Complex aortic arch aneurysm and dissections: hybrid techniques for surgical and endovascular therapy

Prosthetic Graft Dilation at the Aortic Arch in the Era of Hybrid Aortic Surgery

Objective: This study aims to evaluate the chronological size changes of the prosthetic graft in the aortic arch, which is used as a landing zone for a subsequent stent grafting in hybrid aortic surgery.

Materials and Methods: Eighty-five patients who underwent total aortic arch replacement followed by computed tomography follow-up for at least 30 months after the surgery were included in the study.

Results: Prosthetic grafts used were Hemashield (Maquet, Rastatt, Germany), J-Graft (Japan Lifeline Inc., Tokyo, Japan) and Triplex (Terumo, Tokyo, Japan). There was an initial increase in diameter compared to package size after implantation (Hemashield, 1.04±0.035 vs. J-Graft, 1.06±0.027 vs. Triplex, 1.04±0.023, p=0.13). Significant difference in graft dilation ratio was observed in Triplex (1.18±0.062) at long-term compared to Hemashield (1.07±0.052, p<0.001) and J-Graft (1.10±0.071, p<0.001). Multivariate analysis showed that age (r=0.002; 95% confidence interval [CI], 0.0001–0.0037; p=0.035), knitted-type prosthesis (r=0.089; 95% CI, 0.0610–0.1163; p<0.0001), and prevalence of cerebral vascular disease (r=0.038; 95% CI, 0.0030–0.0732; p=0.034) were independently associated with graft dilation after surgery.

Conclusion: Prosthetic graft selection and appropriate sizing of the stent graft should be considered for each individual undergoing hybrid aortic surgery to maintain sufficient oversizing of the stent graft.

Computed tomography angiography of hybrid thoracic endovascular aortic repair of the aortic arch

Endovascular repair of the aorta has traditionally been limited to the abdominal aorta and, more recently, the descending thoracic aorta. However, recently hybrid repairs (a combination of open surgical and endovascular repair) have made endovascular repair of the aortic arch possible. Hybrid repair of the aortic arch typically involves an open surgical debranching procedure that allows for revascularization of the aortic arch vessels and subsequent endovascular stent placement. These approaches avoid the deep hypothermic circulatory arrest required for full, open surgical repair of the aortic arch. In hybrid repairs, the stent landing zone determines which branch vessels will be covered and therefore need revascularization. This article will review the preprocedure assessment with computed tomography angiography, techniques for revascularization and postprocedure complications.

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.

Techniques for supra-aortic trunk preservation in thoracic endovascular aneurysm repair

Stent graft placement for aneurysmal disease of the aortic arch and proximal descending aorta is limited by the need to preserve flow to the supra-aortic trunks. Whilst extra-anatomical bypass and procedures combining open and endovascular arch repair are currently used in this setting, less invasive totally endovascular solutions have been described. These include in-situ fenestration of a thoracic stent graft using a retrograde approach from the target vessel to the lumen of the main device, to which it is connected by a smaller covered stent. Alternatively, so-called 'chimney' stents have been used, placing a parallel stent alongside the main device, connecting the aortic branch vessel with the native aortic lumen proximal to the seal zone of the main thoracic device. We review these techniques and discuss the merits and potential disadvantages of each procedure.