Results From a Nationwide Registry on Scalloped Thoracic Stent-Grafts for Short Landing Zones

Purpose: To report the perioperative results and short-term follow-up of patients treated with scalloped thoracic stent-grafts. Methods: A multicenter registry in the Netherlands captured data on 30 patients (mean age 68 years; 17 men) with thoracic aortic pathology and a short (<20 mm) proximal or distal landing zone who received a custom-made scalloped stent-graft between January 2013 and February 2016. Patients were treated for saccular (n=13) aneurysms, fusiform (n=9) aneurysms, pseudoaneurysms (n=4), or chronic type B dissections (n=4). The scallop was used to preserve flow in the left subclavian artery (LSA) (n=17), left common carotid artery (n=5), innominate artery (n=1), and celiac trunk (n=7). In 7 (23%) patients, the scallop also included the adjacent artery. Results: Technical success was achieved in 28 (93%) patients. In 1 patient, a minor type Ia endoleak was observed intraoperatively, which was no longer visible on computed tomography angiography at 3 months. In another patient, the LSA was unintentionally obstructed due to migration of the stent-graft on deployment. Concomitant carotid-carotid or carotid-subclavian bypass was performed in 4 patients. There was no retrograde type A dissection or conversion to open surgery. In-hospital mortality was 3%, and the perioperative ischemic stroke rate was 3%. At a mean follow-up of 9.7 months (range <1 to 31), 29 of 30 target vessels were patent. Conclusion: The scalloped stent-graft appears to be a safe and relatively simple alternative for the treatment of thoracic aortic lesions with short landing zones. Larger patient series and long-term follow-up are required to confirm these early results.

An experimental model of Stanford type B aortic dissection with intravenous epinephrine injection

The aim of this study was to create an experimental model of aortic dissection (AD) with a long-term patent false lumen to develop new treatments for Stanford type B aortic dissection. Sixteen adult beagle dogs (weight 14-18 kg) were used. After exposure and partially clamping, the descending aorta was cut through the adventitia to one-third of the depth of the tunica media. The aortic wall was divided into two layers by raspatory. Then half the circumference of the inner layer was cut transversely. All of the proximal layers and the distal outer layers were anastomosed together. Epinephrine was immediately used to expand the false lumen, and the effect was terminated using nitroglycerin when necessary. All dogs underwent both digital subtraction angiography (DSA) and computed tomography angiography (CTA) immediately after and 1 week and 1 month after surgery. The dogs were followed up at 1 day, 3 months, 1 year, and 2 years. The surgery was successful in 12 dogs. Dissection formation was observed immediately after epinephrine administration and confirmed by DSA and CTA. Our results showed typical characteristics of AD, such as a tear, septum, and true and false lumens. This is an easy and feasible way of developing a Stanford type B AD model by intravenous injection of epinephrine. In this canine model of AD, the false lumen has excellent long-term patency and the dissection plane is histologically similar to that in human AD. This model may contribute to the development of new treatments for Stanford type B AD.

Scalloped thoracic stent-graft for treatment of aortic arch aneurysms with unfavourable landing zones

Endovascular treatments are limited in cases of thoracic aortic aneurysms extending up or proximal to the origin of the left subclavian artery (LSCA). In such cases, the LSCA is usually either occluded or revascularised. We report our first experience of four patients who underwent thoracic aneursym treatment with new custom-made grafts with a scallop in situ for the LSCA. The graft is tailor made per case, and a re-enforced scallop is positioned proximally allowing for the stent to be deployed beyond the origin of the LSCA; the origin of the LSCA remains patent, thus negating the need for revascularisation of the head and neck vessels on the left. The stent contains markers for identifying the scallop and are located along the midline to ensure correct alignment. All of the patients who underwent this procedure had technical success with flow through the LSCA both immediately after stent deployment and on follow-up imaging. This new stent has further expanded endovascular treatment options for patients with thoracic aneurysms extending up to and beyond the LSCA, which can play a part in improving outcome and decreasing mortality rates because surgery for revascularization will not be needed.