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Vervoort D, Tarola C, Chung JCY, Crawford SA, Lindsay TF, Fremes SE. Aortic Arch Innovation: Branching Out By Branching In? Can J Cardiol 2024; 40:1341-1343. [PMID: 38430958 DOI: 10.1016/j.cjca.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024] Open
Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jennifer C Y Chung
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Sean A Crawford
- Division of Vascular Surgery, Peter Munk Cardiac Centre Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre Toronto General Hospital, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Huang J, Tian H, Chen Z, Teng B, Zhao Y, Li F. Outcomes of thoracic endovascular aortic repair with physician-manufactured partial micropore stent grafts for aortic arch pathologies. J Vasc Surg 2024; 79:1005-1012. [PMID: 38157994 DOI: 10.1016/j.jvs.2023.12.043] [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: 10/19/2023] [Revised: 12/05/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) has been used extensively in the management of thoracic aortic diseases. Numerous efforts have been made to enhance clinical outcomes through the use of stent grafts. This study aimed to investigate the effectiveness and safety of physician-manufactured partial micropore stent grafts (PSMGs) in TEVAR. METHODS Between December 2017 and June 2022, data were collected from 56 patients who underwent TEVAR using physician-manufactured PSMGs. The evaluation encompassed technical success, perioperative and follow-up morbidity and mortality, stroke incidence, and branch artery patency. RESULTS In this investigation, 56 patients received treatment with physician-manufactured PSMGs. Of these patients, 46 were male, with a mean age of 62.1 ± 11.2 years. Aortic pathologies comprised aortic dissection (n = 31 [55.4%]), aortic aneurysms (n = 10 [17.9%]), penetrating aortic ulcer (n = 8 [14.3%]), and intramural hematoma (n = 7 [12.5%]). During a median follow-up of 18 months (interquartile range, 13-25 months), the stroke rate, supra-aortic branch patency rate, and endoleak rate were 0%, 100%, and 7.1%, respectively. There were no occurrences of all-cause mortality, stroke, or the necessity for open conversion. CONCLUSIONS TEVAR with physician-manufactured PSMGs is a viable alternative for addressing aortic arch pathologies in proficient medical centers. The approach demonstrates favorable branch patency, a low complication rate, and minimal postoperative mortality.
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Affiliation(s)
- Junpu Huang
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hao Tian
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng Chen
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Biyun Teng
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Zhao
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fenghe Li
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Vervoort D, An KR, Deng MX, Elbatarny M, Fremes SE, Ouzounian M, Tarola C. The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch. Can J Cardiol 2024; 40:478-495. [PMID: 38052303 DOI: 10.1016/j.cjca.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mimi X Deng
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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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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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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Kus N, Robinson JA, Hall MR, Ghoreishi M, Taylor B, Toursavadkohi S. Emergent Total Endovascular Arch Repair for Contained Aortic Arch Rupture: Another Tool in the Box. Vasc Endovascular Surg 2023; 57:771-775. [PMID: 37058450 DOI: 10.1177/15385744231170919] [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: 04/15/2023]
Abstract
To date, emergent total endovascular aortic arch repair has not been described in the literature. We present a 67-year-old female with a poorly differentiated posterior mediastinal sarcoma. Imaging obtained was concerning for intravascular extension of the tumor into the thoracic aorta. While awaiting radiation therapy, the patient complained of worsening chest and arm pain, vital signs demonstrating tachypnea and hypoxia. Subsequent imaging revealed an increase in vascular erosion, concerning for a contained rupture, with complete obliteration of the left mainstem bronchus. The patient was emergently taken for percutaneous endovascular repair of her aortic arch. A three-vessel physician modified fenestrated graft was created and deployed with concurrent stenting of the innominate, left carotid, and left subclavian arteries. Interval computed tomography angiography revealed patency in all stented vessels, with no endoleak and no evidence of pseudoaneurysm. The patient was able to undergo chemotherapy with favorable decrease in tumor burden. Total endovascular aortic arch repair, when planned carefully, is an attractive option in high-risk patients who are otherwise not ideally suited for open total arch replacement.
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Affiliation(s)
- Nicole Kus
- Division of General Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Justin A Robinson
- Division of Cardiovascular and Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Michael R Hall
- Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mehrdad Ghoreishi
- Division of Cardiovascular and Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Bradley Taylor
- Division of Cardiovascular and Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD, USA
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Saini JS, Coselli JS. Commentary: Aortic arch repair: Custom made versus one size fits all. J Thorac Cardiovasc Surg 2023; 166:1009-1010. [PMID: 35337676 DOI: 10.1016/j.jtcvs.2022.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Jaskaran S Saini
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St. Luke's Medical Center, Houston, Tex.
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Kwan KJS, Li HL, Chan YC, Cheng SWK. Safety and Efficacy of Inner Branched Stent-Graft in the Treatment of Aortic Arch Disease: A Systematic Review. J Endovasc Ther 2023:15266028231197395. [PMID: 37646117 DOI: 10.1177/15266028231197395] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
OBJECTIVE To provide a descriptive overview on the contemporary outcomes of thoracic endovascular arch repair with inner branched endoprosthesis (bTEVAR) for the treatment of aortic arch pathologies. METHODS A comprehensive literature search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Pre-defined search terms were used to interrogate PubMed and OVID Medline databases from January 1999 to July 2022. Patient characteristics, indication for treatment, procedural data, mortality rates, postoperative complications, and reintervention rate during follow-up were evaluated. RESULTS Nineteen articles were included, encompassing a total of 618 patients who received bTEVAR, most of which were double-branched (63.9%, n=395). The main indication for treatment was aneurysm secondary to chronic aortic dissection (38.8%, n=240/618) with a mean maximum diameter of 58.3±11.4 mm. Pooled mean technical success rate was 97.4±4.4% (95% confidence interval [CI]=95.1%-99.5%); 2 and 3 patients required conversion to chimney technique and open repair, respectively. Among the pooled rates of early complications, postoperative stroke was the highest (10.5%; 95% CI=6.8%-14.3%). Thirty-day and in-hospital mortality rate was 5.5% (95% CI=2.6%-9.7%). Forty patients (6.5%; 95% CI=2.5%-9.5%) required early reintervention. During a mean follow-up of 20.7±13.5 months, the mortality rate was 18.2% (n=108/593; 95% CI=8.6%-20.6%) where 12 (11.1%) were aortic-related. Pooled late reintervention rate was 9.6% (95% CI=4.8%-14.3%). Comparison of demographics and outcomes found no significant difference between single and double bTEVAR. CONCLUSION Branched thoracic endovascular aortic repair is a promising approach for aortic arch pathologies with a high technical success rate despite a steep learning curve. However, contemporary outcomes reflect that postoperative stroke remains the predominant concern. Further experience and long-term follow-up are required to sufficiently elucidate the safety and durability of bTEVAR in the management of aortic pathologies for high-risk patients. CLINICAL IMPACT This systematic review summarized the contemporary outcomes of thoracic endovascular aortic repair with different inner branched stent-grafts for the management of aortic arch pathologies. Pooled results from nineteen studies with 618 patients demonstrated a high technical success rate and an acceptable mortality rate. However, postoperative stroke remains the major concern. Long-term follow-up is needed to evaluate its durability.
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Affiliation(s)
- Kristine J S Kwan
- International School, Jinan University, Guangzhou, China
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Hai-Lei Li
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yiu Che Chan
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China
| | - Stephen W K Cheng
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China
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Nana P, Houérou TL, Guihaire J, Gaudin A, Fabre D, Haulon S. Early Outcomes on Triple-Branch Arch Device With Retrograde Left Common Carotid Branch: A Case Series. J Endovasc Ther 2023:15266028231195758. [PMID: 37635649 DOI: 10.1177/15266028231195758] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
INTRODUCTION Endovascular aortic arch repair using multibranch devices has been applied in patients considered at high risk for open repair. The aim of this case series was to report the early outcomes in patients managed with a new design 3 branch arch custom-made device, including a retrograde left common carotid artery (LCCA) branch. METHODS The Preferred Reporting Of CaSe Series in Surgery (PROCESS) guidelines were followed. All consecutive patients undergoing endovascular repair of an aortic arch lesion with a custom-made triple-branch device, including a retrograde LCCA branch (Cook Medical, Bloomington, IN, USA), between October 27, 2022, and February 28, 2023, were included. The presence of an arch aneurysm (degenerative or post-dissection) with diameter ≥55 mm and high risk for a conventional open repair set the indication for treatment. The primary outcomes were technical success and mortality at 30 days. Early morbidity and reinterventions were considered as secondary outcomes. RESULTS Eight elective patients (87.5% men, mean age 72.3±27.0 years) were included. Five of them (62.5%) had undergone a previous ascending aorta repair of an acute type A aortic dissection. All patients were asymptomatic, except one, with left recurrent laryngeal nerve compression. The mean maximum aortic diameter was 70.4±21.0 mm. Percutaneous femoral and axillary access was used in all cases except three in which a cut down for right carotid access was performed. Technical success was 100%. Femoral access to the LCCA and implantation of the bridging stent was performed without technical challenges. No death nor cerebrovascular event was recorded during the 30 day follow-up. Five patients (62.5%) presented major complications, 3 related to access needing reintervention and the remaining related to congestive heart failure (CHF), which were managed successfully with medical treatment. Follow-up (range 1-4 month) was uneventful, except for one patient who presented a secondary type Ia endoleak. CONCLUSIONS According to our early experience, the presence of a retrograde branch facilitated the revascularization of the LCCA through femoral access, decreasing the risk of cerebrovascular morbidity. Further analyses with longer follow-up are needed to evaluate the safety and efficacy of the device. CLINICAL IMPACT Data arising mainly from the retrograde branch for the revascularization of the LSA are encouraging from a variety of devices. The premiminary experience with a triple-branched arch device, with a retrograde branche for the LSA but also for the LCCA, was associated with no 30 day mortality and 100% technical success.The device's design allowed swift catheterization and completion of the LCCA revascularization using femoral access exclusively.
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Affiliation(s)
- Petroula Nana
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
| | - Thomas Le Houérou
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
| | - Julien Guihaire
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
| | - Antoine Gaudin
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
| | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Université Paris-Saclay, Paris, France
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Lin J, Guan X, Nutley M, Panneton JM, Zhang Z, Guidoin R, Wang L. Stent-Graft Fabrics Incorporating a Specific Corona Ready to Fenestrate. MATERIALS (BASEL, SWITZERLAND) 2023; 16:4913. [PMID: 37512188 PMCID: PMC10381316 DOI: 10.3390/ma16144913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023]
Abstract
In situ fenestration of endovascular stent-grafts has become a mainstream bailout technique to treat complex emergent aneurysms while maintaining native anatomical visceral and aortic arch blood supplies. Fabric tearing from creating the in situ fenestration using balloon angioplasty may extend beyond the intended diameter over time. Further tearing may result from the physiologic pulsatile motion at the branching site. A resultant endoleak at the fenestrated sites in stent-grafts could ultimately lead to re-pressurization of the aortic sac and, eventually, rupture. In an attempt to address this challenge, plain woven fabrics were designed. They hold a specific corona surrounding a square-shaped cluster with a plain weave fabric structure, a 2/2 twill, or a honeycomb. The corona was designed to stop potential further tearing of the fabric caused by the initial balloon angioplasty and stent or later post-implantation motion. The cluster within the corona was designed with relatively loose fabric structures (plain weave, 2/2 twill weave, and honeycomb) to facilitate the laser fenestration. Two commercial devices, Anaconda (Vascutek, Terumo Aortic) and Zenith TX2 (Cook), were selected as controls for comparison against this new design. All the specimens were characterized by morphology, thickness, and water permeability. The results demonstrated that all specimens with a low thickness and water permeability satisfied the requirements for a stent graft material that would be low profile and resistant to endoleaks. The in situ fenestrations were performed on all fabrics utilizing an Excimer laser followed by balloon angioplasty. The fabrics were further observed by light microscopy and scanning electron microscopy. The dimension of the fenestrated apertures was smaller than the balloon's diameter. The tearing was effectively confined within the corona. The clinical acceptability of this concept deserves additional bench testing and animal experimentation.
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Affiliation(s)
- Jing Lin
- Key Laboratory of Textile Science and Technology, Ministry of Education, College of Textiles, Donghua University, Shanghai 201620, China
- Key Laboratory of Textile Industry for Biomedical Textile Materials and Technology, Donghua University, Shanghai 201620, China
| | - Xiaoning Guan
- Key Laboratory of Textile Science and Technology, Ministry of Education, College of Textiles, Donghua University, Shanghai 201620, China
- Key Laboratory of Textile Industry for Biomedical Textile Materials and Technology, Donghua University, Shanghai 201620, China
| | - Mark Nutley
- Division of Vascular Surgery and Department of Diagnostic Imaging, University of Calgary, Peter Lougheed Centre, Calgary, AB T2N1N4, Canada
| | - Jean M Panneton
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA 23501, USA
| | - Ze Zhang
- Department of Surgery, Faculty of Medicine, Université Laval and Centre de Recherche du CHU de Québec, Québec, QC G1V 0A6, Canada
| | - Robert Guidoin
- Department of Surgery, Faculty of Medicine, Université Laval and Centre de Recherche du CHU de Québec, Québec, QC G1V 0A6, Canada
| | - Lu Wang
- Key Laboratory of Textile Science and Technology, Ministry of Education, College of Textiles, Donghua University, Shanghai 201620, China
- Key Laboratory of Textile Industry for Biomedical Textile Materials and Technology, Donghua University, Shanghai 201620, China
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Houérou TL, Nana P, Pernot M, Guihaire J, Gaudin A, Lerisson E, Costanzo A, Fabre D, Haulon S. Systematic Review on In Situ Laser Fenestrated Repair for the Endovascular Management of Aortic Arch Pathologies. J Clin Med 2023; 12:jcm12072496. [PMID: 37048580 PMCID: PMC10095564 DOI: 10.3390/jcm12072496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/12/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Background: In situ laser-fenestrated thoracic aortic endovascular repair (FTEVAR) has emerged as a valuable alternative for aortic arch management. This review assessed the early and follow-up outcomes of in situ laser-FTEVAR in aortic arch pathologies. Methods: The PRISMA statement was followed. The English literature was searched, via Ovid, until 15 October 2022. Observational studies, published after 2000, reporting on early and follow-up outcomes for the in situ laser-FTEVAR were eligible. The Newcastle–Ottawa Scale was used to assess the risk of bias. Primary outcomes were the technical success, stroke, and mortality at 30-days, and the secondary were the mortality and reintervention during follow-up. Results: Six retrospective studies from 591 and 247 patients were included. Fifty-nine (23.9%) patients were managed for aortic arch aneurysms and 146 (59.1%) for dissections; 22.6% of them for type A. Technical success was at 98% (range 90–100%). Eight patients died (3.2%) and 11 cases presented any type of stroke (4.5%) during the 30-day follow-up. The mean follow-up was 15 months (1–40 months). Ten deaths were reported (4.2%); one was aortic-related (10%). Thirteen re-interventions (6.0%) were performed. Conclusions: In situ laser-FTEVAR for aortic arch repair may be performed with high technical success and low 30-day and midterm follow-up mortality, stroke, and re-intervention rates when applied in well selected patients and performed by experienced teams.
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Luo ZR, Zhang JX, Huang ZY, Chen LW. Endovascular repair of aortic pathologies involving the aortic arch using castor stent-graft combined with in-vitro fenestration technology. BMC Cardiovasc Disord 2023; 23:107. [PMID: 36829125 PMCID: PMC9960472 DOI: 10.1186/s12872-023-03138-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/21/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Aortic arch pathologies are concerning clinical conditions with poor prognoses. The use of thoracic endovascular aortic repair (TEVAR) has been investigated to treat aortic arch pathologies. Nonetheless, cerebral blood flow regulation during endovascular aortic arch repair therapy remains challenging. Castor, a unique single-branched stent graft, has been proven effective for retaining the left subclavian artery (LSA). This study aimed to determine whether endovascular therapy for pathologies involving the aortic arch using Castor in combination with the in-vitro fenestration technique is promising, effective, and safe. METHODS Eligible patients were enrolled between June 2018 and December 2021. All patients underwent TEVAR with an evaluated proximal landing zone for "Castor" located in Ishimaru zones 0-1. Moreover, the supra-aortic branches (SABs) were reconstructed using the Castor in combination with the in-vitro fenestration technique. RESULTS Herein, 57 patients with aortic arch lesions were treated with Castor in combination with the in-vitro fenestration technique. Innominate artery and the left carotid artery (LCA) were reconstructed in 5 patients, LCA and left subclavian artery (LSA) were reconstructed in 22 patients, and the total SABs were effectively reconstructed in 30 patients (including a hybrid arch repair case). Among them (excluding a hybrid arch repair case) were in-vitro fenestration methodologies for LCA in 32 of 34 cases (2 switched to in-situ fenestration) and LSA in 51 of 56 cases (3 switched to in-situ fenestration and 2 converted to spring coil caulking); furthermore, LCA and LSA in-vitro fenestration were simultaneously successfully performed in 27 of 34 cases. There were no surgical-related neurological complications, and early mortality was estimated at 5.26%. At a mean follow-up of 3.75 months, computed tomography (CTA) images confirmed that each branch stent remained patent. There were no signs of endoleaks, migrative manifestations, or the need for secondary endovascular intervention or conversion to open surgical procedures. CONCLUSION Castor, in combination with in-vitro fenestration, reflects a feasible, efficient procedure for re-developing SABs.
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Affiliation(s)
- Zeng-Rong Luo
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China.,Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian Province, People's Republic of China
| | - Jia-Xin Zhang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China.,Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian Province, People's Republic of China
| | - Zhong-Yao Huang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China.,Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian Province, People's Republic of China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China. .,Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian Province, People's Republic of China.
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13
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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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Lucchese G, Bilkhu R. Surgical management of the aortic arch in patients with inherited aortopathy. Front Cardiovasc Med 2022; 9:974190. [PMID: 36337905 PMCID: PMC9632981 DOI: 10.3389/fcvm.2022.974190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
Surgical management of the aortic root and ascending aorta has seen an evolution over the past 50 years. Despite the widely available guidelines for management of the aortic root and ascending aorta, including in those with connective tissue disease and inherited aortopathies, there are generally no clear guideline indications for when to intervene on the aortic arch in these patients. This perhaps may be related to the fact that whilst the majority of acquired aortopathies, and also in non-syndromic aortopathies such as in bicuspid aortic valve, size criteria are utilized to decide on when to intervene, the use of size criteria may not be appropriate in those with syndromic inherited aortopathies. The aim of the present mini review is to provide a general overview and guidance for the surgical management of patients with inherited aortopathies.
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15
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Liu F, Zhang H, Rong D, Ge Y, Jia X, Xiong J, Ma X, Wang L, Fan T, Guo W. Protocol for Guo's aortIc Arch recoNstrucTion: a prospective, multicentre and single-arm study to evaluate the safety and efficacy of the WeFlow-Arch modular inner branch stent-graft system for aortic arch lesions (GIANT study). BMJ Open 2022; 12:e063245. [PMID: 36216431 PMCID: PMC9557281 DOI: 10.1136/bmjopen-2022-063245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Endovascular repair of the entire aortic arch provides treatment opportunities for patients with aortic arch lesions who are intolerant to open surgery. However, the complex anatomical configuration, high-speed blood flow and long access from the femoral artery increase the difficulty of endovascular aortic arch repair. On the basis of our earlier studies, a new modular inner branch stent-graft system was developed specifically for lesions located in the aortic arch and part of the ascending aorta. This study aims to evaluate the safety and efficacy of the novel modular branch stent-graft system in patients with aortic arch lesions who are unsuitable for open aortic arch replacement. METHODS AND ANALYSIS This prospective, multicentre, single-arm, clinical trial will enrol 80 patients with aortic arch lesions requiring intervention, namely, true aortic arch aneurysms, pseudo-aortic arch aneurysms and penetrating ulcers involving the aortic arch. Clinical information and CT angiography (CTA) images will be collected and analysed to investigate the safety and efficacy of the novel modular branch stent-graft system. Patients will be followed up for 5 years. The primary outcome will be all-cause mortality and severe stroke within 12 months after the procedure. In addition, this trial will evaluate mid-term to long-term clinical and imaging outcomes through the annual clinical and CTA follow-up for 2-5 years postoperatively. ETHICS AND DISSEMINATION We have registered the study on a registry website (https://clinicaltrials.gov/ct2/home). The study findings will be disseminated through peer-reviewed journals, physician newsletters, conferences and the mass media. TRIAL REGISTRATION NUMBER NCT04765592.
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Affiliation(s)
- Feng Liu
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Hongpeng Zhang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Dan Rong
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yangyang Ge
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Xin Jia
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Jiang Xiong
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Xiaohui Ma
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Lijun Wang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Tingting Fan
- Department of Biomechanics and Rehabilitation Engineering, Capital Medical University, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
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16
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Jiménez-Jiménez CE, Randial-Pérez LJ, Héctor Hugo RM, Silva-Restrepo I, Valenzuela-Valenzuela JA. Tratamiento endovascular con técnica de chimenea para patologías del arco aórtico. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introducción. La patología del arco aórtico se ha tratado principalmente con cirugía por vía abierta, pero con una alta morbimortalidad. Las técnicas endovasculares híbridas y las reconstrucciones en “chimenea” son una técnica válida y segura para disminuir el riesgo y la mortalidad.
Métodos. Se presentan dos pacientes con patología del arco aórtico y contraindicación de manejo quirúrgico abierto, atendidos en el Servicio de Cirugía Vascular, Hospital Universitario Clínica de San Rafael, Bogotá, D.C., Colombia.
Resultados. Se realizaron dos procedimientos endovasculares del arco aórtico para tratar un aneurisma torácico roto y una úlcera aórtica sintomática, con cubrimiento de los troncos supra aórticos con una endoprótesis y canalización de los vasos supra aórticos con prótesis cubiertas y uso de la “técnica de chimenea”, de manera exitosa.
Discusión. La patología del arco aórtico es de alta complejidad y se asocia con una morbimortalidad elevada por lo que, en los últimos 20 años se han desarrollado diferentes técnicas utilizando procedimientos percutáneos.
Conclusión. La “técnica de chimenea” se puede realizar de una manera mínimamente invasiva en pacientes con patología del arco aórtico, no candidatos para cirugía abierta, con resultados exitosos.
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Lu H, Huang LC, Chen LW. Endovascular surgery for thoracic aortic pathologies involving the aortic arch. Front Cardiovasc Med 2022; 9:927592. [PMID: 35911538 PMCID: PMC9329620 DOI: 10.3389/fcvm.2022.927592] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Aortic arch pathologies are serious clinical conditions associated with a very dismal prognosis. Traditional open surgery has a high mortality and is not suitable for critically ill patients. Recently years, endovascular treatment of thoracic aorta has made rapid progress and has been gradually applied to the treatment of aortic arch pathologies. However, maintaining cerebral blood flow during endovascular treatment of aortic arch lesions remains a challenge at this time. This study aims to evaluate the feasibility, efficacy, and safety of endovascular treatment of thoracic aortic pathologies involving the aortic arch, and to present initial experience with this technique. Methods From October 2016 to December 2020, patients who met the inclusion criteria were enrolled. All patients underwent thoracic endovascular aortic repair with the proximal landing zone of the stent-graft in the aortic arch at Ishimaru zones 0–1, in which cerebral flow needs to be maintained during surgery, and the supra-aortic branches were reconstruction with either in situ fenestration or the chimney technique. Results A total of 62 cases with lesions involving the arch were treated with endovascular surgery. Total supra-aortic branches reconstruction was successfully performed in 51 cases, the left carotid artery (LCA) and the innominate artery reconstruction were performed in eight cases, the left subclavian artery (LSA) and the LCA were reconstructed in three patients. Among them, the in situ fenestration or chimney repair technique for the LSA was successful performed in 42 and 12 cases. However, in 20 patients, attempts to reconstruction the LSA using the fenestration technique were unsuccessful due to tortuous and angulated vessels. Early mortality was 6.45%. No neurological complications related to surgery occurred. Computer tomography images at post-operative follow-up (mean 3.51 months) confirmed patency of all branch stents without any signs of endoleaks, migration, conversion to retrograde dissection or receive open-heart surgery. Conclusion The endovascular technique is an effective, feasible, safe and repeatable method to reconstruct the aortic arch, which allows for the reconstruction of the supra-aortic branches.
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Affiliation(s)
- Heng Lu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Ling-chen Huang
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
- *Correspondence: Ling-chen Huang,
| | - Liang-wan Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
- Liang-wan Chen,
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18
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Waterford SD, Ghoreishi M, Toursavadkohi S, Taylor BS. The 10 Commandments of Aortic Arch Endovascular Repair. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:266-272. [PMID: 35997683 DOI: 10.1177/15569845221116864] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Stephen D Waterford
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center Hamot, Erie, PA, USA
| | - Mehrdad Ghoreishi
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradley S Taylor
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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Unnikrishnan M, Viswanathan S, Pitchai S, Savlania A, Ramachandran H, Kumar PMV, Mohanan A, Gopalakrishnan P, Kapilamoorthy TR, Dash P. Evolving paradigm of hybrid repair for aortic arch pathologies. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.4103/ijves.ijves_75_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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20
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Gandet T, Westermann D, Conradi L, Panuccio G, Heidemann F, Rohlffs F, Kölbel T. Modular Endo-Bentall Procedure Using a "Rendez-Vous Access". J Endovasc Ther 2021; 29:711-716. [PMID: 34964371 DOI: 10.1177/15266028211065959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The concept of a single endovascular valve-carrying conduit device was designated endo-Bentall, but published experience is limited to a single case. This technical note describes an alternative modular endo-Bentall technique and a novel access technique to implant it. TECHNIQUE A 82-year-old woman with chest pain referred for a 10 cm symptomatic aneurysm of the distal arch and descending aorta. An ascending aortic aneurysm of 5.5 cm prevented endovascular aortic arch repair due to lack of a proximal landing zone. The technique is a modular approach combining a physician-modified endograft (PMEG) with 3 large fenestrations for coronary artery perfusion and a transcatheter aortic valve implantation (TAVI). A "rendez-vous access" with a transapical and transfemoral through-and-through wire offered rapid sequential deployment in a modular fashion of both components. The PMEG was deployed first, landing 5 mm deep in the left ventricular outflow tract (LVOT) and the transcatheter aortic valve was implanted few millimeters below. The endo-Bentall procedure was combined with endovascular aortic arch repair. CONCLUSION A modular endo-Bentall procedure combining a PMEG and TAVI is feasible and adaptable to emergent setting using the "rendez-vous access."
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Affiliation(s)
- Thomas Gandet
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart & Vascular Center, Hamburg, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart & Vascular Center, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart & Vascular Center, Hamburg, Germany
| | - Giuseppe Panuccio
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart & Vascular Center, Hamburg, Germany
| | - Franziska Heidemann
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart & Vascular Center, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart & Vascular Center, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart & Vascular Center, Hamburg, Germany
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Spanos K, Nana P, von Kodolitsch Y, Behrendt CA, Kouvelos G, Panuccio G, Athanasiou T, Matsagkas M, Giannoukas A, Detter C, Kölbel T. Management of Ascending Aorta and Aortic Arch: Similarities and Differences Among Cardiovascular Guidelines. J Endovasc Ther 2021; 29:667-677. [PMID: 34873944 DOI: 10.1177/15266028211061271] [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] [Indexed: 01/16/2023]
Abstract
BACKGROUND Ascending aorta and aortic arch diseases have an increasing interest among cardiovascular specialists regarding diagnosis and management. Innovations in endovascular surgery and evolution of open surgery have extended the indications for treatment in patients previously considered unfit for surgery. The aim of this systematic review of the literature was to present and analyze current cardiovascular guidelines for overlap and differences in their recommendations regarding ascending aorta and aortic arch diseases and the assessment of evidence. METHODS The English medical literature was searched using the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 2009 to December 2020. Recommendations on selected topics were analyzed, including issues from definitions and diagnosis (imaging and biomarkers) and indications for treatment to management, including surgical techniques, of the most important ascending aorta and aortic arch diseases. RESULTS The initial search identified 2414 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from multidisciplinary, cardiovascular societies published between 2010 and 2019. The definition of non-A-non-B aortic dissection is lacking from most of the guidelines. There is a disagreement regarding the class of recommendation and level of evidence for the diameter of ascending aorta as an indication. The indication for treatment of aortic disease may be individualized in specific cases while the growth rate may also affect the decision making. The role of endovascular techniques has not been established in current guidelines except by 1 society. Supportive evidence level in the management of aortic arch diseases remains limited. CONCLUSION In current recommendations of cardiovascular societies, the ascending aorta and aortic arch remain a domain of open surgery despite the introduction of endovascular techniques. Recommendations of the included societies are mostly based on expert opinion, and the role of endovascular techniques has been highlighted only from 1 society. The chronological heterogeneity apparent among guidelines and the inconsistency in evidence level should be also acknowledged. More data are needed to develop more solid recommendations for the ascending aorta and aortic arch diseases.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.,Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Petroula Nana
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Yskert von Kodolitsch
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Christian-Alexander Behrendt
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - George Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Giuseppe Panuccio
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christian Detter
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
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22
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Barnes JA, Wanken ZJ, Columbo JA, Kuwayama DP, Fillinger MF, Suckow BD. Procedure-Associated Costs and Mid-Term Outcomes of Endovascular Zone 0 and Zone 1 Aortic Arch Repair. Ann Vasc Surg 2021; 81:98-104. [PMID: 34780945 DOI: 10.1016/j.avsg.2021.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/24/2021] [Accepted: 10/01/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) of proximal aortic arch pathology provides a less-invasive treatment option for high-risk patients ineligible for open arch reconstruction. However, the fiscal impact of these techniques remains unclear. Therefore, our objective was to characterize the mid-term outcomes after Zone 0 and Zone 1 TEVAR and describe the associated technical costs, revenues, and net margins at a single tertiary medical center. METHODS We examined all patients who underwent TEVAR between April 2011 and August 2019 via retrospective chart review. Patients were categorized by proximal endograft extent to identify Zone 0 or Zone 1 repairs. Procedural characteristics and outcomes were described. Technical costs, revenues, and margins were obtained from the hospital finance department. RESULTS We identified 10 patients (6 Zone 0, 4 Zone 1) who were denied open arch reconstruction. Patients were predominantly female (n = 8; 80%) and the mean age was 72.8 ± 5.5 years. TEVAR was performed in 5 asymptomatic patients, urgently in 3 symptomatic patients, and emergently in 2 ruptured patients. TEVAR plus extra-anatomic bypass was performed in 4 patients. Another 4 patients also received parallel stent-grafting while 1 patient received a branched thoracic endograft and yet another an in-situ laser fenestration followed by branch stent grafting. Within the 30-day postoperative period, 1 patient experienced stroke and 1 patient died. Bypass and branch vessel patency were 100% through the duration of follow-up (mean 19.3 months). Mean total technical cost associated with all procedures or repair stages was $105,164 ± $59,338 while mean net technical margin was -$25,055 ± $18,746. The net technical margin was negative for 9 patients. CONCLUSIONS Endovascular repair of the proximal aortic arch is associated with good mid-term outcomes in patients considered too high-risk for open repair. However, reimbursement does not adequately cover treatment cost, with net technical margins being negative in nearly all cases. To remain financially sustainable, efforts should be made to both optimize aortic arch TEVAR delivery as well as advocate for reimbursement commensurate with associated costs.
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Affiliation(s)
| | - Zachary J Wanken
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David P Kuwayama
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mark F Fillinger
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Bjoern D Suckow
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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23
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Shu X, Xu H, Wang E, Wang L, Guo D, Chen B, Fu W. Midterm Outcomes of an Adjustable Puncture Device for In Situ Fenestration During Thoracic Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2021; 63:43-51. [PMID: 34750032 DOI: 10.1016/j.ejvs.2021.09.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 09/03/2021] [Accepted: 09/19/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the midterm outcomes of in situ fenestration (ISF) with an adjustable puncture device for aortic arch branch preservation during thoracic endovascular aortic repair (TEVAR). METHODS From October 2016 to April 2019, patients with complicated type B aortic dissection, thoracic aortic aneurysm > 5.5 cm in diameter, or aortic penetrating ulcer with a base > 20 mm or depth > 15 mm, who received TEVAR requiring a proximal sealing beyond zone 3 and underwent ISF using an adjustable puncture device, were included. After the procedure, patients were monitored at one, three, six, and 12 months, and annually thereafter. Peri-operative and follow up data were collected and analysed. RESULTS Fifty of 51 patients (98%) received successful ISFs. One, two, or three aortic arch branches were preserved in 44, six, and one patient, respectively. Intra-operatively, eight type Ia endoleaks and one type II endoleak were found on angiography. One patient died of cerebral hernia three days post-procedure from a severe stroke; one patient suffered from transient paraplegia but recovered in two weeks; one patient had a non-disabling stroke. The median follow up was 31 months (22.5 - 36.5 months). At six month follow up, all nine unmanaged endoleaks had disappeared. One new type Ia endoleak was identified in a patient at the one month follow up which resolved spontaneously one year later. All revascularised arteries were patent at the last follow up. No fractures, migrations, or bridging stent kinks were found. CONCLUSION In this largest mechanical based ISF study to date, an adjustable puncture device was shown to facilitate the procedure of ISF during endovascular repair of aortic diseases involving the aortic arch, with high success. The midterm outcome demonstrates the efficacy and safety of the device in assisting with preservation of aortic arch branches.
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Affiliation(s)
- Xiaolong Shu
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China; Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Houpu Xu
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China; Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Enci Wang
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China; Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Lixin Wang
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China; Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; Institute of Vascular Surgery, Fudan University, Shanghai, China.
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Bin Chen
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Xiamen Branch of Zhongshan Hospital, Fudan University, Xiamen, China; Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; Institute of Vascular Surgery, Fudan University, Shanghai, China.
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Stana J, Peterß S, Prendes CF, Stavroulakis K, Rantner B, Pichlmaier M, Tsilimparis N. [Ascending Aorta and Aortic Arch - Endovascular Therapy Today and in the Future]. Zentralbl Chir 2021; 146:479-485. [PMID: 34666362 DOI: 10.1055/a-1644-1759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Jan Stana
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Sven Peterß
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | | | | | - Barbara Rantner
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Maximilian Pichlmaier
- Herzchirurgische Klinik und Poliklinik, Klinikum der Ludwig-Maximilians-Universität München, Standort Großhadern, München, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
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Gombert A, Ketting S, Rückbeil MV, Hundertmark AK, Barbati M, Keschenau P, Pedersoli F, Schurink GW, Mees B, Kotelis D, Jacobs MJ. Perioperative and long-term outcome after ascending aortic and arch repair with elephant trunk and open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2021; 75:824-832. [PMID: 34606958 DOI: 10.1016/j.jvs.2021.09.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/12/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To describe the outcome of open thoracoabdominal aortic aneurysm (TAAA) repair following previous aortic arch repair including elephant trunk (ET) or frozen elephant trunk (FET) for acute and chronic pathologies. METHODS This was a retrospective, observational, multicenter study including 32 patients treated between 2006 and 2019 in two aortic centers using identical surgical protocols. Assessment focused on perioperative and long-term outcome, namely in-hospital morbidity and mortality, as well as procedure-related reintervention rate and aortic-related mortality rate. Kaplan-Meier curves with 95% confidence intervals were used to analyze the overall survival after surgery within the cohort. RESULTS Thirty-two patients (mean age, 45.0 ± 13.6 years; 20 males [62.5%]) were treated because of acute (34.38% [n = 11]) or chronic (65.62% [n = 21]) aortic pathologies, including residual dissection following acute, symptomatic type A dissection (n = 7) and symptomatic mega aortic syndrome (n = 4), as well as post-dissection TAAA (n = 18) and asymptomatic mega aortic syndrome (n = 3). Twenty-eight patients (87.5%) received type II repair, and 4 patients (12.5%) received type III repair after previous ascending aorta and arch repair including ET/FET. Concomitant infrarenal and iliac vessel repair was performed in 38.7% (n = 12) and 29.4% (n = 10), respectively. The in-hospital mortality rate was 18.75% (n = 6). Spinal cord ischemia occurred in two cases, both after one-stage emergency procedure with one case of permanent paraplegia. Temporary acute kidney injury occurred in 41.94% (n = 13). The estimated 1-year survival rate was 78.1% (95% confidence interval, 63.9%-95.6%), with a median follow-up time of 1.29 years (interquartile range, 0.26-3.88 years). No procedure-related reinterventions and one case of aortic-related mortality, namely sepsis because of graft infection, was observed. CONCLUSIONS Open TAAA repair following aortic arch repair including ET or FET because of acute or chronic aortic pathologies is associated with a relevant perioperative morbidity and mortality rate. During follow-up, a low aortic-related mortality rate and procedure-related reintervention rate were observed.
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Affiliation(s)
- Alexander Gombert
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany.
| | - Shirley Ketting
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marcia Viviane Rückbeil
- Department of Medical Statistics, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Ann-Kathrin Hundertmark
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Mohammad Barbati
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Paula Keschenau
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Federico Pedersoli
- Department of Radiology, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Geert W Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Barend Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Drosos Kotelis
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Michael J Jacobs
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany; Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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Bondarenko PB, Shlomin VV, Shloĭdo EA, Puzdriak PD, Gordeev ML, Gusinskiĭ AV, Fionik OV. [Endovascular and hybrid treatment of thoracic and thoracoabdominal aortic aneurysms and dissections]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:50-61. [PMID: 34166344 DOI: 10.33529/angio2021215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The article deals with immediate and medium-term results of hybrid and endovascular treatment of 74 patients with various pathologies of the thoracic and thoracoabdominal aorta (31 with aneurysms, 43 with thoracic and thoracoabdominal aortic dissections). Elective and emergency interventions were performed in 49 and 25 patients, respectively. Endoprosthetic repair of the arch, descending thoracic and thoracoabdominal aorta was performed in 25 patients, hybrid operations in 47 subjects (open switch of brachiocephalic, visceral and renal arteries followed by aortic endoprosthetic repair - 37, endovascular methods of making a landing zone - 12). The duration of the follow-up period after discharge from hospital amounted to 24.9±16.3 months. The technical success level was 98.6%. The overall hospital mortality rate was 11% (n=8), elective - 4% (n=2), emergency - 24% (n=6). Eight patients underwent repeat interventions on the thoracic and thoracoabdominal aorta. The 5-year cumulative survival rate was 82.3%, with freedom from repeat interventions amounting to 51.3%. Hybrid operations on the arch and descending thoracic aorta are considered to be a relatively safe and effective method of treatment. Follow-up and timely treatment of remote complications after hybrid or endovascular operations are obligatory for improving the results.
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Affiliation(s)
- P B Bondarenko
- Department of Cardiovascular Surgery, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - V V Shlomin
- Department of Vascular Surgery, Municipal Multimodality Hospital #2, Saint Petersburg, Russia
| | - E A Shloĭdo
- Department of Vascular Surgery, Municipal Multimodality Hospital #2, Saint Petersburg, Russia
| | - P D Puzdriak
- Department of Vascular Surgery, Municipal Multimodality Hospital #2, Saint Petersburg, Russia
| | - M L Gordeev
- Department of Cardiovascular Surgery, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - A V Gusinskiĭ
- Department of Cardiovascular Surgery, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - O V Fionik
- Department of Cardiovascular Surgery, National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
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Endovascular Solutions for Aortic Arch Diseases: Total and Hybrid. Surg Technol Int 2021. [PMID: 34000753 DOI: 10.52198/21.sti.38.cv1415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Demal TJ, Bax L, Brickwedel J, Kölbel T, Vettorazzi E, Sitzmann F, Reichenspurner H, Detter C. Outcome of the frozen elephant trunk procedure as a redo operation. Interact Cardiovasc Thorac Surg 2021; 33:85-92. [PMID: 33667306 DOI: 10.1093/icvts/ivab059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/01/2020] [Accepted: 01/01/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The goal of this study was to determine the outcome of patients undergoing an elective frozen elephant trunk (FET) procedure as a redo operation following previous cardiac surgery. METHODS One hundred and eighteen consecutive patients underwent FET procedures between October 2010 and October 2019 at our centre. Patients were registered in a dedicated database and analysed retrospectively. Clinical and follow-up characteristics were compared between patients undergoing a FET operation as a primary (primary group) or a redo procedure (redo group) using logistic regression and Cox regression analysis. Emergency procedures (n = 33) were excluded from the analysis. RESULTS A total of 36.5% (n = 31) of the FET procedures were redo operations (redo group) and 63.5% (n = 54) of the patients underwent primary surgery (primary group). There was no significant difference in the 30-day mortality [primary group: 7.4%; redo group: 3.2%; 95% confidence interval (CI) (0.19-35.29); P = 0.63] and the 3-year mortality [primary group: 22.2%; redo group: 16.7%; 95% CI (0.23-3.23); P = 0.72] between redo and primary cases. Furthermore, the adjusted statistical analysis did not reveal significant differences between the groups in the occurrence of transient or permanent neurological deficit, paraplegia, acute renal failure and resternotomy. The redo group showed a higher rate of recurrent nerve palsy, which did not reach statistical significance [primary group: 3.7% (n = 2); redo group: 19.4% (n = 6); P = 0.091]. CONCLUSIONS Elective FET procedures as redo operations performed by a dedicated aortic team following previous cardiac surgery demonstrate an adequate safety profile.
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Affiliation(s)
- Till Joscha Demal
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Lennart Bax
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Jens Brickwedel
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Sitzmann
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Christian Detter
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
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Vento V, Lejay A, Kuntz S, Ancetti S, Heim F, Chakfé N, Gargiulo M. Current status on aortic endografts. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:544-554. [PMID: 32964901 DOI: 10.23736/s0021-9509.20.11614-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Endovascular treatment has become widespread to treat aneurysmal disease, especially located in the aorta. The modern era of abdominal aortic aneurysm repair started between 1986 and 1991, and in the last 30 years, Endovascular Treatment for abdominal aortic aneurysms evolved both due to the development of new materials and devices and the increasing appeal and effectiveness of the endovascular therapy itself. Vascular surgeons are using nowadays different solutions of Endovascular Treatment to treat all the expressions of aortic pathology (aneurysms, dissections and trauma) both in the acute and elective setting. Despite its use in every location of the aorta (the ascending aorta, the aortic arch, the thoracic aorta, thoraco-abdominal aorta, pararenal, iuxtarenal and infrarenal aortic aneurysms and iliac aneurysms), its safety and efficiency, endovascular treatment for aortic aneurysms presents some drawbacks: despite a lower short-term morbi-mortality, reinterventions and long-term patency are higher compared to open repair. In this review, we detail the most used types of endografts according to location, their performances and durability for each device. We conclude by discussing options to overcome ET limitations. Therefore, an obvious question arises: what we need in the future? What can the technological progress gives to physicians to further improve this new way of treating aorta?
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Affiliation(s)
- Vincenzo Vento
- Unit of Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy.,Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Anne Lejay
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Salomé Kuntz
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Stefano Ancetti
- Unit of Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy
| | - Frédéric Heim
- Laboratory of Physics and Textile Mechanics, University of Upper Alsace, Mulhouse, France
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Mauro Gargiulo
- Unit of Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy -
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Kuo HS, Huang JH, Chen JS. Handmade fenestrated stent grafts to preserve all supra-aortic branches in thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2020; 160:629-639.e1. [DOI: 10.1016/j.jtcvs.2019.07.096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 11/16/2022]
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Fujimura N, Ichihashi S, Motoki M, Ohtsubo S, Kawauchi Y, Kichikawa K, Shimizu H, Kato M. Anatomical Analysis and Feasibility Study of Next-Generation Fenestrated or Branched Stent-Grafts for the Treatment of Arch Aneurysms. J Endovasc Ther 2020; 27:777-784. [PMID: 32589119 DOI: 10.1177/1526602820938058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To analyze the anatomical characteristics of arch aneurysms and evaluate the anatomical feasibility of 4 next-generation stent-grafts with either branched or fenestrated configurations. Materials and Methods: A retrospective analysis was conducted of 213 patients (mean age 75.0±7.1 years; 179 men) with arch aneurysms treated using total arch replacement or zone 0 or 1 thoracic endovascular aortic repair (TEVAR) from 2007 to 2017 at 2 Japanese hospitals. Anatomical analyses were performed using the centerline of flow technique on a 3-dimensional workstation. The anatomical feasibility of the Zenith A-branch, TAG Thoracic Branch Endoprosthesis (TBE), Terumo Aortic Relay Plus Double Branched (DB), and fenestrated Najuta stent-grafts were evaluated based on the instructions for use (IFU). Results: The mean lengths from the sinotubular junction (STJ) to the innominate artery (IA) and from the IA to the left common carotid artery were 114.9±15.9 and 12.8±5.6 mm, respectively. The mean aortic diameters at the STJ and IA were 31.3±3.4 and 34.1±5.3 mm, respectively. In terms of feasibility, 5.2% of patients were within the Zenith A-branch IFU, 40.8% for the TAG TBE, 24.9% for the Relay Plus DB, and 13.6% for the Najuta. Significant (>50% circumference) thrombus/calcification at the sealing zone affected nearly half of the patients, but there is currently no standardized definition or evaluation method for "significant" thrombus/calcification. Conclusion: Only 5% to 41% of arch aneurysm patients are anatomically suitable for TEVAR using any one of the next-generation branched or fenestrated stent-grafts. Furthermore, a definitive method of evaluating the thrombus/calcification burden needs to be established in future IFU.
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Affiliation(s)
- Naoki Fujimura
- Division of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Shigeo Ichihashi
- Department of Radiology and IVR Center, Nara Medical University, Nara, Japan
| | - Manabu Motoki
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan
| | - Satoshi Ohtsubo
- Department of Cardiovascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Yasushi Kawauchi
- Department of Radiological Technology, Saiseikai Central Hospital, Tokyo, Japan
| | - Kimihiko Kichikawa
- Department of Radiology and IVR Center, Nara Medical University, Nara, Japan
| | - Hideyuki Shimizu
- Department of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan
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Joseph G. Fenestrated total arch thoracic endovascular aortic repair: coming of age. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2019; 15:387-390. [PMID: 31933653 PMCID: PMC6956461 DOI: 10.5114/aic.2019.90325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- George Joseph
- Department of Cardiology, Christian Medical College, Vellore, India
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Magee GA, Veranyan N, Kuo EC, Ham SW, Ziegler KR, Weaver FA, Fleischman F, Bowdish ME, Han SM. Anatomic suitability for “off-the-shelf” thoracic single side-branched endograft in patients with type B aortic dissection. J Vasc Surg 2019; 70:1776-1781. [DOI: 10.1016/j.jvs.2019.04.461] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/04/2019] [Indexed: 10/26/2022]
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Shah VN, Orlov OI, Meisner RJ, Plestis KA. Hybrid Aortic Arch Repair Using a Ministernotomy. Vasc Endovascular Surg 2019; 54:162-164. [PMID: 31707948 DOI: 10.1177/1538574419887600] [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
Hybrid thoracic endovascular aortic repair with surgical arch debranching is an accepted method for total arch reconstruction. Although off-pump arch debranching is increasingly used as a prophylactic adjunct to endovascular arch repair extending into landing zone 0, this technique is seldom performed with a ministernotomy due to a steep learning curve among surgeons. Herein, we report our standard technique for off-pump hybrid total aortic arch repair using a ministernotomy.
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Affiliation(s)
- Vishal N Shah
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Wynnewood, PA, USA
| | - Oleg I Orlov
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Wynnewood, PA, USA
| | - Robert J Meisner
- Division of Vascular Surgery, Lankenau Medical Center, Wynnewood, PA, USA
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Carino D, Molardi A, Gherli T, Nicolini F, Agostinelli A. A Case of Type I Debranching Complicated by Anastomotic Pseudoaneurysm: Do Not Ask Too Much of the Ascending Aorta. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2019; 7:63-66. [PMID: 31529431 PMCID: PMC6748836 DOI: 10.1055/s-0039-1688439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Treatment of aortic arch aneurysm with standard open surgery is technically demanding, and associated morbidity and mortality are not insignificant. In high-risk patients, hybrid procedures with debranching and reimplantation or bypass of the aortic arch vessel followed by thoracic endovascular aortic repair (TEVAR) in the aortic arch represent a valid alternative to open surgery. However, when the ascending aorta is mildly dilated, the risk of retrograde dissection increases sharply. Here, we report a case of thoracic aortic aneurysm, with normal ascending aorta diameter, treated with Type I debranching and anterograde TEVAR complicated by anastomotic pseudoaneurysm and acute endocarditis, treated ultimately with ascending aortic repair and aortic valve replacement.
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Affiliation(s)
- Davide Carino
- Department of Cardiac Surgery, Parma General Hospital, Parma, Italy
| | - Alberto Molardi
- Department of Cardiac Surgery, Parma General Hospital, Parma, Italy
| | - Tiziano Gherli
- Department of Cardiac Surgery, Parma General Hospital, Parma, Italy
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Abstract
PURPOSE OF REVIEW Given its rarity little is known about natural history, surgical indications, and results of acute non-A non-B dissections. With this review, we aim to review the current knowledge of this subject. RECENT FINDINGS non-A non-B aortic dissections should be differentiated from type B aortic dissections. A strikingly high proportion of these patients have a complicate course requiring treatment and the mortality of patients treated with medical therapy is substantially higher compared to type B dissections. Surgical and endovascular treatment can be accomplished safety, with very good results in terms of mortality and morbidity also in the acute setting. Several treatments options are available including endovascular repair with thoracic endovascular aortic repair (TEVAR) associated with Chimney grafts or carotid to subclavian by pass, open arch replacement mainly by means of the frozen elephant trunk technique and hybrid arch repair with debranching of the supra-aortic vessel and zone 0 TEVAR. SUMMARY considering the high rate of complication, the high mortality of patients managed medically and the safety of surgical and endovascular repair, early invasive treatment of non-A non-B dissections may be further considered. The treatment should be tailored to the morphology of the dissected aorta with TEVAR reserved to more distal lesions and open arch replacement with the FET technique for more proximal lesions.
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Bohan P. Comment on: Indications for Thoracic Endovascular Aortic Repair (TEVAR): A Brief Review by Frank Manetta, MD, Joshua Newman, MS, Allan Mattia, MD. Int J Angiol 2018; 28:177-184. Int J Angiol 2019; 28:151-152. [PMID: 31384116 DOI: 10.1055/s-0039-1679872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Patrick Bohan
- Department of Clinical and Medical Affairs, Terumo Aortic, Sunrise, Florida
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Lazopoulos G, Kalogerakos PD, Pavlopoulos D, Chaniotaki F, Dermitzaki D, Kokotsakis J. Debranching-first and proximal arch replacement for an innominate artery aneurysm: a case study. Perfusion 2019; 35:9-12. [PMID: 31203765 DOI: 10.1177/0267659119856240] [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
The aneurysms of the innominate artery represent a rare form of aneurysmal disease. Management in an early elective basis is recommended due to the risk of stroke and rupture. Treatment options include open surgery, which is the gold standard, and endovascular repair. We describe the debranching-first technique and proximal arch replacement for a huge innominate artery aneurysm and discuss the surgical strategy for cannulation, perfusion and organ protection.
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Affiliation(s)
- George Lazopoulos
- Division of Cardiac Surgery, University General Hospital of Heraklion, Crete, Greece
| | | | - Dionysios Pavlopoulos
- Division of Cardiac Surgery, University General Hospital of Heraklion, Crete, Greece
| | - Foteini Chaniotaki
- Department of Anesthesiology, University General Hospital of Heraklion, Crete, Greece
| | - Despoina Dermitzaki
- Department of Anesthesiology, University General Hospital of Heraklion, Crete, Greece
| | - John Kokotsakis
- Division of Cardiac Surgery, University General Hospital of Heraklion, Crete, Greece
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Carter R, Wee IJY, Petrie K, Syn N, Choong AM. Chimney parallel grafts and thoracic endovascular aortic repair for blunt traumatic thoracic aortic injuries: A systematic review. Vascular 2018; 27:204-212. [PMID: 30522411 DOI: 10.1177/1708538118812548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Whilst the management of blunt traumatic thoracic aortic injury has seen a paradigm shift to an 'endovascular first' approach, the limitations of thoracic endovascular aortic repair remain. An inadequate proximal landing zone limits the use of thoracic aortic stent grafts and in an emergent polytrauma setting, aortic arch debranching via open surgery may not be practical or feasible. A wholly endovascular approach to debranching utilising 'off-the-shelf' stents and parallel graft techniques may represent a possible solution. Hence, we sought to perform a systematic review investigating the use of chimney graft techniques alongside thoracic aortic stenting in blunt traumatic thoracic aortic injury. METHODS We performed the systematic review in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on Medline (PubMed), Web of Science and Scopus to identify articles describing the use of chimney grafts in traumatic aortic transection (PROSPERO: CRD42017082549). RESULTS The systematic search revealed 172 papers, of which 88 duplicates were removed resulting in 84 papers to screen. Based on title, abstract and full text review, six articles were included for final analysis. There were nine patients in total with an average age of 41 (three females, five males, one unspecified), all with significant polytrauma, secondary to the mechanism of injury. A variety of stents were used between centres, with techniques showing a predominance to stenting of the left subclavian artery (77%, n = 7). The technical success rate was 82%, with two (18%) cases of type 1 endoleaks, of which one resolved spontaneously. CONCLUSIONS Despite the encouraging results, this by no means provides for a firm conclusion given the small sample size. Patients should still be judiciously selected on a case-by-case basis when employing the chimney graft technique. Larger cohort studies are needed to establish these findings.
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Affiliation(s)
- Rebeca Carter
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore.,2 Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Ian Jun Yan Wee
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore.,3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kyle Petrie
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore.,2 Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nicholas Syn
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore.,3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Mtl Choong
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore.,4 Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore.,5 Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,6 Division of Vascular Surgery, National University Heart Centre, Singapore, Singapore
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