Single-stage endovascular management of complicated thoracic aorta coarctation concurrent with aortic arch aneurysm using a novel fenestration device

Comparative effectiveness and safety of laser, needle, and "quick fenestrater" in in situ fenestration during thoracic endovascular aortic repair

Background

Special instruments are needed for the revascularization of aortic branches in in situ fenestration during thoracic endovascular aortic repair (TEVAR). This prospective study compared the effectiveness and safety of three currently used fenestraters: laser, needle, and Quick Fenestrater (QF).

Methods

In all, 101 patients who underwent TEVAR for aortic disease (dissection, n = 62; aneurysm, n = 16, or ulcer, n = 23) were enrolled. All patients were randomly assigned to three groups: 34 were assigned to laser fenestration, 36 to needle fenestration, and 31 to QF fenestration. The epidemiological data, treatment, imaging findings, and follow-up outcomes were analyzed using data from the medical records.

Results

The technical success rates of the laser, needle, and QF fenestration groups were 94.1%, 94.4%, and 100% (p > 0.05). After correction of mixed factors such as age and gender, it was showed the average operative time (Laser group: 130.01 ± 9.36 min/ Needle group: 149.80 ± 10.18 min vs. QF group: 101.10 ± 6.75 min, p < 0.001), fluoroscopy time (Laser group: 30.16 ± 9.81 min/ Needle group: 40.20 ± 9.91 min vs. QF group: 19.91 ± 5.42 min, p < 0.001), fenestration time (Laser group 5.50 ± 3.10 min / Needle group 3.50 ± 1.50 min vs. QF group 0.67 ± 0.06 min, p < 0.001), and guide wire passage time after fenestration (Laser group 5.10 ± 1.70 min / Needle group 4.28 ± 1.60 min vs. QF group 0.07 ± 0.01 min, p < 0.001) were all shorter with QF fenestration than with the other two tools. The overall perioperative complication rates of the laser, needle, and QF fenestration groups were 5.9%, 5.6%, and 0% (p > 0.05): One case of sheath thermal injury and one case of vertebral artery ischemia occurred in the laser fenestration group; one case each of access site hematoma and brachial artery thrombosis were reported in the needle fenestration group. 89 (88.1%, 89/101) patients were followed for a median of 12.6 ± 1.6 months. The overall postoperative complication rates of the laser, needle, and QF fenestration groups were 3.3%, 6.5%, and 0% (p > 0.05): In the laser fenestration group, there was one death due to postoperative ST-segment elevation myocardial infarction; in the needle fenestration group, one patient developed occlusion of the bridge stent; no complications occurred in the QF group.

Conclusion

All three fenestration methods were effective in reconstructing supra-arch artery during TEVAR. QF fenestration required less contrast agent, with a shorter surgery duration and fewer complications than laser and needle fenestration.

Endovascular Treatments for Coarctation of the Aorta with Concurrent Poststenotic Aneurysms in Adults

BACKGROUND

Coarctation of the aorta with poststenotic aneurysms is rare and complex. Here we report a relatively large group of endovascular treatments for the disease.

MATERIALS AND METHODS

Fifteen patients from two centers between 2006 and 2019 were included in the study. The patients were retrospectively divided into two groups. Patients in the complex group had insufficient proximal landing zone (<2 cm) or the zigzag shape of aorta. Their demographics, clinical manifestations, endovascular procedures, and follow-up results were analyzed.

RESULTS

There were 7 patients in the simple group and 8 patients in the complex group. Eleven patients were symptomatic. Despite the unfavorable anatomy in the complex group, technical success reached 100%. The diameter of coarctation increased from 8.6 mm to 16.7 mm with poststenotic aneurysms successfully excluded at the same time. In patients without sufficient proximal landing zone, left subclavian artery was covered by the stent grafts and then sacrificed (three patients) or revascularized (four patients). Other than one patient who suffered iliac artery rupture and received open repair, there was no other perioperative complications. Computed tomography angiography repeated at mean 42 months postoperation confirmed patency of stents and the exclusion of aneurysms with no aortic wall injury. Mild endoleaks occurred in two patients in the complex group and were left to observation. During 55.0 months follow-up, except for one patient who received secondary left subclavian artery fenestration, all other patients remained asymptomatic.

CONCLUSIONS

Endovascular treatments for coarctation of the aorta with poststenotic aneurysm showed a high technical success and could be an alternative solution for such disease.

Hybrid Surgical Approach to a Giant Post-Coarctation Aortic Aneurysm

PURPOSE

To report a rare case of giant aortic coarctation (CoA)-related descending thoracic aneurysmal degeneration, complicated by an acute aortic dissection.

CASE REPORT

A 57-year-old man referred with acute chest pain to the emergency department. A computed tomography angiography (CTA) revealed a CoA with a giant post-stenotic descending thoracic aneurysm (14 cm) and a concomitant left subclavian artery (LSA) aneurysm, complicated by an acute type B aortic dissection. A single-stage hybrid procedure was planned in an urgent setting. Initially, a left common carotid-to-left subclavian artery (LCCA-LSA) bypass was performed to gain a suitable proximal landing zone, the procedure was then completed with 3 thoracic endografts and 1 aortic dissection stent through a percutaneous femoral approach. The patient was discharged in postoperative day 8th without complications; the CTA performed at 1 month demonstrated patency of supra-aortic and visceral vessels, dilation of CoA site and exclusion of the false lumen.

CONCLUSIONS

CoA is a congenital malformation rarely found in adults that may represent a challenge for the surgeon, especially when combined with a complication like an acute aortic dissection. This case shows that a hybrid approach is a safe and feasible treatment option even in such complex anatomies.

A Novel Fenestrating Device, "Quick Fenestrater," for Reconstructing Supra-aortic Arteries In Situ during Thoracic Endovascular Aortic Repair

BACKGROUND

In situ fenestration (ISF) is an effective approach for reconstructing supra-aortic branches during thoracic endovascular aortic repair (TEVAR). A dedicated device is needed for ISF.

METHODS

The "Quick Fenestrater" (QF) underwent in vitro, animal-based, and initial clinical testing. In vitro, the polytetrafluoroethylene and Dacron aortic endografts were fenestrated using the QF, and the structure of the graft, fenestration hole, and shed particulate material were evaluated. Eight white swine had QF-aided ISF combined with TEVAR and bridge stent implantation. The outcomes were assessed using intraoperative angiography and biopsy. Finally, 13 patients were treated with QF-assisted ISF, combined with TEVAR, and the success rate, technical details, and intra- and post-operative complications were recorded.

RESULTS

The endograft structure was not damaged during in vitro testing. The fenestration hole was clean, and no particulate material was detected. In animal studies, all animals survived, the supra-aortic arteries were patent, and the endografts and bridge stents had normal morphology. In clinical studies, the technical success rate was 100%, and no fenestration-related neurological complications or death occurred. One patient had a local access-related hematoma perioperatively and recovered after conservative treatment. Three patients had type III endoleaks, which resolved with no additional treatment. During a mean follow-up of 22.1±6 months, no thoracic complications were identified, and the bridge stents were patent with no endoleaks. No adverse cerebrovascular events, cardiovascular events, or death occurred.

CONCLUSIONS

QF-assisted ISF is a safe and effective method for the reconstruction of supra-aortic branches during TEVAR. Intermediate-term follow-up results validate the application of the novel fenestration device.

Saccular "Cauliflower" aneurysm of coarctation of aorta: a hybrid management

Aneurysm formation around the site of coarctation of aortic arch is a well-recognised complication of untreated coarctation and is associated with an increased risk of aortic rupture and mortality. We present a rare case in a teenage girl with the combination of significant aortic arch coarctation, a "cauliflower-like" saccular aneurysm, and stenosis at the origin of the left subclavian artery. She was successfully managed with a hybrid approach, which is a combination of an endovascular surgical repair (a bypass graft placement from left carotid artery to subclavian artery by a vascular surgeon) and a transcatheter covered stent placement across the stenosis and aneurysm. This case highlights the successful role of a hybrid approach in patient's who present with a combination of coarctation of the aorta and aortic arch aneurysms. This approach avoids the conventional surgical aortoplasty, which carries a higher mortality and morbidity risk in teenage patients.

Coarctation of Aorta and Post-Stenotic Dissecting Aortic Aneurysm Successfully Treated with Endovascular Stent

Coarctation associated with a dissected aneurysm is uncommon and has an incidence of less than 1%. There are few reports describing treatment of this condition with stent graft. Challenging as it may be, endovascular treatment of complex cases has become the preferred modality especially when the anatomy is amenable. We describe the case of a 36-year old male, who suffered a car accident and was diagnosed with acute type B aortic dissection (ATBAD). CT-scan revealed a coarctation associated with a large dissected aneurysm (11cm). Complexity of pathology and high risk of rupture required immediate intervention. Open repair necessitates extensive surgery with a considerable risk of morbidity and mortality. We decided to perform an endovascular repair and subsequentially the patient was successfully treated with stent graft deployment, showing durable early-midterm results. Patient remains asymptomatic to this day and CT-scan at 3-year follow-up revealed a reduced and thrombosed aneurysm.

Methods and clinical outcomes of in situ fenestration for aortic arch revascularization during thoracic endovascular aortic repair

OBJECTIVE

Despite endovascular advances in fenestrated and branched devices, thoracic endovascular aortic repair (TEVAR) for arch pathologies remains challenging. The aim of this study was to provide a contemporary review on the current evidence for in situ fenestration during TEVAR and to evaluate its short- and mid-term clinical outcome in the management of arch pathology.

METHODS

A systematic literature review on in situ fenestration of thoracic aortic stent-graft from January 2003 to September 2018 was performed under the instruction of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement.

RESULTS

Our initial search yielded 169 studies, of which 21 articles were relevant to the topic and were finally included. One hundred and forty-five in situ fenestration procedures in 99 patients were reviewed, involving 25 innominate arteries (17%), 33 left common carotid arteries (23%) and 87 left subclavian arteries (60%). Twelve patients (12/99, 12%) had two-vessel fenestration and three-vessel fenestration was performed in 17 patients (17/99, 17%). Technical success was achieved in 136 arteries (136/145, 93%). Talent/Valiant with monofilament twill woven polyester fabric was the most common (50/99, 51%) stent-graft used for fenestration. Three methods reported for in situ fenestration were needle, laser and radiofrequency. Needle was the most frequently used device for fenestration, which was performed in 60 patients (60/99, 61%). Three patients (3/99, 3%) died with 30 days, none were in situ fenestration TEVAR procedure-related. Perioperative complications including one (1%) retrograde type A aortic dissection, two (2%) type II endoleaks, and three (3%) strokes were reported. The pooled estimate for overall technical success, perioperative mortality and stroke was 88.3% (95% CI, 78.6%-93.9%), 5.9% (95% CI, 2.5%-13.4%) and 9.5% (95% CI, 4.1%-20.6%), respectively. Four patients (4/96, 4%) died during follow-up, none were aortic-related. All the fenestration bridging stents were reportedly patent, with only 1 (1/96, 1%) asymptomatic left subclavian stent stenosis. Two patients (2/96, 2%) with type II endoleak from left subclavian artery required secondary intervention.

CONCLUSION

In situ fenestration appeared to be a feasible and effective method to extend proximal landing zone during TEVAR. It had an acceptable short-term result with high technical success and low fenestration related morbidity. Long-term durability data were lacking, and there was no high level evidence to recommend the routine use of in situ fenestration TEVAR for the management of arch pathology.