Ten Years of Endovascular Aortic Arch Repair

Endovascular reconstruction of the aortic arch with new-generation dual-branch and triple-branch endograft: design, applicability, indications, outcomes, and future directions

INTRODUCTION

Repair of aortic arch pathologies such as degenerative aneurysms and dissections still represents a significant challenge for vascular and cardiac surgeons. We focused on the design, evolution, implementation, and prospects of endovascular dual branch technology for treatment of pathologies in the aortic arch.

AREAS COVERED

The literature search was conducted in a non-systematic fashion through the PubMed and Scopus databases; articles deemed relevant to the scope of the work and fully published in English language from January 12,000 until December 2023 were considered for inclusion. Two companies so far have developed and launched in market a dedicated arch dual branch platform: Terumo Aortic and Cook Medical.

EXPERT OPINION

A common limitation to the available technology is represented by the fact that urgent cases (i.e. large or rapidly growing aneurysms, symptomatic patients) cannot be treated because the customization process generally takes between 6 and 8 weeks, and there is an inherent risk for aorta-related adverse events to happen during the waiting time. While the future holds much promise, several technical hurdles still exist and further developments (in device design, operators' skills, patients' selection, and outcomes assessment) are needed to establish the safety and effectiveness of treatment particularly over the long-run.

A meta-analysis on the effect of proximal landing zone location on stroke and mortality in thoracic endovascular aortic repair

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) involving the aortic arch may increase the opportunity for stroke owing to disruption of cerebral circulation and embolization. In this study, a systematic meta-analysis was performed to examine the impact of proximal landing zone location on stroke and 30-day mortality after TEVAR.

METHODS

MEDLINE and Cochrane Library were searched for all original studies of TEVAR reporting outcomes of stroke or 30-day mortality for at least two adjacent proximal landing zones, based on the Ishimaru classification scheme. Forest plots were created using relative risks (RR) with 95% confidence intervals (CI). An I2 of <40% was regarded as minimal heterogeneity. A P value of <.05 was considered significant.

RESULTS

Of the 57 studies examined, a total of 22,244 patients (male 73.1%, aged 71.9 ± 11.5 years) were included in the meta-analysis, with 1693 undergoing TEVAR with proximal landing zone 0, 1931 with zone 1, 5839 with zone 2, and 3089 with zone 3 and beyond. The overall risk of clinically evident stroke was 2.7% for zones ≥3, 6.6% for zone 2, 7.7% for zone 1, and 14.2% for zone 0. More proximal landing zones were associated with higher risks of stroke compared with distal (zone 2 vs ≥3: RR, 2.14; 95% CI, 1.43-3.20; P = .0002; I2 = 56%; zone 1 vs 2: RR, 1.48; 95% CI, 1.20-1.82; P = .0002; I2 = 0%; zone 0 vs 1: RR, 1.85; 95% CI, 1.52-2.24; P < .00001; I2 = 0%). Mortality at 30 days was 2.9% for zones ≥3, 2.4% for zone 2, 3.7% for zone 1, and 9.3% for zone 0. Zone 0 was associated with higher mortality compared with zone 1 (RR, 2.30; 95% CI, 1.75-3.03; P < .00001; I2 = 0%). No significant differences were found in 30-day mortality between zones 1 and 2 (P = .13) and between zone 2 and zones ≥3 (P = .87).

CONCLUSIONS

The risk of stroke from TEVAR is lowest in zone 3 and beyond, increasing significantly as the landing zone is moved proximally. Furthermore, perioperative mortality is increased with zone 0 compared with zone 1. Therefore, risk of stent grafting in the proximal arch should be weighed against alternative surgical or nonoperative options. It is anticipated that the risk of stroke will improve with further development of stent graft technology and implantation technique.

Risk of Stroke with Thoracic Endovascular Aortic Repair of the Aortic Arch

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.

Hybrid Technique Outcomes for High-Risk Uncomplicated Type B Aortic Dissection With Landing Zone 1

In this report, we analyzed the outcomes of the hybrid technique for high-risk uncomplicated type B aortic dissection with landing zone 1. We enrolled 80 patients from January 2016 to January 2020 and retrospectively analyzed their outcomes, including mortality, aortic-related adverse events, and aortic remodeling. The mean age was 51.6 ± 9.9 years, and 68.0% (54 of 80) were men. Technical success was achieved in 100% of cases (80 of 80), and 30-day mortality was 4% of patients (n = 3), including 2 dissection-related deaths. Immediate endoleaks occurred in 16 patients, including 11 type Ia and 5 type II. Four patients (5%) developed minor strokes postoperatively, and no short-term spinal cord ischemia and re-intervention occurred. The average length of stay was 20 ± 8 days. The overall mortality was 8% after a median follow-up of 44 months (38 to 52). Five patients (7%) developed strokes, and 11 (16%) had late endoleaks, including 1 type Ia, 5 type Ib, and 3 type II. Four re-interventions (5%) were necessary, 3 for endoleaks and 1 for retrograde type A dissection. Three bypass graft occlusions (5%) and 5 stoma stenoses (8%) were observed in the latest follow-up computed tomography. In conclusion, the hybrid technique with landing zone 1 might be a viable alternative to open aortic arch replacement in patients at high risk with uncomplicated type B aortic dissection with acceptable early and late outcomes. However, stroke and endoleak complications should be further addressed.

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

Background

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

Methods

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

Results

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

Conclusions

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

Editor's Choice - PRINciples of optimal antithrombotiC therapy and coagulation managEment during elective fenestrated and branched EndovaScular aortic repairS (PRINCE2SS): An International Expert Based Delphi Consensus Study

OBJECTIVE

Management of antithrombotic therapy in patients undergoing elective fenestrated branched endovascular aortic repair (F-BEVAR) is not standardised, nor are there any recommendations from current guidelines. By designing an international expert based Delphi consensus, the study aimed to create recommendations on the pre-, intra-, and post-operative management of antithrombotic therapy in patients scheduled for elective F-BEVAR in high volume centres.

METHODS

Eight facilitators created appropriate statements regarding the study topic that were voted on, using a four point Likert scale, by a selected panel of international experts using a three round modified Delphi consensus process. Based on the experts' responses, only those statements reaching Grade A (full agreement ≥ 75%) or B (overall agreement ≥ 80% and full disagreement < 5%) were included in the final document. The round answers' consistency was graded using Cohen's k, the intraclass correlation coefficient, and, in case of double re-submission, the Fleiss k.

RESULTS

Sixty-seven experts were included in the final analysis and voted the initial 43 statements related to pre- (n = 15), intra- (n = 10), and post-operative (n = 18) management of antithrombotic drugs. At the end of the process, six statements (13%) were rejected, 20 statements (44%) received a Grade B consensus, and 18 statements (40%) reached a Grade A consensus. Most statements (27; 71%) exhibited very high or high consistency grades, and 11 (29%) a fair or poor grading. The intra-operative statements mostly concentrated on threshold for and monitoring of proper heparinisation. The pre- and post-operative statements mainly focused on indications for dual antiplatelet therapy and its management, considering the possible need for cerebrospinal fluid drainage.

CONCLUSION

Based on the elevated strength and high consistency of this international expert based Delphi consensus, most of the statements might guide current clinical management of antithrombotic therapy for elective F-BEVAR. Future studies are needed to clarify the debated issues.

[Ascending Aorta and Aortic Arch - Endovascular Therapy Today and in the Future]

Pathologies in the region of the aortic arch may occur in isolation, but adjacent segments of the thoracic aorta - the ascending or descending aorta - are much more commonly affected. The first surgical procedures to treat the aortic arch were performed nearly six decades ago. Despite numerous improvements and innovations in the 20th and early 21st centuries, these procedures are still associated with relevant operative mortality and neurological complication rates. Endovascular techniques and modern hybrid procedures are increasingly expanding the therapeutic spectrum in the aortic arch, although the open surgical approach is currently still the gold standard. Endovascular treatment of aortic aneurysm was first performed in the early 1990s in the infrarenal abdominal aorta. It was not long before the first attempts at endovascular therapy were made for the treatment of the aortic arch. In 1996, Inoue et al. reported the use of the first commonly used endoprosthesis to treat aneurysms in the aortic arch. Continuous improvements and refinements in implantation techniques and also implanted material have resulted in endovascular therapy now being an increasingly important option compared to open surgical procedures in the descending thoracic and abdominal aorta and has partially replaced them as the gold standard. This review article aims to provide an overview of the prerequisites, results, but also limitations of endovascular surgery of the aortic arch.

Thoracic endograft placement using a transfemoral snare in a patient with angled aortic arch

OBJECTIVE

In complex anatomical challenges, endovascular endograft implantation to the thoracic aorta may not be performed. Various techniques have been put forward for endograft therapy. In this report, we present the effect of femoral snare support for a patient with an aortic arch angle.

METHOD

Thoracic endovascular aneurysm repair (TEVAR) was used for treating a 60-year-old male patient who suffered from severe angulation in the arcus aorta and aneurysmal enlargement of the left subclavian artery and descending aorta. The endovascular graft could not be advanced into the aortic arch with the guidewire because of the aortic arch angle. Therefore, the TEVAR graft distal end was caught with the snare advanced from the femoral artery, and the TEVAR graft was advanced into the aortic arch.

CONCLUSION AND RESULT

The femoral snare technique is a simple and successful method for endograft implantation of the aortic arch disease without the risk of heart trauma, especially in cases with aortic arch tortuosity.

Comparison of Prognosis Between Hybrid Debranching Surgery and Total Open Arch Replacement With Frozen Elephant Trunk for Type A Acute Aortic Syndrome Patients

Background: It is unclear whether the total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation and hybrid debranching surgery have a difference in the prognosis of patients with type A acute aortic syndrome (AAS). We attempted to compare the short-term and long-term prognosis of total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation and hybrid debranching surgery in patients with type A acute aortic syndrome (AAS).

Methods: From January 2014 to September 2020, a total of 518 patients who underwent TAR with FET surgery and 31 patients who underwent hybrid surgery were included. We analyzed the post-operative mortality and morbidity of complications of the two surgical methods, and we determined 67 patients for subgroup analysis through a 1:2 propensity score match (PSM). We identified risk factors for patient mortality and post-operative neurological complications through multivariate regression analysis.

Results: Compared with the TAR with FET group, hybrid surgery could reduce aortic cross-clamp time, reduce intraoperative blood loss and prevent some patients from cardiopulmonary bypass. There was no significant difference in 30-day mortality between the TAR with FET group and the hybrid surgery group (10.6 vs. 9.7%). However, hybrid surgery had increased the incidence of permanent neurological complications in patients (95%CI: 4.7–35.7%, P = 0.001), especially post-operative cerebral infarction (P < 0.001). During the average follow-up period of 31.6 months, there was no significant difference in the 1-year survival rate and 3-year survival rate between the TAR with FET group and the hybrid surgery group (P = 0.811), but hybrid surgery increased the incidence of long-term neurological complications (P < 0.001). In multivariate regression analysis, surgical methods were not a risk factor for post-operative deaths, but hybrid surgery was a risk factor for post-operative neurological complications (P < 0.001).

Conclusions: Hybrid surgery is an acceptable treatment for AAS, and its post-operative mortality is similar to FET. But hybrid surgery may increase the risk of permanent neurological complications after surgery, and this risk must be carefully considered when choosing hybrid surgery.

Endovascular Solutions for Aortic Arch Diseases: Total and Hybrid

Although the endovascular approach is the therapeutic option of choice for thoracic and abdominal aortic diseases, open surgery is still the treatment of choice for aortic arch diseases. While open surgical repair remains the gold standard treatment for complete aortic arch replacement, it continues to be burdened by high mortality and neurologic complications, especially for patients who require redo surgery. Therefore, in the era of endovascular surgery, it is not surprising that hybrid operating rooms, new technologies, and new approaches are strongly challenging open surgery. Less-invasive endovascular procedures, when used to treat aortic arch diseases, when feasible and indicated, have clear advantages over open surgery, primarily because there is no need for cardiopulmonary bypass, hypothermic circulatory arrest, or cerebral protection. Moreover, patients who have already been treated for acute type A aortic dissection continue to have a considerable risk for future aortic reintervention, which is associated with increased risk for short- and long-term mortality. In light of these advantages, it is clear how selected high-risk patients with aortic arch disease could benefit from the endovascular approach. However, the hemodynamic and anatomic characteristics of the aortic arch make the endovascular approach in this region challenging. In fact, uncorrected stent-graft placement can have fatal consequences for the patient and increase the risk of endoleaks and stroke. To minimize these potential risks, precise and accurate preoperative planning to achieve optimal stent-graft dimensions and implantation is essential together with careful patient selection. Endovascular options for the treatment of aortic arch disease include both hybrid procedures and total endovascular solutions. This manuscript provides an overview of the current strategies for endovascular aortic arch treatment, including the most recent available series on this topic. In addition, a literature search offers insight into the current state of the art.

Avoiding Arch Manipulation with Catheterization of Left Subclavian Artery for Endovascular Repair of Distal Descending Aorta: Acibadem Technique

Although thoracic endovascular aortic repair (TEVAR) is associated with reduced mortality and shorter hospital stay compared to open surgery, the decrease in stroke risk did not reach the desired rates. Aortic arch manipulation is one of the main concerns leading to stroke during TEVAR. Here, we describe a new technique called "Acibadem Technique" to avoid arch and ascending aorta manipulation with catheterization of left subclavian artery for endovascular distal descending aortic repair.

Zone 1 Aortic Arch Hybrid Endovascular Repair with Extra-anatomical Bypass: A Meta-analysis

BACKGROUND

The aim of this meta-analysis is to determine the morbidity and mortality outcomes of adult patients with aortic arch disease managed with extra-anatomical bypass avoiding median sternotomy and cardiopulmonary bypass, with simultaneous or staged hybrid zone 1 endovascular aortic repair.

METHODS

Systematic literature searches of the MEDLINE, EMBASE, and Cochrane databases were carried out to identify relevant studies on zone 1 hybrid arch repair. Extracted data were analyzed by random effects models. Primary outcomes included 30-day or in-hospital mortality. Longitudinal survival was analyzed up to 7 years from date of operation. Secondary outcomes included in-hospital morbidity, as well as late endoleak and reintervention.

RESULTS

Twenty studies incorporating 348 patients were included. In-hospital or 30-day mortality was 10.1% (95% confidence interval, 6.7-14.9%). Overall operative technical success was 89.8% (83.7-93.8%). Early type 1 endoleak rate was 14.0% (7.4-24.7%). Stroke prevalence was 9.5% (6.1-14.3%). Spinal cord paraplegia prevalence was 3.8% (1.9-7.6%). Retrograde aortic dissection prevalence was 4.1% (1.5-10.6%). Survival at 1 year postoperatively was 77.2% (66.1-85.4%). Survival at 3 years postoperatively was 73.7% (59.2-84.4%). Survival beyond 4 years postoperatively (range 58-80 months) was 65.9% (53.6-76.4%). Late type 1 endoleak prevalence was 11.8% (5.5-23.7%). Overall rate of reintervention was 11.6% (6.4-20.1%).

CONCLUSIONS

Zone 1 hybrid repair has evidence for satisfactory short- and long-term morbidity/mortality outcomes and may be considered as an alternative approach to aortic arch disease.

Endovascular aortic arch repair using a double-branched approach

The last 15 years have overwhelmed the surgical community with a range of approaches in treating pathologies involving the aortic arch of which some are here to stay. The ones to stay are-in the authors' opinion-refined classical surgical approaches such as the frozen elephant trunk technique, near-orthotopic combined vascular and endovascular approaches such as subclavian to carotid transposition/bypass and double transposition, and finally, near-orthotopic advanced endovascular solutions such as the double-endovascular repair using fenestrated and/or branched solutions which will be the main focus of this article.

Debranching of Supra-aortic Vessels via Femoral Artery Inflow for Late Ascending Aortic Rupture

A 56-year-old man with a history of Marfan's syndrome, total arch replacement, descending thoracic endovascular aortic repair, and twice redo sternotomy for pseudoaneurysm repair, presented with a pulsatile chest mass secondary to a contained rupture of the ascending aorta. The patient underwent supra-aortic debranching via the superficial femoral artery and ascending thoracic stent-graft placement under continuous transesophageal echocardiography. Completion angiography demonstrated successful exclusion of the contained rupture. Postoperatively, the patient was neurologically intact, the pulsatile mass resolved, and the bypass grafts remained patent. Chronic respiratory failure and multidrug-resistant pneumonia led to late mortality. This case demonstrates that hybrid repair is effective in the emergent setting of ascending aortic rupture. Debranching of the ascending arch using the superficial femoral artery as inflow is feasible and provides adequate cerebral perfusion despite the length of the bypass. The use of transesophageal echocardiography during stent-graft deployment allows precise device placement in the high-risk area of the ascending aorta proximal to the innominate artery.

Endovascular total arch replacement techniques and early results

During the last 20 years, a clear shift has been observed towards thoracic endovascular aortic repair for different aortic pathologies. However, total endovascular repair of the aortic arch remains technically demanding. Simultaneous perfusion of all supra-aortic arteries without longer cerebral ischemia time, whilst trying to avoid cerebral embolization, labels endovascular aortic arch repair with highest level of technical difficulty and surgical expertise. The aim of this article is to present an overview of the current technical options for endovascular aortic arch repair and their early results. Currently, early results are reported from four endovascular arch replacement techniques: hybrid repair, total endovascular approach, chimney grafts and in-situ fenestration. The early results of these different arch replacement techniques are promising, especially the total arch replacement with custom-made fenestrated or branched stent-grafts. Long-term results are unknown, and larger series results and comparative studies are needed to determine safety and efficacy.

Hybrid Procedure with Debranching from the Descending Aorta for Aortic Arch Aneurysm after Previous Open Repair

Aortic arch aneurysms can be treated with hybrid procedures by endovascular exclusion and prior debranching of supra-aortic arteries. We report on a case of symptomatic arch aneurysm following previous supracoronary ascending aorta and hemiarch replacement with a very short proximal landing zone. A successful reconstruction was performed by retrograde revascularization of supra-aortic vessels from the descending aorta and subsequent endovascular repair deploying a proximal stent graft directly above the sinotubular junction with good results in the 4-year follow-up. Retrograde supra-aortic debranching may constitute a suitable approach for hybrid endovascular repair of aneurysms of the aortic arch and the ascending aorta in selected cases.

Hybrid Repair of Aortic Arch Aneurysms with Endografting of the Ascending Aorta

BACKGROUND

Different "hybrid" techniques that combine open debranching of the supra-aortic vessels with endografting of the aortic arch have emerged as alternatives to the open arch repair in high-risk patients. This study aims to review the early and mid-term results of single-stage hybrid arch repair with ascending aorta stent graft deployment for aortic arch aneurysms and dissections.

METHODS

Between June 2006 and May 2015, five consecutive patients, with an age range of 54-78 years, with complex aortic arch diseases, were treated with a hybrid approach in which the endograft had a proximal landing zone in the ascending aorta. Indications included: acute and chronic type A aortic dissections and three arch aneurysms associated with distal aortic pathology. Length of postoperative clinical and imaging follow-up ranged from 10 to 121 months and was completed in all patients.

RESULTS

Technical success of the endografting was achieved in all cases. There was one in-hospital mortality secondary to pulmonary embolism, one case of retrograde type A aortic dissection (RTAD) detected before discharge and one case of late type Ib endoleak that required an endografting procedure. No postoperative stroke or transient or permanent spinal cord ischemia occurred.

CONCLUSION

Hybrid arch repair with endograft landing in zone 0 may decrease mortality and morbidity in high-risk patients. doi: 10.1111/jocs.12735 (J Card Surg 2016;31:341-347).

Evolving practice pattern changes and outcomes in the era of hybrid aortic arch repair

OBJECTIVE

The role of hybrid repair in the management of aortic arch pathology, and long-term outcomes with these techniques, remains uncertain. We report a decade of experience with hybrid arch repair (HAR) and assess institutional practice patterns with regard to the use of hybrid and open techniques.

METHODS

Hybrid and open total and distal arch procedures performed between July 2005 and January 2015 were identified from a prospectively maintained, institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term survival were calculated. Hybrid and open procedural volumes over the study period were assessed to evaluate for potential practice pattern changes.

RESULTS

During the study period 148 consecutive procedures were performed for repair of transverse and distal aortic arch pathology, including 101 hybrid repairs and 47 open total or distal arch repairs. Patients in the hybrid repair group were significantly older with a greater incidence of chronic kidney disease, peripheral vascular disease, and chronic lung disease. Perioperative mortality and outcomes were not significantly different between the hybrid and open groups, aside from decreased median length of stay after hybrid repair. Need for subsequent reintervention was significantly greater after hybrid repair. Unadjusted long-term survival was superior after open repair (70% 5-year survival open vs 47% hybrid; P = .03), although aorta-specific survival was similar (98% 5-year aorta-specific survival open vs 93% hybrid; P = .59). Institutional use of HAR decreased over the final 3 years of the study, with an associated increased use of open total or distal arch repairs. This was primarily the result of decreased use of native zone 0 hybrid procedures. Concurrent with this apparent increased stringency around patient selection for HAR, perioperative morbidity and mortality was reduced, including avoidance of retrograde type A dissection.

CONCLUSIONS

HAR remains a viable option for higher-risk patients with transverse arch pathology with perioperative outcomes and long-term aorta-specific survival similar to open repair, albeit at a cost of increased reintervention. This observational single-institution study would suggest decreased use in more recent years in favor of open repair due to avoidance of native zone 0 hybrid procedures. This decline in the institutional use of native zone 0 hybrid repairs was associated with improved perioperative outcomes.

Endovascular aortic repair combined with chimney technique in the treatment of stanford type B aortic dissection involving aortic arch

BACKGROUND

In this study, we sought to explore the efficacy of endovascular aortic repair combined with the chimney technique in the treatment of Stanford type B aortic dissection involving the aortic arch.

METHODS

Between June 2009 and June 2012, 41 consecutive patients were treated with chimney technique at our institute for aortic arch dissection with the primary entry tear adjacent to the orifices of the supra-aortic arteries. The chimney technique was used to reconstruct the left subclavian artery (n = 5) and the left common carotid artery (n = 34). Additionally, in 2 cases, the double chimney technique was used to simultaneously reconstruct the innominate artery and the left common carotid artery.

RESULTS

Eight of the 41 patients had undergone emergent surgery. All the patients survived the surgery, and the mean follow-up period was 17.3 ± 6.1 months. None of the patients had type I endoleak. Four patients had type II endoleak, and 3 of them underwent implantation of the patent ductus arteriosus occluder in the left subclavian artery. Among these 3 patients, one patient who was pregnant with Marfan syndrome and pregnancy-induced hypertension required additional medication for recovery. None of the patients had any severe neurological complications, left ischemia of the subclavian artery, migration of the stent graft, or occlusion of the stent grafts.

CONCLUSIONS

Thus, endovascular aortic repair combined with the chimney technique appears to be a feasible, safe, and effective treatment option for the management of Stanford type B aortic dissection involving the aortic arch.

Application of the Bolton Relay Device for Thoracic Endografting In or Near the Aortic Arch

Endovascular correction of aortic arch pathology remains a challenge, with a variety of techniques proposed over the years to minimize complications and enhance the probability of a successful result. A variety of approaches have been developed in order to deal with the aortic arch pathology and its idiosyncrasies. We review potential interventional techniques for the repair of aortic arch pathologies, beginning with conventional aortic arch surgery, followed by hybrid treatments and those along the endovascular spectrum (parallel and fenestrated endografts, scalloped endografts, and ascending and new branched endografts). We finish with an overview of all the Bolton Medical (Barcelona, Spain and Sunrise, FL, USA) thoracic platforms. Endovascular techniques show acceptable results in selected cases. Both proximal Bolton Relay configurations (with and without a bare stent) offer conformability and accuracy on deployment with very low rates of stroke. Fenestrated and scalloped designs are also useful for selected cases. Ascending and branched Bolton devices are very promising platforms for a serious, full endovascular approach to the aorta.

Hybrid repair of aortic arch pathology

The objective was to evaluate a 13-year single-centre experience of arch endovascular aortic repair using the hybrid approach. Between 1999 and 2013, 491 patients were treated with endografts for thoracic aortic pathologies. The aortic arch was involved in 179 (36.5%) patients (128 men; mean age 70.2 ± 10.8 years, range 27-84). A hybrid approach was performed for all Zone 0 and 1 procedures and in nearly half of Zone 2 procedures. Early and mid-term outcomes were reviewed retrospectively. Overall primary technical success (24 h) was achieved in 162 (90.5%) of the 179 cases; 2 deaths and 15 Type 1 endoleaks were observed. Clinical success at 30 days was achieved in 161 (89.9%) of the 179 patients, with a mortality rate of 4.5% (8/179). Short-term clinical success at 6 months was achieved in 169 (94.4%) of the 179 patients; the rates for the different landing zones did not differ significantly. At a mean follow-up of 27.3 ± 15.7 months (range 1-94), the mid-term clinical success was 165 (92.2%) of the 179 patients; the rates among the different proximal zones did not differ significantly. In selected patients, early and mid-term outcomes of arch endovascular aortic repair using the hybrid approach are promising; however, mortality and morbidity are not negligible. Our results may have practical implications for the ongoing evaluation of the hybrid procedure in the aortic arch, as well as for patients fit for traditional surgery.

A systematic review and meta-analysis of hybrid aortic arch replacement

BACKGROUND

Evolution in the endovascular era has influenced the management of aortic arch pathologies. Several studies have described the use of a combined endovascular and open surgical approach to the treatment of arch diseases. Hybrid repair of arch pathologies has been considered as a less invasive method, and is therefore an appealing option for high-risk patients who are unsuitable for open repairs. The aim of the present meta-analysis was to assess the efficacy of hybrid techniques in patients with aortic arch pathologies.

METHODS

Extensive electronic literature search was undertaken to identify all articles published up to December 2012 that described hybrid aortic arch repair with intrathoracic supra-aortic branch revascularisation and subsequent stent graft deployment. Eligible studies were divided into two groups: group I included studies on the aortic arch debranching procedure and group II included studies that reported an elephant trunk technique (either "frozen" or stented). Separate meta-analyses were conducted in order to assess technical success, stroke, spinal cord ischemia (SCI), renal failure requiring dialysis, and cardiac and pulmonary complications rate, as well as 30-day/in-hospital mortality.

RESULTS

Forty-six studies were eligible for the present meta-analysis: 26 studies with a total of 956 patients reported aortic arch debranching procedures, and 20 studies with 1,316 patients performed either 'frozen' or stented elephant trunk technique. The pooled estimate for 30-day/in-hospital mortality was 11.9% for the arch debranching group and 9.5% for the elephant trunk group. Cerebrovascular events of any severity were found to have occurred postoperatively at a pooled rate of 7.6% and 6.2%, while irreversible spinal cord injury symptoms were present in a pooled estimate of 3.6% and 5.0% in the arch debranching and elephant trunk group, respectively. Renal failure requiring dialysis occurred at 5.7% and 3.8% in both groups, while cardiac complications rate was 6.0% in the arch debranching cohort and pulmonary complication was 19.7% in the elephant trunk cohort.

CONCLUSIONS

Hybrid arch techniques provide a safe alternative to open repair with acceptable short- and mid-term results. However, stroke and mortality rates remain noteworthy. Future prospective trials that compare open conventional techniques with the hybrid method or the entirely endovascular methods are needed.

Endovascular stent graft repair for thoracic aortic aneurysms: the history and the present in Japan

Stent-grafts for endovascular repair of thoracic aortic aneurysms have been commercially available for more than ten years in the West, whereas, in Japan, a manufactured stent-graft was not approved for the use until March 2008. Nevertheless, endovascular thoracic intervention began to be performed in Japan in the early 1990s, with homemade devices used in most cases. Many researchers have continued to develop their homemade devices. We have participated in joint design and assessment efforts with a stent-graft manufacturer, focusing primarily on fenestrated stent-grafts used in repairs at the distal arch, a site especially prone to aneurysm. In March 2008, TAG (W.L. Gore & Associates, Inc., Flagstaff, Arizona, USA) was approved as a stent graft for the thoracic area first in Japan, which was major turning point in treatment for thoracic aortic aneurysms. Subsequently, TALENT (Medtronic, Inc., Minneapolis, Minnesota, USA) was approved in May 2009, and TX2 (COOK MEDICAL Inc., Bloomington, Indiana, USA) in March 2011. Valiant as an improved version of TALENT was approved in November 2011, and TX2 Proform as an improved version of TX2 began to be supplied in October 2012. These stent grafts are excellent devices that showed good results in Western countries, and marked effectiveness can be expected by making the most of the characteristics of each device. A clinical trial in Japan on Najuta (tentative name) (Kawasumi Labo., Inc., Tokyo, Japan) as a line-up of fenestrated stent grafts that can be applied to distal arch aneurysms showing a high incidence, and allow maintenance of blood flow to the arch vessel was initiated. This trial was completed, and Najuta has just been approved in January of 2013 in Japan, and further development is expected. In the U.S., great efforts have recently been made to develop and manufacture excellent stent grafts for thoracic aneurysms, and rapid progress has been achieved. In particular, in the area of the aortic arch, in which we often experience aneurysmal change, but there are no commercially available devices which are urgently needed. Companies are competing keenly to develop devices. To our knowledge, more than 4 manufacturers are involved in the development of functionally new stent grafts in this area. The introduction of branched stent grafts may not be faraway.

Surgically relevant aortic arch mapping using computed tomography

BACKGROUND

Recent advances in surgical repair of aortic arch pathologies have increasingly used endovascular stent-graft technology. The purpose of this study was to map the aortic arch diameters, branch orientations, and center line distances using a commercially available three-dimensional computed tomography-based software package and to propose a prototype design.

METHODS

TeraRecon 3D imaging software was used for morphological assessment of computed tomography scans from 45 patients (mean age: 68 years; 26 males, 19 females). In each patient, 13 measurements were made in relation to the center line, including diameters at several preset points, distances, and branch vessel orientations.

RESULTS

The mode of the proximal diameters (2 cm and 4 cm distal to coronary artery) was 32 mm and 34 mm. The mode of the distance between the innominate and left common carotid arteries was 5 mm and 6 mm, and the mode of the distance between the left common carotid artery and left subclavian artery was 8 mm. Most commonly, the left common carotid artery was anterior to the other arch branches by 3 to 5 mm.

CONCLUSIONS

These anatomic measurements provide useful information for the advancement of minimally invasive and safer surgical repair of the aortic arch. Based on the most commonly observed measurements, a standardized off-the-shelf stent-graft is proposed that would be appropriate for the majority of patients.