Outcomes Of Chimney Technique For Aortic Arch Diseases: A Single-Center Experience With 226 Cases

Comparative Evaluation of the Short-Term Outcome of Different Endovascular Aortic Arch Procedures

Objectives: There are several endovascular treatment options to treat aortic arch and thoracic aortic pathologies with custom-made or surgeon-modified aortic stent grafts. This study seeks to assess endovascular treatment methods for aortic arch and thoracic aortic pathologies with no acceptable proximal landing zone for standard thoracic endovascular aortic repair (TEVAR), comparing different treatment methods and evaluating technical success, intraoperative parameters and short-term outcomes. Methods: All patients undergoing elective or emergency endovascular treatment of aortic arch and thoracic aortic pathologies, with no acceptable landing zone for standard TEVAR, between 1 January 2010 and 31 March 2024, at the University Hospital Düsseldorf, Germany were included. An acceptable landing zone was defined as a minimum of 2 cm for sufficient sealing. All patients were not suitable for open surgery. Patients were categorized by an endovascular treatment method for a comprehensive comparison of pre-, intra- and postoperative variables. IBM SPSS29 was used for data analysis. Results: The patient cohort comprised 21 patients, predominantly males (81%), with an average age of 70.9 ± 9 years with no acceptable proximal landing zone for standard TEVAR procedure. The most treated aortic pathologies were penetrating aortic ulcers and chronic post-dissection aneurysms. Patients were sub-grouped according to the applied procedure as follows: five patients with chimney thoracic endovascular aortic repair (chTEVAR), seven patients with in situ fenestrated thoracic endovascular aortic repair (isfTEVAR), six patients with custom-made fenestrated thoracic endovascular aortic repair (cmfTEVAR) and three patients with custom-made branched thoracic endovascular aortic repair (cmbTEVAR). Emergency procedures involved two patients. There were significant differences in the total procedure and fluoroscopy time, as well as in contrast agent usage among the treatment groups. cmfTEVAR had the shortest total procedure time, while chTEVAR exhibited the highest contrast agent usage. The overall mortality rate among all procedures was 9.5% (two patients) and 4.7% for elective procedures, respectively. Deaths were associated with either retrograde type A dissection or stent graft infection. Both patients were treated with chTEVAR. There was one minor and one major stroke; these patients were treated with isfTEVAR. No endoleak occurred during any procedure. The reintervention rate for chTEVAR was 20% and 0% for all other procedures during the in-hospital stay. The patients who were treated with cmfTEVAR had no complications, the shortest operating and fluoroscopy time, and less contrast agent was needed in comparison with other treatment methods. Conclusions: Complex endovascular procedures of the aortic arch with custom-made or surgeon-modified aortic stent grafts offer a safe solution, with acceptable complication rates for patients who are not suitable for open aortic arch repair. In terms of procedure-related parameters and complication rates, a custom-made fenestrated TEVAR is potentially advantageous compared to the other endovascular techniques.

Systematic Review on Customized and Non-customized Device Techniques for the Endovascular Repair of the Aortic Arch

PURPOSE

Open repair remains the standard of care for aortic arch pathologies. However, endovascular management became an attractive alternative for high-risk patients. This study aimed to assess the outcomes of the available endovascular techniques for aortic arch pathology management.

MATERIALS AND METHODS

A search of the English literature (2000-2022) using PubMed, EMBASE, via Ovid, and CENTRAL databases (February 1, 2022) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies reporting on patients with aortic arch pathologies managed with custom-made devices ([CMDs] fenestrated or branched thoracic endovascular aortic repair [F/BTEVAR]) and non-CMDs (parallel graft or surgeon-modified FTEVAR) were eligible. Studies reporting on hybrid or open repair were excluded. Studies' quality was assessed using the Newcastle-Ottawa Scale. Primary outcomes were technical success, 30 day mortality, and cerebrovascular events (CVEs). Secondary outcomes were re-intervention and mortality during follow-up.

RESULTS

Thirty studies (2135 patients) were included. Treatment indications were mainly dissections (652 cases [48.0%, 652/1358]; 90 type A, 506 type B; 364 acute, 163 chronic) and aneurysms (46.9%, 582/1239). Five studies (211 patients) reported on FTEVAR and 10 (388 patients) on BTEVAR. For FTEVAR, technical success rate was 98.3%. Thirty-day mortality was 3.8% and CVE rate was 12.3%. Ten deaths (9.7%) and 19 re-interventions (9%) were recorded during follow-up (24 months). Regarding BTEVAR, technical success rate was 98.7%, and 30 day mortality and CVE rates were 5.4% and 11.0%, respectively. During follow-up (27 months), 64 deaths (18.7%) and 33 re-interventions (9.6%) were recorded. Parallel graft technique was reported in 11 studies (901 patients). Technical success rate was 76.4%. Thirty-day mortality was 3.9% and 32 (4.3%) CVEs were recorded. Thirty-five deaths (4.4%) and 43 re-interventions (5.5%) were reported during follow-up (27 months). Surgeon-modified FTEVAR was described in 5 studies (635 patients). Technical success rate was 91.6%. At 30 days, 15 deaths (2.3%) and 22 CVEs (3.5%) were recorded. During follow-up (19 months), 26 deaths (4.2%) and 21 re-interventions (3.6%) were detected.

CONCLUSIONS

Endovascular arch repair presented a variable technical success; >95% for F/BTEVAR; ≤90% for non-CMDs. Acceptable 30 day mortality rates were reported. Cerebrovascular event rates ranged up to 10%. These findings, adjacent to the estimated midterm mortality and re-interventions, set the need for further improvement.

CLINICAL IMPACT

Endovascular arch repair gains popularity as a valuable alternative, especially in patients considered unfit for open repair. According the available literature, any endovascular technique, including custom-made or off-the-shelf solutions, may be applied successfully, with acceptable early mortality. However, the perio-operative cerebrovascular event rate is still an issue, indicating the need for further advancements.

Midterm Outcomes of Multicenter Castor Single-Branch Stent Graft Use in the Treatment of Thoracic Aortic Diseases

PURPOSE

The aim of this study was to evaluate the midterm efficacy and safety of a single-branch Castor stent graft in the treatment of thoracic aortic disease.

MATERIALS AND METHODS

Clinical data of 106 patients with thoracic aortic disease treated with Castor single-branch stent graft at 3 centers were collected between May 2018 and June 2023. The indicators included technical success, stent-related complication, reintervention, retrograde dissection, endoleak, distal stent graft-induced entry (dSINE), branch patency, and mortality. The outcomes of the Castor stent graft for multibranch reconstruction above the arch was also analyzed.

RESULTS

The technical success was 98.1% (104/106), while the surgical success was 93.4% (99/106). The reintervention was 2.8% (3/106), consisting of a case of retrograde type A dissection, an endoleak, and a dSINE. The retrograde dissection was 1.9% (2/106), while type I endoleak was 1.9% (2/106). The new dSINE was 2.8% (3/106), and the branch patency rate was 100%. The mortality was 1.9% (2/106). The mean follow-up time was 29.1±17.7 months. The 2-year post-surgery cumulative survival rate was 91.0%±3.1%, while the cumulative branch patency rate was 96.2%±2.2%. In addition, the cumulative freedom from stent-related reintervention rate was 93.2%±2.8%. A comparison showed no significant difference in the stent-related complication, branch patency, endoleak, reintervention, and mortality when the proximal end of the Castor stent graft was anchored to zones 1 or 2 of the aorta.

CONCLUSION

Castor single-branch stent graft showed favorable early and midterm outcomes in the treatment of thoracic aortic disease. In addition, it was feasible to combine Castor stent graft with other advanced techniques for multibranch aortic arch reconstruction.

CLINICAL IMPACT

The Castor single-branch stent graft was approval by the Chinese Food and Drug Administration in 2017. However, there were few studies on the mid-term outcomes for thoracic aortic disease after launching, which mainly focused on small single-center retrospective study. In the study, we assessed the mid-term outcomes of Castor stent graft through multi-center cases, Castor stent graft combined with other advanced techniques (such as fenestration and hybrid) for multi-branch reconstruction of aortic arch were also conducted. We found Castor single-branch stent graft showed favorable early and mid-term outcomes in the treatment of thoracic aortic disease. Additionally, it was feasible to combine Castor stent graft with other advanced technique for multi-branch aortic arch reconstruction. As an off-the-shelf branched stent graft with a wide range of models, it could be also used in most emergent situation. The Castor stent graft was expected to become more widely used in the future.

Meta-analysis and meta-regression of the total endovascular aortic repair in aortic arch

Background: The total endovascular repair of the aortic arch is becoming more and more an acceptable alternative to the open repair in selected patients. The aim of the present study is to perform a meta-analysis of the available data on the outcomes of the various endovascular techniques used to treat the pathologies in this challenging anatomical area. Patients and methods: An extensive electronic search in PubMed/MEDLINE, Science Direct Databases, and the Cochrane Library was conducted. All papers published up to January 2022 on the endovascular techniques in the aortic arch (chimney-thoracic endovascular aortic repair (ChTEVAR), fenestrated/branched grafts as custom made devices (CMD) and surgeon modified TEVAR (SM TEVAR) providing information about at least one of the essential outcomes defined in the inclusion criteria. Results: Out of the 5078 studies found through the search in the databases and registers, 26 studies with a total number of patients of 2327 with 3497 target vessels were included in the analysis. The studies reported a high technical success rate with an estimated proportion of 95.8% (95% CI, 93-97.6%). Moreover, the pooled estimation of the early type Ia/III endoleak was 8.1% (95% CI, 5.4-12.1%). The pooled mortality was 4.6% (95 CI, 3.2-6.6%) with a significant heterogeneity and the stroke had an estimated proportion (major and minor combined) of 4.8% (95% CI, 3.5-6.6%). A meta-regression analysis showed no significant variation between the groups in mortality (P=.324) showed however a significant difference between the therapeutic methods regarding stroke P<.001 (lower rate in ChTEVAR and SM vs. CMD). Conclusions: The present meta-analysis could demonstrate good short- and long-term outcomes of the multiple total endovascular repair methods used in the aortic arch.

Endovascular aortic arch repair with chimney technique for pseudoaneurysm

BACKGROUND

Aortic pseudoaneurysm is a life-threatening clinical condition, and thoracic endovascular aortic repair (TEVAR) has been reported to have a relatively satisfactory effect in aortic pathologies. We summarized our single-centre experience using chimney TEVAR for aortic arch pseudoaneurysms with inadequate landing zones.

METHODS

A retrospective study was conducted from October 2015 to August 2020, 32 patients with aortic arch pseudoaneurysms underwent chimney TEVAR to exclude an aortic lesion and reconstruct the supra-aortic branches, including 3 innominate artery, 12 left common carotid arteries and 29 left subclavian arteries. Follow-up computed tomography was suggested before discharge; at 3, 6, 12 months and yearly thereafter.

RESULTS

The median age of 32 patients was 68.0 years (range, 28-81) with the mean max diameter of aneurysm of 47.9 ± 12.0 mm. Forty-four related supra-aortic branches were well preserved, and the technical success rate was 100%. The Type Ia endoleaks occurred in 3 (9%) patients. Two patients were lost to follow-up and 4 patients died during the follow-up period. The mean follow-up times was 46.5 ± 14.3 months. One patient died due to acute myocardial infarction just 10 days after chimney TEVAR and the other 3 patients passed away at 1.5 months, 20 months, and 31 months with non-aortic reasons. The 4.5-year survival estimate was 84.4%. The primary patency rate of the target supra-arch branch vessels was 97.7% (43/44), and no other aorta-related reinterventions and severe complications occurred.

CONCLUSION

For aortic arch pseudoaneurysms with inadequate landing zones for TEVAR, the chimney technique seems to be feasible, with acceptable mid-term outcomes, and it could serve as an alternative minimally invasive approach to extend the landing zone. Slow flow type Ia endoleak could be treated conservatively after chimney TEVAR. Additional experience is needed, and the long-term durability of chimney TEVAR requires further follow-up.

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

Background

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

Methods

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

Results

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

Conclusions

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

Tratamiento endovascular con técnica de chimenea para patologías del arco aórtico

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.

Type 1A Endoleak after TEVAR in the Aortic Arch: A Review of the Literature

Aortic arch repair is a challenging intervention. Open surgical repair is still considered the gold standard, but in high-risk patients, it is not always a reasonable option, making endovascular approaches an enticing, when not the only available, alternative for treatment. The strategies more commonly adopted are surgical supra-aortic trunk (SAT) rerouting followed by deployment of a standard thoracic endoprosthesis, chimney techniques, custom-made scalloped, fenestrated, and branched devices, and in situ or physician-modified fenestrations. If we excluded techniques involving SAT rerouting where the arch anatomy is surgically modified in order to make deployment in the aortic arch of a standard thoracic endoprosthesis possible, in the other techniques, one or more SATs are incorporated in the thoracic endoprosthesis. In these cases, no matter what solution is adopted, because of the morphology of the aorta at this level, achieving an ideal sealing is extremely difficult, and endovascular treatments of the arch are burdened by an increased risk of type IA endoleaks. PubMed, EMBASE, and Cochrane Library were searched. We identified 1277 records. After reading titles, abstracts, and full texts, we excluded 1231 records. Exclusion criteria were low-quality evidence, abstracts, case reports, conference presentations, reviews, editorials, and expert opinions. A total of 48 studies were included, for a total of 3114 patients. A type IA endoleak occurred in 248 patients (7.7%) with a mean incidence of 18.8% in chimney procedures, 4.8% and 3%, respectively, in fenestrated and branched devices, and 2.2% in in situ fenestration. We excluded from our analysis scalloped technology that is used when the target vessel originates from a healthy landing zone and represents a different anatomical setting. Type IA endoleaks are a concern with all types of endovascular aortic arch repair, and they can compromise the outcomes of the procedure. The rate of type IA endoleaks appears to be significantly higher in chimney procedures. In order to maximize sealing, whenever possible, endovascular repair of the arch should be achieved with custom-made fenestrated devices. However, chimney configurations are still a valuable solution particularly in the emergency setting, although in such a procedure, to guarantee accurate postoperative management and follow-up, an imaging protocol could be useful.

Outcomes of thoracic endovascular aortic repair with chimney technique for aortic arch diseases

Objective

This study aimed to summarize the long-term experience of using the chimney technique in thoracic endovascular aortic repair (TEVAR) for aortic arch diseases.

Methods

From November 2007 to June 2021, a total of 345 consecutive patients (mean age 56 ± 11.3 years, range 28–83, 302 men) with aortic arch pathologies underwent TEVAR combined with chimney technique (cTEVAR). Their medical data and follow-up results were retrospectively reviewed and analyzed.

Results

Among the 345 patients, 278 (80.6%) received single chimneys, 53 (15.4%) received double chimneys, 7 (2%) received triple chimneys, and 7 (2%) underwent cTEVAR accompanied by other techniques (two with extra-anatomical bypass, two with in situ fenestration, and three with physician modified fenestration). A total of 412 chimney stents were used, including 27 in the innominate artery (IA), 113 in the left common carotid artery, 270 in the left subclavian artery, and two in the aberrant right subclavian artery. Early type IA endoleaks were found in 38 (11%) patients, including 12 with the double or triple chimney technique. Early type II endoleak was found in nine (2.6%) patients. Early re-intervention occurred in two patients with double chimney technique, one for chimney stent migration and the other for compression of chimney stent. The 30-day mortality was 1.2% (4 in 345). During a mean follow-up of 42 ± 22 months (range 1–108 months), major stroke occurred in nine (2.6%) patients, chimney occlusion or stenosis occurred in six (1.7%), and retrograde type A aortic dissection occurred in four (1.2%). Fourteen (4.1%) patients received the secondary intervention. The all-cause mortality was 6.7% (23 in 345). Additionally, the total adverse event rate after cTEVAR was 13.9% (48 in 345).

Conclusion

TEVAR with chimney technique provides a minimally invasive alternative with good chimney graft patency and low postoperative mortality during follow-up. However, the double and triple chimney techniques should be used cautiously as they seem to have a higher risk for type IA endoleak and adverse events after the operation.

Total Endovascular Aortic Arch Repair: From Dream to Reality

The gold-standard therapy for the treatment of aortic arch pathologies is conventional open surgery. Recently, total endovascular aortic arch replacement with branched stent-grafts has been introduced into clinical practice with the aim of reducing invasiveness especially in selected high-risk patients. The aim of this review is to describe the two most commonly used branched devices for endovascular arch stent-grafting: Nexus (Endospan, Herzlia, Israle) and RelayBranch (Terumo Aortic, Glasgow, United Kingdom). Nexus is a CE-certified off-the-shelf, single branch, double stent graft system. It consists of two different components: a main module for the aortic arch and the descending aorta with a side-branch for the brachiocephalic artery (BCA), and a curved module for the ascending aorta that lands into the sino-tubular junction and connects to the main module through a side-facing self-protecting sleeve. Nexus may be used in urgent-emergency cases and also in patients with only one suitable supra-aortic target vessel but, on the other hand, it makes cerebral blood flow dependent on one source vessel only. The RelayBranch Thoracic Stent-Graft System is a custom made, double branched endograft with a wide window on its superior portion to accommodate two inner tunnels for BCA and left common carotid artery connection; bilateral cervical accesses are generally used to advance guidewires for catheterization of the inner tunnels in a retrograde fashion. RelayBranch can be customized on every patient’s specific anatomy and provides a double blood source for the brain, but it cannot be used in urgent-emergency conditions. Therefore, in order to optimize outcomes, the choice of the most appropriate device should be made considering pros and cons of each system and patient’s anatomy by an experienced aortic team. In conclusion, total endovascular aortic arch exclusion is a promising reality in selected high-risk patients.

Aortic-related Readmission after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Patients: A Single-center Retrospective Study

OBJECTIVES

This study aimed to investigate the characteristics of and risk factors for aortic-related readmission after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).

METHODS

Data from TBAD patients who underwent TEVAR from 2009-2018 at a Chinese tertiary center were retrospectively collected and analyzed. Enrolled patients were categorized into two groups according to whether aortic-related readmission occurred during follow-up, which was defined as hospitalization at least once after the initial procedure due to events that were related to or caused by aortic dissection or the initial procedure.

RESULTS

A total of 1 288 TBAD patients were enrolled, and 99 patients experienced aortic-related readmissions (7.7%), among whom chronic patients had the highest readmission rate (9.8%). The yearly proportion of readmission during the first year after initial procedure revealed a decreasing trend with a -9.7% annual percentage change. Seventy-one patients underwent reintervention (71.7%). Distal aneurysmal degeneration (43.7%) and distal stent graft-induced new entries (32.4%) were two major causes for reintervention. Fourteen patients in the reintervention subgroup underwent a second reintervention (19.7%). In-hospital mortality was 1.0% during the readmission and 14.3% during the second readmission. The overall survival was comparable between two groups (p=.93).

CONCLUSIONS

This study highlighted the importance of surveillance after initial procedure for TBAD patients with potential risk factors for aortic-related readmission, and the predisposition of patients with reintervention to multiple readmissions deserves attention.

Early Results of a Novel Gutter-Free Chimney Stent-Graft System to Treat Aortic Arch Dissection: Single-Center Data from a Prospective Clinical Trial

AIMS

Discuss the clinical value, technique characteristics, and early follow-up results of a newly designed gutter-free chimney stent-graft system for aortic arch pathology.

METHODS AND RESULTS

About 13 patients with aortic arch dissection were enrolled in a clinical trial testing a novel gutter-free stent-graft between February 2019 and December 2020. All 13 patients were male, age 52.6±10.4 years. The implantation time was 14.0±6.9 minutes; total procedure time was 89.5±19.8 minutes. The volume of contrast was 79.6±7.2 ml. And 15 aortic stent-grafts were implanted, and all 13 patients had chimney branch stent-grafts implanted into the left subclavian artery (LSA). There were 3 (23.1%) cases of immediate type Ιa endoleak after thoracic endovascular aortic repair (TEVAR), and 7.7% type Ιa endoleaks occurred in delayed fashion. Survival at 2 years was 100%, and the 2-year patency of chimney stent-grafts was 100%.

CONCLUSIONS

This study reports early success with good freedom from endoleak using a novel stent-graft designed for chimney TEVAR to treat aortic arch dissection. Postoperative survival and patency of the branch stent-grafts were excellent. Additional data from this multicenter clinical trial will be forthcoming.

What are the endovascular options and outcomes for repair of ascending aortic or aortic arch pathology?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in patients with ascending aortic or aortic arch disease what are the outcomes with endovascular repair in terms of survival, complications and reintervention?' Altogether 585 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We found that the endovascular operative techniques with the greatest evidence were ascending aortic chimney grafts (AACs), branched thoracic endovascular aortic repair (bTEVAR) aortic grafts and fenestrated TEVAR (fTEVAR) aortic grafts. The best evidence available were small case-series or retrospective cohort studies (n < 100), with 1 systematic review, at a short follow-up period (range 0-5 years). Intraoperatively, these techniques have a high technical success rate (84-100%). We found rates of endoleak comparable between AAC (7.4-16%) and bTEVAR/fenestrated TEVAR (11.1-21.4%). Stroke rates are higher in bTEVAR (3.1-42% vs 1-26% in AACs), attributed to more proximal pathology and technically challenging procedures. Following the immediate postoperative period, the 30-day mortality is 0-10.8% and patency is 97-100%. Stroke and reintervention rates remain higher in the bTEVAR group (3.1-42.0% and 0.5-33.3%) compared to the AAC group (1.0-11.1% and 6.7-16.7%). The 3- and 5-year survival ranges from 59% to 90%, but is driven by non-aortic pathology in a high-risk population; 3-year freedom from aortic death is 93-97%. Patency is 97-100% at up to 3 years, conformation and supra-aortic occlusions thereafter remain unknown. We conclude that AACs, bTEVARs and fenestrated TEVARs are safe endovascular options in high-risk elective patients, with results comparable to open or hybrid repair. They remain unverified in acute settings or in patients fit for open intervention.

[Endovascular and hybrid treatment of thoracic and thoracoabdominal aortic aneurysms and dissections]

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.

Endovascular Repair for Acute Type B Aortic Dissection With Unfavorable Proximal Landing Zone

BACKGROUND

The study aimed to compare the safety and effectiveness between fenestrated technique with or without chimney stent and single-branched stent graft for isolated left subclavian artery revascularization during endovascular repair of acute type B aortic dissection with unfavorable proximal landing zone.

METHODS

From January 2016 to December 2019, 65 acute type B aortic dissection patients with unfavorable proximal landing zone were treated with either the fenestrated technique (n = 34, group A) or single-branched stent graft (n = 31, group B). Type I endoleak, retrograde type A dissection, stroke, left subclavian artery patency, 30-day mortality, and aortic remodeling were systematically recorded and retrospectively analyzed.

RESULTS

Technical success rates for groups A and group B were 94.12% and 100%, respectively. Left subclavian artery primary patency was achieved for all enrolled patients. The incidence of type I endoleak, retrograde type A dissection, stroke, and 30-day mortality was 5.9%, 5.9%, 2.9%, and 2.9% in group A, respectively, but none were encountered in group B. Left subclavian artery occlusion was observed in 3 patients in group A and 2 patients in group B during a mean follow-up of 16.18 ± 2.08 months and 15.19 ± 2.68 months, respectively. After the procedure, significant aortic remodeling was detected in both groups during follow-up.

CONCLUSIONS

Both techniques are feasible and safe for isolated left subclavian artery revascularization during endovascular repair for acute type B aortic dissection. Apart from the associated perioperative risks of complications and mortality for the fenestrated technique, both procedures contributed to favorable aortic remodeling.