Hybrid surgery of vertebral artery transposition combined with scallop and fenestration technique for the repair of type B aortic dissection patient with isolated left vertebral artery: A case report

RATIONALE

Acute type B aortic dissection (ABAD) is a fatal cardiovascular disease with high morbidity and mortality. Isolated left vertebral artery (ILVA) is a rare aortic arch mutation originating from the aortic arch. The simultaneous occurrence of both increases the complexity and difficulty of thoracic endovascular aortic repair. However, there have been few reports on the recommendation of thoracic endovascular aortic repair treatment strategies for aortic dissection patients concomitant ILVA with insufficient landing zone. Here, we report a case of ABAD combined with ILVA treated with hybrid surgery of left vertebral artery transposition alliance with Scallop and in vivo fenestration endograft.

PATIENT CONCERNS

A 38-year-old middle-aged man was transferred to our vascular department with persistent pain in his lower abdomen for 8 hours.

DIAGNOSES

Preoperative computed tomography angiogram of the thoracic and abdominal aorta diagnosed with ABAD accompanied with ILVA.

INTERVENTIONS

Hybrid surgery of left vertebral artery transposition alliance with Scallop and in situ fenestration endograft for revascularization of ILVA, left subclavian artery, and left common carotid artery.

OUTCOMES

The hybridization operation was successfully completed. There were no complications of cerebral and spinal cord ischemia after operation. Computed tomography angiogram examination indicated no internal leakage existed in the stent and patency of the arch vessels and the transposed left vertebral artery follow-up 3 months after surgery.

LESSONS

This study gave us experience in the treatment of aortic dissection with left vertebral artery variation and suggested that left vertebral artery transposition combined with scallop and in vivo fenestration stent is safe and effective.

In search for "healthy" landing zones for coronary stent placement: are the largest intrasegmental lumens adequate?

Background

Coronary lesions are supposed to be enclosed between proximal and distal reference segments (RSs), the sites with the largest lumens within the same vessel segment. Finding "healthy" landing zones has been fundamental for efficient stent implantation. Consequently, our study aimed to determine, using optical coherence tomography (OCT), to what degree RSs conform to this concept.

Methods

Sixty-seven patients with a mean age of 63.5 years underwent culprit lesion stenting due to acute myocardial infarction (MI) (Group 1) or stable angina (Group 2). OCT was performed with commercially available equipment; all evaluations were made at RSs and minimal lumens.

Results

Normal vessel wall was infrequent (~10%) at RSs. Acceptable external elastic 220°) occurred in 55% to 67% and in 28% to 31% of RSs, respectively. Tissue composition at RSs was similar in both study groups except for a greater accumulation of thin-cap fibroatheromas (TCFA) in acute MI (29% in Group 1 vs. 9% in Group 2, P=0.035). Flow deterioration after stenting was associated with TCFA clusters extending from culprit main bodies into proximal RSs (P=0.008).

Conclusions

Optimal landing zones for stent placement should frequently be searched for beyond the culprit lesion segments although utilizing the largest intrasegmental lumens does not seem to cause immediate harm. However, TCFA at the landings should definitely be avoided.

Long-Term Outcomes in Thoracic Endovascular Aortic Repair for Complicated Type B Aortic Dissection or Intramural Hematoma Depending on Proximal Landing Zone

Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for complicated type B aortic dissection (TBAD) or intramural hematoma (IMH). This study aimed to investigate the association of the proximal landing zone and its morphology with long-term outcomes in patients with TBAD or IMH. A total of 94 patients who underwent TEVAR for TBAD or IMH between 10/2003 and 01/2020 were included. The cohort was divided according to the proximal landing in Ishimaru zone 2 or 3 and the presence of a healthy landing zone (HLZ; non-dissected or aneurysmatic, ≥2 cm length). Primary outcome was freedom from aortic reintervention. Secondary endpoints were freedom from aortic growth, stroke, spinal cord ischemia, retrograde dissection, proximal stent-graft induced new entry (pSINE), debranching failure, and mortality. Outcomes were assessed using Cox proportional hazard models with mortality as a competing risk. A proximal TEVAR landing in zone 2 was associated with higher rates of reinterventions compared to zone 3 (33% vs. 15%, p = 0.031), spinal cord ischemia (8% vs. 0%, p = 0.037), and pSINE (13% vs. 2%, p = 0.032). No difference was found for the other outcomes, including mortality. Landing in dissected segments was not associated with impaired results. Proximal TEVAR landing in zone 3 may be preferable with regard to long-term aortic reintervention in patients with TBAD or IMH.

Endovascular Repair of Zone 0 Ascending Aortic Pseudoaneurysm: A Case Report

Although open surgery is standard of care for ascending aortic pathology, endovascular approaches can be viable options. We report the case of a 77-year-old man with a 5.7-cm ascending aorta penetrating ulcer. Given his age and clinical profile, the patient underwent Zone 0 thoracic endovascular aortic repair.

The Feasibility and Long-Term Outcomes of the Crossboss/Stingray for Treating Coronary Chronic Total Occlusions Lesions with Distal Diffuse Disease Landing Zone

BACKGROUND

The feasibility and long-term outcomes of the CrossBoss/Stingray for treating coronary chronic total occlusions (CTO) with distal diffuse disease landing zone remain unclear.

METHODS

Consecutive CTO patients with distal diffuse lesions that underwent percutaneous coronary intervention by the CrossBoss/Stingray system at Xijing Hospital from April 2016 to October 2020, were included. Patients were analyzed by two groups according to the extent of stenosis in the distal landing zone: 50%-70% stenosis (moderate stenosis group) and >70% stenosis (severe stenosis group). The primary efficacy outcome was technical success, defined as the frequency of true lumen guidewire placement distal to the CTO. The composite endpoint of all-cause death, any stroke, or any revascularization was also explored.

RESULTS

A total of 91 consecutive patients were included, with 32 patients in the moderate stenosis group and 59 patients in the severe stenosis group. The mean J-CTO score was 2.5 ± 1.1. The technical success rate was 79.1% (72/91) in the overall population and was similar between the 2 groups: 78.1% (25/32) and 79.7% (47/59) (p = 0.608). No coronary perforation occurred. With a median follow-up of 29 months (IQR: 53-92), the estimated rate of the composite endpoint of all-cause death, any stroke, or any revascularization was 50.4% (all-cause death: 16.6%, any stroke: 1.1%, any revascularization: 36.5%) in the overall population. No significant difference was observed in the rate of the composite endpoint between the moderate stenosis group and the severe stenosis group (45.1% vs. 54.3%, respectively, p = 0.797).

CONCLUSIONS

In CTO lesions with distal diffuse disease landing zone, the technical success rates of CrossBoss/Stingray and the long-term clinical outcomes were not significantly different between the moderate stenosis group (50%-70%) and the severe stenosis group (>70%). However, the relatively high rate of long-term clinical outcomes, especially any revascularization, warrants further investigations on this indication in future studies.

Safety and Effectiveness of TEVAR in Native Proximal Landing Zone 2 for Chronic Type B Aortic Dissection in Patients With Genetic Aortic Syndrome

OBJECTIVES

The aim of this study is to report the safety and effectiveness of thoracic endovascular aortic repair (TEVAR) in a native proximal landing zone (PLZ) 2 for chronic type B aortic dissection (TBAD) patients with genetic aortic syndrome (GAS).

METHODS

A retrospective review of a single center database to identify patients with GAS treated with TEVAR in native PLZ 2 for chronic TBAD and thoracic false lumen aneurysm between February 2012 and February 2018 was undertaken.

RESULTS

In total, 31 patients with GAS (24 Marfan syndrome [MFS], 5 Loeys-Dietz syndrome [LDS], and 2 vascular Ehlers-Danlos syndrome [vEDS]) were treated by endovascular repair. Nineteen patients were treated by TEVAR as index procedures with 8 patients (5 females, mean age = 55, range = 36-79 years old) receiving TEVAR in native PLZ 2. Left subclavian artery (LSA) perfusion was preserved in all 8 patients: by left common carotid artery-LSA bypass in 6 patients, chimney stenting of the LSA in 1 patient, and partial coverage of LSA ostium in 1 patient. Technical success was achieved in all patients (100%). There was no 30 day mortality (0%). The 30 day morbidity (0%) was free from major complications. The median follow-up was 40 months (range = 7-79). One patient died due to non-aortic-related cause. Native PLZ 2 was free from complications in MFS patients (5/8). Two patients with LDS developed type Ia endoleak with aneurysmal progression. One patient was treated by proximal extension with a double inner branched arch stent-graft landing in the replaced ascending aorta. The other one was treated with frozen elephant trunk.

CONCLUSION

Thoracic endovascular aortic repair in native PLZ 2 was safe and effective with no early or midterm PLZ complications in patients with MFS with chronic TBAD in this limited series. Native PLZ 2 is not safe in patients with LDS and should only be used in emergencies as a bridging to open repair.

Fate of Aneurysmal Common Iliac Artery Landing Zones Used for Endovascular Aneurysm Repair

PURPOSE

To determine outcomes of aneurysmal common iliac arteries (aCIA) used for landing zones (LZs) during endovascular aneurysm repair (EVAR).

METHODS

This single-center study retrospectively compared 57 EVAR patients (mean age 72±8 years; 56 men) with 70 aCIAs (diameter ≥20 mm) to 25 control EVAR subjects (mean age 73±7 years; 20 men) with 50 normal (≤15-mm) CIA LZs treated consecutively during the same time interval. The CIA LZ measurements were analyzed using random effects linear mixed models to determine diameter change over time. Life tables were used to estimate freedom from endoleak, reintervention, and all-cause mortality.

RESULTS

The mean maximum preoperative CIA diameter in the aCIA LZ group was 24.8±4.5 mm (range 20.0-47.3, median 23.9) vs 13.6±1.5 mm (range 9.2-15.0, median 13.9; p<0.001) in the controls. Nineteen aCIA LZs were treated outside the instructions for use of the device. Median follow-up in the aCIAs LZ cohort was 39.2 months [interquartile range (IQR) 15, 61] vs 49.3 months (IQR 36, 61) in the controls (p=0.06). The rate of aCIA LZ change (0.09 mm/mo, 95% CI 0.07 to 0.1) was significantly greater than controls (0.03 mm/mo, 95% CI -0.009 to 0.07; p<0.0001). No type Ib endoleaks developed in either group; however, aCIA LZ patients had 6 (11%) iliac limb-related reinterventions. There were significantly more endograft-related reinterventions in the aCIA LZ patients (n=10, 14%) compared with controls (n=2, 4%; p=0.06). There was no difference in mortality or freedom from any post-hospital discharge endoleak.

CONCLUSION

Aneurysmal CIA LZs used during EVAR experience greater dilatation compared with normal LZs, but no significant difference in outcome was noted in midterm follow-up. However, an increased incidence of graft limb complications or endograft-related reintervention may be encountered. Use of aCIA LZs appears to be safe; however, greater patient numbers and longer follow-up are needed to understand the clinical implications of morphologic changes in these vessels when used during EVAR.