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Nana P, Spanos K, Panuccio G, Rohlffs F, Detter C, von Kodolitsch Y, Torrealba JI, Kölbel T. Branched and fenestrated endovascular aortic arch repair in patients with native proximal aortic landing zone. J Vasc Surg 2024; 80:621-629.e3. [PMID: 38580160 DOI: 10.1016/j.jvs.2024.03.444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/15/2024] [Accepted: 03/28/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Fenestrated and branched thoracic endovascular repair (f/bTEVAR) have been successfully applied in patients with diverse aortic arch pathologies. The aim of this study is to present the early and mid-term outcomes of patients with native proximal aortic landing (NPAL) managed with f/bTEVAR. METHODS A single-center retrospective analysis of patients with NPAL, managed with f/bTEVAR, between September 1, 2011, and June 30, 2022, was conducted. All patients were treated with custom-made devices (Cook Medical) with landing within Ishimaru zones 0 to 2. Primary outcomes were technical success, mortality, stroke, and retrograde type A dissection at 30 days. Follow-up outcomes were considered secondary. RESULTS A total of 126 patients were included (69.8% males; mean age, 70.8 ± 4.2 years; 18.3% urgent). The main indications (60.4%) for repair were aortic arch (29.4%) and thoracoabdominal aortic aneurysms (31.0%). Seventy-two patients (57.1%) were managed with fTEVAR. Proximal landing in zone 0 and 1 was chosen in 97.6%. Technical success was 94.4%, and 30-day mortality was 11.9%. Strokes were diagnosed in 13.5% of patients and major strokes were identified in 7.9% cases. Retrograde type A dissection rate was 3.9%. The multivariate analysis confirmed landing in Ishimaru zone 0 as an independently related factor for stroke (P = .005), whereas stroke (P < .001), pericardial effusion (P < .001), and acute kidney injury (P < .001) were independently related to 30-day mortality. Mean follow-up was 17.5 ± 9.3 months. The estimated survival rate and the freedom from reintervention rate were 72.6% (standard error, 4.4%) and 46.4% (standard error, 6.0%) at 24-month follow-up, respectively. CONCLUSIONS Stroke rate after endovascular arch repair was alarming among patients with NPAL. Proximal landing to zone 0 was related to higher risk of stroke. Reinterventions were common within the 24-month follow-up.
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Affiliation(s)
- Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany.
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Christian Detter
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - José I Torrealba
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE, Hamburg, Germany
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Rossi MJ, Ilyas S, Abramowitz SD, De Freitas S, Hockstein MA, Maloni KC, Shults C, Fatima J. A Scoping Review of Definitions of Success in Endovascular Aortic Arch Repair. J Endovasc Ther 2024:15266028241271679. [PMID: 39148208 DOI: 10.1177/15266028241271679] [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: 08/17/2024]
Abstract
INTRODUCTION The present standard of care to treat aortic arch pathologies is open surgical repair with cardiopulmonary bypass and deep hypothermic arrest. With approaches for total endovascular and extra-anatomic cervical debranching hybrid arch repair becoming more diverse, understanding what is considered a successful operation is prerequisite for a rigorous comparison of techniques. This review describes the specific outcomes reported, the rates of success, and the definitions of technical and clinical success in total endovascular and extra-anatomic cervical debranching hybrid aortic arch repair. METHODS A comprehensive search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was performed. Studies with patients undergoing total endovascular or hybrid extra-anatomic cervical debranching repair of the aortic arch were included. Any publications including only patients with Ishimaru zone 2 or distal repairs were excluded from this review. Studies with less than 5 patients were excluded. Data extraction was performed by one author. Data items included were study design, procedure type, procedural details, underlying pathology, type of cervical debranching, type of endograft repair, surgical outcomes, definition of cerebrovascular events, technical success, and the definition of technical success. RESULTS Of 1754 studies screened for review, 85 studies with 5521 patients were included. By frequency, the included studies examined the following interventions: fenestrated devices, branched devices, parallel grafting. Most studies were retrospective single-institution studies. There were no randomized controlled trials. Short-term mortality and cerebrovascular events were nearly universally reported, present in 99% and 95% of studies reviewed, respectively. Only 27% of studies provided an explicit definition for cerebrovascular events. While 75% of studies reported a technical success rate, only 45% of those studies provided explicit criteria. Clinical success rates were infrequently reported, present in only 5.9% of studies reviewed. CONCLUSION The definitions of technical success that were provided fell short of analogous defined reporting standards in nearly all studies, inflating technical success rates. Definitions of cerebrovascular events and technical success require stringent criteria to uniformly compare various methods of endovascular aortic arch repair. A societal consensus document for reporting standards of endovascular aortic arch repair would allow for higher-quality outcomes research. CLINICAL IMPACT Total endovascular and extra-anatomic cervical debranching hybrid operations are being increasingly utilized for complex aortic arch repair. These techniques, however, can be associated with serious complications. Currently, there is no accepted metric to define technical or report clinical outcomes. Due to the paucity of high-quality data, use of these approaches may be limited in clinical practice. This study emphasizes the need for the development of standards for reporting outcomes in endovascular aortic arch repair. Future studies can then utilize these benchmarks, whcih will allow for improved efficacy and safety in these techniques.
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Affiliation(s)
- Matthew J Rossi
- Vascular Surgery Integrated Residency Program, MedStar Health, Washington, DC, USA
| | - Sadia Ilyas
- Department of Vascular Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Steven D Abramowitz
- Department of Vascular Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Simon De Freitas
- West Palm Beach Veteran's Affairs Hospital, West Palm Beach, FL, USA
| | - Maxwell A Hockstein
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Krystal C Maloni
- Department of Vascular Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Christian Shults
- Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Javairiah Fatima
- Department of Vascular Surgery, MedStar Washington Hospital Center, Washington, DC, USA
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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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Nana P, Panuccio G, Torrealba JI, Rohlffs F, Spanos K, Kölbel T. Sex Comparative Analysis of Branched and Fenestrated Endovascular Aortic Arch Repair Outcomes. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00366-6. [PMID: 38677467 DOI: 10.1016/j.ejvs.2024.04.030] [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: 11/16/2023] [Revised: 02/15/2024] [Accepted: 04/21/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE Female sex is a risk factor for adverse events after endovascular aortic repair. Sex comparative early and midterm outcomes of fenestrated and branched endovascular aortic arch repair (F/B-Arch) are presented. METHODS A single centre retrospective sex comparative analysis of consecutive patients managed with F/B-Arch was conducted according to STROBE. Primary outcomes were sex comparative technical success, death, and cerebrovascular morbidity at 30 days. Kaplan-Meier estimates were used for follow up outcomes. RESULTS Among 209 patients, 38.3% were women. Coronary artery disease (p < .001) and previous myocardial infarction (p = .001) were more common in women. Non-native proximal aortic landing was higher in women (women: 51.3%; men: 31.8%, p = .005) and the aortic dissection rate was lower (28.8% vs. 48.1%, p = .005). Proximal landing to Ishimaru zones showed no difference (zone 0: p = .18; zone 1: p = .47; zone 2: p = .39). Graft configurations were equally distributed. In total, 416 supra-aortic trunks were bridged. The median number of revascularisations per patient was two (interquartile range 1, 3), with no difference between sexes (p = .54). Technical success (women: 97.5%; men: 96.9%, p = .80), 30 day mortality rate (women: 10%; men: 9.3%, p = .86), and cerebrovascular morbidity (women: 11.3%; men: 17.1%, p = .25) were similar. Women presented more access related complications (women: 32.5%; men: 16.3%, p = .006), without affecting access related re-interventions (p = .55). Survival (women: 81.1%, 95% confidence interval [CI] 76.3 - 85.9%; men: 79.8%, 95% CI 76.0 - 83.6%) and freedom from re-intervention (women: 56.6%, 95% CI 50.4 - 62.8%; men: 55.3%, 95% CI 50.1 - 60.5%) at 12 months were similar (log rank, p = .40 and p = .41, respectively). CONCLUSION Both sexes presented similar outcomes after F/B-Arch. Appropriate patient selection may decrease the effect of sex in F/B-Arch outcomes.
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Affiliation(s)
- Petroula Nana
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany.
| | - Giuseppe Panuccio
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - José I Torrealba
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
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Nana P, Panuccio G, Rohlffs F, Spanos K, Torrealba JI, Kölbel T. Target Vessel-Related Outcomes in Patients Managed With Branch Thoracic Aortic Endovascular Repair. J Endovasc Ther 2024:15266028241231905. [PMID: 38380515 DOI: 10.1177/15266028241231905] [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: 02/22/2024]
Abstract
INTRODUCTION Data on target vessel (TV)-related outcomes in patients managed with branched thoracic endovascular aortic repair (BTEVAR) are limited. This study aimed to present the TV-related outcomes of BTEVAR in patients managed for aortic arch pathologies at 30 days and during follow-up. METHODS A retrospective analysis of consecutive patients, managed between September 1, 2011, and June 30, 2022, with custom-made aortic arch endografts (Cook Medical, Bloomington, IN, USA), presenting at least one branch configuration, were eligible. Primary outcomes were technical success, TV-related patency, and reinterventions at 30 days. RESULTS In total, 255 TVs were revascularized using branches: 107 innominate arteries (IAs), 108 left common carotid arteries (LCCAs), and 40 left subclavian arteries (LSAs). Covered stents were used as bridging stents of which 10.2% were balloon expandable. Relining, using bare-metal stents (BMS), was performed in 14.0% of IAs, 35.2% of LCCAs, and 22.5% of LSAs. Technical success on case basis was 99.2%; no failure was related to unsuccessful TV bridging. At 30 day follow-up, no TV occlusion was detected. In 5.6% of cases, a type Ic or III endoleak, attributed to TVs, was recorded. Two patients needed early branch-related reintervention. The mean follow-up was 18.3±9.2 months. Freedom from TV instability was 94.6% (standard error [SE] 2.5%] at 12 months. No TV stenosis or occlusion was detected up to 48 months of follow-up. Freedom from TV-related reinterventions was 95.4% [SE 2.4%] at 12 months. CONCLUSION TV stenosis or occlusion in BTEVAR cases is rare and TV-related reinterventions and instability events are mainly attributed to type Ic and III endoleak formation. CLINICAL IMPACT Previous studies focusing on target vessel (TV) outcomes after endovascular aortic arch repair are limited. In this study, including 255 TVs revascularized using branched arch devices, bridging was performed with covered stents, of which 90% were self-expanding. Relining was at the discretion of the operator and was 14% for the innominate, 35.2% for the left common carotid and 22.5% for the left subclavian artery branches. No 30-day occlusion was detected. The freedom from TV instability was almost 95% at 12 months. TV instability and reintervention were mainly attributed to endoleaks type Ic and IIIc.
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Affiliation(s)
- Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, UKE Hamburg, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, UKE Hamburg, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, UKE Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, UKE Hamburg, Hamburg, Germany
| | - Jose I Torrealba
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, UKE Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, UKE Hamburg, Hamburg, Germany
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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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