Outcomes of Total Endovascular Aortic Arch Repair with Surgeon-Modified Fenestrated Stent-Grafts on Zone 0 Landing for Aortic Arch Pathologies

Endovascular Repair of Aortic Arch Zones 0 to 2 Using Physician-Modified Endografts: A Systematic Review and Meta-Analysis

PURPOSE

The purpose of this study was to collect all the available evidence concerning technical success and early and mid-term clinical outcomes of physician-modified endografts (PMEGs) for the treatment of aortic arch pathologies in zones 0 to 2.

MATERIAL AND METHODS

We performed a systematic review to identify all the eligible studies that reported outcomes to the PMEGs for aortic arch pathologies in zones 0 to 2 and then conducted a qualitative synthesis and meta-analysis of the results. The main outcomes were technical success, mortality, stroke rate, bridging stents' complications, and reintervention rate. We estimated pooled proportions and 95% confidence intervals (CIs).

RESULTS

A total of 134 study titles were identified by the initial search strategy, of which 14 (zone 0 n=6; zone 1 n=1; zones 1 t o2: n=7) were considered eligible for inclusion in the meta-analysis. A total of 777 patients (80% male; 62±6 years) were identified among the eligible studies. The pooled technical success for the PMEG in zone 0 was 96.6% (95% CI=93.9%-98.2%), whereas in zones 1 to 2 was 95.9% (95% CI=92.9%-97.6%). The pooled 30-day mortality was 4.6% (95% CI=2.0%-10%) and 4.3% (95% CI=2.2%-8.2%) for zones 0 and 1 to 2, respectively, whereas the prevalence of late mortality was 8.2% (95% CI=4.7%-14%) and 3.4% (95% CI=1.9%-6%). The pooled stoke rate was 3.7% (95% CI=2.1%-6.4%) in zone 0 and 2.7% (95% CI=1.4%-5%) in zones 1 to 2. The early reintervention rate was 3.5% (95% CI=1.5%-8.0%) and 4.2% (95% CI=2.4%-7.2%) for zones 0 and 1 to 2, respectively, whereas during the mean follow-up of 26 months was 8.5% (95% CI=3.0%-21%) and 1.9% (95% CI=0.8%-4.3%). The pooled bridging's stent instability was 3.9% (95% CI=1.1%-12.9%) in zone 0 and 3.2% (95% CI=1.8%-5.8%) in zones 1 to 2.

CONCLUSIONS

Endovascular repair of aortic arch pathologies using PMEGs seems to present a satisfactory level of technical success and a low mortality rate. To attain clearer conclusions, further research employing randomized controlled trials, longer-term follow-up, and consistent reporting of results is warranted.

CLINICAL IMPACT

This systematic review and meta-analysis of observational studies analyzed the short- and mid-term outcomes of aortic arch aneurysm and/or dissection using physician-modified endografts. It separately examined the outcomes from zones 0 and 1-2 of the aortic arch. Fourteen studies (n=777 patients) were included. Overall technical success rates were 96.6% for zone 0 and 95.9% for zone 1-2. Regarding early mortality and stroke rates, no significant differences were observed, while late mortality was higher in patients in zone 0. The late reintervention rate favored patients treated with PMEGs in zone 1-2. The physician-modified technique appears to be an excellent and rapidly available alternative for the treatment of aortic arch diseases.

Physician-Modified and In Situ Fenestrated Stent Grafts in Zone 0 for Aortic Arch Pathology After Ascending Aortic Replacement

BACKGROUND

We sought to describe our experience and outcomes of a zone 0 landing physician-modified aortic stent for the treatment of aortic arch pathologies late after open ascending aortic replacement.

METHODS

This study included consecutive patients with aortic arch diseases treated with total endovascular repair using different techniques. The indication for endovascular repair was agreed on in a multidisciplinary discussion. Study end points were technical success, early and late outcomes.

RESULTS

From November 2018 to May 2022, 16 consecutive patients underwent total endovascular repair of aortic arch pathologies. Median time for surgery was 4.8 hours (range, 2.6-6.6 hours). All the new-onset aortic arch pathologies were successfully treated. The 30-day mortality rate was 0%. Two patients had endoleak. The median length of postoperative stay was 4 days (range, 3-6 days). During follow-up, 1 patient underwent reintervention for type II endoleak. There were no conversions to retrograde dissection, aortic rupture and stroke.

CONCLUSIONS

Our experience of using different total endovascular techniques for selective patients with arch pathologies who may be unfit or too risky for reopen surgery revealed favorable initial results. In addition, these techniques are promising options for urgent arch pathologies without availability of custom-manufactured devices. Durability concerns will need to be assessed in additional studies with long-term follow-up.

CLINICAL IMPACT

The use of physician-modified and in situ fenestrated stent grafts in zone 0 landing for aortic arch pathologies in patients with prior open ascending aortic replacement is effective in endovascular therapy. This innovation enables clinicians to offer an alternative option to high-risk patients, potentially reducing morbidity and mortality. It underscores the feasibility of tailored endovascular therapy in complex aortic diseases, where customized devices may not be available.

Physician Modified Fenestrated Endografts for Endovascular Aortic Arch Repair in Zone 0

OBJECTIVE

This multicentre study aimed to assess the early and midterm outcomes of physician modified fenestrated endografts (PMEGs) for endovascular aortic arch repair in zone 0.

METHODS

Between 2018 and 2022, a retrospective study was conducted in three centres of consecutive patients undergoing endovascular aortic arch repair in zone 0 with PMEGs. Endpoints included technical success, 30 day mortality rate, major adverse events, secondary interventions, stent stability, target vessel patency, and overall survival.

RESULTS

A total of 54 patients (mean age 63 years; 45 males) with aortic arch pathology were included, comprising aortic dissections (n = 32; 59%) and aortic arch aneurysms (n = 22; 41%). Technical success was 98%. One patient died from stroke within 30 days. Major adverse events included stroke (n = 4; 7%), retrograde type A dissection (RTAD) (n = 3; 6%), and acute kidney injury (n = 2; 4%). During a median follow up of 12 months, there were two deaths (4%) of unknown cause at one month and 1.5 months, and no aortic related death. Type Ia, type Ic, and type IIIc endoleaks were observed in two (4%), three (6%), and two (4%) patients, respectively. No vessel stenosis was observed. Re-intervention was required in 10 patients (19%). Estimates of overall survival, freedom from secondary intervention, and freedom from target vessel instability at one year were 94.2% (standard error [SE] 3.3%), 81.8% (SE 6.0%), and 92.0% (SE 4.5%), respectively.

CONCLUSION

This study has demonstrated the efficacy of PMEGs for zone 0 endovascular aortic arch repair, with acceptable technical success and mortality rates. Stroke, RTAD, and re-intervention rates remain a concern for endovascular therapy. A larger population and long term outcomes are required to assess the safety and durability of this technique as a beneficial choice for endovascular aortic arch repair in specialised centres.

The Initial Results of Physician-Modified Fenestrated-Branched Endovascular Repairs of the Aortic Arch and Lessons Learned From the First 21 Cases

INTRODUCTION

Physician-modified fenestrated-branched endovascular aortic repair (PM-FBEVAR) for the aortic arch provides a minimally invasive treatment option for patients who are too high-risk for open repair. Improvements in technique are gained with ongoing experience with these complex repairs. This study aims to describe outcomes of arch PM-FBEVAR and technical lessons.

MATERIALS AND METHODS

A retrospective review of consecutive patients who underwent PM-FBEVAR with zone 0 proximal sealing at a single institution between January 2019 and July 2023 was performed. Cases completed using initial techniques (early technique) were compared with cases using the current techniques (current technique). Modification technique changed to include a self-orienting spine trigger wire and anatomically specific fenestrations or inner branches in the current group. The primary outcome was in-hospital mortality. Secondary outcomes included technical success and 30 day stroke.

RESULTS

A total of 21 patients underwent arch PM-FBEVAR, with 7 in the early group and 14 in the current group. Severe comorbidities were present in both groups including chronic obstructive pulmonary disease (COPD) (43% vs 36%), prior open ascending aortic repair (57% vs 43%), and prior stroke (86% vs 21%), respectively. Technical success was the same (86% vs 86%, p=1.0). Fluoroscopy time (56 vs 24 min, p=0.012) and in-hospital death (43% vs 0%, p=0.026) were significantly lower in the current group. A 30 day stroke rate (29% vs 7%, p=0.247) was non-significantly decreased in the current group. All-cause mortality was 100% vs 7% during median follow-up of 8 and 6 months (p<0.001). Three deaths in the early group were related to their aortic arch repair including aortic rupture during endograft advancement and 2 postoperative strokes.

CONCLUSION

There is a significant learning curve associated with aortic arch PM-FBEVAR. This study suggests that gained experience, use of the spine trigger wire technique, and precise creation of fenestrations or inner branches can lead to a shorter procedure time and lower complications.

CLINICAL IMPACT

Physician modified fenestrated branched endografting is feasible for the aortic arch. The high rate of stroke and perioperative mortality was reduced with incorporation of self-orienting spine trigger wire and anatomically specific inner branch creation.

The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch

Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.

Outcomes of Zone 1 Thoracic Endovascular Aortic Repair With Fenestrated Surgeon-Modified Stent-Graft for Aortic Arch Pathologies

OBJECTIVES

This study evaluated the feasibility and safety of zone 1 thoracic endovascular aortic repair (TEVAR) with fenestrated surgeon-modified stent-graft (SMSG) for aortic arch pathologies.

METHODS

Between March 2016 and November 2020, 34 consecutive patients underwent zone 1 TEVAR with fenestrated SMSG for aortic arch pathologies. Outcomes included technical success, perioperative, and follow-up morbidity and mortality.

RESULTS

During the study period, 34 patients were treated with zone 1 TEVAR with fenestrated SMSG. Twenty-four (70.6%) patients presented with type B aortic dissections, 9 (26.5%) patients presented with aneurysms (7 located on the lesser curvature side of aortic arch), 1 (2.9%) patient presented with type Ia endoleak after previous TEVAR owing to traumatic aortic dissection. The proximal landing zone for all patients were in zone 1, and all supra-aortic trunks were reconstructed, except for one left subclavian artery. Technical success was achieved in all cases. The 30-day estimated survival (±SE) was 90.9% ± 5.0% [95% confidence interval (CI): 77.0%-97.0%]. The 30-day estimated freedom from reintervention (±SE) was 87.9% ± 5.7% (95% CI: 73.4%-95.3%). At a median follow-up of 48 months (range, 12-68 months), 2 patients died, including 1 aortic-related death and 1 non-aortic-related death. One patient had reintervention 13 months after the operation owing to type Ia endoleak. All supra-aortic trunks were patent. The estimated survival (±SE) during follow-up was 85.1% ± 6.2% (95% CI: 69.9%-93.6%). One (2.7%) patient had stroke. The estimated freedom from reintervention (±SE) during follow-up was 84.2% ± 6.5% (95% CI: 69.9%-93.5%).

CONCLUSIONS

Zone 1 TEVAR with fenestrated SMSG is an alternate option for treatment of aortic arch pathologies in experienced centers.

Experience with the Ankura Thoracic Stent Graft and In-situ Fenestration for the Left Subclavian Artery with the Fu-Through Needle - a Technical Overview and Comparison to Similar Endovascular Techniques

Thoracic endovascular aortic repair (TEVAR) is a widespread minimally invasive procedure prevalently used to treat thoracic aortic pathologies. However, when the left subclavian artery (LSA) is involved in the pathology, a more complex surgical approach is required to guarantee the perfusion of the vertebral and brachial arteries. In fact, coverage of the LSA has been proven to be associated with a higher risk of stroke, spinal cord ischemia, and arm ischemia.Historically, carotid-subclavian bypass or subclavian transposition has been the only treatment options to restore the perfusion of the LSA. For the past 10 years, different endovascular techniques have been implemented in the endovascular armamentarium to reduce the risk of complications related to surgical treatment such as infection, bleeding, and chylothorax.Currently, physician-modified grafts, in situ fenestration, chimneys, and branched or fenestrated devices are available. The aim of this overview is to describe the technique with the Ankura thoracic stent graft and in situ fenestration with the Futhrough needle and thus to shed light on the different approaches by comparing their pros and cons.

Meta-analysis and meta-regression of the total endovascular aortic repair in aortic arch

Background: The total endovascular repair of the aortic arch is becoming more and more an acceptable alternative to the open repair in selected patients. The aim of the present study is to perform a meta-analysis of the available data on the outcomes of the various endovascular techniques used to treat the pathologies in this challenging anatomical area. Patients and methods: An extensive electronic search in PubMed/MEDLINE, Science Direct Databases, and the Cochrane Library was conducted. All papers published up to January 2022 on the endovascular techniques in the aortic arch (chimney-thoracic endovascular aortic repair (ChTEVAR), fenestrated/branched grafts as custom made devices (CMD) and surgeon modified TEVAR (SM TEVAR) providing information about at least one of the essential outcomes defined in the inclusion criteria. Results: Out of the 5078 studies found through the search in the databases and registers, 26 studies with a total number of patients of 2327 with 3497 target vessels were included in the analysis. The studies reported a high technical success rate with an estimated proportion of 95.8% (95% CI, 93-97.6%). Moreover, the pooled estimation of the early type Ia/III endoleak was 8.1% (95% CI, 5.4-12.1%). The pooled mortality was 4.6% (95 CI, 3.2-6.6%) with a significant heterogeneity and the stroke had an estimated proportion (major and minor combined) of 4.8% (95% CI, 3.5-6.6%). A meta-regression analysis showed no significant variation between the groups in mortality (P=.324) showed however a significant difference between the therapeutic methods regarding stroke P<.001 (lower rate in ChTEVAR and SM vs. CMD). Conclusions: The present meta-analysis could demonstrate good short- and long-term outcomes of the multiple total endovascular repair methods used in the aortic arch.

Management of an Isolated Left Vertebral Artery on the Arch During Zone 2 Landing Thoracic Endovascular Aortic Repair: A Multicentre Retrospective Study

OBJECTIVE

To compare the early and midterm outcomes of three different strategies for an isolated left vertebral artery on the arch (LVoA) revascularisation during thoracic endovascular aortic repair (TEVAR) with a proximal zone 2 landing.

METHODS

Between January 2016 and December 2021, 67 patients with LVoA and aortic arch pathologies who underwent zone 2 landing TEVAR at four medical centres were enrolled. These patients were divided into three groups for comparison: the novel chimney (group A, n = 28) with the right brachial-left brachial through and through (RLT) procedure; in vitro fenestration (group B, n = 24); and transposition (group C, n = 15). The flow direction and velocity of the LVoA was examined by Doppler ultrasound in the pre-, intra-, and post-operative periods. Primary outcomes were all cause mortality and new neurological symptoms.

RESULTS

No deaths or new neurological symptoms occurred within 30 days. Early type Ia endoleak rates were 18% (n = 5), 17% (n = 4), and 0% in groups A, B, and C, respectively (p = .22). All patients had antegrade flow of the LVoA. The mean ± standard deviation duration of follow up was 63.6 ± 4.0 months. No deaths were observed during follow up. The rates of new neurological symptoms were 0%, 8%, and 33% in groups A, B, and C, respectively. The rates of midterm type Ia endoleak were 7%, 12%, and 0% in groups A, B, and C, respectively (p = .35). Bidirectional flow rates in the LVoA were 0%, 21%, and 27% in groups A, B, and C, respectively (p = .021). Two (8%) and three (20%) patients in groups B and C underwent a secondary procedure because of mild dizziness, but this was not necessary in group A (p = .058).

CONCLUSION

The novel chimney technique of the RLT procedure may be feasible for patients with a LVoA requiring zone 2 anchoring. Accurate determination of the safety and feasibility of this novel technique requires larger sample sizes and longer follow up.

Outcomes of thoracic endovascular aortic repair with fenestrated surgeon-modified stent-graft for type B aortic dissections involving the aortic arch

Objectives

This retrospective analysis aimed to evaluate the early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) with fenestrated surgeon-modified stent-graft (f-SMSG) for type B aortic dissections (TBAD) involving the aortic arch.

Methods

From March 2016 to April 2021, 47 consecutive patients were treated using TEVAR with f-SMSG. All patients were diagnosed with TBAD involving the aortic arch.

Results

In total, 47 patients with TBAD involving the aortic arch were treated with f-SMSGs. There were 21 zone 1 and 26 zone 2 TEVAR, and 65 arteries were revascularized successfully with fenestrations. Technical success was achieved in 46 patients (97.88%). The 30-day estimated survival (± SE) and reintervention was 93.6 ± 1.0% (95% Confidence Interval [CI], 92.6-94.6%) and 91.5 ± 1.2% (95% CI, 90.3-92.7%), respectively. During a median follow-up of 51 months (range, 16-71 months), 1 patient died of rupture of aortic dissection (AD) and 3 patients died of non-aortic-related reasons. Reintervention was performed for four patients, including two patients of type IA entry flow and two patients of type IB entry flow. No occlusion of the supra-aortic trunk was observed. The estimated survival and reintervention (± SE) at 4 years was 88.7 ± 1.4% (95% CI, 87.3-90.1%) and 84.8 ± 1.5% (95% CI, 83.3-86.3%), respectively.

Conclusion

Thoracic endovascular aortic repair with f-SMSG is an alternative treatment option for TBAD involving the aortic arch in high-volume centers.

A systematic review and meta-analysis of thoracic endovascular aortic repair with the proximal landing zone 0

Background

Thoracic endovascular aortic repair, initially intended for thoracic aortic disease treatment, has extended its application to the proximal zone of the aorta. However, the safety and surgical outcomes of extending the proximal landing zone into the ascending aorta (zone 0) in selected cases remain unknown. Thus, we performed a systematic review and meta-analysis of zone 0 thoracic endovascular aortic repair (TEVAR) to obtain a deeper understanding of its safety, outcomes, and trends over time.

Methods

A literature search was performed using PubMed, EMBASE, and Web of Science databases in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines, from January, 1997 to January, 2022. Only studies involving zone 0 TEVAR were included. The retrieved data from the eligible studies included basic study characteristics, 30-day/in-hospital mortality rate, indications, comorbidities, stent grafts, techniques, and complications. Summary effect measures of the primary outcomes were obtained by logarithmically pooling the data with an inverse variance-weighted fixed-effects model.

Results

Fifty-three studies with 1,013 patients were eligible for analysis. The pooled 30-day/in-hospital mortality rate of zone 0 TEVAR was 7.49%. The rates of post-operative stroke, type Ia endoleak, retrograde type A aortic dissection, and spinal cord ischemia were 8.95, 9.01, 5.72, and 4.12%, respectively.

Conclusions

Although many novel stent grafts and techniques targeting zone 0 TEVAR are being investigated, a consensus on technique and device selection in zone 0 TEVAR is yet to be established in current practice. Furthermore, the post-operative stroke rate is relatively high, while other complication rates and perioperative death rate are comparable to those of TEVAR for other aortic zones.

Anatomical Feasibility Study on Novel Ascending Aortic Endograft With More Proximal Landing Zone for Treatment of Type A Aortic Dissection

Objective

Type A aortic dissection (TAAD) is associated with high morbidity and mortality, and open surgery is the best treatment option. Development of endovascular repair devices for TAAD will benefit patients deemed unfit for open surgery. In this study, we performed a thorough investigation of anatomical features in Asian patients with TAAD to learn about the patient eligibility of a novel ascending aortic endograft technique.

Methods

Computed tomography angiography (CTA) images of TAAD cases in our institution from January 2015 to November 2021 were reviewed, and three-dimensional reconstructions were performed with the Endosize software (Therenva, Rennes, France). Anatomic structures including length measured along centerline and greater/lesser curvature, ascending aorta/aortic root dimensions, as well as location of entry tear and extent of dissection were analyzed.

Results

A total of 158 patients were included [median age 58 years, interquartile range (IQR), 30–76 years; 115 males, 72.8%]. In 99 (62.7%) of the cases, entry tear was distal to the sinotubular junction (STJ). In 106 (67.1%) of the cases, the pathology proximally extended into the aortic root, which was intramural hematoma in 37 (23.4%) of the cases, and the aortic root was free from the pathology in 52 (32.9%) of the cases. The median distance from the STJ to the proximal edge of the ostium of the innominate artery (IA) measured along the centerline was 65 mm (IQR 58–74 mm). The median distance from the distal edge of the higher coronary ostium to the STJ was 7.95 mm (IQR 5.625–10.9 mm). The bare metal stent part was set between the edge of the higher coronary ostium and the STJ. In our series, 63 (39.9%) of the cases had this distance >10 mm. The relative difference was <20% between the STJ and the proximal edge of the ostium of the IA in 92 (58.2%) of the cases. Ascending aorta radius of curvature was 52.2 mm (IQR 43.7–63.7 mm).

Conclusions

Our study demonstrates that 56.3% of the TAAD cases would be amenable to endovascular repair by the novel ascending aortic endograft, with sufficient landing zone free of the dissected aorta.