Total endograft replacement of aortic arch

Simplifying aortic arch surgery: open zone 2 arch with single branched thoracic endovascular aortic repair completion

Background

Distal aortic complications from acute DeBakey I dissection repair are an important source of late morbidity and mortality. We present an early experience of using a novel single-branched thoracic aortic endograft in conjunction with open techniques to treat acute DeBakey I aortic dissection.

Methods

The patients in this series include five hyperacute dissections managed with a combined zone 2 partial arch replacement and placement of a zone 2 single subclavian branch endograft.

Results

There were no perioperative mortalities, strokes, or spinal cord ischemia in any patients at either stage of the procedure. At follow-up imaging, no patients had anterograde flow into the false lumen. All patients experienced false lumen thrombosis in the stented portion of the aorta.

Conclusions

This combination of open repair techniques and the use of a novel branched endograft resulted in excellent early outcomes in this pioneer series. Further investigation of these techniques in a prospective fashion is warranted.

Minimally Invasive Techniques for Total Aortic Arch Reconstruction

The cumulative experience with endovascular aortic repair in the descending thoracic and infrarenal aorta has led to increased interest in endovascular aortic arch reconstruction. Open total arch replacement is a robust operation that can be performed with excellent results. However, it requires cardiopulmonary bypass and circulatory arrest and, therefore, may not be tolerated by all patients. Minimally invasive techniques have been considered as an alternative and include hybrid arch debranching, parallel stent graft deployment in the chimney and snorkel configurations, and complete endovascular branched reconstruction with multi-branched devices. This review discusses the evolving use of endovascular techniques in the management of aortic arch pathology and considers their relevance in an era of safe and durable open aortic arch reconstruction.

Evolving practice pattern changes and outcomes in the era of hybrid aortic arch repair

OBJECTIVE

The role of hybrid repair in the management of aortic arch pathology, and long-term outcomes with these techniques, remains uncertain. We report a decade of experience with hybrid arch repair (HAR) and assess institutional practice patterns with regard to the use of hybrid and open techniques.

METHODS

Hybrid and open total and distal arch procedures performed between July 2005 and January 2015 were identified from a prospectively maintained, institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term survival were calculated. Hybrid and open procedural volumes over the study period were assessed to evaluate for potential practice pattern changes.

RESULTS

During the study period 148 consecutive procedures were performed for repair of transverse and distal aortic arch pathology, including 101 hybrid repairs and 47 open total or distal arch repairs. Patients in the hybrid repair group were significantly older with a greater incidence of chronic kidney disease, peripheral vascular disease, and chronic lung disease. Perioperative mortality and outcomes were not significantly different between the hybrid and open groups, aside from decreased median length of stay after hybrid repair. Need for subsequent reintervention was significantly greater after hybrid repair. Unadjusted long-term survival was superior after open repair (70% 5-year survival open vs 47% hybrid; P = .03), although aorta-specific survival was similar (98% 5-year aorta-specific survival open vs 93% hybrid; P = .59). Institutional use of HAR decreased over the final 3 years of the study, with an associated increased use of open total or distal arch repairs. This was primarily the result of decreased use of native zone 0 hybrid procedures. Concurrent with this apparent increased stringency around patient selection for HAR, perioperative morbidity and mortality was reduced, including avoidance of retrograde type A dissection.

CONCLUSIONS

HAR remains a viable option for higher-risk patients with transverse arch pathology with perioperative outcomes and long-term aorta-specific survival similar to open repair, albeit at a cost of increased reintervention. This observational single-institution study would suggest decreased use in more recent years in favor of open repair due to avoidance of native zone 0 hybrid procedures. This decline in the institutional use of native zone 0 hybrid repairs was associated with improved perioperative outcomes.

Complete endovascular debranching of the aortic arch: A report of two cases

Patients suffering from aortic arch aneurysms continue to encounter few treatment options. Because of co-morbidities, most are deemed to not be open surgical candidates. The two cases presented here demonstrate a novel endovascular approach in the care of an arch aneurysm complicated by dissection. Even though final graft configurations differed slightly between the two cases, all three great vessels were successfully de-branched through the combination of standard endovascular aneurysm repair techniques and modifications to off-the-shelf devices. Aortic flow was compartmentalized in the ascending aorta at or near the level of the sinotubular junction. This was done with a physician-assembled endografts. One of these lumens was dedicated to the descending aorta, while the other was further divided into three channels used to stent the great vessels. Completion angiography demonstrated patency in the arch, great vessels, and descending aorta. No endoleaks have been reported. Although data is limited, this approach appears promising.