Hybrid thoracic endovascular aortic repair: Pushing the envelope

Hybrid repair of type II thoracoabdominal aortic aneurysm using modified branch-first technique

The hybrid modified branch-first technique has extended the feasibility of open thoracoabdominal aortic aneurysm (TAAA) repair in otherwise hostile aortic anatomy that is not entirely amenable for extent II open TAAA conventional repair or total endovascular repair. The modified branch-first open TAAA technique has been developed successfully at our center and has been used to treat extent III TAAAs with successful outcomes. By combining the modified technique with endovascular thoracic aortic repair, we have been able to successfully extend its use to more extensive extent II TAAAs. This could prove to be a useful technique in the armamentarium of aortic surgeons.

Aortic arch debranching in hybrid thoracic aortic replacement

OBJECTIVE

To analyze the outcomes of aortic arch debranching in hybrid thoracic aortic replacement.

MATERIAL AND METHODS

There were 107 patients who underwent hybrid thoracic aortic repair with debranching of supra-aortic vessels between 2015 and 2021. Patients underwent total and partial debranching (subtotal debranching and subclavian-carotid anastomosis/bypass). Debranching was performed in patients with type 3 dissection, type B aneurysms, post-traumatic aortic isthmus and arch aneurysms, thoracoabdominal aneurysms type A and DeBakey type 1 dissections.

RESULTS

One patient (0.9%) died from thoracic aorta rupture after retrograde dissection. There was a moderate decrease of blood flow velocity through the left vertebral artery after subtotal debranching without severe hemodynamic disorders. Despite mild surgical trauma, subtotal and especially total debranching are characterized by higher risk of thrombosis of branches with potential fatal outcomes. In young patients requiring subtotal aortic arch debranching, open reconstruction or repair with fenestrated stents is preferred. We recommend a Bavaria type II hybrid procedure for patients with high surgical risk. In our opinion, more physiological hybrid interventions with anatomical arrangement of supra-aortic vessels such as Elephant Trunk and Frozen Elephant Trunk procedures are preferred.

Hybrid Surgery to Manage Aortic Arch Pathology

Background and Objectives: Aortic arch disease is still a high-risk surgical challenge despite major advances both in surgical and anesthesiological management. A combined surgical and endovascular approach has been proposed for aortic arch disease treatment to avoid hypothermia and circulatory arrest in high-risk patients. Materials and Methods: Between June 2004 and June 2021, 112 patients were referred to our department for aortic arch surgery; 38 (33.9%) patients underwent supra-aortic debranching and endovascular treatment. Of these, 21 (55%) patients underwent type I aortic arch hybrid debranching procedure and in 17 (45%) patients a type II aortic arch hybrid debranching procedure was performed. None of the patients were emergent. Results: No intra-operative deaths were recorded. In the type I aortic arch hybrid debranching patients’ group, one patient died at home waiting the endovascular step, one developed ascending aortic dissection and another one developed a pseudoaneurysm at the site of the debranching at follow-up. In the type II aortic arch hybrid debranching patients’ group, left carotid artery branch closure was detected at follow-up in one patient. Thirty day/in-hospital rates of adverse neurological events for both the surgical and endovascular procedures were 3% for minor stroke, with no permanent neurological deficit and 0% for permanent paraplegia/paraparesis. In 100% of the cases, the endovascular step succeeded and the type Ia endoleak rate was 0%. Conclusions: Hybrid arch surgery is a valuable option for aortic arch aneurysm treatment in patients with high surgical risk. The choice of aortic arch debranching between type I or type II is crucial and depends on anatomic and clinical patient characteristics. Further larger scale studies are needed to better define the advantages of these techniques.

Trends and outcomes of thoracic endovascular aortic repair with open concomitant cervical debranching

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.

Which is the Optimal Frozen Elephant Trunk? A Systematic Review and Meta-Analysis of Outcomes in 2161 Patients Undergoing Thoracic Aortic Aneurysm Surgery Using E-vita OPEN PLUS Hybrid Stent Graft versus Thoraflex™ Hybrid Prosthesis

Objective

To systematically review the rate of morbidity and mortality associated with the use of E-vita hybrid stent graft and ThoraflexTM in patients undergoing complex aortic surgery.

Methods

A comprehensive search was undertaken among the four major databases to identify published data about E-vita or Thoraflex™ in patients undergoing repair of thoracic aortic aneurysms.

Results

In total, 28 papers were included in the study, encompassing a total of 2,161 patients (1,919 E-vita and 242 Thoraflex™). Patients undergoing surgery with E-vita or Thoraflex™ were of similar age and sex. The number of patients undergoing non-elective repair with Thoraflex™ was higher than with E-vita (35.2% vs. 28.7%, respectively). Cardiopulmonary bypass time was associated with increasing mortality in E-vita patients, however a meta-analysis of proportions showed higher 30-day mortality, permanent neurological deficit, and one-year mortality for Thoraflex™ patients. Direct statistical comparisons between E-vita and Thoraflex™ was not possible due to heterogeneity of studies.

Conclusion

Although there are limited studies available, the available data suggests that mortality and morbidity are lower for the E-vita device in thoracic aortic aneurysm surgery than for Thoraflex™. Long-term data of comparative studies do not yet exist to assess viability of these procedures.

The life-saving emergency thoracic endovascular aorta repair management on suspected aortoesophageal foreign body injury

BACKGROUND

Fatal aortic rupture caused by esophageal foreign body (EFB), is associated with a high mortality, but can be prevented by thoracic endovascular aorta repair (TEVAR) that performed increasingly as technology improves. This study aims to investigate the cause, management and prognosis of suspected penetrating aortoesophageal foreign body injury.

METHODS

Twelve cases who met the criteria were enrolled in this study. The demographic and clinical data were reviewed for evaluating the characteristics of EFB.

RESULTS

Among 12 cases enrolled, 7 were males and 5 were females, with an age 27-86 years. The distance of EFB from aorta (DFA) of 7 cases were less than or equal to 0 mm, 5 cases were 0-2 mm. Eleven cases were managed with TEVAR, only one case was with open surgery standby but finally treated by flexible endoscopy (FE) successfully, without TEVAR. In group with TEVAR, EFB of 7 cases were successfully removed by rigid endoscopy (RE), and one of them was failed at the first RE treatment. EFB of 2 cases were successfully removed by open surgery with TEVAR, and other 9 cases were managed by endoscopies with TEVAR. The mean length of stay of hospitalization (LOS) and length of ICU stay of patients treated by open surgery with TEVAR (18.50±2.12 days and 5.50±0.71 days) was significantly longer than those of patients treated by endoscopy with TEVAR (7.00±2.74 days and 1.33±1.12 days, P<0.001 and P=0.001, respectively). Five cases had severe complications.

CONCLUSION

Rational application of TEVAR can be a life-saving management for aortoesophageal foreign body injury, and jointed with endoscopy is safe and effective with a shorter length of ICU or total hospital stay.

Off pump hybrid extra-anatomic techniques for aortic arch repair-own experience

Background

Treatment of the aortic arch pathologies is technically challenging. In this study we assess early and late outcomes of hybrid aortic arch repairs that comprise extra-anatomic surgical procedures completed by thoracic endovascular interventions [thoracic endovascular aortic repair (TEVAR)].

Methods

Since 2007, 21 patients (8 women and 13 men) with a median age of 48 years have undergone hybrid procedures for aortic arch pathologies. All of them were treated without cardio-pulmonary bypass. All survivors were followed up regularly and imaging examination were performed. A technical success, procedural complications as well as the early and late mortality and morbidity rates were evaluated.

Results

All patients survived surgery and TEVAR was technically successful in all of them. However, 2 individuals died (in-hospital mortality rate 9.5%) during in-hospital stay, both due to multi-organ failure (MOF). Additionally, one patient developed symptoms of cerebral stroke, another one of spinal cord ischemia. During the follow-up that ranged from 6 to 118 months and was completed by 100% of the survivors, one patient died 3 years after procedure because of sepsis (aorto-oesophageal fistula prior to intervention) and late vascular graft occlusions were noted in three cases.

Conclusions

Hybrid procedures on the aortic arch that comprise surgical and endovascular interventions has become an attractive and safe therapeutic option with acceptable mortality and morbidity rate. They may be considered as a method of choice in treatment of the elderly and high-risk patients.

Debranching of Supra-aortic Vessels via Femoral Artery Inflow for Late Ascending Aortic Rupture

A 56-year-old man with a history of Marfan's syndrome, total arch replacement, descending thoracic endovascular aortic repair, and twice redo sternotomy for pseudoaneurysm repair, presented with a pulsatile chest mass secondary to a contained rupture of the ascending aorta. The patient underwent supra-aortic debranching via the superficial femoral artery and ascending thoracic stent-graft placement under continuous transesophageal echocardiography. Completion angiography demonstrated successful exclusion of the contained rupture. Postoperatively, the patient was neurologically intact, the pulsatile mass resolved, and the bypass grafts remained patent. Chronic respiratory failure and multidrug-resistant pneumonia led to late mortality. This case demonstrates that hybrid repair is effective in the emergent setting of ascending aortic rupture. Debranching of the ascending arch using the superficial femoral artery as inflow is feasible and provides adequate cerebral perfusion despite the length of the bypass. The use of transesophageal echocardiography during stent-graft deployment allows precise device placement in the high-risk area of the ascending aorta proximal to the innominate artery.

Outcomes of thoracic endovascular aortic repair using aortic arch chimney stents in high-risk patients

BACKGROUND

Aortic arch disease is a challenging clinical problem, especially in high-risk patients, in whom open repair can have morbidity and mortality rates of 30% to 40% and 2% to 20%, respectively. Aortic arch chimney (AAC) stents used during thoracic endovascular aortic repair (TEVAR) are a less invasive treatment strategy than open repair, but the current literature is inconclusive about the role of this technology. The focus of this analysis is on our experience with TEVAR and AAC stents.

METHODS

All TEVAR procedures performed from 2002 to 2015 were reviewed to identify those with AAC stents. Primary end points were technical success and 30-day and 1-year mortality. Secondary end points included complications, reintervention, and endoleak. Technical success was defined as a patient's surviving the index operation with deployment of the AAC stent at the intended treatment zone with no evidence of type I or type III endoleak on initial postoperative imaging. The Kaplan-Meier method was used to estimate survival.

RESULTS

Twenty-seven patients (age, 69 ± 12 years; male, 70%) were identified, and all were described as being at prohibitive risk for open repair by the treating team. Relevant comorbidity rates were as follows: coronary artery disease/myocardial infarction, 59%; oxygen-dependent emphysema, 30%; preoperative creatinine concentration >1.8 mg/dL, 19%; and congestive heart failure, 15%. Presentations included elective (67%; n = 18), symptomatic (26%; n = 7), and ruptured (7%; n = 2). Eleven patients (41%) had prior endovascular or open arch/descending thoracic repair. Indications were degenerative aneurysm (49%), chronic residual type A dissection with aneurysm (15%), type Ia endoleak after TEVAR (11%), postsurgical pseudoaneurysm (11%), penetrating ulcer (7%), and acute type B dissection (7%). Thirty-two brachiocephalic vessels were treated: innominate (n = 7), left common carotid artery (LCCA; n = 24), and left subclavian artery (n = 1). Five patients (19%) had simultaneous innominate-LCCA chimneys. Brachiocephalic chimney stents were planned in 75% (n = 24), with the remainder placed for either LCCA or innominate artery encroachment (n = 8). Overall technical success was 89% (one intraoperative death, two persistent type Ia endoleaks in follow-up). The 30-day mortality was 4% (n = 1; intraoperative death of a patient with a ruptured arch aneurysm), and median length of stay was 6 (interquartile range, 4-9) days. Seven (26%) patients experienced a major complication (stroke, three [all with unplanned brachiocephalic chimney]; respiratory failure, three; and death, one). Nine (33%) patients underwent aorta-related reintervention, and no chimney occlusion events occurred during follow-up (median follow-up, 9 [interquartile range, 1-23] months). The 1-year and 3-year survival is estimated to be 88% ± 6% and 69% ± 9%, respectively.

CONCLUSIONS

TEVAR with AAC can be performed with high technical success and acceptable morbidity and mortality in high-risk patients. Unplanned AAC placement during TEVAR results in an elevated stroke risk, which may be related to the branch vessel coverage necessitating AAC placement. Acceptable midterm survival can be anticipated, but aorta-related reintervention is not uncommon, and diligent follow-up is needed.

[Hybrid operating rooms versus conventional operating rooms : Economic comparisons in vascular surgery using the example of endovascular aneurysm repair]

BACKGROUND

With changing treatment modalities in vascular surgery towards incorporating more endovascular solutions, increased numbers of hybrid operating theatres are being introduced to meet the sterility and imaging quality requirements. These cost-intensive acquisitions however have never been evaluated from an economic perspective. In this study we evaluated cost-relevant parameters before and after the introduction of a hybrid operating room using the example of endovascular aneurysm repair (EVAR) performed in patients with abdominal aortic aneurysms (AAA).

METHODS

Retrospective analysis of prospectively collected data. The 4‑year period before the introduction of a hybrid operating room were compared with the 4‑year period following introduction. Between 2007 and 2010, 97 EVAR procedures were performed before the implementation of a hybrid operating room and 50 EVAR procedures were performed with a hybrid operating room (2012-2015). We evaluated process cost-relevant parameters (operating time) and diagnosis-related group (DRG) parameters (case load, case mix, case mix index).

RESULTS

The operating time was significantly reduced on average by 23.5 min (120 min [102-140] vs. 96.5 min [90-120]; p < 0.0001) with a hybrid operating room. This led to a reduction in costs of 276.17 EUR for an EVAR procedure. The case load of EVAR increased from 308 cases from 2007-2010 to 380 cases from 2012-2015 . The associated case mix also increased from 1580 to 1986 points. The total number of case mix points of all managed operative interventions in the operating theatre before and after conversion to a hybrid operating room grew significantly by 17.33% from 8420 to 9880 (p < 0.03) in the compared time periods.

CONCLUSION

With detailed, demand-oriented planning, a hybrid operating room can have a favourable economic effect due to a reduction of operating time and the overall lowering of process costs. Thus a refinancing in the long-term is feasible. In addition, this can lead to an increase in the total number and complexity of endovascular procedures.

A novel technique of total debranching TEVAR with inflow from the descending aorta

An 82-year-old male with TAA was considered high risk for conventional surgery because of previous CABG. Therefore, a hybrid repair was performed. First, the arch vessels were debranched extra-anatomical bypass. Second, left thoracotomy was performed. The proximal side of a bifurcated graft was anastomosed to the descending aorta. To arch vessels' debranch graft, two bifurcated graft distal limbs were anastomosed with a 10-mm distance. Two stentgrafts were deployed from the ascending to descending aorta. Postoperative CT did not reveal any endoleak, and all debranch grafts were patent.

Hybrid Procedure with Debranching from the Descending Aorta for Aortic Arch Aneurysm after Previous Open Repair

Aortic arch aneurysms can be treated with hybrid procedures by endovascular exclusion and prior debranching of supra-aortic arteries. We report on a case of symptomatic arch aneurysm following previous supracoronary ascending aorta and hemiarch replacement with a very short proximal landing zone. A successful reconstruction was performed by retrograde revascularization of supra-aortic vessels from the descending aorta and subsequent endovascular repair deploying a proximal stent graft directly above the sinotubular junction with good results in the 4-year follow-up. Retrograde supra-aortic debranching may constitute a suitable approach for hybrid endovascular repair of aneurysms of the aortic arch and the ascending aorta in selected cases.

Chimney technique for aortic arch pathologies: an 11-year single-center experience

PURPOSE

To report our single-center experience with the chimney technique for aortic arch pathologies and the mid- to long-term results in these patients.

METHODS

From June 2002 to May 2013, 26 patients (18 men; mean age 71.2 years, 53-86) underwent thoracic endovascular aortic repair (TEVAR) combined with chimney technique. Indications for treatment were: a proximal landing zone <15 mm long distal to the left subclavian artery (LSA), thoracic aortic aneurysm (n=13), complicated type B aortic dissection (n=10), type I endoleak after previous TEVAR (n=2), and penetrating aortic ulcer (n=1). Treatment was performed in the emergency setting in 7 cases. The 28 chimney stent-grafts (double chimneys in 2 patients) were deployed in the innominate artery (n=7), left common carotid artery (n=10), and LSA (n=11). All patients underwent computed tomography before discharge, at 1, 6, and 12 months, and yearly thereafter.

RESULTS

Technical success was 100%. One (3.8%) perioperative death was due to a cerebral hemorrhage. No major stroke was registered, but 3 (11.5%) minor strokes occurred (all resolved). Paraparesis developed in 2 (7.7%) patients. Median follow-up was 36.8 months (range 1-131), during which an additional 4 (15.4%) patients died, but only 1 death was aneurysm-related. Chimney graft patency was 89.3% (25/28); an asymptomatic fracture was found in a patent chimney stent-graft at the 18-month follow-up. The type I endoleak rate was 23% (n=6); 3 endoleaks associated with aneurysm sac enlargement were treated.

CONCLUSION

The chimney technique for aortic arch pathologies is safe and feasible and may be an option in patients considered at high risk for surgery or who are ineligible for conventional TEVAR, especially in the emergency setting. Concern persists regarding type I endoleak, and long-term follow-up remains mandatory.

Hybrid arch debranching and proximal endograft extension to repair a type I endoleak after endovascular thoracic aneurysm repair

Endovascular repair of complex aortic disease has emerged over the past decade as an alternative to traditional open repair, especially for patients with significant medical comorbidities and/or anatomic challenges, such as reoperative fields. However, the possibility of graft migration and endoleak mandates long-term follow-up of these grafts. We present a patient who underwent hybrid repair after stent graft migration and proximal type I endoleak after thoracic endovascular aneurysm repair. This approach allowed us to avoid extensive surgery that would also necessitate circulatory arrest.

A Case Series of a Hybrid Approach to Aortic Arch Disease

<p><b>Objective:</b> Debranching of the aortic arch and endovascular stent placement as a combination therapy for complex aortic arch pathology has emerged over the past few years as an alternative to traditional repair. This hybrid approach is a viable option for patients who would not tolerate conventional arch replacement, as well as for patients with a failed stent graft of the descending aorta and a subsequent type I endoleak.</p><p><b>Methods:</b> We retrospectively reviewed the preoperative characteristics and postoperative outcomes of 5 patients who underwent debranching of the aortic arch and implantation of an endovascular stent across the aortic arch between 2008 and 2011. Data were analyzed with the Student t test and the Kaplan-Meyer method.</p><p><b>Results:</b> The mean age was 70.6 � 18 years; 4 men and 1 woman were evaluated. One patient had previous aortic surgery for dissection. The preoperative morbidities included arrhythmia (1 patient), chronic obstructive pulmonary disease (2 patients), cerebrovascular accident (1 patient), diabetes mellitus (2 patients), coronary artery disease (2 patients), and active angina (1 patient). One patient had a myocardial infarction 3 weeks before surgery. The primary technical-success rate was 100%, and none of the patients died in the perioperative phase. The mean follow-up time was 22 � 18.4 months, and the median follow-up time was 13.8 months (range, 7.13-50.7 months). Two patients died during follow-up. The pathology of the aorta in the patients who died was arch aneurysm; the 3 remaining patients are alive and regularly followed at our institution.</p><p><b>Conclusion:</b> The combination of surgery and simultaneous endovascular stenting in the operating room is an alternative approach for patients who are poor candidates for traditional arch repair under circulatory arrest.</p>

Anatomical characteristics of the thoracic aortic arch in an Asian population

Background: Endovascular repair of the aortic arch is often unsatisfactory due to poor stent-vessel conformity and inadequate landing zones.

Objective: To study the anatomical characteristics of the aortic arch and provide basic information for the development of arch-specific endovascular devices.

Materials and methods: Three-dimensional models were reconstructed in Mimics (image segmentation software) from computed tomography aortograms of 120 elderly Asian patients, by manual segmentation. The centerline of each Three-dimensional aortic model was calculated using a repulsive force field method. Measurements of the aorta and supra-aortic branches were analyzed using Patran (finite-element software). A three-dimensional statistical aortic arch model was built using principal component analysis.

Results: The mean diameters of the ascending and descending aorta, and the origins of the innominate, left common carotid, and left subclavian artery were 39.4 ± 6.7, 34.5 ± 7.9, 18.0 ± 3.8, 12.6 ± 2.7, and 14.1 ± 2.5 mm, respectively. The length of the ascending aorta, innominate to left common carotid artery, and left common carotid to left subclavian artery were 62.6 ± 11.4, 12.0 ± 5.6, and 18.7 ± 5.6 mm along the centerline. The mean angle of curvature was 103.8 ± 25 degrees. Principal component analysis of the three-dimensional centerlines derived 3 main modes of variation, which account for 61% of the overall shape range.

Conclusion: Aortic arch anatomical information from an elderly Asian population can be useful for the development of future endovascular devices.

Reversed sequence arch debranching for treatment of a ruptured juxta-innominate artery saccular aneurysm

PURPOSE

To describe a hybrid approach for the treatment of a ruptured juxta-innominate artery saccular aneurysm.

CASE REPORT

A 68-year-old smoker male with poor exercise tolerance sustained a contained ruptured saccular aneurysm at the origin of the innominate artery. Although under the femoral-axillary bypass to allow direct brain perfusion, a 36 × 110 mm thoracic endograft was successfully deployed with total coverage of the distal ascending and aortic arch. A sternotomy was performed and an aorto-innominate and left common carotid artery bypass was done. At 1-month follow-up, a type 2 endoleak at the innominate artery stump was noted and successfully treated with coil embolization. The patient remains neurologically intact 1 year after the surgery.

CONCLUSION

Juxta-innominate artery saccular aneurysms are rare. A hybrid open-endovascular repair using a reversed sequence arch debranching after endovascular repair is feasible and may be an alternative to deep hypothermic circulatory arrest particularly in frail patients.

Triple-barrel graft as a novel strategy to preserve supra-aortic branches in arch-TEVAR procedures: clinical study and systematic review

OBJECTIVE

To report our early experience with total endovascular repair of aortic-arch aneurysm using double chimney-grafts and present a literature overview.

PATIENTS AND METHODS

The double chimney-graft technique was performed in six male patients with contained ruptured aneurysm, dissecting aneurysm, pseudoaneurysm, penetrating aortic ulcer and proximal endoleak after TEVAR. Furthermore, a systematic electronic health database search of available articles was conducted according to PRISMA Guidelines.

RESULTS

In all cases, all supra-aortic vessels had to be covered with aortic stent-graft to receive a sufficient landing and sealing zone. Chimney-grafts were introduced to the ascending aorta slightly deeper than the thoracic stent-grafts through the cut-down exposure of the common carotid arteries. We deployed aortic stent-grafts and self-expandable chimney-grafts simultaneously and successfully. The patient with contained ruptured aneurysm died due to cardiopulmonary failure on day 19, the others survived. We detected two 'gutter' endoleaks. As a result of literature search, 12 articles met the inclusion criteria. Two articles described the double-chimney technique.

CONCLUSIONS

The use of double chimney-grafts is possible in high-risk patients where the proximal landing zone of endograft would be in zone 0. The available data is still limited. The long-term follow-up remains to be evaluated with the increased number of patients treated.

Is total debranching a safe procedure for extensive aortic-arch disease? A single experience of 27 cases

OBJECTIVE

Thoracic, arch, and proximal descending thoracic aorta diseases are still considered an enormous challenge. The hybrid approach developed in recent years (supra-aortic trunks debranching and thoracic endovascular repair aortic repair; TEVAR) may improve the morbidity and mortality of the population at risk. The aim of this study was to analyze retrospectively our experience in the hybrid treatment of aortic-arch aneurysms and dissections.

METHOD

We carried out a retrospective review of 27 patients who required a surgical debranching of the supra-aortic trunks and a TEVAR in the management of the aortic arch and proximal descending thoracic aortic disease. The aortic lesions included 18 degenerative arch-aortic aneurysms, four complicated aortic dissections, two subclavian artery aneurysms, and three penetrating atherosclerotic ulcers. Technical success was achieved in all patients.

RESULTS

The 30-day mortality rate was 11.1% (3/27). Mean follow-up was 16.7 months (range, 1-56), and the survival rate was 77.8%. The endoleaks' rate was 3.7% (1/27), due to a stent-graft migration.

CONCLUSION

Hybrid approaches may represent an alternative option in the treatment of complex aortic lesions involving the arch and the proximal descending thoracic aorta in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger comparative series.

Hybrid arch repair including supra-aortic debranching on the descending aorta

A 49-year-old patient with an anastomotic pseudoaneurysm in the aortic arch was considered at high risk for conventional surgery through a median sternotomy because he had previously undergone several operations to treat aortic dissection and had a deep sternal infection after one procedure. Therefore, a hybrid repair was performed. Stent grafts were placed bridging two previously implanted aortic prostheses, which were in the ascending aorta and descending aorta, respectively. The supra-arch vessels were perfused by means of an extra-anatomic bypass from the descending aorta. The aneurysm was completely excluded from the blood flow, and the patient had no serious complications.

Failed surgical ligation of the proximal left subclavian artery during hybrid thoracic endovascular aortic repair successfully managed by percutaneous plug or coil occlusion: a report of 3 cases

Open surgical rerouting and proximal ligation of one or more supra-aortic vessels prior to endovascular stent-graft placement has become an alternative to major open thoracic surgery in the treatment of complex thoracic aortic disease. Complications owing to failed surgical ligation of the left subclavian artery are rare. In this report, 3 cases of failed ligation are presented. Diagnosis was made by CT-scan and treatment was performed by transcatheter coil and plug embolization, avoiding redo neck surgery.

A complex thoracoabdominal aneurysm in a Loeys-Dietz patient: an open, hybrid, anatomic repair

We report the successful treatment of a life-threatening thoracoabdominal aneurysm in a young patient affected by type I Loeys-Dietz syndrome. To overcome anatomic and surgical difficulties, we used an original strategy and a specially designed surgical tool. The clinical and technical aspects of this approach are presented.