In Situ Fenestration and Carotid-Subclavian Bypass for Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair

PURPOSE

To evaluate the safety and feasibility of left subclavian artery (LSA) revascularization techniques during thoracic endovascular aortic repair (TEVAR)-the in situ needle fenestration (ISNF) technique and the carotid-subclavian bypass (CS-Bp)-for complicated aortic pathologies.

METHODS

A retrospective single-center observational study was conducted to identify all patients with thoracic aortic pathologies who underwent TEVAR with LSA revascularization using either CS-Bp or ISNFs from January 2014 to December 2020.

RESULTS

One hundred and twelve consecutive patients who received TEVAR with LSA revascularization were included. Among them, 69 received CS-Bp and 43 received ISNF (29 using the Futhrough adjustable puncture needles, 14 using the binding stent-graft puncture systems). Technical success, defined as achieving aortic arch pathology exclusion and LSA preservation, was attained in 99.1% patients. Early mortality was 0.9%. Major adverse events within 30 days, including one cerebral hemorrhage, one cervical incision hemorrhage, one stroke and two paraplegia, were exclusively observed in the CS-Bp group. Immediate type I, II and III endoleaks occurred in 0%, 4.7% and 2.3% in the ISNF group, respectively, compared to 0%, 2.9% and 0% in the CS-Bp group.One hundred and eight (97.2%) patients were available for follow-up at a median 50 (maiximum of 103) months, revealing a LSA patency rates of 99.1%. Six patients died during follow-ups-five in the CS-Bp group and one in the ISNF group. Cause of death include one aortic-related stent-graft infection, three non-related and two with unknow causes. The survival exhibited no significantly different between the ISNF (97.7%) and CS-Bp (89.9%) groups (p = 0.22).

CONCLUSIONS

Both CS-Bp and ISNF are feasible techniques for LSA reconstruction in TEVAR. ISNF, whether using Futhrough or BPS, seems to be competitive with CS-Bp.

Mid-term results of a prospective study for aortic dissection with a gutter-plugging chimney stent graft

OBJECTIVES

Our goal was to access early and mid-term outcomes of a gutter-plugging chimney stent graft for treatment of Stanford type B aortic dissections in the clinical trial Prospective Study for Aortic Arch Therapy with stENt-graft for Chimney technology (PATENCY).

METHODS

Between October 2018 and March 2022, patients with Stanford type B aortic dissections were treated with the Longuette chimney stent graft in 26 vascular centres. The efficiency and the incidence of adverse events over 12 months were investigated.

RESULTS

A total of 150 patients were included. The technical success rate was 99.33% (149/150). The incidence of immediate postoperative endoleak was 5.33% (8/150, type I, n = 6; type II, n = 1; type IV, n = 1) neurologic complications (stroke or spinal cord ischaemia); the 30-day mortality was 0.67% (1/150) and 1.33% (2/150), respectively. During the follow-up period, the median follow-up time was 11.67 (5-16) months. The patent rate of the Longuette graft was 97.87%. Two patients with type I endoleak underwent reintervention. The follow-up rate of the incidence of retrograde A type aortic dissection was 0.67% (1/150). There was no paraplegia, left arm ischaemia or stent migration.

CONCLUSIONS

For revascularization of the left subclavian artery, the Longuette chimney stent graft can provide an easily manipulated, safe and effective endovascular treatment. It should be considered a more efficient technique to prevent type Ia endoleak. Longer follow-up and a larger cohort are needed to validate these results.

CLINICAL TRIAL REGISTRY NUMBER

NCT03767777.

Subclavian artery revascularization with subclavian-carotid transposition for TEVAR and non-TEVAR patients

BACKGROUND

Subclavian artery revascularization (SAR) has become an increasingly performed technique in patients undergoing thoracic endovascular aortic aneurysm repair (TEVAR), in order to optimize the proximal landing zone, or in patients with significant atherosclerotic diseases. SAR was usually achieved through carotid-subclavian bypass (CSB) which is daunted by graft and patency-related issues, or through subclavian carotid transposition (SCT) which has recently been reconsidered as a potential solution. Nowadays, multiple endovascular strategies including parallel grafts, chimney graft and branch-fenestrated repair, are available in patients unfit for open SAR. However, there is no consensus on the preferable technique in both TEVAR- and non TEVAR-patients. The purpose of this study was to evaluate our experience with SCT in terms of overall postoperative adverse events and mid-term patency rate.

METHODS

We performed a retrospective cohort study, including all patients who underwent SCT between June 2014 and March 2020 at our Division. Preoperative risk factors, symptoms, intraoperative details, postoperative outcomes and follow-up data were collected.

RESULTS

A total of 27 patients were included in this study. Indications for SCT included aortic arch debranching for TEVAR for thoracic aortic aneurysm and type B dissection and symptomatic subclavian steal syndrome (SSS). There were no major perioperative adverse events or major neurological complications; five minor adverse events occurred (18.5%) (3 Horner' Syndrome, 1 hematoma requiring reoperation,1 pneumothorax). Peripheral nerve injuries and lymphatic lesions were not recorded. On a mean follow-up of 21±16 months, SCT patency was confirmed in all patients and no deaths occurred. Comparison of baseline and operative characteristics and intraoperative details between groups of patients with or without adverse events did not found differences.

CONCLUSIONS

SCT should be considered a feasible, effective and safe technique for SAR, with low perioperative complications and optimal mid-term patency. This surgical technique appears to provide a lower risk of neurological events and mortality, particularly in TEVAR patients, reducing the complications caused by the coverage of the left subclavian artery.

Endovascular repair of an intrathoracic subclavian artery aneurysm with a single-branched thoracic endograft in a hostile anatomy

OBJECTIVE

Subclavian artery aneurysms (SAA) are rare and usually involve the proximal segment of the artery. In this setting traditional surgical treatment or hybrid procedures are associated with significative morbidity rate so that new endovascular solutions are preferred.

METHODS

Authors report a case of a patient with an intrathoracic left SAA involving the aortic arch's outer curve. Patient's comorbidities contraindicated open surgical treatment while anatomical issues were not favourable to hybrid or standard endovascular solutions. Thus a single-branched custom-made thoracic stent-graft (Castor, MicroPort Medical, Shanghai, China) was implanted.

RESULTS

Technical success was achieved with no intra-operative complications and technical steps of the procedure are accurately described.A pre-discharge CT scan showed the correct position of the endograft, complete aneurysm exclusion and branch patency.

CONCLUSION

Single-branched thoracic stentgrafts could be a good option in unfavourable anatomies with supra-aortic vessels disease involving the aortic arch, with good results in terms of morbidity and early outcomes.

Mid-term efficacy of castor stent and in situ fenestration stent in the treatment of type B aortic dissection involving the left subclavian artery: A retrospective single-center study

To evaluate the midterm efficacy of the Castor stent (CS) versus in situ fenestration (ISF) for reconstructing the left subclavian artery (LSA) in patients with type B aortic dissection (TBAD). Between July 2017 and July 2022, a total of 247 patients with TBAD were enrolled. One hundred thirty-seven patients were treated using CSs (group A), while the remaining 110 patients received ISFs (group B). Data of the two groups were retrospectively analyzed. The success rates of surgery were 99.3% and 95.5% in groups A and B (p = .053), There were no deaths during hospitalization. During surgery, group B showed a longer surgical duration [68.0 (66.0, 77.0) vs. 62.0 (59.0, 66.0) min, p < .001] and intraoperative fluoroscopy time [18.0 (16.0, 20.0) vs. 16.0 (14.0, 18.0) min, p < .001] than group A. The follow-up duration was similar for both groups (44.0 vs. 43.0 months, p = .877), and no patient died. Stent-related complications were significantly lower in group A than in group B (1.5% vs. 8.4%, p = .009). Group A had fewer instances entry flow (0.7% vs. 4.7%, p = .048) and stent stenosis (0.7% vs. 2.8%, p = .206) than group B. All reintervention cases (4.7%) were from group B (p = .011). The rate of false aortic lumen thrombosis was significantly higher in group A than in group B (84.6% vs. 72.9%, p = .024). Both CSs and ISFs are evidently safe, feasible, and effective in achieving positive early outcomes in patients undergoing treatment for TBAD. Notably, at midterm follow-up, CSs appeared to be superior to ISF in terms of reducing stent-related complications and minimizing the need for reintervention.

Anatomic Feasibility of In-Situ Fenestration for Isolate Left Subclavian Artery Preservation during Thoracic Endovascular Aortic Repair Using an Adjustable Needle Puncturing System

OBJECTIVES

To evaluate the feasibility of thoracic endovascular aortic repair (TEVAR) using the Ankura™ device (Lifetech Scientific, Shenzhen, China) with left subclavian artery (LSA) in-situ fenestration (ISF) using an adjustable puncture device system.

METHODS

It is a single center, retrospective, financially unsupported cohort study of TEVAR performed from 16 February 2007 to 10 January 2023. Inclusion criteria were isolate LSA revascularization for elective or urgent/emergent "zone 2" TEVAR, and the availability of the preoperative computed tomography angiography.

RESULTS

Post-hoc analysis identified 52 TEVARs. There were 39 (75.0%) males, and 13 (25.0%) females: median age was 74.5 years (IQR, 65.5-78). Index TEVAR was performed for atherosclerotic aneurysm in 27 (51.9%) cases, dissection-related diseases in 18 (34.6%), penetrating aortic ulcer in 5 (9.6%), and blunt traumatic aortic injury in 2 (3.8%). Access-vessel feasibility rate of TEVAR using the Ankura™ device would have been 98.1% (51/52). Considering the morphology of the aortic arch, ISF TEVAR feasibility would have been 61.5% (32/52). Binary logistic regression analysis identified LSA angulation (OR: 1.1, 95%CI: 1.03-1.14, p = 0.003) to be associated with ISF feasibility using this endograft and a self-centering adjustable needle-based puncture device.

CONCLUSIONS

Potential feasibility of TEVAR using the Ankura™ endograft with ISF using a self-centering adjustable needle system was 61.5%. Left subclavian artery angulation seems to be the most important and limiting anatomical constraint.

Chimney Technique and Single-Branched Stent Graft for the Left Subclavian Artery Preservation During Zone 2 Thoracic Endovascular Aortic Repair for Type B Acute Aortic Syndromes

PURPOSE

The purpose of this study was to evaluate the efficacy and safety of zone 2 thoracic endovascular aortic repair assisted by the chimney technique or single-branched stent graft for the preservation of the left subclavian artery, and summarize our single-center experience with the techniques.

MATERIALS AND METHODS

From February 2017 to June 2020, 137 patients who underwent left subclavian artery revascularization during zone 2 thoracic endovascular aortic repair were enrolled. Patients had acute type B aortic dissection and penetrating aortic ulcer associated with intramural hematoma. The chimney technique was performed in 68 patients (group A), and single-branched stent graft was deployed in 69 patients (group B). All procedures were performed during the acute phase. Primary technical success, immediate postoperative endoleak, neurologic complications (stroke or spinal cord ischemia), 30-day mortality, 1-year technical success, all-cause mortality, patency of the left subclavian artery, and reintervention were analyzed. Comparing the occurrence of the Bird-Beak Configuration, defined as a gap between the aortic wall and the sent graft with stent protrusion into the aortic lumen more than 5 mm, was also performed.

RESULTS

Primary technique success was achieved in 66 and 67 patients in groups A and B, respectively. The incidence of immediate postoperative endoleak, neurologic complications (stroke or spinal cord ischemia), and 30-day mortality were 5.9%, 1.5%, and 4.4% in group A, and 2.9%, 2.9%, and 2.9% in group B, respectively. During follow-up, the 1-year technical success rate was similar in both groups. All-cause mortality was similar in both groups (3.1% in group A and 4.5% in group B). The patency of the left subclavian artery was not significantly different between the 2 groups with 2 and 3 occlusions in groups A and B, respectively. The rate of reintervention was higher in group B (3.1% vs 1.6%, p=0.536), with a non-significant difference. Bird-Beak Configuration was more prominent in group B with the incidence of 59.42%.

CONCLUSIONS

Acting as minimally invasive alternatives, both techniques are feasible for left subclavian artery preservation during zone 2 thoracic endovascular aortic repair for type B acute aortic syndromes with encouraging mid-term outcomes. Long-term follow-up is required to confirm these findings.

Comparison of surgical and endovascular left subclavian artery revascularization during thoracic aortic endovascular repair: a systematic review and meta-analysis

Objective

The purpose of this systematic review and meta-analysis was to incorporate data from the latest clinical studies and compare the safety and efficacy of surgical left subclavian artery (LSA) revascularization and endovascular LSA revascularization during thoracic endovascular aortic repair (TEVAR).

Methods

This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered with the PROSPERO database on 16 April 2023 (CRD42023414579). The Embase, MEDLINE (PubMed), and the Cochrane Library databases were searched from January 2000 to May 2023.

Results

A total of 14 retrospective cohort studies with a total of 1,695 patients, were included for review. The peri-operative stroke rates of the surgical and endovascular LSA revascularization groups were 3.8% and 2.6%, respectively (P = 0.97). The peri-operative technical success rates for the surgical and endovascular LSA revascularization groups were 95.6% and 93.0%, respectively (P = 0.24). The peri-operative spinal cord ischemia rates were 1.6% (n = 18) and 1.9% (n = 7) in the surgical and endovascular LSA revascularization groups, respectively (P = 0.90). The peri-operative type Ⅰ endoleak rates for the surgical and endovascular LSA revascularization groups were 6.6% and 23.2%, respectively (P = 0.25). The subgroup analysis showed that the incidence of peri-operative type I endoleak in the parallel stent group was significantly higher than that in the surgical LSA revascularization group (P < 0.0001). The peri-operative left upper limb ischemia rates for the surgical and endovascular LSA revascularization groups were 1.2% and 0.6%, respectively (P = 0.96). The peri-operative mortality rates of the surgical and endovascular LSA revascularization groups were 2.0% and 2.0%, respectively (P = 0.88).

Conclusion

There was no significant difference in the terms of short-term outcomes when comparing the two revascularization techniques. The quality of evidence assessed by GRADE scale was low to very-low. Surgical and endovascular LSA revascularization during TEVAR were both safe and effective. Compared with surgical LSA revascularization techniques, parallel stent revascularization of LSA significantly increased the rate of type I endoleak.

Comparison of Chimney and Fenestrated Techniques for Supra-Aortic Branch Revascularization During Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis

PURPOSE

To compare the technical and clinical outcomes of fenestrated thoracic endovascular aortic repair (F-TEVAR) and chimney thoracic endovascular aortic repair (CH-EVAR) of aortic disease.

METHODS

PubMed, Embase and Cochrane databases were systematically searched to identify studies on the management of thoracic aortic pathologies using chimney or fenestrated techniques published between 2000 and 2022. Individual studies provided at least one of the following essential outcomes: technical success, immediate and follow-up type I endoleak, 30-day and aorta-related mortality, cerebral events and supra-aortic branch patency.

RESULTS

24 chimney (1106 patients) and 21 fenestrated technique studies (1040 patients) were included. The scope of the study encompassed various thoracic aortic conditions, such as thoracic aortic dissection, thoracic aortic aneurysm, thoracic aortic ulcer, and other thoracic aortic diseases. Technical success was defined as the handling of the principal ailment affecting the aorta, devoid of any instances of complications. The technical success rates were higher in fenestrated group compared with chimney group (98.0% vs. 95.8% p < 0.001), and the rate of type I endoleak either immediately or during follow-up was higher in the chimney technique group (9.3% vs. 1.3% p < 0.001, 4.0% vs. 0.0% p < 0.001). The chimney technique group had higher 30-day mortality and aorta-related mortality than those in the fenestrated technique group (2.1% vs. 0.3% p < 0.001, 0.4% vs. 0.0% p < 0.001). Morbidity rates of cerebral events and supra-aortic branch patency were same in both groups (2.2% vs. 1.1% p = 0.116, 98.2% vs. 99.4% p = 0.094). The chimney technique group had longer operative time (110.0 min vs. 90.8 min p < 0.001). Two groups had same fluoroscopy time (34.0 min vs. 33.4 min p = 0.614).

CONCLUSIONS

The finding suggest that both the chimney and fenestrated techniques are efficacious in supra-aortic branch reconstruction. However, the fenestrated technique exhibits potential superiority as an interventional strategy, as it demonstrates a lower incidence of type 1 Endoleak, 30-day mortality, and aorta-related death following TEVAR.

Single-Center Preliminary Experience with Gutter-Plugging Chimney Stent-Graft for Aortic Dissection

PURPOSE

To report the early 2-year results and experience of a novel gutter-plugging chimney stent-graft in a single center that participated in the clinical trial of Prospective Study for Aortic Arch Therapy with stENt-graft for Chimney technology.

MATERIALS AND METHODS

Patients diagnosed with aortic dissection were treated with the novel chimney stent-grafts named Longuette™ for the left subclavian artery revascularization. Primary study outcomes were the incidence of freedom from major adverse events within 30 days and success rate of the operation over 12 months.

RESULTS

A total of 34 patients were enrolled between September 2019 and December 2020. The immediate technical success rate (stent-grafts successfully deployed without fast-flow type Ia or type III endoleak intraoperatively) was 100%, and there were no conversions to open repair. Type Ia and type II endoleaks were noted in three patients (8.8%) and one patient (2.9%) at discharge, respectively. One patient (2.9%) with type Ia endoleak underwent coil embolization at 12 months because of false lumen dilation, and one (2.9%) case of type Ia endoleak resolved spontaneously at 24 months. One chimney stent (2.9%) was revealed with stenosis at discharge and occluded with thrombosis at 6 months postoperatively. During the 2-year follow-up, there was no death, rupture, stroke, paraplegia, left arm ischemia, retrograde dissection, stent-graft induced new entry, or stent migration.

CONCLUSION

The initial results of the Longuette™ stent-graft for revascularization of the left subclavian artery are encouraging with a high technical success rate. Further multicenter follow-up outcomes are required to assess the long-term durability.

LEVEL OF EVIDENCE

Level 4, Case Series.

Comparison of techniques for left subclavian artery preservation during thoracic endovascular aortic repair: A systematic review and single-arm meta-analysis of both endovascular and surgical revascularization

Background

Currently, the optimal technique to revascularize the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) remains controversial. Our study seeks to characterize early and late clinical results and to assess the advantages and disadvantages of endovascular vs. surgical strategies for the preservation of LSA.

Methods

PubMed, Embase and Cochrane Library searches were conducted under the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analyses) standards. Only literature published after January 1994 was included. Studies reporting on endovascular revascularization (ER), surgical revascularization (SR) for LSA preservation were included. 30-day mortality and morbidity rates, restenosis rates, and rates of early and late reintervention are measured as outcomes.

Results

A total of 28 studies involving 2,759 patients were reviewed. All articles were retrospective in design. Single-arm analysis found no significant statistical differences in ER vs. SR in terms of 30-day mortality and perioperative complication rates. The mean follow-up time for the ER cohort was 12.9 months and for the SR cohort was 26.6 months, respectively. Subgroup analysis revealed a higher risk of perioperative stroke (4.2%) and endoleaks (14.2%) with the chimney technique compared to the fenestrated and single-branched stent approaches. Analysis of the double-arm studies did not yield statistically significant results.

Conclusion

Both ER and SR are safe and feasible in the preservation of LSA while achieving an adequate proximal landing zone. Among ER strategies, the chimney technique may presents a greater risk of neurological complications and endoleaks, while the single-branched stent grafts demonstrate the lowest complication rate, and the fenestration method for revascularization lies in an intermediate position. Given that the data quality of the included studies were relatively not satisfactory, more randomized controlled trials (RCTs) are needed to provide convincing evidence for optimal approaches to LSA revascularization in the future.

Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes

The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.

Surgical Debranching versus Branched Endografting in Zone 2 Thoracic Endovascular Aortic Repair

INTRODUCTION

Left subclavian artery (LSA) revascularization is recommended in patients undergoing elective thoracic endovascular aortic repair (TEVAR) with proximal zone 2 landing requiring coverage of the LSA. The gold-standard remains surgical LSA revascularization, but recently the feasibility of branched endografts has been demonstrated. We compared the perioperative and mid-term outcomes of these approaches.

METHODS

A retrospective review of consecutive patients undergoing TEVAR with proximal zone 2 landing at a single center from 2014-2020 was performed. Patients were divided into cohorts for comparison: those undergoing surgical revascularization (SR-TEVAR group) and those undergoing thoracic branched endografting with an investigational device (TBE group). Patients who did not receive LSA revascularization were excluded. Perioperative outcomes including procedural success, death, stroke, limb ischemia, and length of stay were compared. Kaplan-Meier survival curves were compared with the log-rank test. The cumulative incidences of device-related endoleak (type I and III) and device-related reintervention, accounting for death as a competing hazard, were compared with the Fine-Gray test.

RESULTS

A total of 55 patients were included: 31 (56%) SR-TEVAR and 24 (44%) TBE. Preoperative demographics and comorbidities were similar between the groups. Procedural success was 100% in both cohorts, and there were no periprocedural strokes or left upper extremity ischemic events. One operative/30-day mortality (TBE 4.2% vs SR-TEVAR 3.2%, p=0.99) occurred in each cohort. Total operative time (minutes, TBE 203 ± 79 vs SR-TEVAR 250 ± 79 p=0.03) and total length of stay (days, TBE 5.2 ± 3.6 vs SR-TEVAR 9.9 ± 7.2, p=0.004) were both significantly shorter in the TBE group. There was no difference in mid-term survival (log-rank p=0.50), nor the cumulative incidence of device-related endoleak (Fine-Gray p=0.51) or reintervention (Fine-Gray p=0.72). There have been no occlusions of the TBE graft nor surgical bypass/transpositions after a mean follow-up for 28 ± 16 and 34 ± 24 months, respectively.

CONCLUSIONS

Thoracic branched endografting can be performed with similar procedural success and comparable safety profile to TEVAR with surgical revascularization, while reducing total length of stay, in patients requiring proximal zone 2 coverage. Mid-term outcomes of each approach are also similar. Prospective, randomized comparisons of these techniques are warranted.

Early and Mid-Term Outcomes of Open versus Endovascular Left Subclavian Artery Debranching for Thoracic Aortic Diseases

Purpose: To compare open versus endovascular left subclavian artery debranching for thoracic endovascular aortic repair of thoracic aortic pathologies.

Methods: This is a retrospective study of patients receiving left subclavian artery debranching in our institution from October 2009 to January 2020. The primary outcome was freedom from aortic reintervention. Secondary outcomes were type I endoleaks, left subclavian artery (LSA) debranching failure, stroke, technical or clinical success, procedure-related reintervention, as well as 30-day or overall all-cause and aorta-related mortality.

Results: Forty-eight patients received parallel graft-based (n = 24, ENDO; median age 75 years [70–80 years]) or open (n = 24, OPEN; median age 71 years [59–75 years]) debranching for type B aortic dissection (n = 25), degenerative aneurysm (n = 12), type IA endoleak (n = 6), suture-associated (n = 3) or ostial LSA aneurysm (n = 1), or penetrating aortic ulcer (n = 1). The median follow-up was 36 months (13–61 months). After 16 months, aortic reintervention-free survival in groups OPEN and ENDO was 91% (95% confidence interval [CI]: 79 to 100%) and 86% (73 to 100%) (p = 0.71), respectively. After 36 months, all-cause survival in groups OPEN and ENDO was 74% (95% CI: 55 to 99%) and 79% (95% CI: 64 to 97%) (p = 0.74), respectively; freedom from aorta-related mortality was 81% (95% CI: 62 to 100%) and 91% (95% CI: 80 to 100%) (p = 0.78), respectively. Group OPEN presented less type I endoleaks (OPEN/ENDO = 3/19, p <0.001) and higher technical (OPEN/ENDO = 81/36%, p = 0.003) and clinical success rates (OPEN/ENDO = 67/36%, p = 0.047). No statistical differences were found for other outcomes.

Conclusion: Both strategies achieved comparable reintervention and mortality rates, but open debranching should be preferred due to its higher technical and clinical success and less type I endoleaks.

Endovascular Repair for Acute Type B Aortic Dissection With Unfavorable Proximal Landing Zone

BACKGROUND

The study aimed to compare the safety and effectiveness between fenestrated technique with or without chimney stent and single-branched stent graft for isolated left subclavian artery revascularization during endovascular repair of acute type B aortic dissection with unfavorable proximal landing zone.

METHODS

From January 2016 to December 2019, 65 acute type B aortic dissection patients with unfavorable proximal landing zone were treated with either the fenestrated technique (n = 34, group A) or single-branched stent graft (n = 31, group B). Type I endoleak, retrograde type A dissection, stroke, left subclavian artery patency, 30-day mortality, and aortic remodeling were systematically recorded and retrospectively analyzed.

RESULTS

Technical success rates for groups A and group B were 94.12% and 100%, respectively. Left subclavian artery primary patency was achieved for all enrolled patients. The incidence of type I endoleak, retrograde type A dissection, stroke, and 30-day mortality was 5.9%, 5.9%, 2.9%, and 2.9% in group A, respectively, but none were encountered in group B. Left subclavian artery occlusion was observed in 3 patients in group A and 2 patients in group B during a mean follow-up of 16.18 ± 2.08 months and 15.19 ± 2.68 months, respectively. After the procedure, significant aortic remodeling was detected in both groups during follow-up.

CONCLUSIONS

Both techniques are feasible and safe for isolated left subclavian artery revascularization during endovascular repair for acute type B aortic dissection. Apart from the associated perioperative risks of complications and mortality for the fenestrated technique, both procedures contributed to favorable aortic remodeling.

Narrative review on endovascular techniques for left subclavian artery revascularization during thoracic endovascular aortic repair and risk factors for postoperative stroke

OBJECTIVES

The aim of this study was to present a narrative review on endovascular techniques (ET) for revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) and on risk factors for postoperative stroke following TEVAR procedures.

METHODS

Non-systematic search of the literature from the PubMed, Ovid and Scopus databases to identify relevant English-language articles fully published in the period 1 January 2010-1 August 2020.

RESULTS

Current general agreement is that LSA revascularization should be always attempted in the elective setting. Under urgent circumstances, it can be delayed but might be considered during the same session on a case-by-case basis. Three ET are currently available: (i) chimney/snorkels (also known as parallel grafts), (ii) fenestrations or branches and (iii) proximal scallops. The main issue with ET is the potential for increased peri-operative stroke risk owing to increased manipulation within the aortic arch. Also, they are relatively novel and further assessment of their long-term durability is needed. Intra-operative embolism and loss of left vertebral artery perfusion are hypothesized as the main causes of stroke in patients undergoing TEVAR.

CONCLUSIONS

The overall risk of stroke seems higher without LSA revascularization during zone 2 TEVAR. As LSA revascularization might have a direct effect in preventing posterior stroke, it should be routinely performed in elective cases, while a case-by-case evaluation can be made under urgent circumstances. While ET can provide effective options for LSA revascularization during zone 2 TEVAR, they are novel and need further durability assessment. Stroke after TEVAR is a multifactorial pathological process and preventing TEVAR-related cerebral injury remains a significant unmet clinical need.

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.

In Situ Laser Stent Graft Fenestration of the Left Subclavian Artery during Thoracic Endovascular Repair of Type B Aortic Dissection with Limited Proximal Landing Zones: 5-Year Outcomes

PURPOSE

To assess safety and feasibility of in situ laser stent graft fenestration to revascularize the left subclavian artery (LSA) during thoracic endovascular repair (TEVAR) of type B aortic dissection (TBAD) with limited proximal landing zones with 5 years of follow-up.

MATERIALS AND METHODS

In a single-center retrospective study, 130 patients with TBAD with limited proximal landing zones (≤ 1.5 cm) underwent in situ laser stent graft fenestration revascularizing the LSA during TEVAR from April 2014 to April 2019. Outcomes were assessed by CT angiography and clinic visits, including technical success rate, operative time, LSA patency, ischemic events, and late aorta-related complications during follow-up.

RESULTS

Mean age of patients was 53 y (range, 33-73 y). Primary technical success rate was 96.9% (126/130). Three chimney stents were placed instead of fenestration, and 1 LSA fenestration was combined with a left common carotid artery (LCCA) chimney stent. Mean operative time was 53 min ± 28 with fluoroscopy time of 40 min ± 15. There were no neurologic complications and no deaths, with a mean duration of hospital stay of 9 d (range, 5-21 d). At a mean follow-up of 42 mo (range, 5-60 mo), there was a 97% primary LSA patency. Four patients had a type I endoleak, which disappeared during follow-up. One LCCA became occluded after 6 months. No type II or III endoleaks were found. Retrograde type A aortic dissection and stent graft-induced new distal entry were not found during follow-up.

CONCLUSIONS

In situ laser fenestration to revascularize the LSA during TEVAR of TBAD with limited proximal landing zones was efficient, safe, and feasible based on 5-year follow-up.

Periscope sandwich stenting as an alternative to open cervical revascularization of left subclavian artery during zone 2 thoracic endovascular aortic repair

OBJECTIVE

Revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) maintains collateral circulation to decrease ischemic complications, including stroke, spinal cord ischemia, and upper extremity ischemia. Both open surgical and endovascular LSA revascularization techniques have been described, each with unique risks and benefits. We describe our "periscope sandwich" technique for the LSA during zone 2 TEVAR, which maintains antegrade access to the distal abdominal aorta if subsequent interventions are necessary. Technical results and short-term outcomes are compared with LSA open surgical debranching.

METHODS

A single-institution retrospective review was performed for patients requiring zone 2 TEVAR with LSA revascularization by periscope sandwich technique or open surgical debranching with subclavian to carotid transposition (SCT) or carotid-subclavian bypass (CSB). The presenting aortic disease and perioperative details were recorded. Intraoperative angiography and postoperative computed tomography images were reviewed for occurrence of endoleak and branch patency.

RESULTS

Between January 2013 and December 2018, the LSA was revascularized by periscope sandwich in 18 patients, SCT in 22 patients, and CSB in 13 patients. Compared with open surgical debranching, periscope sandwich had a lower median estimated blood loss (100 mL vs 200 mL for pooled SCT and CSB; P = .03) and lower median case duration (133.5 minutes vs 226 minutes; P < .001). Contrast material volume (120 mL vs 120 mL; P = .98) and fluoroscopy time (13.1 minutes vs 13.3 minutes; P = .92) did not differ significantly between the groups. There was no difference in aorta-related mortality (P = .14), and LSA patency was 100%. Median follow-up for the periscope sandwich group was 11 months, with an overall estimated 91% freedom from gutter leak at 6 months.

CONCLUSIONS

LSA periscope sandwich technique provides safe and effective LSA revascularization during zone 2 TEVAR. LSA periscope sandwich can be used emergently with off-the-shelf endovascular components and facilitates future branched-fenestrated endovascular repair of thoracoabdominal aortic diseases.

Midterm Outcomes of Endovascular Repair for Stanford Type B Aortic Dissection with Aberrant Right Subclavian Artery

PURPOSE

To evaluate the early and midterm outcomes of endovascular repair of Stanford type B aortic dissection (TBAD) with an aberrant right subclavian artery (ARSA).

MATERIALS AND METHODS

From November 2012 to July 2018, 15 patients (13 male, 2 female) who had TBAD with ARSA underwent total endovascular repair, including thoracic endovascular aortic repair (TEVAR), left subclavian artery (LSA) chimney technique, LSA fenestration technique, and double chimney technique (LSA chimney and ARSA periscope). The mean age was 55 years. Kommerell diverticulum (KD) occurred in 2 patients, which were covered by means of oversized aortic stents. All patients had preoperative imaging examinations for assessing cerebral blood flow and the dominant vertebral arteries.

RESULTS

All procedures were completed successfully. There was no in-hospital mortality. The mean procedural time was 98 ± 40 minutes (range 50-190). The mean preoperative diameters of the maximum descending aorta, false lumen, and true lumen in the descending aorta versus postoperative were 37 ± 10 mm (range 28-67), 18 ± 9 mm (range 9-41), and 19 ± 6 mm (range 10-35) versus 34 ± 9 mm (range 25-64), 5 ± 8 mm (range 0-28), and 28 ± 5 mm (range 19-37), respectively. Right upper extremity weakness was observed in 2 patients, which recovered gradually during follow-up. Immediate type Ia endoleak was detected in 1 patient. The mean follow-up time was 33 ± 20 months. During follow-up, no ARSA steal syndrome, spinal cord ischemia, or strokes were not observed.

CONCLUSIONS

Endovascular treatment for TBAD with ARSA was feasible and safe with a satisfactory midterm follow-up outcome.