, Shanghai, China
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34
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Zhang L, Li Z, Li S, Zhao Z, Bao J, Zhou J, Jing Z. Systematic review of endovascular repair of ascending aortic dissection. Catheter Cardiovasc Interv 2019; 94:1018-1025. [PMID: 31595660 DOI: 10.1002/ccd.28511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/16/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Lei Zhang
- Department of Vascular SurgeryChanghai Hospital, Navy Medical University Shanghai China
| | - Zhenjiang Li
- Vascular Surgery Departmentthe First Affiliated Hospital of the Medical School of Zhejiang University Hangzhou Zhejiang
| | - Shuangshuang Li
- Department of Vascular SurgeryChanghai Hospital, Navy Medical University Shanghai China
| | - Zhiqing Zhao
- Department of SurgeryChanghai Hospital, Navy Medical University Shanghai China
| | - Junmin Bao
- Department of Vascular SurgeryChanghai Hospital, Navy Medical University Shanghai China
| | - Jian Zhou
- Department of Vascular SurgeryChanghai Hospital, Navy Medical University Shanghai China
| | - Zaiping Jing
- Department of Vascular SurgeryChanghai Hospital, Navy Medical University Shanghai China
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35
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Li X, Li Q, Zhang W, Li M, He H, Luo M, Fang K, Yang C, Zhu J, Shu C. Early experience and technical aspects of physician-modified fenestration in thoracic endovascular aortic repair for aortic arch pathologies. J Int Med Res 2019; 48:300060519870903. [PMID: 31547732 PMCID: PMC7607183 DOI: 10.1177/0300060519870903] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective This study was performed to describe the treatment of aortic arch pathologies
with a physician-modified fenestration (PMF) technique in thoracic
endovascular aortic repair (TEVAR). Methods From August 2015 to August 2017, 32 patients with aortic arch pathologies
underwent TEVAR with the PMF technique. All patients’ clinical data were
analyzed with GraphPad Prism 7.0. Results Thirty-four aortic stent-grafts were implanted in 32 patients. The mean
proximal diameter of the stent-graft was 32.4 ± 3.4 cm, and the mean length
was 170.0 ± 25.2 cm. Twenty-nine PMF procedures were performed to preserve
the left subclavian artery (LSA) and three to preserve both the LSA and left
common carotid artery. The mean distance between the pathology and LSA was
8.4 ± 4.0 mm. The mean procedure time (from first to last digital
subtraction angiography) was 22.8 ± 20.8 min. The mean follow-up time was
8.3 ± 5.3 months. During follow-up, the all-cause survival rate was 83.3%
and the patency rate of the branch artery after PMF was 96.0%. Conclusion The PMF technique is a relatively safe, feasible, and time-saving method to
preserve the branch artery in TEVAR for aortic arch pathologies. The short-
to middle-term result of this technique is satisfactory.
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Affiliation(s)
- Xin Li
- Department of Vascular Surgery, The Secondary Xiangya Hospital,
Central South University, Changsha, Hunan, China
- Vascular Diseases Institute of Central South University,
Changsha, Hunan, China
| | - Quanming Li
- Department of Vascular Surgery, The Secondary Xiangya Hospital,
Central South University, Changsha, Hunan, China
- Vascular Diseases Institute of Central South University,
Changsha, Hunan, China
| | - Weichang Zhang
- Department of Vascular Surgery, The Secondary Xiangya Hospital,
Central South University, Changsha, Hunan, China
- Vascular Diseases Institute of Central South University,
Changsha, Hunan, China
| | - Ming Li
- Department of Vascular Surgery, The Secondary Xiangya Hospital,
Central South University, Changsha, Hunan, China
- Vascular Diseases Institute of Central South University,
Changsha, Hunan, China
| | - Hao He
- Department of Vascular Surgery, The Secondary Xiangya Hospital,
Central South University, Changsha, Hunan, China
- Vascular Diseases Institute of Central South University,
Changsha, Hunan, China
| | - Mingyao Luo
- State Key Laboratory of Cardiovascular Disease, Center of
Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease,
Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing,
China
| | - Kun Fang
- State Key Laboratory of Cardiovascular Disease, Center of
Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease,
Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing,
China
| | - Chenzi Yang
- Department of Vascular Surgery, The Secondary Xiangya Hospital,
Central South University, Changsha, Hunan, China
- Vascular Diseases Institute of Central South University,
Changsha, Hunan, China
| | - Jieting Zhu
- Department of Vascular Surgery, The Secondary Xiangya Hospital,
Central South University, Changsha, Hunan, China
- Vascular Diseases Institute of Central South University,
Changsha, Hunan, China
| | - Chang Shu
- Department of Vascular Surgery, The Secondary Xiangya Hospital,
Central South University, Changsha, Hunan, China
- State Key Laboratory of Cardiovascular Disease, Center of
Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease,
Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing,
China
- Vascular Diseases Institute of Central South University,
Changsha, Hunan, China
- Chang Shu, Department of Vascular Surgery,
The Secondary Xiangya Hospital, No. 139 Renmin Road, Changsha, Hunan 410011,
China.
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36
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Liu F, Zhang W, Wang G, Yuan T, Shu X, Guo D, Wang L, Fu W. Long-term outcomes of balloon-expandable bare stent as chimney stent in thoracic endovascular aortic repair for supra-aortic branches reconstruction. J Thorac Dis 2019; 11:1261-1268. [PMID: 31179068 DOI: 10.21037/jtd.2019.04.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To report the long-term outcomes of balloon-expandable bare stent (BEBS) as chimney stent (CS) in thoracic endovascular aortic repair (TEVAR) for supra-aortic branches reconstruction. Methods A total of 33 patients with thoracic aortic diseases underwent TEVAR using BEBSs as CSs for supra-aortic branches reconstruction in our center from 2010 to 2015. The demographics and procedural details were prospectively collected and retrospectively reviewed. All patients were followed up at 1, 3, 6 months and every 1 year thereafter. Postoperative complications and long-term outcomes were recorded. Results The technical success rate was 100%. A total of 36 BEBSs were utilized as CSs to reconstruct the supra-aortic branches during TEVAR. The rate of immediate endoleak was 42.4% (14/33), including 12 (36.4%) type Ia endoleaks and 2 (6.1%) type II endoleaks. Two of type Ia endoleaks were managed by balloon dilation and disappeared, while the rest were left with close follow-up. Two type II endoleaks were embolized by coils and excluded by a plug, respectively. One patient (3.0%) died 2 days after the procedure due to the acute rupture of aortic dissection. The mean follow-up time was 61.8 (ranged from 12 to 102) months. The unmanaged 10 type Ia endoleaks were closely observed during the follow-up, of which 7 disappeared at 1 year and 1 disappeared at 2 years. The rest 2 type Ia endoleaks existed without further dilation of the aorta. One patient (3.0%) was re-intervened for the increased false lumen due to the distal residual tears. The long-term mortality was 9.1% (3/33). All CSs kept patent till the end of follow-up. No other complications were found. Conclusions The balloon-expandable stent (BES) is a feasible choice as CS for supra-aortic branches reconstruction with long-term patency during TEVAR. However, BEBS may be related to a higher rate of early endoleak.
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Affiliation(s)
- Fei Liu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Vascular Surgery Institute of Fudan University, Shanghai 200032, China
| | - Wei Zhang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Vascular Surgery Institute of Fudan University, Shanghai 200032, China
| | - Guili Wang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Vascular Surgery Institute of Fudan University, Shanghai 200032, China
| | - Tong Yuan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Vascular Surgery Institute of Fudan University, Shanghai 200032, China
| | - Xiaolong Shu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Vascular Surgery Institute of Fudan University, Shanghai 200032, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Vascular Surgery Institute of Fudan University, Shanghai 200032, China
| | - Lixin Wang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Vascular Surgery Institute of Fudan University, Shanghai 200032, China.,Department of Vascular Surgery, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen 361015, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China.,Vascular Surgery Institute of Fudan University, Shanghai 200032, China.,Department of Vascular Surgery, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen 361015, China
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37
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Rousseau H, Revel-Mouroz P, Saint Lebes B, Bossavy JP, Meyrignac O, Mokrane FZ. Single aortic branch device: the Mona LSA experience. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:81-90. [DOI: 10.23736/s0021-9509.18.10665-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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38
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Zhang H, Huang H, Zhang Y, Liu Z, Qiao T, Zhang X, Liu C, Jiao Y, Zhou M. Comparison of Chimney Technique and Single-Branched Stent Graft for Treating Patients with Type B Aortic Dissections that Involved the Left Subclavian Artery. Cardiovasc Intervent Radiol 2018; 42:648-656. [DOI: 10.1007/s00270-018-2145-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 12/06/2018] [Indexed: 10/27/2022]
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39
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Tsilimparis N, Detter C, Heidemann F, Spanos K, Rohlffs F, von Kodolitsch Y, Debus SE, Kölbel T. Branched endografts in the aortic arch following open repair for DeBakey Type I aortic dissection. Eur J Cardiothorac Surg 2018; 54:517-523. [PMID: 29608660 DOI: 10.1093/ejcts/ezy133] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/25/2018] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES DeBakey Type I aortic dissections are frequently treated by an ascending aortic tube graft or hemiarch replacement with the residual dissection remaining untreated. We investigated the outcomes of branched thoracic endovascular repair for post-dissection aneurysms of the aortic arch. METHODS We conducted a retrospective, single-centre evaluation of 20 consecutive patients with a false-lumen aneurysm after a DeBakey I aortic dissection treated with branched thoracic endovascular repair. The indication for endovascular repair was agreed on in an interdisciplinary case conference. Study end points were technical success, 30-day mortality rate, complications and late complications and reinterventions. RESULTS Between 2012 and 2016, 20 patients (14 men, age 65 ± 9 years) were treated for false-lumen aneurysm formation after a DeBakey Type I aortic dissection. All patients had undergone open ascending aortic repair either isolated (n = 16) or with partial arch repair (n = 4). Technical success was achieved in 19 of 20 cases. The 30-day mortality rate and incidence of stroke were each 5% (1/20). Simultaneous procedures to exclude false-lumen perfusion included implantation of a Knickerbocker graft in 3 (15%) patients and a candy-plug graft in 7 (35%) patients. Early postoperative computed tomography angiography revealed persistent false-lumen perfusion in 10 cases that required secondary interventions in 6 cases. During 17 ± 14 months of mean follow-up, there was 1 aortic-related death and 2 deaths of non-aortic reasons. The estimated overall survival was 89 ± 7% and 75 ± 15% at 12 and 36 months, respectively. CONCLUSIONS Treatment of residual aortic arch dissections with branched thoracic endovascular repair appears feasible and safe with few deaths and low stroke rates. A high rate of secondary procedures is required to achieve thoracic false-lumen occlusion.
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Affiliation(s)
- Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Christian Detter
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Yskert von Kodolitsch
- Department of Cardiology, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Sebastian E Debus
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, University Hospital Eppendorf, Hamburg, Germany
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40
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Lu Q, Liu L, Chang G, Chen X, Feng H, Zhang X, Fu W, Dong Z, Jing Z. Mid-term outcomes from a multicenter study: Is TEVAR safe for ascending aortic dissection? Int J Cardiol 2018; 265:218-222. [DOI: 10.1016/j.ijcard.2018.04.095] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/23/2018] [Accepted: 04/20/2018] [Indexed: 11/25/2022]
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41
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Makaloski V, Tsilimparis N, Rohlffs F, Heidemann F, Debus ES, Kölbel T. Endovascular total arch replacement techniques and early results. Ann Cardiothorac Surg 2018; 7:380-388. [PMID: 30155417 DOI: 10.21037/acs.2018.04.02] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
During the last 20 years, a clear shift has been observed towards thoracic endovascular aortic repair for different aortic pathologies. However, total endovascular repair of the aortic arch remains technically demanding. Simultaneous perfusion of all supra-aortic arteries without longer cerebral ischemia time, whilst trying to avoid cerebral embolization, labels endovascular aortic arch repair with highest level of technical difficulty and surgical expertise. The aim of this article is to present an overview of the current technical options for endovascular aortic arch repair and their early results. Currently, early results are reported from four endovascular arch replacement techniques: hybrid repair, total endovascular approach, chimney grafts and in-situ fenestration. The early results of these different arch replacement techniques are promising, especially the total arch replacement with custom-made fenestrated or branched stent-grafts. Long-term results are unknown, and larger series results and comparative studies are needed to determine safety and efficacy.
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Affiliation(s)
- Vladimir Makaloski
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eike Sebastian Debus
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
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van Bakel TM, de Beaufort HW, Trimarchi S, Marrocco-Trischitta MM, Bismuth J, Moll FL, Patel HJ, van Herwaarden JA. Status of branched endovascular aortic arch repair. Ann Cardiothorac Surg 2018; 7:406-413. [PMID: 30155420 PMCID: PMC6094020 DOI: 10.21037/acs.2018.03.13] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 03/13/2018] [Indexed: 11/06/2022]
Abstract
Multiple medical device manufacturers are developing branched endografts for thoracic endovascular aortic repair (TEVAR), to provide a minimally invasive alternative for the treatment of aortic arch pathologies in patients who are deemed unfit for open or hybrid arch repair. Different branched endografts have been introduced, with varying number, size and orientation of the branches that redirect flow to the supra-aortic arteries. We present an overview of the currently investigated devices and review their outcomes. The results of branched TEVAR are promising, yet stroke remains the predominant periprocedural concern. For now, these procedures should be limited to select expert centers where the design and deployment procedure of branched endografts can be further developed to reduce the risk of stroke.
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Affiliation(s)
- Theodorus M. van Bakel
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy
- Department of Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Hector W. de Beaufort
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | | | - Jean Bismuth
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Himanshu J. Patel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
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Gandet T, Seghrouchni A, Ozdemir BA, Captier G, Demaria R, Alric P, Albat B, Canaud L. Experimental evaluation of homemade distal stent graft fenestration for thoracic endovascular aortic repair of type A dissection by a transapical approach. J Vasc Surg 2018; 68:1217-1224. [PMID: 29680298 DOI: 10.1016/j.jvs.2017.08.095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 08/25/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The use of off-the-shelf stent grafts for thoracic endovascular aortic repair of type A dissections is limited by variability in both the length of the ascending aorta and the location of the proximal intimal tear. This experimental study aimed to assess the feasibility of using a physician-modified thoracic aortic stent graft to treat acute type A dissection by a transapical cardiac approach. METHODS The experiments were performed on six cadaveric human heart, ascending aorta, aortic arch, and descending aorta specimens. Fenestration was fashioned in each standard tubular Valiant thoracic stent graft (Valiant Captivia; Medtronic Vascular, Santa Rosa, Calif) to match the anatomy of each specimen. Stent grafts of sufficient length were selected to cover the entire ascending aorta and aortic arch. Stent graft diameters in proximal sealing zones were oversized by 5% to 10%. The length of the fenestration was the distance between the left subclavian artery and the proximal edge of the origin of the brachiocephalic trunk with an additional 10 mm. The diameter of the scallop was that of the brachiocephalic trunk with an additional 5 mm on all sides. The length of the covered portion of the stent graft was the distance between coronary arteries and the proximal edge of the origin of the brachiocephalic trunk. Two lateral radiopaque markers were positioned to delineate the distal and lateral edge of the scallop. Another 3-cm radiopaque marker was sutured onto the sheath to ensure accurate radiologic positioning of the scallop on the outer curve of the aorta. The left ventricle and the thoracic aorta were connected to a benchtop aortic pulsatile flow model. A 5-mm 30-degree lens was introduced through the left subclavian artery to monitor the procedure. The customized stent graft was deployed by a transapical approach under fluoroscopic control. RESULTS Median duration of stent graft modification was 21 minutes (range, 17-40 minutes). All attempts to deploy the homemade proximal scalloped stent graft by a transapical approach were successful. Completion angiography demonstrated patency of the supra-aortic trunks and of the coronary arteries in all cases. Macroscopic evaluation did not identify any deterioration of the customized stent graft. CONCLUSIONS The use of physician-modified stent grafts is feasible for thoracic endovascular aortic repair of type A dissection by a transapical approach in this model.
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Affiliation(s)
- Thomas Gandet
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
| | - Anis Seghrouchni
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Guillaume Captier
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Roland Demaria
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Pierre Alric
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Bernard Albat
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Ludovic Canaud
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
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44
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A current systematic evaluation and meta-analysis of chimney graft technology in aortic arch diseases. J Vasc Surg 2017; 66:1602-1610.e2. [DOI: 10.1016/j.jvs.2017.06.100] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 06/19/2017] [Indexed: 12/20/2022]
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45
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Treatment of postoperative distal anastomotic endoleak with the Amplatzer Vascular Plug II in chronic aortic arch dissection: A case report. J Thorac Cardiovasc Surg 2017; 155:e7-e10. [PMID: 28918209 DOI: 10.1016/j.jtcvs.2017.07.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/28/2017] [Accepted: 07/30/2017] [Indexed: 11/22/2022]
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46
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Implantation of Unibody Single-Branched Stent Graft for Patients with Type B Aortic Dissections Involving the Left Subclavian Artery: 1-Year Follow-Up Outcomes. Cardiovasc Intervent Radiol 2017; 40:1678-1686. [DOI: 10.1007/s00270-017-1748-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 07/13/2017] [Indexed: 10/18/2022]
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47
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Andrási TB, Grossmann M, Zenker D, Danner BC, Schöndube FA. Supra-aortic interventions for endovascular exclusion of the entire aortic arch. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.04.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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48
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Fiorucci B, Tsilimparis N, Rohlffs F, Heidemann F, Debus ES, Kölbel T. How to Confirm Catheterization of Inner Branches in Aortic Endografting: The Universal Flush Test. J Endovasc Ther 2017; 24:539-541. [DOI: 10.1177/1526602817713305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Beatrice Fiorucci
- Department of Vascular Medicine, German Aortic Center, Hamburg, Germany
- Unit of Vascular Surgery, Ospedale S. Maria della Misericordia, University of Perugia, Italy
| | | | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center, Hamburg, Germany
| | | | | | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, Hamburg, Germany
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Abstract
Stanford type B aortic dissections (TBADs) involve the descending aorta and can present with complications, including malperfusion syndrome or aortic rupture, which are associated with significant morbidity and mortality if left untreated. Clinical diagnosis is straightforward, typically confirmed using CT angiography. Treatment begins with immediate anti-impulse medical therapy. Acute TBAD with complications should be repaired with emergent thoracic endovascular aortic repair (TEVAR). Uncomplicated TBAD with high-risk features should undergo TEVAR in the subacute phase. Open surgical repair is seldom required and reserved only for select cases. It is critical to follow these patients clinically and radiographically in the outpatient setting.
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Affiliation(s)
- Daniel B Alfson
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street, HCC II, Suite 4300, Los Angeles, CA 90033-5330, USA
| | - Sung W Ham
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street, HCC II, Suite 4300, Los Angeles, CA 90033-5330, USA.
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50
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Cannavale A, Santoni M, Fanelli F, O’Sullivan G. Aortic Dissection: Novel Surgical Hybrid Procedures. Interv Cardiol 2017; 12:56-60. [PMID: 29588732 PMCID: PMC5808688 DOI: 10.15420/icr.2016:16:3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 01/19/2017] [Indexed: 01/16/2023] Open
Abstract
The management of patients with aortic dissection is challenging and its treatment is an area of development and innovation. Conventional surgical techniques are associated with significant risks in terms of mortality and morbidity in such high-risk patients. As a result of cumulative advances in technology, classical surgical techniques have been improved and enhanced by the newer endovascular approaches, leading to novel surgical hybrid procedures. Impressive early results have been seen with frozen elephant techniques, revascularisation of the supra-aortic branches and branched/fenestrated thoracic endovascular aortic repair-alone procedures. This review describes the techniques involved in the latest hybrid procedures for aortic dissection and their outcomes.
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Affiliation(s)
| | - Mariangela Santoni
- Department of Radiological Sciences, “Sapienza” University of Rome, Rome, Italy
| | - Fabrizio Fanelli
- Department of Radiological Sciences, “Sapienza” University of Rome, Rome, Italy
| | - Gerard O’Sullivan
- Department of Interventional Radiology, University College Hospital Galway, Galway, Ireland
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