Combined surgical and endovascular treatment of aortic arch aneurysms

Long-Term Outcomes of Endovascular Repair of Thoracic Aortic Aneurysms

The thoracic aorta is a dynamic structure composed of the aortic root, ascending aorta, aortic arch, and descending aorta. It is subject to the pressure and volume of the cardiac cycle and susceptible to atherosclerotic and aneurysmal changes. With these changes, the risk for acute aortic syndromes increases, thus creating the impetus for earlier interventions. The previous standard of open surgical repair has undergone a transition in recent years toward endovascular repair being favored in the descending and abdominal aortas with ongoing investigation into approaches for the ascending and aortic arch. These therapies have been shown to improve early mortality and morbidity outcomes with the caveat of more interventions compared with open surgery. We undertook this review to analyze the current data available regarding long-term outcomes in patients undergoing endovascular repair for thoracic aortic disease. The data support long-term benefit of endovascular repair for thoracic aortic disease. The primary indications identified for reintervention are endoleak and further aneurysmal degeneration. As the devices available for endovascular repair evolve, ongoing review of these outcomes will be necessary. It will also be important to trend the results as further techniques become available for endovascular repair of the ascending aorta and aortic arch.

Comprehensive review of hybrid aortic arch repair with focus on zone 0 TEVAR and our institutional experience

Even with increasing operator experience and a better understanding of the disease and the operation, intervention for aortic arch pathologies continues to struggle with relatively higher mortality, reintervention, and neurologic complications. The hybrid aortic arch repair was introduced to simplify the procedure and improve the outcome. With recent industry-driven advances, hybrid repairs are not only offered to poor surgical candidates but have become mainstream. This review discusses the evolution of hybrid repair, terminology pertinent to this technique, and results. In addition, we aim to provide a pervasive review of hybrid aortic arch repairs with reference to relevant literature for a detailed understanding. We have also discussed our institutional experience with hybrid repairs.

Hybrid repair of aortic arch with zone zero endografting-Case series with review of the literature

INTRODUCTION

We present single-institution results of types I and II hybrid procedures for aortic arch disease with 30-day and long-term results and review of the literature.

MATERIALS AND METHODS

This is a retrospective study of all patients that underwent zone 0 endografting and open bypass from ascending aorta to the arch vessels at our institution between January 2013 and 2020. The following data for the systematic review were extracted from eligible studies: 30-day/in-hospital mortality, stroke rate, spinal cord ischemia (SCI) rate, renal failure requiring dialysis, development of retrograde dissection, early (<30 days) types I and III endoleak, follow-up length, late (>30 days) endoleak, and late (>30 days) mortality.

RESULTS

Twelve patients underwent hybrid aortic arch treatment in our institution. The most common aortic arch pathology was degenerative aortic aneurysm. The rate of retrograde dissection and SCI was 8.33%. Regarding the literature data, a total of 768 patients undergoing types I and II hybrid aortic arch debranching procedure. The pooled rate of 30-day/in-hospital mortality was 10.96% (95% confidence interval [CI], 8.21-14.06), SCI pooled rate was 2.91% (95% CI, 1.76%-4.33%), and retrograde dissection pooled rate was 3.22% (95% CI, 1.99-4.72).

CONCLUSION

Hybrid arch techniques provide safe alternative to open repair with acceptable short- and midterm results.

Antegrade Hybrid Chimney TEVAR Endograft in a Patient with Blunt Aortic Injury: A Challenging Case with Technical Success but Unfavorable Result

Thoracic Endovascular Aortic Repair (TEVAR) has modified aortic medicine, particularly in patients with traumatic aortic injury (TAI). Conventional repair of TAI in the aortic arch is technically demanding as it requires cardiopulmonary bypass and deep hypothermic arrest with still a significant number of complications. Despite recent improvements in endovascular techniques, many patients have been excluded from endovascular repair due to unfavorable anatomy. To increase the feasibility of endovascular repair, adjunctive open extra-anatomical bypasses may be required to provide an adequate proximal landing zone. Several methods, for instance, chimney technique, hybrid technique, and fenestrated or branched stent-grafts, have been proposed as options to preserve the supra-aortic branches, each with its own advantages and disadvantages. We herein present a patient with complex anatomical features and blunt aortic injury, who underwent antegrade chimney stent-graft deployment through the ascending aorta, not otherwise amenable to standard retrograde delivery because of severe peripheral artery disease. The remarkable aspect, in this case, is that both stents were placed antegrade, through the ascending aorta.

Late complications after hybrid aortic arch repair

OBJECTIVE

Although hybrid arch repair has gained widespread application as an alternative option for high-risk patients, concerns about its long-term durability remain an important issue. The aim of this study was to investigate late complications after hybrid arch repair.

METHODS

From January 2002 to December 2017, hybrid arch repair was performed in 65 patients with aortic arch disease (median age, 66.1 years; range, 41-86 years). Hybrid arch repair was defined as debranching involving at least one supra-aortic vessel bypass and simultaneous or staged endovascular thoracic stent grafting. We retrospectively analyzed late complications including reintervention, open conversion, and aortic-related death. The median follow-up period was 60.1 months (range, 1-170 months).

RESULTS

The in-hospital mortality rate was 6% (4/65). Except for early death (n = 4) and early open conversion (n = 2), late complications were observed in 25 patients (25/59 [42%]). The median time interval between the initial procedure and late complication was 36.6 months (range, 1-92 months). Late complications included delayed type I endoleak (n = 8), distal stent-induced new entry (n = 3), stent migration (n = 3), retrograde type A dissection (n = 2), aortopulmonary fistula (n = 2), aortoesophageal fistula (n = 1), stent fracture (n = 1), infection (n = 1), and sudden death (n = 4). Six of these patients (10%) underwent late open conversion. The overall survival rates at 3 years and 6 years were 71.1 ± 7.4% and 57.2 ± 11.3%, respectively. The aortic event-free rates at 3 years and 6 years were 52.1 ± 7.3% and 39.4 ± 10.3%, respectively.

CONCLUSIONS

Late complications in hybrid arch repair occurred in a substantial proportion of patients during midterm follow-up. Regardless of zone type, the incidence of late complications was relatively high. This study suggests that timely reintervention and open conversion are important for rescuing patients, but repeated reinterventions and conservative strategies are not recommended. Aggressive management and life-long surveillance after hybrid arch repair are mandatory for better outcomes.

Endovascular Treatment Options for the Aortic Arch

Endovascular aortic repair to treat aortic arch abnormality has rapidly expanded in the last 2 decades, and surgeons now have options to treat patients who are poor candidates for open surgery. The devices and techniques should be tailored to the extension of the aortic abnormality and anatomy of the individual. Recent studies demonstrate promising results with branched endografts, but one of the major drawbacks of the devices is that considerable time is required to prepare the custom-made graft, which may not be available for emergent or urgent cases. Introduction of commercially available devices is forthcoming.

Open Versus Endovascular or Hybrid Thoracic Aortic Aneurysm Repair

Thoracic aortic aneurysms are associated with significant morbidity and mortality. There are multiple underlying etiologies, including genetic abnormalities, that have important implications in their natural history. The variable histologic, anatomic, and clinical presentations necessitate careful consideration of available treatment options. Surgical repair of these aneurysms has been the mainstay of treatment; however, these approaches can carry a relatively high risk of morbidity and mortality. Endovascular approaches have now become first-line therapy for descending thoracic aneurysms, and with advancements in graft technology, endovascular approaches are being increasingly employed for hybrid repairs of the aortic arch and even the ascending aorta. However, to date, clinical outcomes from randomized trials and long-term follow-up are limited. As technology continues to advance, there is the potential for further integration of surgical and endovascular treatments so that patients have the best opportunity for a favorable outcome.

Analysis of Risk Factors for Early Type I Endoleaks After Thoracic Endovascular Aneurysm Repair

Purpose: To evaluate risk factors for early (<30 days) type I endoleak following thoracic endovascular aortic repair (TEVAR). Methods: A retrospective study was conducted of 439 consecutive patients (mean age 74.0±10.0 years; 333 men) who underwent TEVAR at a single center between June 2006 and June 2013. Pathologies included 237 aortic arch aneurysms and 202 descending thoracic aortic aneurysms (dTAA). Maximum TAA diameter was 63.6±13.7 mm. Among the distal aortic arch aneurysms, 124 required coverage of the left subclavian artery (LSA), while the remaining 113 arch aneurysms had debranching (n=40), the chimney technique (n=52), and a branched stent-graft (n=13). Eight patients with dilatation of the ascending aorta underwent arch replacement with elephant trunk prior to TEVAR. Predictive factors for type I endoleak were explored in univariate analysis and examined for each outcome using logistic regression models; results are given as the odds ratio (OR) and 95% confidence interval (CI). Results: Among 439 TEVAR cases, 37 (8.4%) had type I endoleaks on imaging at 1 month; 31 were in the 237 arch cases (13.1%). Endoleak investigation by site indicated a low incidence (3.0%) for dTAAs and markedly low (1.4%) in zone 4. Significantly more endoleaks were observed in zones 0–2 than in zone 4 (p<0.001). On univariate analysis, significant associations were found between endoleak and LSA coverage (OR 5.8, 95% CI 2.4 to 14.4, p<0.001), operative time ≥240 minutes (OR 3.7, 95% CI 1.5 to 6.2, p=0.002), and ≥270 mL of contrast (OR 2.8, 95% CI 1.4 to 5.8, p=0.004). Among the aortic branch reconstruction procedures, the chimney technique was the only maneuver associated with a significant risk of endoleak (OR 5.3, 95% CI 2.3 to 11.2, p<0.001). Arch state was not correlated with endoleaks, but ≥38-mm proximal neck diameter (OR 3.6, 95% CI 1.2 to 10.8, p=0.023), stent-graft diameter ≥40 mm (OR 9.9, 95% CI 1.4 to 30.5, p=0.015), and excessively oversized (≥14%) stent-grafts (OR 3.5, 95% CI 1.2 to 10.3, p=0.020) were; the proximal neck length was not correlated with endoleaks if a proximal neck length >10 mm can be secured. Conclusion: Risks for early type I endoleaks after TEVAR for aneurysm were landing zone 0–2, LSA coverage, large proximal neck and stent-graft diameters, excessive oversizing, and the use of the chimney technique.

Short- and Long-term Results of Hybrid Arch and Proximal Descending Thoracic Aortic Repair

Purpose: To evaluate the short- and long-term outcomes of hybrid repair of the arch and proximal descending aorta in a single tertiary center for aortic disease. Methods: A retrospective analysis was performed of 55 patients (median age 67 years; 36 men) who underwent hybrid repair of thoracic aortic pathology with involvement of the arch between January 2005 and May 2015 at a single tertiary center. The pathologies included 40 (73%) with aneurysmal disease, 10 (18%) acute type B aortic dissections, 2 with acute aortic syndrome, an acute type A dissection, and left and aberrant right subclavian artery aneurysms. Seven (13%) procedures were performed as an emergency. Demographics and procedure characteristics were collected for analysis of survival and reinterventions. Results: Complete aortic debranching was performed in 14 (25%) to facilitate endograft placement in zone 0; debranching was partial in 20 (36%) patients for zone 1 deployments and 21 (38%) for zone 2. Primary technical success was achieved in 51 (93%) cases. One patient died in-hospital from aneurysm rupture following aortic debranching prior to stent-graft repair. In another, the stent-graft procedure proved infeasible and was abandoned. The other 2 technical failures were due to type Ia endoleaks. Five (9%) patients died in-hospital (4 of 48 elective and 1 of 7 emergency cases); 2 of these patients died within 30 days (4%). Eight (14%) patients had a stroke, 6 of 48 elective and 2 of the 7 emergency patients. Spinal cord ischemia was reported in 3 (6%) patients. Mean follow-up was 74.6 months. Overall cumulative survival was 70% at 1 year, 68% at 2 years, and 57% at 5 years. Reintervention to the proximal landing zone for type Ia endoleak was required in 6% of cases. The overall rate of aortic reintervention was 18% at 1 year, 21% at 2 years, and 36% at 5 years. Overall extra-anatomic graft patency was 99%. Conclusion: Hybrid repair of the aortic arch and proximal descending thoracic aorta is technically feasible, with acceptable short-term mortality. There is a low rate of proximal landing zone reintervention when hybrid techniques are used to create an adequate proximal landing zone. Extra-anatomic bypass grafts have good long-term patency. Ongoing disease progression means that further distal aortic interventions are often necessary in patients with extensive disease.

Totally endovascular aortic arch repair by branched stent graft placement

Several methods for endovascular aortic arch repair have been proposed to reduce the morbidity and mortality associated with conventional open surgery for aortic arch aneurysms. We report our experience with aortic arch aneurysm repair by a totally endovascular technique, that is, a “reversed” stent graft technique using branched stent grafts.

Hybrid repair of aortic arch pathology

The objective was to evaluate a 13-year single-centre experience of arch endovascular aortic repair using the hybrid approach. Between 1999 and 2013, 491 patients were treated with endografts for thoracic aortic pathologies. The aortic arch was involved in 179 (36.5%) patients (128 men; mean age 70.2 ± 10.8 years, range 27-84). A hybrid approach was performed for all Zone 0 and 1 procedures and in nearly half of Zone 2 procedures. Early and mid-term outcomes were reviewed retrospectively. Overall primary technical success (24 h) was achieved in 162 (90.5%) of the 179 cases; 2 deaths and 15 Type 1 endoleaks were observed. Clinical success at 30 days was achieved in 161 (89.9%) of the 179 patients, with a mortality rate of 4.5% (8/179). Short-term clinical success at 6 months was achieved in 169 (94.4%) of the 179 patients; the rates for the different landing zones did not differ significantly. At a mean follow-up of 27.3 ± 15.7 months (range 1-94), the mid-term clinical success was 165 (92.2%) of the 179 patients; the rates among the different proximal zones did not differ significantly. In selected patients, early and mid-term outcomes of arch endovascular aortic repair using the hybrid approach are promising; however, mortality and morbidity are not negligible. Our results may have practical implications for the ongoing evaluation of the hybrid procedure in the aortic arch, as well as for patients fit for traditional surgery.

Coverage of the left subclavian artery without revascularization during thoracic endovascular repair is feasible: a prospective study

BACKGROUND

To effectively isolate thoracic aortic lesions in thoracic endovascular aortic repair (TEVAR), an adequate proximal landing zone length is required. The left subclavian artery (LSCA) and other branches of the aortic arch commonly impose limitations on proximal landing zone length, restricting the use of TEVAR. In this study, we investigated the outcomes of LSCA coverage during TEVAR.

METHODS

Between March 2009 and February 2010, we recruited patients with thoracic dissection, aneurysm or trauma from a single center for TEVAR. We categorized patients into 3 groups: full coverage, partial coverage, or noncoverage of the LSCA. We measured pre- and postoperative blood pressures and evaluated complications during follow-up.

RESULTS

We recruited 111 patients for our study: 55 (50%) and 25 (23%) patients had full and partial LSCA coverage, respectively. The upper left arm blood pressures before and after the operations were significantly different between the full-coverage group and the other groups (P < 0.0001). Follow-up occurred between 6 and 20 months, and the mean follow-up time was 10.4 months. Thirteen patients (24%) in the full-coverage group and 2 patients (8%) in the partial-coverage group suffered from simple vertebrobasilar ischemia (VBI). Eleven of the patients with VBI (20%) in the full-coverage group and 2 (8%) patients with VBI in the partial-coverage group had left subclavian steal syndrome at follow-up. No paraplegia or stroke was observed.

CONCLUSIONS

Intentional coverage of the LSCA to obtain an adequate proximal landing zone for TEVAR can be a treatment option for thoracic aortic lesions, although some patients experienced mil complications.

A systematic review and meta-analysis of hybrid aortic arch replacement

BACKGROUND

Evolution in the endovascular era has influenced the management of aortic arch pathologies. Several studies have described the use of a combined endovascular and open surgical approach to the treatment of arch diseases. Hybrid repair of arch pathologies has been considered as a less invasive method, and is therefore an appealing option for high-risk patients who are unsuitable for open repairs. The aim of the present meta-analysis was to assess the efficacy of hybrid techniques in patients with aortic arch pathologies.

METHODS

Extensive electronic literature search was undertaken to identify all articles published up to December 2012 that described hybrid aortic arch repair with intrathoracic supra-aortic branch revascularisation and subsequent stent graft deployment. Eligible studies were divided into two groups: group I included studies on the aortic arch debranching procedure and group II included studies that reported an elephant trunk technique (either "frozen" or stented). Separate meta-analyses were conducted in order to assess technical success, stroke, spinal cord ischemia (SCI), renal failure requiring dialysis, and cardiac and pulmonary complications rate, as well as 30-day/in-hospital mortality.

RESULTS

Forty-six studies were eligible for the present meta-analysis: 26 studies with a total of 956 patients reported aortic arch debranching procedures, and 20 studies with 1,316 patients performed either 'frozen' or stented elephant trunk technique. The pooled estimate for 30-day/in-hospital mortality was 11.9% for the arch debranching group and 9.5% for the elephant trunk group. Cerebrovascular events of any severity were found to have occurred postoperatively at a pooled rate of 7.6% and 6.2%, while irreversible spinal cord injury symptoms were present in a pooled estimate of 3.6% and 5.0% in the arch debranching and elephant trunk group, respectively. Renal failure requiring dialysis occurred at 5.7% and 3.8% in both groups, while cardiac complications rate was 6.0% in the arch debranching cohort and pulmonary complication was 19.7% in the elephant trunk cohort.

CONCLUSIONS

Hybrid arch techniques provide a safe alternative to open repair with acceptable short- and mid-term results. However, stroke and mortality rates remain noteworthy. Future prospective trials that compare open conventional techniques with the hybrid method or the entirely endovascular methods are needed.

A case of constrictive pericarditis and thoracic aortic aneurysm: a hybrid therapeutic approach

The authors describe the case of a 59-year-old man, a former smoker, with hypertension, chronic renal failure undergoing hemodialysis, and a history of stent grafting for repair of an abdominal aortic aneurysm and miliary tuberculosis, who was diagnosed with constrictive pericarditis and a thoracic aortic aneurysm. In a patient with such a complex medical history, there were several etiologies to consider. The treatment consisted of pericardiectomy and a hybrid technique of supra-aortic debranching and subsequent endovascular stent-graft repair.

[Hybrid repair for a ruptured aortic arch and descending aortic aneurysm in a kidney-transplanted patient]

CASE REPORT

We present a case of a 53 year old male renal transplanted patient, who presented with severe dyspnea. Chest X-ray and CT angiography showed a left sided haemothorax caused by an aortic arch aneurysm rupture. Acute operation was carried out, an ascendo-anonymo-carotid "Y" bypass was performed from sternotomy and a stent graft implantation through femoral artery. As a second step, the blood clot mass, which caused compression atelectasis of the left lung, was removed by a thoracic surgeon. At follow-up the patient was in good condition, the bypass graft functioned well, the stent graft stayed in good position, the aneurysm sack was reduced and the left lung expanded well.

DISCUSSION

Traditional operation of aortic arch aneurysm carries high mortality and morbidity rate, because of use of extracorporeal perfusion and deep hypothermic circulatory arrest. Hybrid operation became an alternative treatment. After circulation of supra-aortic arteries secured by "debranching procedure", a stent graft implantation is done. Such interventions means less strain for patients, but strict follow up is required, because lack of long-term data. Hybrid reconstruction of the aortic arch aneurysm is rarely performed in acute cases, but means an alternative treatment for high risk patients with acceptable results.

Initial experience in the treatment of thoracic aortic aneurysmal disease with a thoracic aortic endograft at Baylor University Medical Center

A retrospective review of 27 patients who underwent endovascular repair of thoracic aneurysms and of other thoracic aortic pathology with the thoracic aortic endograft (Gore Medical, Flagstaff, AZ) from June 2005 to July 2007 was performed. The mean follow-up period was 13.5 months (range, 2-25 months). Indications for thoracic endografting included descending thoracic aneurysms (n = 18), thoracoabdominal aneurysms (n = 3), traumatic aortic injuries (n = 3), penetrating aortic ulcers (n = 2), and contained rupture of a type B dissection (n = 1). One patient died during the procedure, for an overall mortality rate of 3.7%. The average length of stay was 8.1 days, with an average stay in the intensive care unit of 4.2 days. If patients with traumatic aortic injuries were excluded, the average overall and intensive care unit length of stay were 5.6 and 1.8 days, respectively. There was one incident of spinal cord ischemia (3.7%). There were five type I or type III endoleaks, three of which required revision (11.1%). In conclusion, thoracic endografting is a safe and viable option for the repair of descending thoracic aneurysms and other aortic pathologies. We have found it to be less invasive, even in conjunction with preoperative debranching procedures, with a shorter recovery time, decreased perioperative morbidity and blood loss, and decreased peri-operative mortality compared with standard open repair.

Pull-through technique for entire thoracic aortic dissection without additional left thoracotomy

Urgent single-staged replacement of the aortic dissection involving the entire thoracic aorta was performed by using the modified pull-through technique via median sternotomy. Distal anastomosis was achieved via posterior pericardium to avoid the lateral thoracotomy and then the graft was pulled through the false lumen of the descending aorta into the aortic arch. Each lumen between proximal and distal anastomosis was closed for hemostasis. The aortic arch was replaced with a four-branched graft. Postoperative course was uneventful. This procedure might be an alternative in selected patients to the left thoracotomy.

Combined open and endovascular repair for aortic arch pathology

Background and Objectives

We describe our experience with combined open and endovascular repair in patients who have aortic arch pathology.

Subjects and Methods

This study is a retrospective analysis of 7 patients who underwent combined open and endovascular repair for aortic arch pathology. Medical records and radiographic information were reviewed.

Results

A total of 7 consecutive patients (5 men, 71.4%) underwent thoracic stent graft implantation. The mean age was 59.9±16.7 years. The indication for endovascular repair was aneurysmal degeneration in 5 patients, and rupture or impending rupture in 2 patients. In all 7 cases, supra-aortic transposition of the great vessels was performed successfully. Stent graft implantation was achieved in all cases. Surgical exposure of the access vessel was necessary in 2 patients. A total of 9 stent grafts were implanted (3 stent grafts in one patient). The Seal thoracic and the Valiant endovascular stent graft were implanted in 6 patients and 1 patient, respectively. There were no post-procedure deaths or neurologic complications. In 2 patients, bleeding and injury of access vessel were noted after the procedure. Postoperative endoleak was noted in 1 patient. One patient died at 10 months after the procedure due to a newly developed ascending aortic dissection. No patients required secondary intervention during the follow-up period. The aortic diameter decreased in 4 patients. In 3 patients, including 1 patient with endoleak, there was no change in aortic diameter.

Conclusion

Our experience suggests that combined open and endovascular repair for aortic arch pathology is safe and effective, with few complications.

Current strategy of endovascular aortic repair for thoracic aortic aneurysms

Thoracic aortic aneurysms are extremely burdensome to treat owing to their surgical complexity. In particular, major postoperative complications lower significantly patients' quality of life. Surgical treatment has recently shifted to thoracic endovascular aortic repair (TEVAR) to respect the patients' needs and improve postoperative quality of life. This procedure is radical and innovated for thoracic aortic pathology, but the devices and the delivery systems are immature because only a little over a decade and a half has passed since starting to use them. Ready-made stent-grafts were originally indicated only for degenerated aortic aneurysms, but aortic dissection and traumatic aortic transection will become the next targets for TEVAR. This review addresses the history and changes in TEVAR as well as the current TEVAR strategy. Finally, we describe a new trial of TEVAR for aortic dissections, traumatic aortic transections, and aortic arch aneurysms.