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Bacri C, Hireche K, Alric P, Canaud L. Total aortic arch repair with double-fenestrated physician-modified endografts, at least 3-year follow-up. J Vasc Surg 2024; 80:344-354. [PMID: 38552884 DOI: 10.1016/j.jvs.2024.03.029] [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: 01/19/2024] [Revised: 02/21/2024] [Accepted: 03/11/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE This study aims to report the efficacy and safety of double-fenestrated physician-modified endovascular grafts (PMEGs) for total aortic arch repair with at least 3 years of follow-up. METHODS All consecutive patients with a pathological aortic arch who underwent aortic arch repair combined with a homemade double-fenestrated stent graft from 2017 to 2020 were reviewed. RESULTS 74 patients were treated for pathological arch conditions with a double-fenestrated PMEG. Of these, 81% were male, the mean age was 69.9 years, and 59% were classified as American Society of Anesthesiology 3 or 4. Thirty-five percent were treated for a postdissection aneurysm, 36% for a degenerative aneurysm, and 14% for acute type B dissection. Fifteen percent had supra-aortic trunk dissection. Fenestration on the subclavian artery was performed in 96%; if not, a carotid-subclavian bypass was carried out. Technical success was 100%. The proximal landing zone is consistently in zone 0. Early outcomes revealed a 3% occurrence of type 1 endoleak, which was successfully treated by prompt reintervention. One retrograde dissection occurred, and one patient died from hemorrhage on an iliac conduit. A 5% stroke rate was reported. During long-term follow-up (mean time 40.7 months), one type 1 endoleak appeared and was successfully treated; no type 2 or type 3 endoleak requiring intervention occurred. No stent fractures or migrations were reported. Four percent of patients required reintervention, but no surgical conversion to open surgical repair was needed on the aortic arch. No patient died from a cause related to the main procedure. CONCLUSIONS Total aortic arch repair with double-fenestrated PMEGs is associated with acceptable early and midterm major morbidity and mortality. It is suitable for the main aortic pathologies. Moreover, it is easily available for emergency situations.
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Affiliation(s)
- Christoph Bacri
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Kheira Hireche
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Ludovic Canaud
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France.
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Pinheiro Ribeiro Alves A, da Costa Cettolin Q, Dos Santos Domingues G, Dos Santos HÁG, Sampaio RC, Aquino MDA. Results of the in situ fenestration technique for preservation of the Left subclavian artery in the endovascular repair of acute aortic syndromes in a reference center. Vascular 2024; 32:490-498. [PMID: 36750245 DOI: 10.1177/17085381231155959] [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] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The in situ fenestration (ISF) technique consists of maintaining the patency of the aortic branch after the endoprosthesis is already in place as a viable, effective, and fast-performing alternative to revascularize the aortic arch arteries. OBJECTIVE To report the experience with a series of cases of endovascular treatment of Acute Aortic Syndromes involving the aortic arch, using the ISF technique in a specialized center. METHODS We analyzed data collected from patients treated with ISF during TEVAR for Acute Aortic Syndromes involving the aortic arch from June 2020 to January 2022, assessing perioperative outcomes, including immediate and late success rates, complications, morbidity and mortality, and short and medium term aortic branch patency. RESULTS Of the 11 patients eligible for the ISF procedure, 9 were successful, with a technical success rate of 81%. No patient had a type 1A endoleak related to fenestration. There was complete thrombosis of the false lumen in the thoracic aorta in 77% cases. No death was related to the fenestration technique. CONCLUSION ISF as feasible and with a high rate of technical success and good results in the short and medium term. Prospective studies with long-term clinical follow-up are still needed to fully assess the durability of these unreinforced fenestrations.
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Affiliation(s)
- André Pinheiro Ribeiro Alves
- Departamento de Hemodinâmica, Hospital Geral Roberto Santos, Serviço de Angiorradiologia e Cirurgia Endovascular, Salvador, Brazil
| | - Queise da Costa Cettolin
- Departamento de Hemodinâmica, Hospital Geral Roberto Santos, Serviço de Angiorradiologia e Cirurgia Endovascular, Salvador, Brazil
| | - Gustavo Dos Santos Domingues
- Departamento de Hemodinâmica, Hospital Geral Roberto Santos, Serviço de Angiorradiologia e Cirurgia Endovascular, Salvador, Brazil
| | | | - Renata Caires Sampaio
- Departamento de Hemodinâmica, Hospital Geral Roberto Santos, Serviço de Angiorradiologia e Cirurgia Endovascular, Salvador, Brazil
| | - Mauricio de Amorim Aquino
- Departamento de Hemodinâmica, Hospital Geral Roberto Santos, Serviço de Angiorradiologia e Cirurgia Endovascular, Salvador, Brazil
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Antonello M, Spertino A, Rodinò G, Tarantini G. Emergent In Situ Fenestration in the Ascending Aorta for the Endovascular Repair of a Large Pseudoaneurysm: A Technical Note. J Endovasc Ther 2024; 31:366-370. [PMID: 36214426 DOI: 10.1177/15266028221125587] [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] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this article is to describe an emergent in situ fenestration (ISF) technique in the ascending aorta for the endovascular repair of a large pseudoaneurysm using a trans-septal needle device through direct right common carotid artery access, in a patient with left ventricular assist device (LVAD). TECHNIQUE We performed, in a multidisciplinary team-work approach, an emergent ISF to correct the displacement of a physician-modified thoracic endograft released in the ascending aorta to correct a large anastomotic pseudoaneurysm in a patient who underwent ascending aorta replacement and subsequent LVAD implantation. We used a trans-septal needle device inserted through a direct access to the right carotid artery and performed an ISF to restore the patency of the outflow ostium of the LVAD. Window was then completed and stabilized with a nitinol balloon expandable covered stent graft obtaining an effective exclusion of the anastomotic aortic aneurism and the regular patency of the LVAD outflow graft with no signs of leaks. CONCLUSIONS Multidisciplinary teamwork approach can be crucial in challenging procedures where an alternative approach may lead to problem solving. The ISF technique may be a valid option to adopt in emergency cases in which no other technical solutions are suitable. CLINICAL IMPACT The endovascular approach has become more and more frequent for the treatment of vascular pathologies, getting increasingly refined and complex. Thereby the chance of incurring intraprocedural troubles has grown and bailout strategies should always be present. In situ fenestration is a technique to be aware of and that could help you recover from difficult situations. We report a possible rescue maneuver that can be applied also in arduous anatomies such as the ascending aorta. Moreover, we would like to highlight the importance of a multidisciplinary working environment that can enrich our everyday practice accomplishing effective and unexpected solutions.
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Affiliation(s)
- Michele Antonello
- Vascular and Endovascular Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Andrea Spertino
- Vascular and Endovascular Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulio Rodinò
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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DiBartolomeo AD, Kazerounim K, Fleischman F, Han SM. The Initial Results of Physician-Modified Fenestrated-Branched Endovascular Repairs of the Aortic Arch and Lessons Learned From the First 21 Cases. J Endovasc Ther 2024:15266028241255539. [PMID: 38778636 DOI: 10.1177/15266028241255539] [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: 05/25/2024]
Abstract
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.
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Affiliation(s)
- Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Kayvan Kazerounim
- Division of Cardiothoracic Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Fernando Fleischman
- Division of Cardiothoracic Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
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Ren J, Chen Y, E E, Ma M, Liu Z, Zhu J, Wang S, Bi J, Li P, Dai X. Midterm Outcomes of Multicenter Castor Single-Branch Stent Graft Use in the Treatment of Thoracic Aortic Diseases. J Endovasc Ther 2024:15266028241234500. [PMID: 38414233 DOI: 10.1177/15266028241234500] [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: 02/29/2024]
Abstract
PURPOSE The aim of this study was to evaluate the midterm efficacy and safety of a single-branch Castor stent graft in the treatment of thoracic aortic disease. MATERIALS AND METHODS Clinical data of 106 patients with thoracic aortic disease treated with Castor single-branch stent graft at 3 centers were collected between May 2018 and June 2023. The indicators included technical success, stent-related complication, reintervention, retrograde dissection, endoleak, distal stent graft-induced entry (dSINE), branch patency, and mortality. The outcomes of the Castor stent graft for multibranch reconstruction above the arch was also analyzed. RESULTS The technical success was 98.1% (104/106), while the surgical success was 93.4% (99/106). The reintervention was 2.8% (3/106), consisting of a case of retrograde type A dissection, an endoleak, and a dSINE. The retrograde dissection was 1.9% (2/106), while type I endoleak was 1.9% (2/106). The new dSINE was 2.8% (3/106), and the branch patency rate was 100%. The mortality was 1.9% (2/106). The mean follow-up time was 29.1±17.7 months. The 2-year post-surgery cumulative survival rate was 91.0%±3.1%, while the cumulative branch patency rate was 96.2%±2.2%. In addition, the cumulative freedom from stent-related reintervention rate was 93.2%±2.8%. A comparison showed no significant difference in the stent-related complication, branch patency, endoleak, reintervention, and mortality when the proximal end of the Castor stent graft was anchored to zones 1 or 2 of the aorta. CONCLUSION Castor single-branch stent graft showed favorable early and midterm outcomes in the treatment of thoracic aortic disease. In addition, it was feasible to combine Castor stent graft with other advanced techniques for multibranch aortic arch reconstruction. CLINICAL IMPACT The Castor single-branch stent graft was approval by the Chinese Food and Drug Administration in 2017. However, there were few studies on the mid-term outcomes for thoracic aortic disease after launching, which mainly focused on small single-center retrospective study. In the study, we assessed the mid-term outcomes of Castor stent graft through multi-center cases, Castor stent graft combined with other advanced techniques (such as fenestration and hybrid) for multi-branch reconstruction of aortic arch were also conducted. We found Castor single-branch stent graft showed favorable early and mid-term outcomes in the treatment of thoracic aortic disease. Additionally, it was feasible to combine Castor stent graft with other advanced technique for multi-branch aortic arch reconstruction. As an off-the-shelf branched stent graft with a wide range of models, it could be also used in most emergent situation. The Castor stent graft was expected to become more widely used in the future.
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Affiliation(s)
- Jianli Ren
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Cardiovascular Surgery, Yan'an University Affiliated Hospital, Yan'an, China
| | - Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Erdemutu E
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Vascular Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Ming Ma
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Vascular Surgery, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Zongwei Liu
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiechang Zhu
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Shuaishuai Wang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiaxue Bi
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Peng Li
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiangchen Dai
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
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Nana P, Le Houérou T, Rockley M, Guihaire J, Gaudin A, Costanzo A, Fabre D, Haulon S. Early and Midterm Outcomes of Endovascular Aortic Arch Repair Using In Situ Laser Fenestration. J Endovasc Ther 2024:15266028241234497. [PMID: 38409773 DOI: 10.1177/15266028241234497] [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: 02/28/2024]
Abstract
INTRODUCTION The aim of this study is to present single-center outcomes in patients treated with in situ laser fenestration thoracic endovascular aortic repair (LFTEVAR) for various aortic arch pathologies and assess the impact of increasing experience. METHODS The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement was followed. A retrospective analysis of prospectively collected single aortic center data was conducted, including baseline information and peri- and post-operative outcomes of consecutive patients managed with LFTEVAR for aortic arch pathologies. Patients were enrolled from April 1, 2017 to January 31, 2023. The cohort was dichotomized to compare early (2017-2019) and late experience (2020-2023). Primary outcomes were peri-operative mortality and cerebrovascular morbidity. RESULTS Thirty patients were included (63.3% males, mean age 69.8±9.6 years); 21.4% presented with aortic ruptures. Aortic aneurysm involving the aortic arch was the most frequent pathology (53.3%). Forty target vessels (TVs) were revascularized, including 19 left subclavian arteries (47.5%) and 17 left common carotid arteries (42.5%). Double fenestrations were performed in 10 patients. The proximal landing zone was Ishimaru zone 0 in 5 patients (16.7%) and zone 1 in 13 patients (43.3%). Technical success was 93%. No spinal cord ischemia was recorded, and 3 patients (10%) suffered a post-operative stroke, of which 1 was major (3.3%). The median follow-up was 12 months (range=1-48 months). Thirty-day and follow-up mortality rates were 13.5% and 15.3%, respectively. Target vessel instability was 10%, of which 3.8% required reintervention. There was no statistically significant difference in outcomes between the early and late experience groups. CONCLUSIONS Laser fenestration thoracic endovascular aortic repair of the aortic arch performed in experienced aortic centers is associated with low early mortality and stroke rates. It is a safe and effective therapeutic option in patients considered unfit for open repair. CLINICAL IMPACT Custom-made devices for arch pathologies requiring urgent repair are not an option because of manufacturing delays. Off-the-shelf devices with single branch arch prostheses, and outside IFU techniques such as parallel-grafts and surgeon-modified endografts have been proposed in this setting. Another off-the-shelf alternative is in situ laser fenestration thoracic endovascular repair (LFTEVAR), which addresses many limitations of the other off-the-shelf options. Our study reports the outcomes of 30 patients treated with LFTEVAR, showing that it is a viable therapeutic option in patients considered unfit for open repair acknowledging that sufficient experience with complex endovascular aortic repair is mandatory to achieve acceptable outcomes in these high-risk patients with challenging aortic anatomies.
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Affiliation(s)
- Petroula Nana
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Thomas Le Houérou
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Mark Rockley
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Julien Guihaire
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Antoine Gaudin
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Alessandro Costanzo
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
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Piffaretti G, Franchin M, Gnesutta A, Gatta T, Piacentino F, Rivolta N, Lomazzi C, Bissacco D, Fontana F, Trimarchi S. Anatomic Feasibility of In-Situ Fenestration for Isolate Left Subclavian Artery Preservation during Thoracic Endovascular Aortic Repair Using an Adjustable Needle Puncturing System. J Clin Med 2023; 13:162. [PMID: 38202169 PMCID: PMC10779778 DOI: 10.3390/jcm13010162] [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: 10/24/2023] [Revised: 12/14/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
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.
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Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery—Department of Medicine and Surgery, University of Insubria School of Medicine, 21100 Varese, Italy; (M.F.); (N.R.)
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Marco Franchin
- Vascular Surgery—Department of Medicine and Surgery, University of Insubria School of Medicine, 21100 Varese, Italy; (M.F.); (N.R.)
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Aroa Gnesutta
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Tonia Gatta
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Filippo Piacentino
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
- Interventional Radiology—Department of Medicine and Surgery, University of Insubria School of Medicine, ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Nicola Rivolta
- Vascular Surgery—Department of Medicine and Surgery, University of Insubria School of Medicine, 21100 Varese, Italy; (M.F.); (N.R.)
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Chiara Lomazzi
- Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy (S.T.)
| | - Daniele Bissacco
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Federico Fontana
- ASST Settelaghi University Teaching Hospital, 21100 Varese, Italy
| | - Santi Trimarchi
- Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy (S.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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Bacri C, Ata Ozdemir B, Hireche K, Alric P, Canaud L. Zone 2 Aortic Arch Repair With Single-Fenestrated Physician-Modified Endografts, at Least 3 Years of Follow-up. J Endovasc Ther 2023:15266028231215779. [PMID: 38049943 DOI: 10.1177/15266028231215779] [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: 12/06/2023]
Abstract
OBJECTIVE The aim of this study is to report the efficiency and safety of single-fenestrated physician-modified endografts (PMEGs) in zone 2 aortic arch pathologies with at least 3 years of follow-up. METHODS All consecutive patients with a pathological aortic arch who underwent aortic repair combined with homemade single-fenestrated stent-graft from 2015 to 2020 were reviewed. The patients with a target vessel different from the left subclavian artery (LSA) were excluded. RESULTS A total of 63 patients were treated for a pathological arch in zone 2 with a single-fenestrated PMEG. 73% were male, and the mean age was 65 years old. 25% were treated for a degenerative aneurysm, 19% for a post dissection aneurysm and 24% for an acute type B dissection. 52% of the patients were treated as an emergency and half of those for an aortic rupture. The LSA fenestration was stented in 70%. During 30 days of follow-up, 2 strokes (3%) were reported, 6 patients (10%) died with 4 of those treated for aortic rupture and 1 had a retrograde aortic dissection. During at least 3 years of follow-up (median 49 months), no reintervention was needed for endoleaks, there was no stent fracture or stent migration. No patient died from an aortic cause. Subgroup analysis comparing the endovascular treatment for various aortic pathologies did not find significant differences in death rate or comorbidity including stroke. When comparing emergent and elective aortic repair, operating time was similar (64 vs 65 minutes), and the LSA fenestration was less frequently stented (52%) in the emergency group. There was no difference in stroke frequency. There was a higher rate of death in the emergency group at 30 days of follow-up, but no patient died from aortic cause in the long-term follow-up. CONCLUSIONS Aortic arch repair with single-fenestrated PMEGs for zone 2 pathological arch disease is associated with acceptable early and midterm major morbidity and mortality. It is suitable for emergency situations. CLINICAL IMPACT Single-fenestrated PMEG for the left subclavian artery is a safe and efficient option in the short and medium term for the treatment of the aortic arch in zone 2 with 98% technical success. It allows for aortic repair and subclavian artery revascularization in a single step for all patients. It is suitable for a range of main pathologies, including degenerative, dissection-related, isthmus rupture, and embolic pathologies. Additionally, it is always available and easily utilized in emergency cases.
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Affiliation(s)
- Christoph Bacri
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Vascular Surgery, North Bristol National Health Service Trust, University of Bristol, Bristol, UK
| | - Kheira Hireche
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, University Hospital of Montpellier, Montpellier, France
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, University Hospital of Montpellier, Montpellier, France
| | - Ludovic Canaud
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- Physiology and Experimental Medicine of the Heart and Muscles, University of Montpellier, CNRS, INSERM, University Hospital of Montpellier, Montpellier, France
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DiBartolomeo AD, Ding L, Weaver FA, Han SM, Magee GA. Risk of Stroke with Thoracic Endovascular Aortic Repair of the Aortic Arch. Ann Vasc Surg 2023; 97:37-48. [PMID: 37121336 DOI: 10.1016/j.avsg.2023.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) involving the aortic arch is increasingly being performed and novel endografts have been developed for this procedure, but the association of stroke and relative risk of procedural techniques remains unclear. This study evaluates the procedural risk factors for stroke and mortality with zone 0-2 TEVAR. METHODS The Society for Vascular Surgery Vascular Quality Initiative registry was queried for patients who underwent TEVAR with proximal landing in zone 0-2 from 2013 to 2022. Emergent and ruptured cases were excluded. Primary exposure variables included proximal seal zone (0-2) and branch vessel revascularization technique: open debranching/bypass, total endovascular incorporation, or combination (at least 1 branch open and 1 branch endovascular). The primary outcome was perioperative inhospital stroke and the secondary outcome was inhospital mortality. Univariable and multivariable regression analyses were performed. RESULTS In total, 4,355 cases were analyzed with 350 in zone 0 (8%), 513 in zone 1 (12%), and 3,492 in zone 2 (80%). For zone 0, 1, and 2, the stroke rates were 11.1%, 5.3% and 4.7% (P < 0.0001) and inhospital mortality rates were 6.9%, 5.3% and 3.5% (P = 0.002), respectively. Branch vessel revascularization technique was associated with stroke in zone 0 with a 3-fold higher stroke rate for total endovascular incorporation of branches compared to combination and open techniques (P = 0.002). On multivariable analysis, zone 0 was independently associated with a greater than 2-fold increased odds of stroke compared to zone 2 (95% CI 1.4-3.2, P = 0.0008). CONCLUSIONS Stroke rate was 2-3 times higher for zone 0 TEVAR compared to zones 1 and 2. Within zone 0, total endovascular branch incorporation was associated with a 3-fold higher stroke rate than open and combination techniques. Future device design modifications and novel endovascular strategies for stroke prevention are required to make total endovascular repair of the aortic arch an acceptable alternative to combination and open debranching/bypass techniques.
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Affiliation(s)
- Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Li Ding
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA.
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10
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da Silva MLF, de Freitas Gonçalves S, Costa MCB, Huebner R, Navarro TP. Structural numerical analysis of a branched modular stent-graft for aneurysms encompassing all zones of the aortic arch. J Mech Behav Biomed Mater 2023; 147:106135. [PMID: 37769370 DOI: 10.1016/j.jmbbm.2023.106135] [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: 07/06/2023] [Revised: 09/16/2023] [Accepted: 09/18/2023] [Indexed: 09/30/2023]
Abstract
The development of stent-grafts for the total repair of aneurysms in the aortic arch is still a technical challenge due mainly to the anatomical complexity of this region. Research performed here structurally evaluated a modular branched stent-graft for aneurysms encompassing all zones of the aortic arch by means of numerical simulations using fluid-structure interaction. The geometric domain obtained by means of computed tomography was subjected to physiological boundary conditions. The blood was modelled as non-Newtonian by the Carreau model, and the arterial wall was modelled as anisotropic hyperelastic by the Holzapfel model. The material adopted for the stents was Nitinol, and expanded polytetrafluoroethylene (ePTFE) was used for the graft. A comparison of the structural behaviour of the aneurysmal aortic arch before and after stent-graft implantation was performed. The numerical flow model was experimentally verified in vitro on a representative test bench of blood flow in the aortic arch. The stent-graft was shown to minimally modify arterial wall dynamics and was not susceptible to migration and endoleak. Peak stresses and strains were found in the stents and graft, respectively, while the stresses in the aneurysm sac were significantly reduced, of the order of 97.5%, due to the isolation of the arterial wall by the stent-graft.
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Affiliation(s)
- Mário Luis Ferreira da Silva
- Graduate Programme in Mechanical Engineering, Department of Mechanical Engineering, Universidade Federal de Minas Gerais, Avenida Presidente Antônio Carlos, 6627, 31270-901 Pampulha, Belo Horizonte, Minas Gerais, Brazil.
| | - Saulo de Freitas Gonçalves
- Graduate Programme in Mechanical Engineering, Department of Mechanical Engineering, Universidade Federal de Minas Gerais, Avenida Presidente Antônio Carlos, 6627, 31270-901 Pampulha, Belo Horizonte, Minas Gerais, Brazil.
| | - Matheus Carvalho Barbosa Costa
- Graduate Programme in Mechanical Engineering, Department of Mechanical Engineering, Universidade Federal de Minas Gerais, Avenida Presidente Antônio Carlos, 6627, 31270-901 Pampulha, Belo Horizonte, Minas Gerais, Brazil.
| | - Rudolf Huebner
- Department of Mechanical Engineering, Universidade Federal de Minas Gerais, Avenida Presidente Antônio Carlos, 6627, 31270-901 Pampulha, Belo Horizonte, Minas Gerais, Brazil.
| | - Túlio Pinho Navarro
- Faculty of Medicine, Department of Surgery, Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190, 30130-100 Santa Efigênia, Belo Horizonte, Minas Gerais, Brazil.
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11
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Qiu C, Li Z, Dai X, Lu X, Lu Q, Li X, Zhou W, Guo P, Pan J, Li D, Wu Z, Zhang H. Technical details of thoracic endovascular aortic repair with fenestrations for thoracic aortic pathologies involving the aortic arch: A Chinese expert consensus. Front Cardiovasc Med 2022; 9:1056229. [PMID: 36606283 PMCID: PMC9807668 DOI: 10.3389/fcvm.2022.1056229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/18/2022] [Indexed: 12/24/2022] Open
Abstract
Thoracic aortic pathologies involving the aortic arch are a great challenge for vascular surgeons. Maintaining the patency of supra-aortic branches while excluding the aortic lesion remains difficult. Thoracic EndoVascular Aortic Repair (TEVAR) with fenestrations provides a feasible and effective approach for this type of disease. The devices needed in the procedure are off-the-shelf, with promising results reported in many medical centers. Up until now, there have been no guidelines focusing exclusively on the details of the TEVAR technique with fenestrations. Experts from China have discussed the technical parts of both in situ fenestrations (needle and laser) and fenestrations in vitro (direction inversion strategy and guidewire-assisted strategy), providing a technical reference to standardize the procedure and improve its results.
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Affiliation(s)
- Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhenjiang Li
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiangchen Dai
- Department of Vascular Surgery, General Hospital, Tianjin Medical University, Tianjin, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qingsheng Lu
- Department of Vascular Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xiaoqiang Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Weimin Zhou
- Department of Vascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Pingfan Guo
- Department of Vascular Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jun Pan
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Donglin Li
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China,*Correspondence: Hongkun Zhang,
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12
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Yao S, Chen X, Liao Y, Ding G, Li D, Qin G, Qiao R, Sun X, Zheng Q. Systematic review and meta-analysis of type B aortic dissection involving the left subclavian artery with a Castor stent graft. Front Cardiovasc Med 2022; 9:1052094. [PMID: 36523362 PMCID: PMC9745178 DOI: 10.3389/fcvm.2022.1052094] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/07/2022] [Indexed: 09/05/2023] Open
Abstract
OBJECTIVE Despite the rapid development of thoracic endovascular aortic repair (TEVAR), it is still a challenge to maintain the blood flow of the branch arteries above the aortic arch in Stanford type B aortic dissection involving the left subclavian artery (LSA). The Castor stent graft is an integrated, customized, single-branch stent that enables reconstruction of the LSA. The purpose of this systematic review and meta-analysis was to assess the efficacy of the Castor stent graft for type B aortic dissection. MATERIALS AND METHODS An extensive electronic literature search (PROSPERO registration number: CRD42022322146) was undertaken to identify all articles published up to August 2022 that described thoracic aortic repair with branch stents in the treatment of type B aortic dissection involving the LSA. The quality of the included studies was analyzed using the MINORS criteria. The primary outcome measures were the technical success rate, early mortality rate, endoleak rate, and 1-year survival rate. The secondary outcome measures were the stroke rate, left upper extremity ischemia rate, and target vessel patency rate. RESULTS Eleven studies involving 415 patients were eligible for this meta-analysis. The LSA was successfully preserved in all procedures. The technical success rate was 97.5% (95% CI: 0.953-0.991); the intraoperative endoleak rate was 0.1% (95% CI: 0.000-0.012); the intraoperative LSA patency rate was 99.52%; the intraoperative LSA stent deformation and stenosis rate was 0.15% (95% CI: 0.000-0.051); the early type I endoleak rate was 1.6% (95% CI: 0.003-0.035); the 30-day mortality rate was 0.96%; the early reintervention rate was 0.9% (95% CI: 0.000-0.040); and the perioperative stroke rate was 0% (95% CI: 0.000-0.005). The 1-year survival rate was 99.7% (95% CI: 0.976-1.000). The half-year LSA patency rate was 99.3%, the 1-year LSA patency rate was 97.58%, and the 2-year LSA patency rate was 95.23%. During the follow-up period, the leakage rate was 0.3% (95% CI: 0.000-0.017), the incidence of left upper extremity ischemia rate was 0.5% (95% CI: 0.000-0.035), and the deformation and stenosis rate of the LSA stent was 2.2% (95% CI: 0.06-0.046). CONCLUSION This meta-analysis shows that endovascular repair of type B aortic dissection using the Castor stent-graft may be technically feasible and effective. However, this conclusion needs to be interpreted with caution, as the quality of evidence for all outcomes is between low and very low. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022322146].
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Affiliation(s)
- Shihua Yao
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Xu Chen
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Yalin Liao
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Gangbing Ding
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Dagang Li
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Gengliang Qin
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Ruiguo Qiao
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Xin Sun
- Department of Cardiovascular Medicine, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
| | - Qijun Zheng
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital, Second Clinical Medical College, Jinan University, Shenzhen, Guangdong, China
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13
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Athiyappan KM, Cherian M, Poyyamoli S. Rescue of Compromised Cerebral Circulation in Hybrid TEVAR for Type B Aortic Dissection. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2022. [DOI: 10.1055/s-0042-1755610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
| | - Mathew Cherian
- Department of Interventional Radiology, Kovai Medical Centre, Coimbatore, Tamil Nadu, India
| | - Santhosh Poyyamoli
- Department of Interventional Radiology, Kovai Medical Centre, Coimbatore, Tamil Nadu, India
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14
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Asciutto G, Usai MV, Ibrahim A, Oberhuber A. Early experience with the Bolton Relay Pro/Plus for physician-modified fenestrated TEVAR. INT ANGIOL 2022; 41:105-109. [PMID: 35005873 DOI: 10.23736/s0392-9590.22.04745-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) can be challenging in cases involving the aortic arch and the visceral segment. We report our initial experience with fenestrated TEVAR (f-TEVAR) for thoracic aortic disease involving aortic branches using physician-modified stent grafts (PMSGs). MATERIALS AND METHODS Between February 2019 and November 2020 nine patients were treated with a PMSG. Indication to treatment were a symptomatic acute type B aortic dissection (TBAD) in three cases, a penetrating aortic ulcer in three cases (two in zone 3 and one in zone 6), one case of an endoleak type I A after TEVAR, a chronic TBAD after TEVAR in one case and one case of a contained rupture of a thoracoabdominal aneurysm in zone 3. Pre-, intra- and postoperative clinical data were recorded. RESULTS The median patient age was 65 (IQR 60.5-71) years, and 8 (89%) patients were men. Nine stent grafts (six Bolton Relay Plus and three Bolton Relay Pro, Terumo Aortic, Vascutek Ltd., Inchinnan, United Kingdom) were deployed. Small fenestrations (8 mm) were created on table, median duration for on table stent graft modifications was 20 minutes (13-22). The technical success rate was 100%. Median operative time was 188 (116-252) minutes. No major adverse events of any sort occurred during the first 30-day postoperatively. There were no type I or type III endoleaks at the end of the procedure, and no cases of spinal cord ischemia. Two access related complications occurred (22%). After a median of 12 (range 5-12) months all patients survived and all target vessels remained patent with one case of fenestration-related type I endoleak, which required open conversion. CONCLUSIONS The results of our initial experience with f-TEVAR using PMSGs with the Bolton Relay stentgraft for the treatment of aortic diseases are acceptable. These results should be confirmed on larger patient cohorts.
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Affiliation(s)
- Giuseppe Asciutto
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany.,Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Marco V Usai
- Department of Vascular and Endovascular Surgery, St. Franziskus Hospital Münster, Münster, Germany
| | - Abdulhakim Ibrahim
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany -
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
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15
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Li X, Shu C, Li Q, He H, Li M, Wang L, Li J, Liu D, Du M. Self-Radiopaque Markers Guiding Physician-Modified Fenestration (S-Fenestration) in Aortic Arch Endovascular Repair. Front Cardiovasc Med 2021; 8:713301. [PMID: 34490376 PMCID: PMC8417741 DOI: 10.3389/fcvm.2021.713301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/07/2021] [Indexed: 11/13/2022] Open
Abstract
Backgrounds and Objectives: Thoracic endovascular aortic repair (TEVAR) has currently become the “first-line choice” for descending aortic pathologies. For pathologies located at the aortic arch, TEVAR with physician-modified fenestration (PMF) has been gained popularity as an alternative choice. However, stent fenestration is an experience-dependent technique and comes with possible adverse events such as misalignment. This study aims to introduce the self-radiopaque PMF (SF), which uses the radiopaque marker as a guiding indicator. Methods: This is a single-center retrospective study of 125 patients who underwent the SF-TEVAR in Second Xiangya Hospital from December 2015 to December 2020. Data include basic clinical information and technique records of SF-TEVAR with follow-up results. Results: According to the SF-TEVAR protocol, we have performed the procedures on 125 patients and obtained an instant success rate of 98.4%. A total of 140 aortic stent-grafts and 44 bridging stents have been implanted in this study. The operation time is 64.6 ± 19.3 min, X-ray exposure time (from first digital subtraction angiography (DSA) to last DSA) is 25.6 ± 14.3 min, and contrast volume is 82.2 ± 22.6 ml. The success rate of PMF alignment is 98.4%. One bailout stent-graft was implanted into the left subclavian artery (LSA) by the chimney technique (0.8%). One fenestration was successfully and immediately corrected after misalignment (0.8%). Large simultaneous fenestration was performed in six patients (4.8%) for the left common carotid artery (LCCA) and LSA and in two patients (1.6%) for IA, LCCA, and LSA. One hundred twenty-two out of 125 patients' LSAs have been kept patent by the technique during the follow-up. The bridging stent group consists of 44 patients who received LSA stents, while the non-bridging stent group includes the other 81 patients. Type I endoleak has occurred in seven patients (5.6%) 1 week after the procedure. During follow-up (23 ± 18 months), survival rate is 95.7% and branch artery patent rate is 97.4%. Conclusions: The SF-TEVAR technique, which utilizes the radiopaque marker in stent-graft as an indication for PMF in TEVAR, seems a likely safe, effective, and efficient procedure that brings acceptable survival rate and branch artery patency rate. SF-TEVAR serves as a progressive alternative method to keep the branch artery patent in aortic arch endovascular reconstruction.
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Affiliation(s)
- Xin Li
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,The Institute of Vascular Diseases, Central South University, Changsha, China
| | - Chang Shu
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,The Institute of Vascular Diseases, Central South University, Changsha, China.,Center of Vascular Surgery, State Key Laboratory of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Quanming Li
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,The Institute of Vascular Diseases, Central South University, Changsha, China
| | - Hao He
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,The Institute of Vascular Diseases, Central South University, Changsha, China
| | - Ming Li
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,The Institute of Vascular Diseases, Central South University, Changsha, China
| | - Lunchang Wang
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,The Institute of Vascular Diseases, Central South University, Changsha, China
| | - Jiehua Li
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,The Institute of Vascular Diseases, Central South University, Changsha, China
| | - Dingxiao Liu
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,The Institute of Vascular Diseases, Central South University, Changsha, China
| | - Mingyuan Du
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,The Institute of Vascular Diseases, Central South University, Changsha, China
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16
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Evans E, Veeraswamy R, Zeigler S, Wooster M. Laser in situ Fenestration in Thoracic Endovascular Aortic Repair: A Single-Center Analysis. Ann Vasc Surg 2021; 76:159-167. [PMID: 34153488 DOI: 10.1016/j.avsg.2021.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/13/2021] [Accepted: 05/16/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Laser in situ fenestration (LISF) is an expanding technique for arch vessel revascularization in thoracic endovascular aortic repair (TEVAR). We present a single center's early and midterm outcomes using adjunctive LISF with TEVAR for treatment of various arch pathologies. METHODS 24 patients underwent TEVAR with LISF (2017-2020). Patients were evaluated by an Aortic Team consisting of cardiothoracic and vascular surgeons and were deemed unfit for open surgical repair. Informed consent emphasized the procedure's off-label nature. Thoracic stent-grafts were sized by preoperative Computed Tomography Angiogram and intraoperative Intravascular Ultrasound, with oversizing determined by pathology. Extra-anatomic debranching was performed in staged or concurrent fashion based on urgency of repair and access site options for branch fenestration. A 2.3 mm Spectranetics laser was used, with access site determined at surgeon discretion. Covered balloon expandable stent-grafts were deployed with 0-10% oversizing. RESULTS In 24 patients, a total of 30 fenestrations were created (LSA N = 19, LCCA N = 3, Innominate N = 7, RSA N = 1) with 1 (N = 18) or 2 (N = 6) fenestrations/patient. Indications included aneurysm (8), chronic dissection with aneurysmal degeneration (8), acute dissection (4), intramural hematoma (2), and pseudoaneurysm (2). 13 cases were elective, and 11 were emergent. Technical success was 100%. 12 patients underwent concurrent (N = 8) or staged (N = 4) extra-anatomic bypass. The major complication rate was 21%, including stroke (N = 3) and 30-day mortality (N = 2). The overall complication rate was 58%. Over a mean follow up of 261 days (15-864 days), 7 patients (32%) have required reinterventions. CONCLUSIONS LISF for branch revascularization in TEVAR is technically feasible for treating various aortic arch pathologies, demonstrating practicality in both elective and emergent settings. With a morbidity and mortality profile that is favorable compared to that of open repair, LISF with TEVAR is a promising potential option for patients with complex arch pathology and prohibitive open surgical risk.
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Affiliation(s)
- Elizabeth Evans
- Medical University of South Carolina, Ashley River Tower, Charleston, SC
| | | | - Sanford Zeigler
- Medical University of South Carolina, Ashley River Tower, Charleston, SC
| | - Mathew Wooster
- Medical University of South Carolina, Ashley River Tower, Charleston, SC.
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17
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Sun X, Kan Y, Huang L, Dong Z, Guo D, Si Y, Fu W. Evaluation for the safety and effectiveness of the in situ fenestration system in TEVAR for aortic arch pathologies: protocol for a prospective, multicentre and single-arm study. BMJ Open 2021; 11:e043599. [PMID: 33619193 PMCID: PMC7903081 DOI: 10.1136/bmjopen-2020-043599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) has gradually become the mainstream therapy for aortic arch pathologies (AAP). Our centre developed the in situ fenestration (ISF) system according to years of clinical experience and technological innovation. This study aims to evaluate the safety and effectiveness of the innovative, self-developed ISF system in TEVAR for AAP. METHODS AND ANALYSIS The study is a prospective, multicentre and single-arm study. Patients diagnosed with AAPs in five centres on 1 January 2021 will be recruited and general TEVAR with ISF system will be performed. Clinical information and CT angiography images will be collected and recorded. Patients will be followed up for 5 years. Safety and efficacy endpoints are planned to be reported to evaluate this self-developed ISF system. ETHICS AND DISSEMINATION The study is a registry. We have registered the study on the Chinese Clinical Trial Registry website (http://www.chictr.org.cn/). This study has been approved by the Ethics Committee of Zhongshan Hospital Fudan University (B2020-371) and individual consents will be signed at the time of enrolment. We anticipate that this self-developed ISF system will result in favourable social and economic benefits. Findings will be disseminated in peer-reviewed journals to provide reference for future clinical practice. TRIAL REGISTRATION NUMBER ChiCTR1900026696.
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Affiliation(s)
- Xiaofan Sun
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Yuanqing Kan
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Lihong Huang
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
- Department of Biostatistics, Zhongshan Hospital Fudan University, Shanghai, China
| | - Zhihui Dong
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Yi Si
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
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18
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Shatila W, Krajcer Z. Thoracic aortic disease: Can we safely cover the branches? Catheter Cardiovasc Interv 2020; 95:1169-1170. [PMID: 32421238 DOI: 10.1002/ccd.28916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 11/11/2022]
Abstract
Thoracic aortic disease has usually been treated with surgery. Thoracic endovascular aortic repair is challenging if supra-aortic vessels are involved. In situ fenestration of the main graft from a retrograde approach while using bare-metal stents as bridge stents appears to be a safe and practical technique.
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Affiliation(s)
- Wassim Shatila
- Department of Cardiology, Texas Heart Institute, Houston, Texas.,Department of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Zvonimir Krajcer
- Department of Cardiology, Texas Heart Institute, Houston, Texas.,Department of Cardiology, Baylor College of Medicine, Houston, Texas.,Department of Internal Medicine, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas
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19
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Luo M, Fang K, Fan B, Li Q, Li M, He H, Li X, Guo Y, Xue Y, Zhao J, Wang T, Yang C, Li J, Nienaber CA, Shu C. Midterm Results of Retrograde In Situ Needle Fenestration During Thoracic Endovascular Aortic Repair of Aortic Arch Pathologies. J Endovasc Ther 2020; 28:36-43. [PMID: 32869716 DOI: 10.1177/1526602820953406] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE To evaluate the safety and feasibility of the in situ needle fenestration (ISNF) technique for reconstruction of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) of complicated aortic arch pathologies. MATERIALS AND METHODS A retrospective review was conducted from January 2014 to December 2019 of 50 patients (mean age 60.2±11.1; 45 men) who underwent ISNF to revascularize the LSA during TEVAR. Twenty-one of the patients also required revascularization of the left common carotid artery (LCCA; n=19) and innominate artery (IA; n=2) using physician-modified in vitro fenestration. Overall, 73 supra-aortic branches were targeted for revascularization. RESULTS ISNF was successful in 48 patients (96%); one LSA could not be stented and a tortuous LSA prevented the needle from fenestrating the graft. No perioperative major adverse event occurred. There were no type I and 4 type III endoleaks (8%), 3 of which occurred among the first 20 cases. Types II and IV endoleaks were found in 3 (6%) and 6 (12%) cases, respectively; all disappeared during a median follow-up of 15 months (range 3-66). One death (2%) occurred within 12 months due to cerebral hemorrhage. Two patients (4%) required open reinterventions at 6 and 62 months. CONCLUSION ISNF for revascularization of the LSA during TEVAR seems to be feasible with acceptable midterm outcomes. The learning curve and evolving patient selection criteria affected technical success, complications, and the need for reinterventions. Long-term durability requires further evaluation.
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Affiliation(s)
- Mingyao Luo
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Xicheng District, Beijing, China.,Department of Vascular Surgery, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Kun Fang
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Xicheng District, Beijing, China
| | - Bowen Fan
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Xicheng District, Beijing, China
| | - Quanming Li
- Department of Vascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ming Li
- Department of Vascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Hao He
- Department of Vascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xin Li
- Department of Vascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yuanyuan Guo
- Department of Vascular Surgery, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Yunfei Xue
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Xicheng District, Beijing, China
| | - Jiawei Zhao
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Xicheng District, Beijing, China
| | - Tun Wang
- Department of Vascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Chenzi Yang
- Department of Vascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jiehua Li
- Department of Vascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton Hospital, Royal Brompton & Harefield NHS Trust, Imperial College London, UK
| | - Chang Shu
- State Key Laboratory of Cardiovascular Disease, Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Xicheng District, Beijing, China.,Department of Vascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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