Outcomes of thoracic endovascular aortic repair using fenestrated stent grafts in patients with thoracic aortic distal arch aneurysms

OBJECTIVES

Thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is challenging because of anatomical restrictions and the presence of cervical branches. Revascularization of the cervical branch is required when conventional commercial stent grafts are used. TEVAR using fenestrated stent grafts (FSG) often does not require additional procedures to revascularize cervical branches. This study aimed to evaluate the features and initial and midterm outcomes of TEVAR using fenestrated stent grafts.

METHODS

From April 2007 to December 2016, 101 consecutive patients underwent TEVAR using fenestrated stent grafts for distal aortic arch aneurysms at a single centre. Technical success, complications, freedom from aneurysm-related death, secondary intervention and aneurysm progression were retrospectively investigated.

RESULTS

All the patients underwent TEVAR using fenestrated stent grafts. The 30-day mortality rate was zero. Cerebral infarction, access route problems and spinal cord injury occurred in 4, 3 and 2 patients, respectively. Each type of endoleak was observed in 38 of the 101 patients during the course of the study; 20/38 patients had minor type 1 endoleaks at the time of discharge. The endoleak disappeared in 2 patients and showed no significant change in 8 patients; however, the aneurysm expanded over time in 10 patients. Additional treatment was performed in 8 of the 10 patients with type 1 endoleaks and dilatation of the aneurysm. The rate of freedom from aneurysm-related death during the observation period was 98%.

CONCLUSIONS

TEVAR with FSG is a simple procedure, with few complications. Additional treatment has been observed to reduce aneurysm-related deaths, even in patients with endoleaks and enlarged aneurysms. Based on this study, the outcomes of endovascular repair of aortic arch aneurysms using a fenestrated stent graft seem acceptable.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Endovascular aortic arch repair: A comparison of outcomes and current trends

OBJECTIVE

Application of thoracic endovascular aortic repair (TEVAR) to the aortic arch has been met with the development of purpose-made endoprostheses for on-label use in the aortic arch. An appraisal of the clinical efficacy of each major device is therefore useful towards informing clinical decision making for patients eligible for endovascular arch repair (EAR) rather than open surgical reconstruction.

METHODS

A literature review of publications outlining clinical experience with the RELAY™ Branched and Zenith™ devices was undertaken, and the results therefrom analysed to evaluate the clinical efficacies of each device.

RESULTS

Early- and long-term mortality rates associated with EAR appear favourable, especially compared against open surgical repair. EAR is also associated with good neurological outcomes and target vessel patency rates. However, EAR continues to be associated with substantial reintervention rates.

CONCLUSIONS

At the present stage, EAR represents a promising alternative option to open surgical reconstruction in patients that meet its eligibility criteria. Though there remains a substantial learning curve associated with EAR, its favourable outcome profile is likely to increase its applicability in the future.

Avoiding Stroke in Patients Undergoing Endovascular Aortic Arch Repair: JACC Review Topic of the Week

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.

Mid-term outcomes of left subclavian artery revascularization with Castor stent graft in treatment of type B aortic dissection in left subclavian artery

Background

Here we analyzed mid-term data of thoracic endovascular aneurysm repair (TEVAR) surgery with Castor single-branched stent graft placement for the management of Stanford type B aortic dissection (STBAD) involving the left subclavian artery (LSA).

Methods

Between April 2014 and February 2019, 32 patients with STBAD involving a Castor single-branched stent graft were included. We analyzed their outcomes, including technical success rate (TSR), surgical duration (SD), presence of ischemia, perioperative complications, LSA patency, and survival rate (SR), using computed tomography angiography and clinical evaluation during mid-term follow-up.

Results

The mean patient age was 54.63 ​± ​12.37 years (range, 36-83 years). The TSR was 96.88% (n ​= ​31/32). The mean SD was 87.44 ​± ​10.89 with a mean contrast volume of 125.31 ​± ​19.30 ​mL. No neurological complications or deaths occurred during the study period. The patients had a mean hospital stay of 7.84 ​± ​3.20 days. At a mean follow-up of 68.78 ​± ​11.26 months, four non-aortic deaths (12.5%) were observed. The LSA patency rate was 100% (n ​= ​28/28). There was only one case of type I endoleak immediately after surgery (3.12%) (type I from LSA). However, none of the patients experienced type II endoleaks, and there were no cases of retrograde type A aortic dissection or stent graft-driven new distal entry. Finally, all patients exhibited good LSA patency.

Conclusion

TEVAR using a Castor single-branched stent graft may be a highly feasible and efficient procedure for the management of STBAD involving the LSA.

Stroke Following Thoracic Endovascular Aortic Repair: Determinants, Short and Long Term Impact

We performed a contemporary assessment of clinical and radiographic factors of stroke after thoracic endovascular aortic repair (TEVAR). Patients undergoing TEVAR from 2006 to 2017 were identified. We assessed clinical and radiographic data, including preoperative head and neck computed tomography, Doppler ultrasonography, and intraoperative angiography. Our primary outcome was stroke after TEVAR. Four hundred seventy-nine patients underwent TEVAR, mean age 68.1 ± 19.5 years, 52.6% male. Indications for TEVAR included aneurysms (n = 238, 49.7%) or dissections (n = 152, 31.7%). Ishimaru landing zones were Zone 2 (n = 225, 47.0%), Zone 3 (n = 151, 31.5%), or Zone 4 (n = 103, 21.5%). Stroke occurred in 3.8% (n = 18) of patients, with 1.9% (8) major events (modified Rankin Scale >3). Pathophysiology was predominantly embolic (n = 14), and occurred in posterior (n = 6), anterior (n = 6), or combined circulation (n = 4), and in the left hemisphere (n = 10) or bilateral (n = 6). Univariate analysis suggested use of lumbar drain (33.3% versus 57.2%, P = 0.04), inability to revascularize the left subclavian artery (16.7% vs 5.2%, P = 0.04) and number of implanted components (2.5 ± 1.2 vs 2.0 ± 0.97, P = 0.03) were associated with stroke. Multivariable analysis identified number of implanted components (OR 1.7, 95%CI 1.17-2.67 P = 0.00) and inability to revascularize the left subclavian artery as independent predictors of stroke. Stroke was associated with a higher perioperative mortality (27.8% vs 3.9%, P < 0.01). Stroke after TEVAR is primarily embolic in nature and related to both anatomic and procedural factors. This may have important implications for device development in the era of endovascular arch repair.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Midterm Outcomes of Endovascular Repair of Aortic Arch Aneurysms with the Gore Thoracic Branch Endoprosthesis

OBJECTIVE

Aortic aneurysms involving aortic arch vessels are anatomically unsuitable for standard thoracic endovascular repair (TEVAR) without cervical debranching of the arch vessels. Three year outcomes of a single branched thoracic endograft following previous publication of peri-operative and one year outcomes are reported.

METHODS

This was a multicentre feasibility trial of the GORE TAG Thoracic Branch Endoprosthesis (TBE), a thoracic endovascular graft incorporating a single retrograde branch for aortic arch vessel perfusion. The first study arm enrolled patients with an intact descending thoracic aortic aneurysm extending to the distal arch with left subclavian artery (LSA) incorporation (zone 2). The second arm enrolled patients with arch aneurysms requiring incorporation of the left carotid or innominate artery (zone 0/1) and extra-anatomic surgical revascularisation of the remaining aortic arch vessels. Outcomes at three years are reported.

RESULTS

The cohort comprised 40 patients (31 zone 2, nine zone 0/1). The majority were male (52%). Mean follow up was 1 408 ± 552 days in the zone 2 and 1 187 ± 766 days in the zone 0/1 cohort. During three year follow up there was no device migration, fracture, or aortic rupture in either arm. In the zone 2 arm, freedom from re-intervention was 97% at one and three years but there were two side branch occlusions. Two patients had aneurysm enlargement > 5 mm without documented endoleak or re-intervention. Freedom from death at one and three years was 90% and 84%. In the zone 0/1 arm there were no re-interventions, loss of branch patency, or aneurysm enlargement at three years. Cerebrovascular events occurred in three patients during follow up: two unrelated to the device or procedure, and one of unknown relationship. Two patients in this arm died during the follow up period, both unrelated to the procedure or the aneurysm.

CONCLUSION

Initial three year results of the TBE device for endovascular repair of arch aneurysms show favourable patency and durability with low rates of graft related complications.

Hybrid and endovascular approaches to the aortic arch

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.

The Mini-Cross Prefenestration for Endovascular Repair of Aortic Arch Pathologies

Objective: To examine the feasibility, integrity, efficacy, and safety of endovascular repair of the aortic arch pathologies with the mini-cross prefenestration (MCPF) on stent grafts.

Methods: First, to prove the feasibility of the MCPF, an in-vitro prefenestration experiment was conducted. Second, to examine the integrity of the MCPF stent grafts, a fatigue test was conducted. Then, the membranes and metal structures of stent grafts were examined by light microscopy and scanning electron microscopy (SEM). Third, a clinical experiment was conducted to investigate the efficacy and safety of this novel technique (ClinicalTrials.gov Identifier: NCT04544579).

Results: All the 12 branch stents were successfully implanted and flared in vitro. After the fatigue test stimulating a 5-year cardiac cycle, no obvious disintegration or fracture was found in light microscopy or SEM. From December 2017 to February 2020, 26 patients with left subclavian arteries and/or left common carotid arteries involved received the novel technique. The endovascular repair with the MCPF was successfully performed on all the 26 (100%) patients. Eighteen (69.2%) patients underwent the reconstruction of the left subclavian artery (LSCA) only. The fenestrations of both the LSCA and left common carotid artery (LCCA) were conducted in 8 (30.8%) patients. Median operative time was 120 [interquartile range (IQR), 95–137.5] min and median revascularization time of the LSCA and LCCA was 30.5 (IQR, 22.8–42.0) s and 20.0 (IQR, 18.0–32.0) s separately. During the median follow-up duration of 38.9 (range, 18.8–44.2) months, one case needed an open surgery because of retrograde type A aortic dissection 3 months after implantation and no other complications or mortality occurred. The maximum aortic diameters were significantly decreased in patients with thoracic aortic dissection and thoracic aortic aneurysm (p < 0.05).

Conclusion: The existing evidence demonstrated the safety, rapid branch artery revascularization, and positive aortic remodeling of the novel technique. Long-term observation is warranted to prove the durability.

Endovascular repair of the aortic arch: State of the art

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.

Endovascular Repair of Aortic Dissection Involving the Left Subclavian Artery by Castor Stent Graft: A Multicentre Prospective Trial

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.

The midterm results of thoracic endovascular aortic repair with a precurved fenestrated endograft in zone 0-1

OBJECTIVES

Thoracic endovascular aortic repair (TEVAR) for the treatment of aortic arch disease remains challenging due to certain anatomical and haemodynamic features. The purpose of this study was to evaluate the midterm results of TEVAR with a second-generation fenestrated endograft for aortic arch disease.

METHODS

This non-randomized, interventional study was part of a multicentre clinical trial conducted between 2010 and 2011 and was designed to assess the effectiveness of a second-generation precurved fenestrated endograft for aortic arch disease. Midterm data collected during the fifth postoperative year from 205 patients treated with this endograft with the proximal landing of zone 0 or 1 were assessed regarding survival, reoperation and complications.

RESULTS

The initial and technical success rates were 94% and 91%, respectively. Ninety-seven percent of patients were treated using zone 0. The rate of in-hospital deaths was 3%. Overall survival was 71% at 5 years; thoracic aorta-related death-free survival rates at 1 and 5 years after surgery were 99.5% and 97.8%, respectively. Aneurysm-related event-free survival rates at 1 and 5 years after surgery were 86.8% and 77.1%, respectively. Reoperation-free survival rates at 5 years were 86.6%. The most frequent reason for reoperation was type Ia endoleak (5%), followed by type II endoleak (2%). Incidences of cerebral infarction, device migration, spinal cord ischaemia and supra-aortic branch stenosis were 6%, 1%, 1% and 1%, respectively.

CONCLUSIONS

The precurved fenestrated endograft provided appropriate conformability to the aortic arch and made zone 0 landing possible with simplified, less-invasive manipulations. The midterm results of TEVAR with this endograft suggest this method is a valuable endovascular treatment option for aortic arch disease.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000007213.

Early and midterm results of thoracic endovascular aortic repair using a branched endograft for aortic arch pathologies: A retrospective single-center study

Background

Zone 0 landing hybrid thoracic endovascular aortic repair (TEVAR) includes a few moderately invasive surgical procedures. To reduce invasiveness, TEVAR with a branched aortic arch stent-graft can be considered. This study aimed to elucidate the effectiveness of performing TEVAR using a Bolton (Bolton Medical, Inc, Sunrise, Fla) branched endograft by analyzing early and midterm results.

Methods

We enrolled 28 patients (mean age, 78.4 years) who underwent TEVAR with the Bolton branched endograft in Osaka University Hospital between October 2012 and June 2018 with a mean follow-up period of 4.0 years. Double-side and single-side branched devices were used in 24 (85.7%) and 4 (14.3%) patients, respectively.

Results

All procedures were successful; no cases of endoleak or conversion to open repair were noted during the 30-day postoperative period. The perioperative stroke rate was 14.3% (4 out of 28); midterm stroke was not detected. All patients with perioperative stroke had atheroma grade ≥2 in the brachiocephalic artery. No type 1a endoleak was reported during the early or midterm results. The cumulative survival rate, aorta-related death-free rate, and aortic event-free survival rate at 5 years were 80.8%, 95.8%, and 81.6%, respectively.

Conclusions

We achieved satisfactory early and midterm results by using a Bolton branched endograft for high-risk patients with arch pathologies except for high postoperative stroke. Although this treatment method is associated with postoperative stroke, performing strict evaluation of atheroma may prevent such complication. By preventing intraoperative stroke, TEVAR with this custom-made Bolton branched endograft may be considered a less-invasive treatment.

Endovascular exclusion of the entire aortic arch with branched stent-grafts after surgery for acute type A aortic dissection

Background

The treatment of residual pathology of the aortic arch after surgical repair for type A acute dissection (AAD) represents a therapeutic challenge. Recently, new branched endovascular devices have expanded the possibility of aortic arch stent-grafting (ASG) with proximal landing in zone 0. The aim of this retrospective, single-center study was to evaluate outcomes of patients with a history of surgical repair for AAD undergoing ASG with branched devices.

Methods

We analyzed patients undergoing ASG after treatment for type AAD with 2 different branched devices: Nexus (dual-module, single branch, off-the-shelf) and RelayBranch (single-module, dual branch, custom-made). Before ASG, surgical bypass of supra-aortic vessels was performed according to patient's anatomy and to the selected device. All patients underwent clinical and computed tomography scan evaluation before hospital discharge, at 6 months, and on a yearly basis thereafter.

Results

From March 2017 to April 2019, 4 consecutive patients underwent ASG after surgery for AAD at our institution. Mean time from surgery for AAD to ASG was 20 months. Mean age at the time of ASG was 72 years. Nexus and Relay were implanted in 2 patients each. All patients survived and were successfully discharged. Mean intensive care unit stay and hospital stay were 3 and 19 days, respectively. We did not observe any major adverse events. At a mean follow-up of 28 months, all patients are alive and computed tomography scans showed good anatomic results with no endoleaks.

Conclusions

This preliminary experience shows that ASG after surgery for AAD is feasible and provides encouraging clinical and anatomic early results.

Off-the-Shelf Devices for Treatment of Thoracic Aortic Diseases: Midterm Follow-up of TEVAR With Chimneys or Physician-Made Fenestrations

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.

Hybrid and total endovascular repair of the aortic arch

Background

Recent advances in endovascular technology have enabled minimally invasive repair of the aortic arch, with specifically designed stent-grafts. This article reviews hybrid and total endovascular repair in the management of aortic arch pathology.

Methods

Studies relating to aortic arch management were identified using MEDLINE and Embase, focusing on endovascular repair.

Results

Hybrid arch repair is associated with an early mortality rate of some 12 per cent, and carries significant risk of stroke (up to 15 per cent), paraplegia (up to 6 per cent), retrograde dissection (up to 6·5 per cent) and proximal endoleak (6 per cent). Despite patients being of overall higher perioperative risk, hybrid repair has morbidity and early mortality rates comparable to those of open arch replacement. However, rates of freedom from aortic rupture or reintervention are significantly lower in the longer term, owing to the incidence of endoleak. Total endovascular arch repair may be achieved by the use of parallel stents or in situ fenestration in the emergency setting, or use of custom-made devices (scalloped, fenestrated or branched stent-grafts) in the elective setting. Reports of these relatively novel technologies suggest acceptable short-term outcomes, but long-term data are still awaited.

Conclusion

Repair of aortic arch pathology presents a formidable challenge for endovascular technology. Open aortic arch repair remains the standard in younger, fitter patients, but endovascular technology and experience continue to evolve with encouraging early outcomes and expanding indications.

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.

Minimally Invasive Techniques for Total Aortic Arch Reconstruction

The cumulative experience with endovascular aortic repair in the descending thoracic and infrarenal aorta has led to increased interest in endovascular aortic arch reconstruction. Open total arch replacement is a robust operation that can be performed with excellent results. However, it requires cardiopulmonary bypass and circulatory arrest and, therefore, may not be tolerated by all patients. Minimally invasive techniques have been considered as an alternative and include hybrid arch debranching, parallel stent graft deployment in the chimney and snorkel configurations, and complete endovascular branched reconstruction with multi-branched devices. This review discusses the evolving use of endovascular techniques in the management of aortic arch pathology and considers their relevance in an era of safe and durable open aortic arch reconstruction.

Results From a Nationwide Registry on Scalloped Thoracic Stent-Grafts for Short Landing Zones

Purpose: To report the perioperative results and short-term follow-up of patients treated with scalloped thoracic stent-grafts. Methods: A multicenter registry in the Netherlands captured data on 30 patients (mean age 68 years; 17 men) with thoracic aortic pathology and a short (<20 mm) proximal or distal landing zone who received a custom-made scalloped stent-graft between January 2013 and February 2016. Patients were treated for saccular (n=13) aneurysms, fusiform (n=9) aneurysms, pseudoaneurysms (n=4), or chronic type B dissections (n=4). The scallop was used to preserve flow in the left subclavian artery (LSA) (n=17), left common carotid artery (n=5), innominate artery (n=1), and celiac trunk (n=7). In 7 (23%) patients, the scallop also included the adjacent artery. Results: Technical success was achieved in 28 (93%) patients. In 1 patient, a minor type Ia endoleak was observed intraoperatively, which was no longer visible on computed tomography angiography at 3 months. In another patient, the LSA was unintentionally obstructed due to migration of the stent-graft on deployment. Concomitant carotid-carotid or carotid-subclavian bypass was performed in 4 patients. There was no retrograde type A dissection or conversion to open surgery. In-hospital mortality was 3%, and the perioperative ischemic stroke rate was 3%. At a mean follow-up of 9.7 months (range <1 to 31), 29 of 30 target vessels were patent. Conclusion: The scalloped stent-graft appears to be a safe and relatively simple alternative for the treatment of thoracic aortic lesions with short landing zones. Larger patient series and long-term follow-up are required to confirm these early results.

A custom-made scalloped stentgraft to preserve left subclavian artery flow in descending thoracic aortic disease with a short neck

In thoracic stentgrafting, a short proximal landing zone may necessitate intentional occlusion of the left subclavian artery, which may lead to brain, spinal cord, and left arm malperfusion. A scalloped stentgraft is designed for adequate proximal sealing and preserving the left subclavian artery flow. We performed a systematic review, describe the required pre-operative planning and details of the perioperative technique used and report our own experience. In literature, only 29 patients were reported so far using a proximal scalloped stentgraft. Results show a high technical success rate and low complication rate. These results are comparable to the results from our own institution. From these first small series the scalloped thoracic endovascular aortic repair appears to be a safe and relatively simple solution for thoracic aortic disease involving the left subclavian artery.

Hybrid Repair of Aortic Arch Aneurysms with Endografting of the Ascending Aorta

BACKGROUND

Different "hybrid" techniques that combine open debranching of the supra-aortic vessels with endografting of the aortic arch have emerged as alternatives to the open arch repair in high-risk patients. This study aims to review the early and mid-term results of single-stage hybrid arch repair with ascending aorta stent graft deployment for aortic arch aneurysms and dissections.

METHODS

Between June 2006 and May 2015, five consecutive patients, with an age range of 54-78 years, with complex aortic arch diseases, were treated with a hybrid approach in which the endograft had a proximal landing zone in the ascending aorta. Indications included: acute and chronic type A aortic dissections and three arch aneurysms associated with distal aortic pathology. Length of postoperative clinical and imaging follow-up ranged from 10 to 121 months and was completed in all patients.

RESULTS

Technical success of the endografting was achieved in all cases. There was one in-hospital mortality secondary to pulmonary embolism, one case of retrograde type A aortic dissection (RTAD) detected before discharge and one case of late type Ib endoleak that required an endografting procedure. No postoperative stroke or transient or permanent spinal cord ischemia occurred.

CONCLUSION

Hybrid arch repair with endograft landing in zone 0 may decrease mortality and morbidity in high-risk patients. doi: 10.1111/jocs.12735 (J Card Surg 2016;31:341-347).

Endovascular treatment of complex aortic aneurysms: prevalence of acute kidney injury and effect on long-term renal function

Objectives

To analyse predictors for short- and long-term renal function changes after fenestrated and branched endovascular aortic repair (EVAR).

Methods

A total of 157 patients underwent fenestrated and branched EVAR. Procedural intra-arterial iodinated contrast volume was documented. Serum creatinine and estimated glomerular filtration rate (eGFR) at baseline, during 48 h following EVAR, at discharge and latest moment of follow-up were recorded. Development of post-EVAR acute kidney injury (AKI; according to AKIN criteria), and potential risk factors for renal failure were recorded. Multivariate regression analyses were used to identify independent risk factors for AKI and eGFR decrease during follow-up.

Results

Forty-three patients (28 %) developed post-EVAR AKI. Long procedure time and occlusion of accessory renal arteries were independent risk factors for development of AKI. (odds ratio (OR) 1.005 per minute, 95 % CI 1.001–1.01; p = 0.025 and OR 3.02, 95 % CI 1.19–8.16; p = 0.029). Post-EVAR AKI was associated with a significantly increased risk for eGFR decrease at discharge and latest follow-up (hazard ratio (HR) 3.47, 95 % CI 1.63–7.36, p = 0.001 and HR 3.01, 95 % CI 1.56–5.80; p = 0.001). Iodinated contrast volume was not an independent risk factor for AKI or eGFR decrease during follow-up.

Conclusion

Development of post-EVAR AKI is an independent risk factor for long-term renal function decrease.

Key Points

• Longer procedure time is associated with an increased risk for AKI.

• Renal perfusion defects on angiography are associated with increased risk for AKI.

• Post-EVAR AKI is associated with higher probability for long-term eGFR decrease.

• Iodinated contrast volume is not an independent risk factor for AKI.

• Iodinated contrast volume is not an independent risk factor for long-term eGFR decrease.

Application of the Bolton Relay Device for Thoracic Endografting In or Near the Aortic Arch

Endovascular correction of aortic arch pathology remains a challenge, with a variety of techniques proposed over the years to minimize complications and enhance the probability of a successful result. A variety of approaches have been developed in order to deal with the aortic arch pathology and its idiosyncrasies. We review potential interventional techniques for the repair of aortic arch pathologies, beginning with conventional aortic arch surgery, followed by hybrid treatments and those along the endovascular spectrum (parallel and fenestrated endografts, scalloped endografts, and ascending and new branched endografts). We finish with an overview of all the Bolton Medical (Barcelona, Spain and Sunrise, FL, USA) thoracic platforms. Endovascular techniques show acceptable results in selected cases. Both proximal Bolton Relay configurations (with and without a bare stent) offer conformability and accuracy on deployment with very low rates of stroke. Fenestrated and scalloped designs are also useful for selected cases. Ascending and branched Bolton devices are very promising platforms for a serious, full endovascular approach to the aorta.

Case report of an endovascular repair of a residual type A dissection using a not CE not FDA-approved Najuta thoracic stent graft system

This report describes an endovascular repair of a residual type A dissection using a medical device that is not marked by european conformity (CE) or Food and Drug Administration (FDA).The patient underwent ascending aortic surgery for acute type A dissection. The 2-year angio-computed tomography demonstrated patency of the residual false lumen with evolution into a 6 cm aneurysm, the extension of the dissection from the aortic arch to the aortic bifurcation with thrombosis of the right common iliac artery. There was no CE- or FDA-marked medical device indicated for this case or any other acceptable therapeutic alternative.We used the Najuta thoracic stent graft and successfully handled the pathology in a multiple-phase treatment.Technology is evolving with specific grafts for the ascending and fenestrated grafts for the aortic arch. In this single case the Najuta endograft, in spite of the periprocedural problems, was a valid therapeutic option.

The chimney-graft technique for preserving supra-aortic branches: a review

Evolution in the endovascular era has influenced the management of aortic arch pathologies. "Chimney" or "snorkel" graft technique has been used as an alternative in high risk patients unfit for open repair. We reviewed the published literature on the chimney graft technique for preservation of the supra-aortic branches in order to provide an extensive insight of its feasibility and efficacy and investigate its outcomes. 18 reports were identified, with a total of 124 patients and 136 chimney. Primary technical success was achieved in 123/124 patients (99.2%). The perioperative mortality rate was 4.8% and the stroke rate was 4%, while events of spinal cord ischemia were rare. The overall endoleak rate was 18.5%; 13 patients (10.5%) developed a type I endoleak and 10 (8%) patients a type II endoleak. During a median follow-up period of 11.4 months (range, 0.87-20.1 months) all implanted chimney grafts remained patent. From this, we conclude that endovascular aortic arch repair with chimney grafts is associated with a lower mortality rate compared to totally open or hybrid reconstruction. However, the stroke rate remains noteworthy, and requires longterm data to elucidate.