The arch and beyond: bare stents in the ascending aorta

Debranching solutions in endografting for complex thoracic aortic dissections

BACKGROUND

Conventional surgical repair of thoracic aortic dissections is a challenge due to mortality and morbidity risks.

OBJECTIVES

We analyzed our experience in hybrid aortic arch repair for complex dissections of the aortic arch.

METHODS

Between 2009 and 2013, 18 patients (the mean age of 67 ± 8 years-old) underwent hybrid aortic arch repair. The procedural strategy was determined on the individual patient.

RESULTS

Thirteen patients had type I repair using trifurcation and another patient with bifurcation graft. Two patients had type II repair with replacement of the ascending aorta. Two patients received extra-anatomic bypass grafting to left carotid artery allowing covering of zone 1. Stent graft deployment rate was 100%. No patients experienced stroke. One patient with total debranching of the aortic arch following an acute dissection of the proximal arch expired 3 months after TEVAR due to heart failure. There were no early to midterm endoleaks. The median follow-up was 20 ± 8 months with patency rate of 100%.

CONCLUSION

Various debranching solutions for different complex scenarios of the aortic arch serve as less invasive procedures than conventional open surgery enabling safe and effective treatment of this highly selected subgroup of patients with complex aortic pathologies.

Application of protective stents in endovascular repair of acute complicated Stanford type B aortic dissections

PURPOSE

To describe the use of protective stents in the endovascular repair of acute complicated Stanford type B aortic dissections.

METHODS

From 2009 to 2011, 33 patients (27 men; mean age 47 years, range 31-73) with acute complicated Stanford type B aortic dissection underwent thoracic endovascular aortic repair (TEVAR) assisted by protective stents. In all cases, the proximal and distal landing zones differed in size by >5 mm, and the primary entry tear was in the proximal descending aorta. A bare self-expanding stent (protective stent) was deployed initially at the intended distal landing site of the primary stent-graft in the true lumen. The intention was that the bare stent would prevent excessive dilation of the distal end of the stent-graft in the vicinity of the entry tear, thus avoiding intimal rupture.

RESULTS

Successful stent deployment and sealing of the entry tear was achieved in all patients. The median diameter and length of the protective bare stents was 20.3 mm (range 18-24) and 72.7 mm (range 60-80), respectively, while the corresponding dimensions of the covered stent-grafts were 32.8 mm (range 26-40) and 157.4 mm (range 120-200 mm), respectively. There was no stent twisting, migration, of rupture of the false or true lumen. Computed tomography 1 week postoperatively demonstrated closure of the primary entry tear with thrombosis of the false lumen in all cases. No patients were lost to follow-up, which has ranged from 3 months to 3 years. No late endoleaks or stent complications, such as angulation, dislodgment, persistent leaks, branch obstruction, or stent-graft migration, have been observed, and there has been no chronic progressive true or false lumen dilatation, recurrences, or deaths.

CONCLUSION

Adjunctive use of a protective stent when treating acute Stanford type B aortic dissections in which the diameters of the proximal and distal landing zones differ by >5 mm is feasible and safe and provides good short-term outcomes.