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Ahmad W, Liakopoulos OJ, Mylonas S, Wegner M, Brunkwall J, Dorweiler B. Long-Term Outcomes after Thoracic Endovascular Aortic Repair Using Chimney Grafts for Aortic Arch Pathologies: 10 Years of Single-Center Experience. Ann Vasc Surg 2020; 72:400-408. [PMID: 32927039 DOI: 10.1016/j.avsg.2020.08.129] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study reports the early- and long-term outcomes of the thoracic endovascular aortic repair using the Chimney-Graft technique (ChTEVAR) for the treatment of aortic arch pathologies. METHODS From January 2010 to December 2019, patients who underwent aortic ChTEVAR technique in our institution were included. Early, mid, and long-term outcomes in this group of patients were evaluated. Patient follow-up data were obtained by imaging follow-up that are routinely performed after 3-6 months following initial surgery and then at yearly intervals. RESULTS Aortic arch repair with a ChTEVAR was performed in 54 patients. The 30-day mortality was 18.5% (n = 10). All-cause 30-day mortality was higher in the subgroup of patients operated urgently (33% vs. 14%) without a significant difference (P = 0.141). Permanent neurological deficit (PND) was observed in 15% (8/54 patients); stroke in 11% (6/54), and paraplegia 4% (2/54). During follow-up the primary and primary-assisted chimney-graft patency was 96.8% and 97.8%, respectively. The multivariate analysis identified the age >70 years and the aortic diameter as independent risk factors for elevated mortality during the follow-up (P = 0.015 and 0.001, respectively). The PND was an independent predictor for 30-day mortality (P = 0.014, hazard ratio 13.5, 95% confidence interval 1.7-106.6). CONCLUSIONS The ChTEVAR has noninferior results to other open and endovascular aortic arch repair methods with an acceptable long-term survival especially in elective procedures.
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Affiliation(s)
- Wael Ahmad
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany.
| | - Oliver J Liakopoulos
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Spyridon Mylonas
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Moritz Wegner
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
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Ahmad W, Buse C, Kröger JR, Mylonas S, Majd P, Brunkwall S, Maintz D, Brunkwall JS. A Shorter Aortic Arch Sealing Ring (< 10 mm) Distal to the Most Distal Chimney Seems to Be an Additional Important Factor Contributing to a Gutter Endoleak in Aortic Arch TEVAR. Ann Vasc Surg 2019; 61:116-123. [PMID: 31394247 DOI: 10.1016/j.avsg.2019.05.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 05/26/2019] [Accepted: 05/29/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of the present study was to define the possible anatomical and technical parameter that might predict the occurrence of gutter endoleak or type Ia endoleak (EL Ia) in patients treated with the chimney graft (CG) technique for the brachiocephalic trunk (BCT) and left common carotid artery (LCCA) due to aortic arch pathologies. METHODS We reviewed our institutional endovascular aortic database of patients, who between 2010 and 2018 had undergone thoracic endovascular aortic repair (TEVAR) with chimney graft technique (ChTEVAR) as a debranching method of the supraaortic arteries. RESULTS ChTEVAR was performed in 45 patients of whom a chimney in both the LCCA and the BCT was used in 32 patients, only in the LCCA in twelve patients, and only in the BCT in one patient. Eight patients (17.8%) had an EL Ia (based on postoperative computed tomography angiography). No late EL Ia was detected during the follow-up period. All patients with a postoperative EL Ia received 2 CGs with one each for the BCT, and LCCA had either no or a sealing ring distal to the most distal chimney of less than 10 mm versus patients with a longer sealing zone (P = 0.043). Patients with an endoleak did not differ from those without endoleak with respect to stent-graft oversizing, the diameter of the proximal and distal landing zones, or the aortic diameter directly proximal to the pathology. CONCLUSIONS A sealing ring distal to the most distal chimney of more than 10 mm seems to be associated with a reduced risk of an EL Ia. The relatively few patients and the single-center nature require larger studies to verify the present results.
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Affiliation(s)
- Wael Ahmad
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany.
| | - Christian Buse
- Faculty of Medicine, University of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Jan Robert Kröger
- Department of Radiology, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Spyridon Mylonas
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Payman Majd
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Silke Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - David Maintz
- Chairman, Department of Radiology, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Jan Sigge Brunkwall
- Chairman, Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
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Marrocco-Trischitta MM, Spampinato B, Mazzeo G, Mazzaccaro D, Milani V, Alaidroos M, Ambrogi F, Nano G. Impact of the Bird-Beak Configuration on Postoperative Outcome After Thoracic Endovascular Aortic Repair: A Meta-analysis. J Endovasc Ther 2019; 26:771-778. [DOI: 10.1177/1526602819865906] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose: To investigate the association between the bird-beak configuration (BBC), a wedge-shaped gap between the undersurface of a thoracic endograft and the lesser curvature of the arch after thoracic endovascular aortic repair (TEVAR), and postoperative outcome after TEVAR. Methods: The study was performed according to the PRISMA guidelines. The PubMed, EMBASE, and Cochrane databases were searched to identify all case series reporting BBC after TEVAR between 2006 and April 2018. Data analysis was performed considering the difference in the risk of complications for presence vs absence of BBC. After screening 1633 articles, 21 studies were identified that matched the selection criteria; 12 of these reported detailed information to investigate the postoperative outcome using proportion meta-analysis with a random effects model. The pooled risk difference is reported with the 95% confidence interval (CI). Heterogeneity of the included studies was assessed with the I2 statistic (low 25%, medium 50%, high 75%). Results: Complications occurred within a range of 0 to 72 months in 14.7% (95% CI 7.4% to 27.3%) of patients with BBC and in 6.3% (95% CI 2.5% to 15.4%) of patients without BBC. A cumulative incidence could not be assessed. The summary risk difference was 11.1% (95% CI −0.1% to 22.3%, p=0.052). There was significant heterogeneity ( I2=85.6%). The Egger test did not show evidence of publication bias (p=0.975). When specifically considering type Ia endoleak and endograft migration, the risk difference between BBC and non-BBC patients was 8.2% (95% CI 0.3% to 16.1%, p=0.042; I2=69.0%). The specific risk difference for endograft collapse/infolding and thrombosis was 3.7% (95% CI −3.5% to 11.1%, p=0.308; I2=10.2%). Conclusion: At present the literature does not provide statistical evidence to establish an overall prognostic value of the BBC. Nevertheless, the BBC appears to be associated with a high risk of type Ia endoleak and endograft migration, which warrants specific and long-term surveillance. Clinically relevant values for BBC grading should be established to perhaps define indications for preemptive treatment based on the presence of BBC only.
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Affiliation(s)
- Massimiliano M. Marrocco-Trischitta
- Clinical Research Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Benedetta Spampinato
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Residency Program in Vascular Surgery, University of Milan, Italy
| | - Girolomina Mazzeo
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Residency Program in Vascular Surgery, University of Milan, Italy
| | - Daniela Mazzaccaro
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Valentina Milani
- Biostatistics Service, IRCCS Policlinico San Donato, Milan Italy
| | - Moad Alaidroos
- Vascular Surgery Unit, Policlinico San Marco, Zingonia, Italy
| | - Federico Ambrogi
- Biostatistics Service, IRCCS Policlinico San Donato, Milan Italy
- Laboratory of Medical Statistics, University of Milan, Italy
| | - Giovanni Nano
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Department of “Scienze Biomediche per la Salute,” University of Milan, Italy
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Seike Y, Matsuda H, Inoue Y, Omura A, Uehara K, Fukuda T, Kobayashi J. Balloon protection of the left subclavian artery in debranching thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2018; 157:1336-1345.e1. [PMID: 30447961 DOI: 10.1016/j.jtcvs.2018.10.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 09/25/2018] [Accepted: 10/11/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Since 2012, we have routinely applied balloon protection of the proximal left subclavian artery to prevent embolic events through the left vertebral artery during debranching thoracic endovascular aortic repair. This study aimed to study the effectiveness of balloon protection of the proximal left subclavian artery. METHODS We reviewed the medical records of 157 patients who underwent debranching thoracic endovascular aortic repair between 2007 and 2017. Of these, 71 patients for whom balloon protection of the proximal left subclavian artery was used were assigned to the balloon protection of the proximal left subclavian artery group (58 men; age: 78 ± 6.7 years), and 86 patients were assigned to the control group (66 men; age: 78 ± 8.9 years). A total of 51 patients from each group were matched by their propensity scores to adjust for differences in the patients' characteristics. RESULTS Perioperative stroke was significantly lower in the balloon protection of the proximal left subclavian artery group than in the control group (0%: 0/71 vs 7.9%: 7/86, P = .014). Freedom from all causes of mortality at 2 and 4 years was significantly higher in the balloon protection of the proximal left subclavian artery group compared with the control group (93%/76% vs 77%/59%, P = .015). Freedom from aortic death at 2 and 4 years was similar in both groups (97%/97% vs 91%/86%, P = .094). Propensity score matching yielded similar results of better freedom from all causes of mortality in the balloon protection of the proximal left subclavian artery group (93%/93% vs 81%/63%, P = .017) and equivalent aortic death in both groups (95%/95% vs 92%/88%, P = .30). CONCLUSIONS Debranching thoracic endovascular aortic repair using balloon protection of the proximal left subclavian artery demonstrated more appropriate early and late outcomes. Evaluation using propensity score matching enhanced the efficacy of balloon protection of the proximal left subclavian artery.
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Affiliation(s)
- Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Atsushi Omura
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kyokun Uehara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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Total arch replacement versus debranching thoracic endovascular aortic repair for aortic arch aneurysm: what indicates a high-risk patient for arch repair in octogenarians? Gen Thorac Cardiovasc Surg 2018; 66:263-269. [DOI: 10.1007/s11748-018-0894-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/22/2018] [Indexed: 01/14/2023]
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A current systematic evaluation and meta-analysis of chimney graft technology in aortic arch diseases. J Vasc Surg 2017; 66:1602-1610.e2. [DOI: 10.1016/j.jvs.2017.06.100] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 06/19/2017] [Indexed: 12/20/2022]
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