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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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da Silva MLF, de Freitas Gonçalves S, Costa MCB, Huebner R, Navarro TP. Structural numerical analysis of a branched modular stent-graft for aneurysms encompassing all zones of the aortic arch. J Mech Behav Biomed Mater 2023; 147:106135. [PMID: 37769370 DOI: 10.1016/j.jmbbm.2023.106135] [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: 07/06/2023] [Revised: 09/16/2023] [Accepted: 09/18/2023] [Indexed: 09/30/2023]
Abstract
The development of stent-grafts for the total repair of aneurysms in the aortic arch is still a technical challenge due mainly to the anatomical complexity of this region. Research performed here structurally evaluated a modular branched stent-graft for aneurysms encompassing all zones of the aortic arch by means of numerical simulations using fluid-structure interaction. The geometric domain obtained by means of computed tomography was subjected to physiological boundary conditions. The blood was modelled as non-Newtonian by the Carreau model, and the arterial wall was modelled as anisotropic hyperelastic by the Holzapfel model. The material adopted for the stents was Nitinol, and expanded polytetrafluoroethylene (ePTFE) was used for the graft. A comparison of the structural behaviour of the aneurysmal aortic arch before and after stent-graft implantation was performed. The numerical flow model was experimentally verified in vitro on a representative test bench of blood flow in the aortic arch. The stent-graft was shown to minimally modify arterial wall dynamics and was not susceptible to migration and endoleak. Peak stresses and strains were found in the stents and graft, respectively, while the stresses in the aneurysm sac were significantly reduced, of the order of 97.5%, due to the isolation of the arterial wall by the stent-graft.
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Affiliation(s)
- Mário Luis Ferreira da Silva
- Graduate Programme in Mechanical Engineering, Department of Mechanical Engineering, Universidade Federal de Minas Gerais, Avenida Presidente Antônio Carlos, 6627, 31270-901 Pampulha, Belo Horizonte, Minas Gerais, Brazil.
| | - Saulo de Freitas Gonçalves
- Graduate Programme in Mechanical Engineering, Department of Mechanical Engineering, Universidade Federal de Minas Gerais, Avenida Presidente Antônio Carlos, 6627, 31270-901 Pampulha, Belo Horizonte, Minas Gerais, Brazil.
| | - Matheus Carvalho Barbosa Costa
- Graduate Programme in Mechanical Engineering, Department of Mechanical Engineering, Universidade Federal de Minas Gerais, Avenida Presidente Antônio Carlos, 6627, 31270-901 Pampulha, Belo Horizonte, Minas Gerais, Brazil.
| | - Rudolf Huebner
- Department of Mechanical Engineering, Universidade Federal de Minas Gerais, Avenida Presidente Antônio Carlos, 6627, 31270-901 Pampulha, Belo Horizonte, Minas Gerais, Brazil.
| | - Túlio Pinho Navarro
- Faculty of Medicine, Department of Surgery, Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190, 30130-100 Santa Efigênia, Belo Horizonte, Minas Gerais, Brazil.
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Cao L, Zhang H, Ge Y, Guo W. Avoiding Stroke in Patients Undergoing Endovascular Aortic Arch Repair: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:265-277. [PMID: 37438011 DOI: 10.1016/j.jacc.2023.04.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 07/14/2023]
Abstract
As the bottleneck of endovascular aortic arch repair, early postoperative stroke remains a devastating complication in high-risk patients and a critical concern for the development of optimal endovascular techniques and devices. The incidence of early postoperative stroke varies widely among currently available endovascular techniques and devices, with reported rates ranging from 0.0% to 42.9%, and is significantly influenced by the severity of the patient's preexisting aortic atherosclerotic burden, air released from the endovascular device, and a variety of factors leading to cerebral perfusion insufficiency. Currently, preidentification of high-risk patients and careful perioperative management appear to play a critical role in reducing stroke incidence. Specific intraoperative prevention methods are still lacking, but embolic protection devices and carbon dioxide or high-volume saline flushing of endovascular devices appear promising. Detailed preoperative stroke risk stratification and screening for optimal endovascular techniques and devices for aortic arch treatment are unmet clinical needs.
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Affiliation(s)
- Long Cao
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China; Department of General Surgery, The 983rd Hospital of Joint Logistic Support Force of PLA, Tianjin, China
| | - Hongpeng Zhang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yangyang Ge
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China.
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Tish S, Chase JA, Scoville C, Vogel TR, Cheung S, Bath J. A Systematic Review of Contemporary Outcomes from Aortic Arch In Situ Laser Fenestration During Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2023; 91:266-274. [PMID: 36642166 DOI: 10.1016/j.avsg.2023.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/21/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND In situ laser fenestrated endovascular aortic repair (L-FEVAR) is a novel and creative solution for complex aortic pathologies in the urgent and emergency setting. Outcomes of this technique, however, are poorly reported. We sought to evaluate the efficacy, safety, and outcomes of L-FEVAR in aortic arch pathologies. METHODS A systematic literature review and analysis were conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses and Cochrane guidelines. A search was conducted using Google, PubMed, and Scopus to identify studies evaluating L-FEVAR. Two independent reviewers determined study inclusion. Case reports and series including < 10 patients were excluded. Reviewers also assessed the methodological quality and extracted data regarding outcomes. A meta-analysis of endoleak event rates was conducted using a fixed-effect model due to small sample size. RESULTS Eight studies met inclusion criteria between 2013 and 2021. Most studies were retrospective (87.5%) with median follow-up duration of 12.5 months (range 10-42). There were 440 patients included (range 15-148), mostly men (64%). Mean age was 61 years (range 53-68). Included patients were all symptomatic with L-FEVAR being technically successful in 93.3% of cases. The main indication for aortic arch intervention was aortic dissection. Single fenestrations occurred most frequently (68%), followed by triple (22%) then double fenestrations (9%). Meta-analysis of 8 studies (n = 440) demonstrated an endoleak event rate of 0.06 (95% confidence interval 0.04-0.09, P < 0.001) with no observed statistically significant heterogeneity of effects (Q = 7.91, P = 0.34). The median operative time was 162 min (range 53-252) with median length of stay of 10 days (range 7-17). Primary branch patency was 96.6%. Secondary patency rate was 97%. Pooled complication rates such as endoleak occurred in 4.8%, stroke in 2.0%, spinal cord ischemia in 0.2%, retrograde dissection in 0.9%, and 30-day death in 2.0%. Access complications occurred in 0.4%. Antiplatelet regimen was poorly reported in the study cohort. CONCLUSIONS In situ laser fenestration is a feasible, safe, and effective approach to treat aortic arch disease in patients who are unsuitable for open or custom-made endovascular means. High technical success and excellent short-term branch patency can be achieved. These single-institution series exhibit promising short-term outcomes. In a similar paradigm to investigational device exemptions studies for custom-made and physician modified endografts, these preliminary data make a persuasive argument for larger long-term multi-institutional prospective study of this promising technique.
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Affiliation(s)
- Shahed Tish
- Department of Surgery, University of Missouri, Columbia, MO
| | - Jo-Ana Chase
- University of Missouri School of Nursing, Columbia, MO
| | - Caryn Scoville
- Health Sciences Library, University of Missouri, Columbia, MO
| | - Todd R Vogel
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Steven Cheung
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, Columbia, MO.
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Nana P, Spanos K, Dakis K, Giannoukas A, Kölbel T, Haulon S. Systematic Review on Customized and Non-customized Device Techniques for the Endovascular Repair of the Aortic Arch. J Endovasc Ther 2022:15266028221133701. [PMID: 36346051 DOI: 10.1177/15266028221133701] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE Open repair remains the standard of care for aortic arch pathologies. However, endovascular management became an attractive alternative for high-risk patients. This study aimed to assess the outcomes of the available endovascular techniques for aortic arch pathology management. MATERIALS AND METHODS A search of the English literature (2000-2022) using PubMed, EMBASE, via Ovid, and CENTRAL databases (February 1, 2022) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies reporting on patients with aortic arch pathologies managed with custom-made devices ([CMDs] fenestrated or branched thoracic endovascular aortic repair [F/BTEVAR]) and non-CMDs (parallel graft or surgeon-modified FTEVAR) were eligible. Studies reporting on hybrid or open repair were excluded. Studies' quality was assessed using the Newcastle-Ottawa Scale. Primary outcomes were technical success, 30 day mortality, and cerebrovascular events (CVEs). Secondary outcomes were re-intervention and mortality during follow-up. RESULTS Thirty studies (2135 patients) were included. Treatment indications were mainly dissections (652 cases [48.0%, 652/1358]; 90 type A, 506 type B; 364 acute, 163 chronic) and aneurysms (46.9%, 582/1239). Five studies (211 patients) reported on FTEVAR and 10 (388 patients) on BTEVAR. For FTEVAR, technical success rate was 98.3%. Thirty-day mortality was 3.8% and CVE rate was 12.3%. Ten deaths (9.7%) and 19 re-interventions (9%) were recorded during follow-up (24 months). Regarding BTEVAR, technical success rate was 98.7%, and 30 day mortality and CVE rates were 5.4% and 11.0%, respectively. During follow-up (27 months), 64 deaths (18.7%) and 33 re-interventions (9.6%) were recorded. Parallel graft technique was reported in 11 studies (901 patients). Technical success rate was 76.4%. Thirty-day mortality was 3.9% and 32 (4.3%) CVEs were recorded. Thirty-five deaths (4.4%) and 43 re-interventions (5.5%) were reported during follow-up (27 months). Surgeon-modified FTEVAR was described in 5 studies (635 patients). Technical success rate was 91.6%. At 30 days, 15 deaths (2.3%) and 22 CVEs (3.5%) were recorded. During follow-up (19 months), 26 deaths (4.2%) and 21 re-interventions (3.6%) were detected. CONCLUSIONS Endovascular arch repair presented a variable technical success; >95% for F/BTEVAR; ≤90% for non-CMDs. Acceptable 30 day mortality rates were reported. Cerebrovascular event rates ranged up to 10%. These findings, adjacent to the estimated midterm mortality and re-interventions, set the need for further improvement. CLINICAL IMPACT Endovascular arch repair gains popularity as a valuable alternative, especially in patients considered unfit for open repair. According the available literature, any endovascular technique, including custom-made or off-the-shelf solutions, may be applied successfully, with acceptable early mortality. However, the perio-operative cerebrovascular event rate is still an issue, indicating the need for further advancements.
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Affiliation(s)
- Petroula Nana
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Le Plessis-Robinson, France
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Konstantinos Dakis
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Stephan Haulon
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Le Plessis-Robinson, France
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Li J, Xue Y, Li S, Sun L, Wang L, Wang T, Fang K, Luo M, Li X, He H, Li M, Li Q, Dardik A, Shu C. Outcomes of thoracic endovascular aortic repair with chimney technique for aortic arch diseases. Front Cardiovasc Med 2022; 9:868457. [PMID: 35990957 PMCID: PMC9386043 DOI: 10.3389/fcvm.2022.868457] [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: 02/02/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
Objective This study aimed to summarize the long-term experience of using the chimney technique in thoracic endovascular aortic repair (TEVAR) for aortic arch diseases. Methods From November 2007 to June 2021, a total of 345 consecutive patients (mean age 56 ± 11.3 years, range 28–83, 302 men) with aortic arch pathologies underwent TEVAR combined with chimney technique (cTEVAR). Their medical data and follow-up results were retrospectively reviewed and analyzed. Results Among the 345 patients, 278 (80.6%) received single chimneys, 53 (15.4%) received double chimneys, 7 (2%) received triple chimneys, and 7 (2%) underwent cTEVAR accompanied by other techniques (two with extra-anatomical bypass, two with in situ fenestration, and three with physician modified fenestration). A total of 412 chimney stents were used, including 27 in the innominate artery (IA), 113 in the left common carotid artery, 270 in the left subclavian artery, and two in the aberrant right subclavian artery. Early type IA endoleaks were found in 38 (11%) patients, including 12 with the double or triple chimney technique. Early type II endoleak was found in nine (2.6%) patients. Early re-intervention occurred in two patients with double chimney technique, one for chimney stent migration and the other for compression of chimney stent. The 30-day mortality was 1.2% (4 in 345). During a mean follow-up of 42 ± 22 months (range 1–108 months), major stroke occurred in nine (2.6%) patients, chimney occlusion or stenosis occurred in six (1.7%), and retrograde type A aortic dissection occurred in four (1.2%). Fourteen (4.1%) patients received the secondary intervention. The all-cause mortality was 6.7% (23 in 345). Additionally, the total adverse event rate after cTEVAR was 13.9% (48 in 345). Conclusion TEVAR with chimney technique provides a minimally invasive alternative with good chimney graft patency and low postoperative mortality during follow-up. However, the double and triple chimney techniques should be used cautiously as they seem to have a higher risk for type IA endoleak and adverse events after the operation.
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Affiliation(s)
- Jiehua Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Vascular Diseases Institute of Central South University, Changsha, China
| | - Yunfei Xue
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shangqian Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Vascular Diseases Institute of Central South University, Changsha, China
| | - Likun Sun
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Vascular Diseases Institute of Central South University, Changsha, China
| | - Lunchang Wang
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Vascular Diseases Institute of Central South University, Changsha, China
| | - Tun Wang
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Vascular Diseases Institute of Central South University, Changsha, China
| | - Kun Fang
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingyao Luo
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Vascular Diseases Institute of Central South University, Changsha, China
| | - Hao He
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Vascular Diseases Institute of Central South University, Changsha, China
| | - Ming Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Vascular Diseases Institute of Central South University, Changsha, China
| | - Quanming Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Vascular Diseases Institute of Central South University, Changsha, China
| | - Alan Dardik
- Department of Vascular Surgery, School of Medicine, Yale University, New Haven, CT, United States
| | - Chang Shu
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Vascular Diseases Institute of Central South University, Changsha, China
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Chang Shu,
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Total endovascular aortic arch repair using the Terumo Aortic triple-branch arch endograft. Ann Vasc Surg 2021; 77:351.e7-351.e14. [PMID: 34437959 DOI: 10.1016/j.avsg.2021.05.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/14/2021] [Accepted: 05/15/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the feasibility and outcomes of total endovascular repair of aortic arch aneurysms using a novel triple-branch arch endograft. METHODS Retrospective review of the clinical data and outcomes of 3 patients with arch aneurysms treated at a single institution using a custom-made triple-branch aortic endograft (Terumo Aortic, Sunrise, FL) between 2015 and 2020. The device has 3 internal branches corresponding to the principal branches of the standard aortic arch, obviating the need for any surgical revascularization. This initial experience represents the first three cases ever performed in the world using this endograft. RESULTS All procedures were technically successful. There were no strokes, in-hospital, or 1 year mortality. All 3 patients required secondary re-interventions. One patient died 14 months after the index procedure due to endocarditis unrelated to the arch repair. CONCLUSION The initial experience with the Terumo Aortic triple-branch endograft for treatment aortic arch aneurysms showed that, while the procedure is technically feasible, there remain significant anatomic and mechanical challenges in the endovascular repair of this segment of the thoracic aorta. Further refinements of endograft design and identification of optimal bridging stent technology are needed.
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