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Becker D, Tsilimparis N, Ali A, Stana J, Mihály Z, Pichlmaier M, Peterss S, Prendes CF. Sex Related Anatomical Differences in Patients With Aortic Arch Pathology and Their Impact on the Feasibility of Double and Triple Branched Endografts. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00485-4. [PMID: 38879148 DOI: 10.1016/j.ejvs.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 05/20/2024] [Accepted: 06/07/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVE To evaluate sex based differences in ascending aorta and arch anatomy in patients with underlying proximal aortic disease and to evaluate their impact on feasibility for total endovascular repair with custom made, branched arch devices. METHODS This was a retrospective cross sectional review of all patients undergoing open and or total endovascular arch repair due to distal ascending aorta and or aortic arch pathologies in a single high volume aortic centre between 2012 and 2022. Anatomical ascending aorta and aortic arch parameters were analysed on a flow centreline on a dedicated 3D workstation. Sex related differences of the ascending aorta, aortic arch, and supra-aortic vessels were evaluated. Subsequently, four endovascular devices were assessed for feasibility: double and triple branched devices both for the Zenith (Cook Medical) and Relay (Terumo Aortic) platforms, first in accordance with the instructions for use and then considering the possibility of adjunctive cervical debranching. The primary endpoints were sex specific differences in aortic anatomy, while secondary endpoints included sex based feasibility of branched endograft devices. RESULTS During the study period, 395 patients underwent total aortic arch repair, of whom 152 (51 female, 33.5%) had high quality computed tomography angiograms available and were included in the study. Female patients had a shorter proximal landing zone than males (22 mm vs. 47 mm; p < .001). Left subclavian artery dissection was more frequent in men (24.8% vs. 3.9%; p < .001). Other anatomical parameters showed a similar distribution between sexes. Female patients presented a lower feasibility for double branched devices (35.3% vs. 58.4%; p = .015) as well as a tendency for lower feasibility rates for triple branched devices (31.4% vs. 47.5%; p = .081). CONCLUSION Although most ascending aortic and arch parameters showed similar trends in both sexes, the availability of a suitable proximal landing zone was lower in female patients. Consequently, female patients had lower feasibility rates for double arch branched endografts and, to lesser extent, for triple arch branched endografts.
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Affiliation(s)
- Daniel Becker
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Nikolaos Tsilimparis
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Ahmed Ali
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Jan Stana
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Zsuzsanna Mihály
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany
| | - Maximilian Pichlmaier
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Sven Peterss
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Carlota F Prendes
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany; Department of Vascular Surgery, LMU University Hospital, Munich, Germany.
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Fujimura N, Ichihashi S, Shibata T, Matsumura H, Watanabe M, Morikage N, Kurimoto Y, Banno H, Uchiyama H, Obara H. Early Clinical Results From the Japanese Prospective Multicenter Study to Evaluate Zenith Alpha Abdominal Stent Graft for Abdominal Aortic Aneurysm (JUSTICE) Registry Demonstrate Acceptable Limb Patency at 12 Months. J Endovasc Ther 2024:15266028241248311. [PMID: 38654524 DOI: 10.1177/15266028241248311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE Recent reports of the Zenith Alpha abdominal endovascular graft (Zenith Alpha AAA, Cook, Inc., Bloomington, Indiana) have demonstrated an unexpectedly high incidence of limb graft occlusion (LGO). The purpose of this study was to prospectively evaluate the performance of the Zenith AAA in Japan, with a specific focus on LGO. MATERIALS AND METHODS All endovascular aneurysm repairs (EVARs) for abdominal aortic aneurysms performed using the Zenith Alpha AAA from July 2020 to October 2021 in 23 Japanese hospitals were prospectively evaluated. All computed tomographic images were analyzed in the core laboratory. Late complications were defined as any aneurysm-related events occurring >30 days after EVAR, including aneurysm sac enlargement of >5 mm and any reinterventions performed. Endoleaks without sac enlargement or reintervention were excluded as late complications. RESULTS During the study period, 147 EVARs were performed using the Zenith Alpha AAA. The mean patient age was 76.5±7.7 years, 84.4% of patients were male, and the mean aneurysm diameter was 52.4±9.2 mm. Instruction-for-use violations were observed in 76 patients (51.7%), primarily associated with a severely angulated proximal neck (>60°). There were six intraoperative complications and 62 additional intraoperative treatments reported, most of which involved preemptive coil embolization of the inferior mesenteric artery (37 cases). Technical success, defined as the absence of type 1 or 3 endoleaks on final angiography, was achieved in 99.3% of patients. At 12 months, there was only one case of type 1/3 endoleak (0.8%) and one aneurysm sac enlargement exceeding 5 mm (0.8%); however, a high incidence of type 2 endoleaks was observed in 35.2% of patients, and aneurysm sac regression exceeding 5 mm was achieved in 30.1% of patients. Nine late complications were observed, and the rate of freedom from late complications at 12 months was 93.5%, encompassing four LGOs and one limb graft stenosis (3.4%). CONCLUSIONS In contrast to recent reports, our Japanese multicenter prospective study demonstrated satisfactory early clinical results, including an acceptable LGO rate, for the low-profile Zenith Alpha AAA. Long-term follow-ups will be performed to confirm the persistence of these outcomes. CLINICAL IMPACT This study prospectively evaluated the performance of 147 Zenith Alpha AAAs used for endovascular aneurysm repair with core-lab adjudication focusing especially on limb graft occlusion (LGO). At 12 months, aneurysm sac regression exceeding 5 mm was achieved in 30.1% of patients, and there was only one type 1/3 endoleak, one aneurysm sac enlargement (>5 mm), and nine late complications including five LGOs (3.4%), resulting in rate of freedom from late complications at 93.5%. Satisfactory early clinical results, including an acceptable rate of LGO can be achieved, particularly with cautious usage of the Zenith Alpha Spiral-Z Endovascular Leg." 5mm), and nine late complications including five LGOs (3.4%), resulting in rate of freedom from late complications at 93.5%. Satisfactory early clinical results, including an acceptable rate of LGO can be achieved, particularly with cautious usage of the Zenith Alpha Spiral-Z Endovascular Leg.
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Affiliation(s)
- Naoki Fujimura
- Department of Vascular Surgery, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | | | - Tsuyoshi Shibata
- Department of Cardiovascular Surgery, Sapporo Medical University, Hokkaido, Japan
| | - Hitoshi Matsumura
- Department of Cardiovascular Surgery, School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Michiko Watanabe
- Department of Cardiovascular Surgery, Chiba University, Chiba, Japan
| | - Noriyasu Morikage
- Department of Vascular Surgery, Yamaguchi University, Yamaguchi, Japan
| | - Yoshihiko Kurimoto
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Hiroshi Banno
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetoshi Uchiyama
- Department of Vascular Surgery, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Tan SZ, Jubouri M, Bashir M. Endovascular aortic arch repair: A comparison of outcomes and current trends. Asian Cardiovasc Thorac Ann 2023; 31:589-595. [PMID: 36397652 DOI: 10.1177/02184923221140756] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVE Application of thoracic endovascular aortic repair (TEVAR) to the aortic arch has been met with the development of purpose-made endoprostheses for on-label use in the aortic arch. An appraisal of the clinical efficacy of each major device is therefore useful towards informing clinical decision making for patients eligible for endovascular arch repair (EAR) rather than open surgical reconstruction. METHODS A literature review of publications outlining clinical experience with the RELAY™ Branched and Zenith™ devices was undertaken, and the results therefrom analysed to evaluate the clinical efficacies of each device. RESULTS Early- and long-term mortality rates associated with EAR appear favourable, especially compared against open surgical repair. EAR is also associated with good neurological outcomes and target vessel patency rates. However, EAR continues to be associated with substantial reintervention rates. CONCLUSIONS At the present stage, EAR represents a promising alternative option to open surgical reconstruction in patients that meet its eligibility criteria. Though there remains a substantial learning curve associated with EAR, its favourable outcome profile is likely to increase its applicability in the future.
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Affiliation(s)
- Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull-York Medical School, University of York, York, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Health Education and Improvement Wales, Velindre University NHS Trust, Wales, UK
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Benfor B, Prendes CF, Peterss S, Stavroulakis K, Stana J, Pichlmaier M, Tsilimparis N. Anatomical analysis of the aortic arch and feasibility study of double and triple branched thoracic endografts in the treatment of isolated arch pathologies. Eur J Cardiothorac Surg 2022; 62:6567563. [PMID: 35413109 DOI: 10.1093/ejcts/ezac246] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/17/2022] [Accepted: 04/05/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to determine the proportion of patients undergoing open arch repair who would be anatomically suitable for multi-branched endovascular arch repair. METHODS This study was a single-centre review of patients undergoing open arch repair between 2000 and 2020. Anatomical feasibility was determined by comparing arch measurements to the anatomical criteria of the Zenith® double and triple inner branched-arch endografts (Cook Medical) and the Relay® double arch branched device (Terumo-Aortic). RESULTS Ninety (90) patients were included in this study, with 43/90 presenting degenerative aneurysm. The distance between the sinotubular junction and the brachiocephalic trunk measured 114 ± 30 mm on the outer curvature, and the maximum diameter of the proximal landing zone (PLZ) was 41 ± 11mm. A total of 42/90 patients (47%) were anatomically suitable for at least 1 stent graft and 29/90 patients (32%) were eligible for a triple-branched endograft. The most important determinant factors of anatomical suitability were the PLZ diameter (Cramer's V = 0.743, P < 0.001) and length (Cramer's V = 0.777, P < 0.001). CONCLUSIONS This study shows that the proportion of patients who may be anatomically suitable for branched-arch repair remains limited. The PLZ dimensions tend to be the most important anatomical limitations and should receive more emphasis in the development of branched-arch devices.
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Affiliation(s)
- Bright Benfor
- Department of Vascular Surgery, LMU Klinikum-Grosshadern, Munich, Germany
| | - Carlota F Prendes
- Department of Vascular Surgery, LMU Klinikum-Grosshadern, Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, LMU Klinikum-Grosshadern, Munich, Germany
| | | | - Jan Stana
- Department of Vascular Surgery, LMU Klinikum-Grosshadern, Munich, Germany
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Reyes Valdivia A, Milner R, Heijmen R, Riambau V, Rousseau H, Tinelli G, Kotelis D, Zanabili Al-Sibbai AA, Pitoulias G, Zúñiga CG, de Beaufort HWL, Panagiotis D, Chaudhuri A. Mid-term outcomes of the use of endoanchors during thoracic endovascular aortic repair in multicentre analysis. Vascular 2022; 31:455-462. [DOI: 10.1177/17085381221076320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To describe mid-term outcomes of the use of EndoAnchors as an adjunct for arch and thoracic endovascular aortic repair (TEVAR). Methods A retrospective multicentre series from nine centres using the Heli-FX EndoAnchor System (Medtronic Inc, Minneapolis, USA) at TEVAR over May 2014–May 2019 is presented. The study is registered at ClinicalTrials.gov with number NCT04100499. The primary outcome was freedom from Type I endoleak at EndoAnchors deployments; secondary outcomes included evaluation of aortic wall penetration (AWP) at first computed tomography scan, EndoAnchor-related issues and mortality. Results 54 high-risk patients (35 males/19 females, age 73 ± 11 years) with arch, thoracic and thoracoabdominal aneurysmal disease (3 chronic post-dissection and one patch pseudoaneurysm), with a mean neck length 19.7 ± 6.6 mm that were treated with multiple hybrid and endovascular techniques were included. A total of 329 EndoAnchors were used with a mean of 6.1 ± 2.5 per patient. Overall adequate AWP was 86%, whereas arch (Ishimaru’s zones 0–2) deployments achieved 80.6% when compared to 87.3% in descending thoracic aorta (dTA); although there was no statistical significance. Freedom from type I endoleaks was 88% at 2 year follow-up, due to 4 type IA endoleaks, two of them successfully treated, one with conservative treatment due to complexity of repair and remaining patient died 1 year later due to endograft infection. There were reported five EndoAnchor-related issues; four losses and one renal stent-graft was crushed due to catheter deflection solved with balloon reinflation. None of the losses had clinical significance. Overall mortality is described for 7 (9.5%) patients, one of them aneurysm-related. Conclusions The adjunctive use of EndoAnchors in TEVAR and complex TEVAR procedures achieved acceptable outcomes at midterm in a high-risk series with hostile seal zones. Still, they should be still judiciously used as there is lack of data to suggest a more liberal use; therefore, the landing zone should not be compromised in favour of their use.
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Affiliation(s)
- Andrés Reyes Valdivia
- Department of Vascular and Endovascular Surgery, Ramón y Cajal´s University Hospital, Madrid, Spain
| | - Ross Milner
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago Medicine, Chicago, Ill
| | - Robin Heijmen
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Vicente Riambau
- Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain
| | - Hervé Rousseau
- Department of Radiology, Rangueil Hospital, CHU de Toulouse, Toulouse Cedex, France
| | - Giovanni Tinelli
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Drosos Kotelis
- Department of Vascular Surgery, University Hospital RWTH Aachen, European Vascular Center Aachen-Maastricht, Aachen, Germany
| | | | - Georgios Pitoulias
- Aristotle University of Thessaloniki - Faculty of Medicine, Second Department of Surgery Division of Vascular Surgery. G. Gennimatas” Thessaloniki General Hospital
| | - Claudio Gandarias Zúñiga
- Department of Vascular and Endovascular Surgery, Ramón y Cajal´s University Hospital, Madrid, Spain
| | | | - Doukas Panagiotis
- Department of Vascular Surgery, University Hospital RWTH Aachen, European Vascular Center Aachen-Maastricht, Aachen, Germany
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Gleason TG. Limiting factors of current thoracic aortic endovascular technologies. Ann Cardiothorac Surg 2021; 10:787-789. [PMID: 34926182 DOI: 10.21037/acs-2021-taes-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 06/16/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Thomas G Gleason
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Stana J, Peterß S, Prendes CF, Stavroulakis K, Rantner B, Pichlmaier M, Tsilimparis N. [Ascending Aorta and Aortic Arch - Endovascular Therapy Today and in the Future]. Zentralbl Chir 2021; 146:479-485. [PMID: 34666362 DOI: 10.1055/a-1644-1759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pathologies in the region of the aortic arch may occur in isolation, but adjacent segments of the thoracic aorta - the ascending or descending aorta - are much more commonly affected. The first surgical procedures to treat the aortic arch were performed nearly six decades ago. Despite numerous improvements and innovations in the 20th and early 21st centuries, these procedures are still associated with relevant operative mortality and neurological complication rates. Endovascular techniques and modern hybrid procedures are increasingly expanding the therapeutic spectrum in the aortic arch, although the open surgical approach is currently still the gold standard. Endovascular treatment of aortic aneurysm was first performed in the early 1990s in the infrarenal abdominal aorta. It was not long before the first attempts at endovascular therapy were made for the treatment of the aortic arch. In 1996, Inoue et al. reported the use of the first commonly used endoprosthesis to treat aneurysms in the aortic arch. Continuous improvements and refinements in implantation techniques and also implanted material have resulted in endovascular therapy now being an increasingly important option compared to open surgical procedures in the descending thoracic and abdominal aorta and has partially replaced them as the gold standard. This review article aims to provide an overview of the prerequisites, results, but also limitations of endovascular surgery of the aortic arch.
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Affiliation(s)
- Jan Stana
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Sven Peterß
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | | | | | - Barbara Rantner
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Maximilian Pichlmaier
- Herzchirurgische Klinik und Poliklinik, Klinikum der Ludwig-Maximilians-Universität München, Standort Großhadern, München, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
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