Repair of complicated type B dissection with an isolated left vertebral artery using the stented elephant trunk technique

Utilizing physician modified fenestration on the castor branched stent technique for reconstruction of an isolated left vertebral artery on the aortic arch

The study aimed to provide physician modified fenestration (PMF) on a single-branched stent for the aortic arch (Castor) to protect the isolated left vertebral artery (ILVA) during thoracic endovascular aortic repair (TEVAR). Patients who underwent TEVAR involving ILVA reconstruction through PMF performing on the Castor branched stent were included in a retrospective, multi-centre study from June 2018 to December 2022. In these patients, all proximal landing zones of "Castor" were positioned in Ishimaru zone 2a. A total of twenty-five patients met the inclusion criteria and the achievement rate showed 25/25 (100%) success in them. The twenty-five patients had a median follow-up length of 28.5 ± 14.6 months. One patient (4.0%) suffered from postoperative ischemic stroke before discharge. One patient (4.0%) died from a hemodialysis-related brain hemorrhage before discharge on the 29th day after the procedure. One patient died of advanced liver cancer in the 33th month after discharge. Aortic rupture, stroke or spinal cord injury did not occur throughout the follow-up period after discharge. Two patients (8.0%) experienced endoleak at the fenestration, however, resulting in only one's necessity for reintervention. Notably, the procedure effectively maintained ILVAs patency for all patients during follow up. According to our preliminary findings, performing a TEVAR under local anaesthesia using PMF on a Castor branched stent for ILVA preservation appeared practical, secure, and effective.

Endovascular repair of thoracic aortic disease with isolated left vertebral artery and unfavorable proximal landing zone using fenestrated castor stent-graft

Objective

The main purpose of this study was to evaluate the safety and efficacy of Castor single-branched stent-graft combined with fenestrated technique in treatment of thoracic aortic disease (TAD) with unfavorable proximal landing area (PLZ) and isolated left vertebral artery (ILVA).

Methods

From January 2018 to March 2022, 8 patients with TAD (6 patients with type B aortic dissections, 1 patient with type B intramural hematomas, and 1 patient with thoracic aortic aneurysm) underwent thoracic endovascular aortic repair with fenestrated Castor stent-graft due to the existence of ILVA and unfavorable PLZ. Demographic characteristics, surgical details, postoperative complications, follow-up and postoperative CTA imaging results were collected and analyzed.

Results

The primary technical success rate was 100%. The mean operation time was 115 min (range, 70-180 min). All the left subclavian arteries (LSAs) and ILVAs of the eight patients were revascularized by fenestrated Castor stent-grafts. During the follow-up period, no deaths and complications were observed. No internal leakage, aortic rupture, retrograde type A dissection were found on computed tomography angiography. All of the LSAs and ILVAs maintained patency without stenosis.

Conclusion

Castor single-branched stent-graft implantation combined with fenestration technique may be safe and feasible for TAD patients with ILVA and unfavorable PLZ.

Physician-modified fenestration or in situ fenestration for preservation of isolated left vertebral artery in thoracic endovascular aortic repair

Objective

To present our experience of preserving the isolated left vertebral artery (ILVA) with physician-modified fenestration (PM-F) or in situ fenestration (ISF) during thoracic endovascular aortic repair (TEVAR) for aortic pathologies involving aortic arch.

Methods

This is a single-center, retrospective, observational cohort study. Between June 2016 and December 2021, 9 patients (8 men; median age 60.0 years old) underwent TEVAR with ILVA reconstruction (PM-F, n = 6; ISF, n = 3) were identified and analyzed.

Results

The technical success rate was 100%. No early (<30 days) death occurred. No aortic rupture, major stroke or spinal cord injury was observed. The median follow up was 38.0 (rang: 1.0-66.0) months. One death occurred at 56 months, while the reason cannot be identified. No aortic rupture, major stroke or spinal cord injury was observed during follow up. No patient required reintervention. Out of the 22 successfully revascularized target vessels, 2 ILVAs were found occluded in 2 patients at 6 months and 7 months, respectively. However, these two patients were asymptomatic.

Conclusions

Our initial experience reveals that PM-F or ISF for ILVA preservation was feasible, safe, and effective during TEVAR for complex thoracic aortic pathologies. However, the patency of preserved ILVA should be improved.

Prior reconstruction of an isolated left vertebral artery for Stanford type A aortic dissection

Although isolated left vertebral artery is a supra-aortic trunk variant, it is not so rare. It may pose additional difficulties during total arch replacement surgeries. The aim of this study was to present our experience with prior reconstruction of isolated left vertebral artery by isolated left vertebral artery-left common carotid artery during total arch replacement combined with stented elephant trunk implantation.

One-stage supraclavicular hybrid procedure for type B aortic dissection involving three rare anatomical anomalies: a case report and literature review

Managing type B aortic dissection (TBAD) involving Kommerell's diverticulum (KD), aberrant right subclavian artery (ARSA), and isolated left vertebral artery (ILVA), is extremely challenging. As treatment, we described a one-stage hybrid technique combined with thoracic endovascular aortic repair (TEVAR) with open surgery through a supraclavicular incision. A 57-year-old man with TBAD and the three anomalies successfully underwent hybrid TEVAR. A side-to-side artificial bypass between the ARSA and the right common carotid artery was established through a right supraclavicular incision before TEVAR. The release of the stent-graft was designed from the distal aortic ostium to the left common carotid artery (LCCA) to cover the ILVA, ARSA, and left subclavian artery (LSA). Then, the ILVA and LSA were transposed to the LCCA through a left supraclavicular incision. Intraoperative angiography confirmed complete false lumen exclusion and KD, with all branches patent and without endoleaks. Computed tomography angiography 7 days and 1 year postoperatively demonstrated well-perfused ARSA, LSA, and ILVA, and a fully expanded stent-graft with no endoleaks, migration, disconnection, or stenosis. TBAD involving KD, ARSA, and ILVA in one case is rare. This is the first report to treat this pathology with a one-stage supraclavicular hybrid procedure.

Thoracic aortic surgery: status and upcoming novelties

Several novel technological developments and surgical approaches have characterized the field of aortic surgery in the recent decade. The progressive introduction of endovascular procedures, minimally invasive surgical techniques and hybrid approaches have changed the practice in aortic surgery and generated new trends and questions. Also, the advancements in the manufacturing of tissue engineered vascular grafts as substitutes for aortic replacements are enlightening new avenues in the treatment of aortic disease. This review will provide an overview of the current novel perspectives, debates and trends in major thoracic aortic surgery.

Three Rare Structural Anomalies: Right Aberrant Subclavian Artery, Kommerell's Diverticulum, and Isolated Left Vertebral Artery All Associated with Type B Aortic Dissection

Introduction and Background

Right aberrant subclavian artery accounts for 0.5-1.8% of the population as the most frequently encountered aortic arch anomaly, while the prevalence of an isolated left vertebral artery ranges from 3 to 8%. Despite the low prevalence and the asymptomatic presentation of these structural anomalies, the development of cardiovascular complications and aneurysmal formation could happen as in Kommerell's diverticulum in a complicated right aberrant subclavian artery, which can undergo aneurysmal degeneration and dissection. Depending on the severity and the degree of the symptoms, the management of the patient can be determined.

Case Presentation

A 51-year-old male hypertensive Pakistani patient was admitted complaining of chest and back pain; a CT of the aorta was done and showed type B aortic dissection associated with a right aberrant subclavian artery with an isolated left vertebral artery. A thoracic endovascular aneurysmal repair was done, and the patient improved afterward.

Conclusion

The prevalence of these structural anomalies, the right aberrant subclavian artery, Kommerell's diverticulum, and isolated left vertebral artery with type B aortic dissection, is uncommon. Therefore, the earlier the diagnosis, the better the treatment. This is the first case report explaining the occurrence of these vascular anomalies together in Saudi Arabia.

Management of type B aortic dissection with an isolated left vertebral artery

OBJECTIVE

The objective of this study was to report our single-center experience of thoracic endovascular aortic repair (TEVAR) and concomitant procedures in patients with type B aortic dissection (TBAD) with an isolated left vertebral artery (ILVA) and the early to midterm outcomes in these patients.

METHODS

Between March 2011 and June 2018, there were 31 patients (27 men; median age, 55 years; range, 31-66 years) with TBAD and an ILVA who received TEVAR and concomitant procedures in our center. Demographics, coexisting medical conditions, imaging features, operation details, and follow-up outcomes in these patients were retrospectively collected and analyzed.

RESULTS

All patients received aortic stent grafts; nine patients also received chimney stents, and 10 patients received aortic arch bypasses. The technical success rate was 96.8% (30/31), with only one patient (3.2%) showing immediate type IA endoleak. One patient experienced transient neurologic deficit, and a puncture-related femoral artery pseudoaneurysm was observed in one patient; both recovered completely before their hospital discharge. There was no death in the early term. The median duration of follow-up was 33 months (range, 2-90 months). Reintervention for a type II endoleak by using coils to seal the origin of the left subclavian artery was performed in one (3.1%) case 72 months postoperatively. One (3.2%) death occurred 42 months after operation as a result of rectal cancer. No neurologic deficits, chimney stent occlusions, or bypass occlusions were observed during the follow-up period.

CONCLUSIONS

Our limited experience reveals that TEVAR and concomitant procedures are relatively safe and viable for treatment of TBAD with an ILVA. Further studies with larger samples of patients and longer follow-ups are needed to confirm these findings.