Thoracic endovascular aortic repair in penetrating aortic ulcer combined with isolated left vertebral artery: A case report

Fenestrated Thoracic Endovascular Repair for Acute Type B Aortic Dissection with Isolated Left Vertebral Artery: A Case Report

Thoracic endovascular aortic repair (TEVAR) of acute uncomplicated type B aortic dissection (uTBAD) has been discussed for its potential to prevent future aortic events. We present a fenestrated TEVAR in the case of an 86-year-old man with acute uTBAD with an isolated left vertebral artery (ILVA). The ILVA originated from the distal side of the left subclavian artery, the left subclavian artery, and the intramural hematoma with an ulcer-like projection extended close to the left subclavian artery. We selected a fenestrated stent graft to achieve a proximal healthy landing. This case demonstrates that a fenestrated stent graft for acute uTBAD is useful for preserving arch vessels.

Hybrid surgery of vertebral artery transposition combined with scallop and fenestration technique for the repair of type B aortic dissection patient with isolated left vertebral artery: A case report

RATIONALE

Acute type B aortic dissection (ABAD) is a fatal cardiovascular disease with high morbidity and mortality. Isolated left vertebral artery (ILVA) is a rare aortic arch mutation originating from the aortic arch. The simultaneous occurrence of both increases the complexity and difficulty of thoracic endovascular aortic repair. However, there have been few reports on the recommendation of thoracic endovascular aortic repair treatment strategies for aortic dissection patients concomitant ILVA with insufficient landing zone. Here, we report a case of ABAD combined with ILVA treated with hybrid surgery of left vertebral artery transposition alliance with Scallop and in vivo fenestration endograft.

PATIENT CONCERNS

A 38-year-old middle-aged man was transferred to our vascular department with persistent pain in his lower abdomen for 8 hours.

DIAGNOSES

Preoperative computed tomography angiogram of the thoracic and abdominal aorta diagnosed with ABAD accompanied with ILVA.

INTERVENTIONS

Hybrid surgery of left vertebral artery transposition alliance with Scallop and in situ fenestration endograft for revascularization of ILVA, left subclavian artery, and left common carotid artery.

OUTCOMES

The hybridization operation was successfully completed. There were no complications of cerebral and spinal cord ischemia after operation. Computed tomography angiogram examination indicated no internal leakage existed in the stent and patency of the arch vessels and the transposed left vertebral artery follow-up 3 months after surgery.

LESSONS

This study gave us experience in the treatment of aortic dissection with left vertebral artery variation and suggested that left vertebral artery transposition combined with scallop and in vivo fenestration stent is safe and effective.

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.

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.

Midterm Outcomes of an Adjustable Puncture Device for In Situ Fenestration During Thoracic Endovascular Aortic Repair

OBJECTIVE

To evaluate the midterm outcomes of in situ fenestration (ISF) with an adjustable puncture device for aortic arch branch preservation during thoracic endovascular aortic repair (TEVAR).

METHODS

From October 2016 to April 2019, patients with complicated type B aortic dissection, thoracic aortic aneurysm > 5.5 cm in diameter, or aortic penetrating ulcer with a base > 20 mm or depth > 15 mm, who received TEVAR requiring a proximal sealing beyond zone 3 and underwent ISF using an adjustable puncture device, were included. After the procedure, patients were monitored at one, three, six, and 12 months, and annually thereafter. Peri-operative and follow up data were collected and analysed.

RESULTS

Fifty of 51 patients (98%) received successful ISFs. One, two, or three aortic arch branches were preserved in 44, six, and one patient, respectively. Intra-operatively, eight type Ia endoleaks and one type II endoleak were found on angiography. One patient died of cerebral hernia three days post-procedure from a severe stroke; one patient suffered from transient paraplegia but recovered in two weeks; one patient had a non-disabling stroke. The median follow up was 31 months (22.5 - 36.5 months). At six month follow up, all nine unmanaged endoleaks had disappeared. One new type Ia endoleak was identified in a patient at the one month follow up which resolved spontaneously one year later. All revascularised arteries were patent at the last follow up. No fractures, migrations, or bridging stent kinks were found.

CONCLUSION

In this largest mechanical based ISF study to date, an adjustable puncture device was shown to facilitate the procedure of ISF during endovascular repair of aortic diseases involving the aortic arch, with high success. The midterm outcome demonstrates the efficacy and safety of the device in assisting with preservation of aortic arch branches.

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.