Total Arch Thoracic Endovascular Aortic Repair Using Double Fenestrated Physician-Modified Stent-Grafts: 100 Patients

OBJECTIVE

The aim was to evaluate early and medium-term outcomes of double fenestrated physician-modified endovascular grafts for total endovascular aortic arch repair.

METHODS

This single-center retrospective analysis of prospectively-collected data included 100 patients, from January 2017 to December 2021, undergoing thoracic endovascular aortic repair (TEVAR) for zone 0. The fenestrations were a proximal larger fenestration that incorporated the brach2iocephalic trunk and left common carotid artery and a distal smaller fenestration for the left subclavian artery (LSA). Only the LSA fenestration was stented.

RESULTS

The median duration for stent-graft modification was 23±6 minutes. Of the 100 patients, 70 were men. The mean patient age was 70±10.5 years. Indications for treatment included degenerative aortic arch aneurysm (n=32), dissecting aortic arch aneurysm after type A dissections (n=23) and (n=19) after type B dissections, acute complicated type B dissection (n=16), and other pathologies (n=10). Technical success rate was 97%. The 30 day mortality was 2% (n=2). Four patients (4%) had minor stroke with full recovery. One patient (1%) had a type IA endoleak, 1 patient (1%) had a type IB endoleak, and 2 patients (2%) have a type II endoleak from the LSA. Eight patients (8%) required reintervention: 1 type IA endoleak, 1 type IB endoleak, 1 retrograde type A dissection, and 5 because of access-related complications. During a mean follow-up of 24±7.2 months, there were no aortic rupture, paraplegia, and all supra-aortic trunks were patent.

CONCLUSIONS

Double homemade fenestrated TEVAR is both feasible and effective for total endovascular aortic arch repair avoiding the need for anatomical and extra-anatomical surgical revascularization. The long-term durability will need to be assessed in studies with long-term follow-up.

CLINICAL IMPACT

Double homemade fenestrated TEVAR is effective for total endovascular aortic arch repair avoiding the need for anatomical and extra-anatomical surgical revascularization. The standout feature of this double fenestrated device is its simple handling during operation with the proximal fenestrations being directed to the orifices of the BT and LCCA automatically when the LSA fenestration is catheterized and secured by covered stent placement. The deployment algorithm actively steers the operator away from superfluous manipulations of the device within the arch and avoids guidewire manipulation in carotid arteries. The long-term durability will need to be assessed in studies with long-term follow-up.

Zone 2 Aortic Arch Repair With Single-Fenestrated Physician-Modified Endografts, at Least 3 Years of Follow-up

OBJECTIVE

The aim of this study is to report the efficiency and safety of single-fenestrated physician-modified endografts (PMEGs) in zone 2 aortic arch pathologies with at least 3 years of follow-up.

METHODS

All consecutive patients with a pathological aortic arch who underwent aortic repair combined with homemade single-fenestrated stent-graft from 2015 to 2020 were reviewed. The patients with a target vessel different from the left subclavian artery (LSA) were excluded.

RESULTS

A total of 63 patients were treated for a pathological arch in zone 2 with a single-fenestrated PMEG. 73% were male, and the mean age was 65 years old. 25% were treated for a degenerative aneurysm, 19% for a post dissection aneurysm and 24% for an acute type B dissection. 52% of the patients were treated as an emergency and half of those for an aortic rupture. The LSA fenestration was stented in 70%. During 30 days of follow-up, 2 strokes (3%) were reported, 6 patients (10%) died with 4 of those treated for aortic rupture and 1 had a retrograde aortic dissection. During at least 3 years of follow-up (median 49 months), no reintervention was needed for endoleaks, there was no stent fracture or stent migration. No patient died from an aortic cause. Subgroup analysis comparing the endovascular treatment for various aortic pathologies did not find significant differences in death rate or comorbidity including stroke. When comparing emergent and elective aortic repair, operating time was similar (64 vs 65 minutes), and the LSA fenestration was less frequently stented (52%) in the emergency group. There was no difference in stroke frequency. There was a higher rate of death in the emergency group at 30 days of follow-up, but no patient died from aortic cause in the long-term follow-up.

CONCLUSIONS

Aortic arch repair with single-fenestrated PMEGs for zone 2 pathological arch disease is associated with acceptable early and midterm major morbidity and mortality. It is suitable for emergency situations.

CLINICAL IMPACT

Single-fenestrated PMEG for the left subclavian artery is a safe and efficient option in the short and medium term for the treatment of the aortic arch in zone 2 with 98% technical success. It allows for aortic repair and subclavian artery revascularization in a single step for all patients. It is suitable for a range of main pathologies, including degenerative, dissection-related, isthmus rupture, and embolic pathologies. Additionally, it is always available and easily utilized in emergency cases.

Urgent Juxtarenal Aortic Aneurysm Repair With Modified Off-the-shelf Endograft to Preserve Intercostal Arteries and Branch Incorporation by Transfemoral Access

PURPOSE

To demonstrate the feasibility of the modification to preserve intercostal arteries of the t-Branch Endograft (Cook Medical, Bloomington, IN) in an urgent setting, associated with a less invasive approach for branch incorporation from percutaneous femoral access with steerable sheaths.

TECHNIQUE

A 73-year-old female patient presented at our institution with intense abdominal pain. Angiotomography showed a 50-mm juxtarenal aortic aneurysm, with no signs of rupture. Urgent endovascular repair was indicated due to abdominal symptom with an off-the-shelf multi-branched endograft. To limit descending thoracic aortic coverage, we performed t-Branch modification to preserve intercostal arteries and minimize the risk of spinal cord injury, associated with a percutaneous transfemoral approach and branch incorporation with steerable sheaths to avoid the risks associated with a superior axillary or brachial access. Control angiotomography showed adequate aneurysm sac exclusion with patency of all four visceral vessels.

CONCLUSION

t-Branch-modified endograft to limit aortic coverage is an alternative option in urgent cases to diminish the risk of spinal cord injury, and association of steerable sheaths with branch incorporation is leading complex aortic repairs to an even less invasive procedure.

CLINICAL IMPACT

This paper highlights the possibility of performing complex endovascular aortic repair in an urgent setting with modification of an off-the-shelf multi branched endograft limiting intercostal arteries coverage, thereby diminishing the risk of spinal cord ischemia. This technical innovation provides an alternative for clinicians when treating large, rapidly expanding, or symptomatic juxtarenal, pararenal, paravisceral or type 4 thoracoabdominal aortic aneurysms that could not wait for a custom-made device and do not need extensive thoracic aortic coverage that an off-the-shelf device provides. In summary, expand the possibilities of an endovascular repair of complex aortic aneurysms.

Systematic Review and Meta-Analysis of Ex-Situ and In-Situ Fenestrated Stent-Grafts for Endovascular Repair of Aortic Arch Pathologies

PURPOSE

To gain insight into safety and efficacy of in situ and ex-situ fenestration techniques for total endovascular arch repair. The term ex-situ fenestration is referring to physician-modified stent-graft technique where fenestration is performed on a back table.

METHODS

Electronic search was conducted according to PRISMA (Preferred Reporting Items for Systematic review and Meta-analyses) guidelines from 2000 to 2020. The main outcomes measured were 30-day mortality, stroke, aortic-related mortality, and reintervention rates.

RESULTS

Fifteen studies were eligible: 7 ex-situ fenestration (189 patients) and 8 in-situ fenestration (149 patients). In ex-situ group, dissection was the main pathology treated and proximal sealing zones were Z0 or 1 in 53.5% of patients. In in-situ group, dissection and aneurysm were equally represented in around 40% of cases and proximal sealing zones were Z0 or 1 in 46.5% of patients. Cumulative 30-day all-cause mortality was similar in both groups: 3.8% (95% confidence interval [CI]: 1.7%-8.2%) and 3.8% (95% CI: 1.6%-8.9%), respectively, in ex-situ and in-situ groups and stroke rate of 2.8% (95% CI: 1.1%-7%) and 5.3% (95% CI: 2.6%-10.5%). After a 11.1 ± 2.6 months mean follow-up for ex-situ and 16.7 ± 2.3 months for in-situ group, there were 5.2 and 1.4 reinterventions per 100 patients-years, respectively, for ex-situ and in situ groups. Aortic-related mortality rates of, respectively, 3.2% (95% CI: 1.3%-7.4%) and 2.6% (95% CI: 0.9%-7.3%) were noted in ex-situ and in situ groups.

CONCLUSION

The reported data show favorable short-term results of both ex-situ and in-situ fenestration techniques with low mortality and strokes rates. However, durability is still questionable given the lack of long-term data. Both options may have their place in arch repair beyond the spectrum of emergent and urgent cases, on condition that results stand the test of time.

CLINICAL IMPACT

In situ and ex-situ fenestration techniques have been initially developed to overcome emergency or as a bail out techniques however giving the promessing favorable short term results indications of these techniques may be extended to elective patients ineligible to customized stent-grafts and possibly in the futur to more elective cases as an option for total endovascular arch repair.

Homemade fenestrated physician-modified stent-grafts for arch aortic degenerative aneurysms

OBJECTIVE

To evaluate early and medium-term outcomes of single and double fenestrated physician-modified endovascular grafts (PMEGs) for total endovascular degenerative aortic arch aneurysm repair.

METHODS

This single-center retrospective analysis of prospectively collected data included 52 patients, from August 2013 through January 2021, undergoing home-made fenestrated thoracic endovascular aortic repair (TEVAR) for degenerative aortic aneurysms. In all cases a distal smaller fenestration for the left subclavian artery (LSA) was fashioned and the only one stented. For double-fenestrated endograft a proximal larger fenestration that incorporated both the brachiocephalic trunk and left common carotid artery was added.

RESULTS

52 patients with degenerative aortic arch aneurysms were treated. There were 36 men and the mean age was 75 ± 8 years. 31% treated with a single LSA fenestration, while 69% had a double-fenestrated TEVAR. 10% (n=5) were emergent procedures. Technical success was 100%. The median time requirement for stent graft modification was 22 ± 6 minutes. Thirty-day mortality was 2% (n=1). 5 patients (10%) had a cerebrovascular event including 2 transient ischemic attack, one minor stroke with full neurological recovery and 2 with sequelae. 2 patients (4%) experienced perioperative retrograde dissection during follow-up. No patient had a type I, type III or type II endoleak from the LSA. No patient required re-intervention. All supra-aortic trunks were patent. During a mean follow up of 18 ± 11 months, there were no conversion to open surgical repair, aortic rupture or paraplegia.

CONCLUSIONS

Single or double PMEG is a safe and suitable tool for the treatment of high morbidity pathology such as aortic arch degenerative aneurysm repair. This device can be used in elective and emergency patients.

Stent Graft Modification to Preserve Intercostal Arteries Using Thoracoabdominal Off-the-Shelf Multibranched (t-Branch) Endograft

Purpose: To demonstrate an off-the-shelf multibranched (t-Branch) modification to allow intercostal arteries preservation during juxtarenal, pararenal, paravisceral, and extent IV thoracoabdominal aortic aneurysm repair. Technique: The t-Branch is an off-the-shelf device not customized for specific patient anatomy and may be offered for urgent endovascular repair for patients with complex aortic aneurysms. However, a concern when treating patients who do not aneurysms extending above the celiac axis is that the more proximal extension which is required with this device may render patients at high risk for spinal cord injury. We report a novel technique with t-Branch modification performing a 180° fabric back windows at the first 2 sealing stents that allow perfusion to the intercostal arteries. Conclusion: T-Branch-PIA (preserving intercostal arteries) modification limits intercostal arteries coverage while optimizing proximal seal zone in juxtarenal, pararenal, paravisceral, and extent IV thoracoabdominal aneurysms, thereby may decrease the risk of spinal cord injury.

Midterm Results of Retrograde In Situ Needle Fenestration During Thoracic Endovascular Aortic Repair of Aortic Arch Pathologies

PURPOSE

To evaluate the safety and feasibility of the in situ needle fenestration (ISNF) technique for reconstruction of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) of complicated aortic arch pathologies.

MATERIALS AND METHODS

A retrospective review was conducted from January 2014 to December 2019 of 50 patients (mean age 60.2±11.1; 45 men) who underwent ISNF to revascularize the LSA during TEVAR. Twenty-one of the patients also required revascularization of the left common carotid artery (LCCA; n=19) and innominate artery (IA; n=2) using physician-modified in vitro fenestration. Overall, 73 supra-aortic branches were targeted for revascularization.

RESULTS

ISNF was successful in 48 patients (96%); one LSA could not be stented and a tortuous LSA prevented the needle from fenestrating the graft. No perioperative major adverse event occurred. There were no type I and 4 type III endoleaks (8%), 3 of which occurred among the first 20 cases. Types II and IV endoleaks were found in 3 (6%) and 6 (12%) cases, respectively; all disappeared during a median follow-up of 15 months (range 3-66). One death (2%) occurred within 12 months due to cerebral hemorrhage. Two patients (4%) required open reinterventions at 6 and 62 months.

CONCLUSION

ISNF for revascularization of the LSA during TEVAR seems to be feasible with acceptable midterm outcomes. The learning curve and evolving patient selection criteria affected technical success, complications, and the need for reinterventions. Long-term durability requires further evaluation.

Endovascular Repair of Ascending Aortic Pathologies With Tubular Endografts: A Single-Center Experience

Purpose: To investigate the endovascular treatment of ascending aortic pathologies of high-risk patients unsuitable for open repair. Materials and Methods: From 2010 to 2017, 24 patients (mean age 70±15 years, range 29-90; 18 men) were treated at a single center for various pathologies of the ascending aorta, including acute or chronic type A aortic dissections (n=16), pseudoaneurysms (n=6), fixation of a dislocated percutaneous aortic valve (n=2), and miscellaneous indications (n=3). The patients were selected following an interdisciplinary case evaluation, attended by cardiologists and cardiac and vascular surgeons. The Zenith Ascend TAA Endovascular Graft was implanted; simultaneous procedures were performed in 13 patients. Of the total 27 Ascend TEVAR procedures (24 primary and 3 reinterventions), 17 were performed urgently and 10 electively. The primary outcome measure was 30-day survival. The secondary outcomes were cardiovascular complications, midterm survival, and reintervention rate. Results: Clinical success was achieved in all but 1 case. The 30-day survival was 79% (19/24); of the 5 deaths only 1 was directly related to the endograft implanted. In the 30-day postoperative period, there was 1 myocardial infarction, 2 major strokes, a mycotic pseudoaneurysm, a case of Ascend TEVAR-induced high-grade aortic insufficiency, and a minor stroke; 1 patient developed paraplegia after concurrent implantation of a 4-branched abdominal stent-graft. Two patients had a reintervention within 30 days for the pseudoaneurysm and the aortic insufficiency, respectively. During a mean follow-up of 11 months (0-35 months), there was 1 late death (cancer) and 1 additional reintervention at 10 months for a late type Ia endoleak (12.5% reintervention rate). Conclusion: Endovascular repair of ascending aortic pathologies with stent-grafts is a feasible treatment option with acceptable early and midterm outcomes in high-risk patients unsuitable for open surgery. The complexity of Ascend TEVAR might justify higher reintervention rates.

A 3-Dimensional Printed Aortic Arch Template to Facilitate the Creation of Physician-Modified Stent-Grafts

PURPOSE

To demonstrate the utility of a 3-dimensional (3D) printed template of the aortic arch in the construction of a fenestrated and scalloped physician-modified stent-graft (PMSG).

CASE REPORT

A 73-year-old woman with descending thoracic aneurysm was scheduled for thoracic endovascular aortic repair after being disqualified for open surgery. Computed tomography angiography (CTA) revealed no proximal landing zone as the aneurysm began from the level of the left subclavian artery, so a fenestrated/scalloped PMSG was planned. To facilitate accurate placement of the openings in the graft, a 3D printed aortic arch template was prepared from the CTA data and gas sterilized. In the operating room, a Valiant stent-graft was inserted into the 3D printed template and deployed. Using ophthalmic cautery, a fenestration and a scallop were created; radiopaque markers were added. The PMSG was successfully deployed with no discrepancy between the openings and the target vessels.

CONCLUSION

A 3D printed aortic arch template facilitates handmade fenestrations and scallops in PMSGs and may improve accuracy and quality.

Candy-Plug Technique Using an Excluder Aortic Extender for Distal Occlusion of a Large False Lumen Aneurysm in Chronic Aortic Dissection

PURPOSE

To describe the candy-plug technique using an Excluder aortic extender for distal occlusion of a large false lumen aneurysm in chronic aortic dissection.

TECHNIQUE

A 60-year-old female patient with a history of chronic type B aortic dissection and high-dose steroid use for Churg-Strauss syndrome developed a large 6.2 cm maximum diameter false lumen aneurysm. She underwent thoracic endovascular aortic repair from the left common carotid artery to the descending aorta to cover the proximal entry at the level of distal arch, with coil embolization of the left subclavian artery. To occlude the large false lumen from the reentry just below the level of the left renal artery ostium, a modified 32×45-mm Excluder aortic extender was deployed in the false lumen through the reentry, and a 16-mm Amplatzer Vascular Plug I was deployed in the waist of the modified Excluder aortic extender for complete occlusion. No obvious technical complication was seen. Contrast-enhanced computed tomography at 1 and 14 months revealed no endoleaks and showed complete false lumen thrombosis.

CONCLUSION

The candy-plug technique using the Excluder aortic extender is feasible for occlusion of a large false lumen aneurysm in chronic aortic dissection.

Externalized Guidewires to Facilitate Fenestrated Endograft Deployment in the Aortic Arch

Purpose: To describe a precannulated fenestrated endograft system utilizing externalized guidewires to facilitate aortic arch endovascular repair and to report its use in 2 patients with challenging anatomy. Technique: For distal arch repair, a fenestration for the left subclavian artery (LSA) is made onsite in a standard thoracic endograft tailored to the patient anatomy; it is precannulated with a nitinol guidewire (NGw), which is passed from the femoral artery and externalized from the left brachial artery prior to endograft delivery system introduction over a parallel stiff guidewire. Steps are then taken to remove guidewire intertwining, prevent NGw wrapping around the delivery system, and orient the LSA fenestration superiorly when the delivery system moves into the arch. Gentle traction on the ends of the NGw during endograft deployment facilitates proper fenestration alignment. A covered stent is deployed in the LSA fenestration. The technique is illustrated in a patient with congenital coarctation of the aorta and descending aortic aneurysm. For total arch repair, endograft fenestrations are made for all 3 arch branches; the left common carotid artery (LCCA) and LSA fenestrations are each cannulated with NGws, which travel together from the femoral artery, pass through a LSA snare loop, and are exteriorized from the LCCA. After endograft deployment, the innominate artery fenestration is separately cannulated using right brachial access. Placement of a parallel externalized hydrophilic guidewire passing through the LCCA fenestration (but not the LSA snare loop) and removal of the LCCA fenestration NGw allows exteriorization of the LSA fenestration NGw from the left brachial artery by pulling the LSA snare. Covered stents are deployed in all 3 fenestrations. The technique is presented in a patient with type B aortic dissection. Conclusion: Use of the precannulated fenestrated endograft system described is feasible and has the potential to make aortic arch endovascular repair simpler, more reliable, and safer.