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Nana P, Spanos K, Panuccio G, Rohlffs F, Detter C, von Kodolitsch Y, Torrealba JI, Kölbel T. Branched and fenestrated endovascular aortic arch repair in patients with native proximal aortic landing zone. J Vasc Surg 2024; 80:621-629.e3. [PMID: 38580160 DOI: 10.1016/j.jvs.2024.03.444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/15/2024] [Accepted: 03/28/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Fenestrated and branched thoracic endovascular repair (f/bTEVAR) have been successfully applied in patients with diverse aortic arch pathologies. The aim of this study is to present the early and mid-term outcomes of patients with native proximal aortic landing (NPAL) managed with f/bTEVAR. METHODS A single-center retrospective analysis of patients with NPAL, managed with f/bTEVAR, between September 1, 2011, and June 30, 2022, was conducted. All patients were treated with custom-made devices (Cook Medical) with landing within Ishimaru zones 0 to 2. Primary outcomes were technical success, mortality, stroke, and retrograde type A dissection at 30 days. Follow-up outcomes were considered secondary. RESULTS A total of 126 patients were included (69.8% males; mean age, 70.8 ± 4.2 years; 18.3% urgent). The main indications (60.4%) for repair were aortic arch (29.4%) and thoracoabdominal aortic aneurysms (31.0%). Seventy-two patients (57.1%) were managed with fTEVAR. Proximal landing in zone 0 and 1 was chosen in 97.6%. Technical success was 94.4%, and 30-day mortality was 11.9%. Strokes were diagnosed in 13.5% of patients and major strokes were identified in 7.9% cases. Retrograde type A dissection rate was 3.9%. The multivariate analysis confirmed landing in Ishimaru zone 0 as an independently related factor for stroke (P = .005), whereas stroke (P < .001), pericardial effusion (P < .001), and acute kidney injury (P < .001) were independently related to 30-day mortality. Mean follow-up was 17.5 ± 9.3 months. The estimated survival rate and the freedom from reintervention rate were 72.6% (standard error, 4.4%) and 46.4% (standard error, 6.0%) at 24-month follow-up, respectively. CONCLUSIONS Stroke rate after endovascular arch repair was alarming among patients with NPAL. Proximal landing to zone 0 was related to higher risk of stroke. Reinterventions were common within the 24-month follow-up.
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Affiliation(s)
- Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany.
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Christian Detter
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - José I Torrealba
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
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Berger T, Kreibich M, Mueller F, Breurer-Kellner L, Rylski B, Kondov S, Schröfel H, Pingpoh C, Beyersdorf F, Siepe M, Czerny M. Risk factors for stroke after total aortic arch replacement using the frozen elephant trunk technique. Interact Cardiovasc Thorac Surg 2022; 34:865-871. [PMID: 35092274 PMCID: PMC9070457 DOI: 10.1093/icvts/ivac013] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study aimed to analyse risk factors for postoperative stroke, evaluate the underlying mechanisms and report on outcomes of patients suffering a postoperative stroke after total aortic arch replacement using the frozen elephant trunk technique. METHODS Two-hundred and fifty patients underwent total aortic arch replacement via the frozen elephant trunk technique between March 2013 and November 2020 for acute and chronic aortic pathologies. Postoperative strokes were evaluated interdisciplinarily by a cardiac surgeon, neurologist and radiologist, and subclassified to each's cerebral territory. We conducted a logistic regression analysis to identify any predictors for postoperative stroke. RESULTS Overall in-hospital was mortality 10% (25 patients, 11 with a stroke). A symptomatic postoperative stroke occurred in 42 (16.8%) of our cohort. Eight thereof were non-disabling (3.3%), whereas 34 (13.6%) were disabling strokes. The most frequently affected region was the arteria cerebri media. Embolism was the primary underlying mechanism (n = 31; 73.8%). Mortality in patients with postoperative stroke was 26.2%. Logistic regression analysis revealed age over 75 (odds ratio = 3.25; 95% confidence interval 1.20-8.82; P = 0.021), a bovine arch (odds ratio = 4.96; 95% confidence interval 1.28-19.28; P = 0.021) and an acute preoperative neurological deficit (odds ratio = 19.82; 95% confidence interval 1.09-360.84; P = 0.044) as predictors for postoperative stroke. CONCLUSIONS Stroke after total aortic arch replacement using the frozen elephant trunk technique remains problematic, and most lesions are of embolic origin. Refined organ protection strategies, and sophisticated monitoring are mandatory to reduce the incidence of postoperative stroke, particularly in older patients presenting an acute preoperative neurological deficit or bovine arch.
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Affiliation(s)
- Tim Berger
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Felix Mueller
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Lara Breurer-Kellner
- Department of Neurology, Faculty of Medicine, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Holger Schröfel
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Clarence Pingpoh
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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