Endovascular treatment of chronic aortic dissection with fenestrated and branched stent grafts

OBJECTIVE

Chronic aortic dissection with aneurysm development that includes the aortic arch and/or thoracoabdominal aorta (TAAA) is traditionally treated with open or hybrid surgery. Total endovascular treatment with fenestrated and branched aortic repair (F/B-EVAR) has recently been introduced as a less invasive alternative. The aim was to report the short- and midterm outcomes from a single tertiary vascular center.

METHODS

All patients with chronic aortic dissection treated with F/B-EVAR from 2010 to 2019 at Uppsala University Hospital were identified. Perioperative and postoperative parameters were analyzed, with focus on short- (<30 days) and midterm survival, complication, and reintervention rates.

RESULTS

F/B-EVAR was performed on 26 patients (median age, 63 years; range, 33-87 years; 18 men; median aortic diameter, 70 mm; range, 50-98 mm); with a median follow-up of 23 months (range, 0.5-118.0 months). One patient underwent both arch and TAAA repair. Overall, 13 arch repairs (arch group) after type A (n = 8) and type B (n = 5) dissection (all elective) were performed, and 14 TAAA repairs (TAAA group) after type A (n = 5) and type B (n = 9) dissection (one rupture). A total of 72 aortic branches were targeted (22 arch, 50 TAAA). Short-term technical success was achieved in 24 of 27 procedures (89%). Failures were related to one intraoperative retrograde type A dissection (RTAD) requiring open conversion (arch group), one persistent type IC endoleak on completion angiography (arch group), and one persistent type III endoleak (TAAA group). Mortality was 4% (n = 1) at 30 days and related to a second RTAD that occurred after discharge and was found on autopsy. Both RTADs occurred in patients with chronic type B dissection undergoing fenestrated arch repair. Paraplegia occurred in three cases (two arch, one TAAA) (11%), none permanent, and stroke in three cases (one arch, one TAAA) (11%); one was permanent. In the midterm, endoleaks were detected in 12 patients (44%); persistent false lumen flow (n = 3), type IB (n = 1), type IC (n = 3), type II (n = 7), and type IIIC (n = 2). The 3-year survival (Kaplan-Meier) of the arch repair was 75% and for the TAAA, 93%. Freedom from reintervention at 3 years were 100% for arch repairs and 48% for TAAA. In patients with a follow-up of more than 6 months (n = 23), all had stable or decreased aortic diameters and complete false lumen thrombosis at the level of stent graft was present in 65% (n = 15).

CONCLUSIONS

Endovascular treatment of postdissection aneurysms is feasible, with acceptable short-term and midterm outcomes. RTAD after fenestrated and branched endovascular arch repair warrants caution when performed on patients with native ascending aortas, and reinterventions are frequent in TAAA repair.

Pre-Loaded Fenestrated Thoracic Endografts for Distal Aortic Arch Pathologies: Multicentre Retrospective Analysis of Short and Mid Term Outcomes

OBJECTIVE

To determine short and midterm outcomes of a pre-loaded fenestrated thoracic endograft (f-TEVAR) for exclusion of distal aortic arch pathologies.

METHODS

This was a multicentre, retrospective study including consecutive patients from six experienced European vascular centres undergoing f-TEVAR for distal arch pathologies. Primary endpoints included peri-operative mortality and peri-operative stroke and/or spinal cord ischaemia rates. Secondary outcomes were technical success and mid to late events, including death and re-interventions. Statistical analysis was performed with SPSS 26. Mid to late term events were calculated using Kaplan-Meier survival analysis.

RESULTS

One hundred and eight patients were included (mean age 68 ± 11 years, 70% men). A total of 38% (n = 42) had a prior history of aortic dissection, and 24% (n = 26) prior aortic surgery. The mean aneurysm diameter was 59 ± 12 mm and the most frequent indication for treatment was post-dissection aneurysms (n = 42, 39%). Technical success was 99% (n = 107) despite intra-operative wire entanglement occurring in 29% (n = 31). The 30 day mortality rate was 3.7% (n = 4), with a 5.6% major stroke incidence (n = 6) and 3.7% (n = 4) spinal cord ischaemia rate. Three cases of retrograde dissection occurred (two of which were fatal), all in post-type B dissecting aneurysm patients without prior aortic surgery (three of 19, 15.8%). Median follow up was 12 months (range, 1 - 26). Endoleaks were documented during follow up, with 3.5% type Ia (4/104) and 2.9% type Ib (3/104) as a result of persistent false lumen perfusion. The one, two, and three year survivals and freedom from re-intervention rates were 93.2% and 92.1%, 89.1% and 86.3%, and 84.4% and 73%, respectively.

CONCLUSION

This multicentre study shows that treatment of the distal aortic arch by f-TEVAR is feasible, with promising 30 day mortality, stroke, and spinal cord ischaemia rates.

Innominate Versus Axillary Artery Cannulation for the Hemiarch Repair

BACKGROUND

Innominate artery cannulation has gained some popularity over the last decade as an alternative to axillary artery cannulation for providing selective antegrade cerebral perfusion during repair of the ascending aorta and arch. Innominate artery cannulation provides several advantages including avoidance of an additional incision and use of a larger caliber artery to provide less resistance to high flow during bypass and selective antegrade cerebral perfusion. We hypothesize that these advantages make innominate artery cannulation superior to axillary artery cannulation as it can decrease operative times and potentially decrease blood loss.

METHODS

This was a single-center retrospective analysis of 206 patients who underwent hemiarch replacement between 2009 and 2017. All patients qualified including emergent cases. Groups were separated by mode of cannulation: axillary and innominate. Outcomes evaluated included cardiopulmonary bypass (CPB) time, cross-clamp time, circulatory arrest (CA) time, postoperative transfusions, intensive care unit length of stay, development of any neurological complications, end-organ failure, and mortality. Subgroup analysis was performed for elective and emergent cases.

RESULTS

Axillary and innominate artery cannulation accounted for 37% (n = 77) and 67% (n = 129) of cases, respectively. There was no difference in patient characteristics except for a higher incidence of renal disease in the axillary group (16% versus 6%, P = 0.05). More emergent cases were performed in the axillary group (61% versus 17%, P < 0.001). Innominate cases had shorter CPB times (189 versus 150 min, P < 0.001) and CA (22.5 versus 11 min, P < 0.001) times overall. In the elective subgroup, CA times were shorter for the innominate cases. However, the emergent subgroup displayed no difference in operative times. Less transfusions were given in the innominate group including units of red blood cells (2 [0-6] versus 0 [0-2], P < 0.001), units of platelets (2 [1-3] versus 1 [0-2], P = 0.001), and units of plasma (6 [2-9] versus 2 [0-4], P < 0.001). A similar trend was observed in the elective subgroup. No difference in transfusions was observed in the emergent subgroup. There was no statistical difference in remaining outcomes between cases of axillary and innominate cannulation in the combined, elective, and emergent groups.

CONCLUSIONS

Alternate cannulation strategies for open arch anastomoses are evolving with a trend toward using the innominate artery. These data suggest that innominate cannulation is at least equivalent to, and may be superior to, axillary cannulation. The innominate artery provides a larger conduit vessel for perfusion and this decrease in resistance to flow, allowing for faster cooling and rewarming, maybe why CPB times were lower in this group. Innominate cannulation is a safe and potentially advantageous technique for hemiarch repair.

Surgical modification for preventing a gothic arch after aortic arch repair without the use of foreign material

OBJECTIVES

Systemic hypertension is the main late complication after arch reconstruction in patients with arch obstruction. Gothic arch geometry is suspected to be one of its possible causes. Accordingly, we evaluated here if a modified arch repair technique using an autologous pulmonary patch is effective in preventing gothic arch development.

METHODS

Fifty infants who underwent arch repair with either a modified (n = 17) or conventional (n = 33) technique between January 2006 and August 2012 by a single surgeon were retrospectively reviewed. Arch geometry was compared using three categories (gothic, crenel or roman), classified by the height/width (H/W) ratio and the arch angle measured in computed tomography.

RESULTS

No gothic arch geometry was observed in the modified group, whereas it was observed in 9 cases in the conventional group (P = 0.005). Moreover, reintervention for arch restenosis was performed only in the conventional group (n = 4; P = 0.29). No associated complications were observed, although the selective cerebral perfusion time was longer in the modified group than in the conventional group (28.5 ± 6.2 vs 17.1 ± 9.9 min; P < 0.001). Otherwise, there were no significant differences in clinical variables between the groups. The mean follow-up duration was 55.3 ± 26.7 months. Significant systemic hypertension was not observed in our study cohort.

CONCLUSIONS

Our modified technique was proven to be not only highly effective in preventing gothic arch geometry, but also as equally safe in terms of early clinical outcomes as conventional arch reconstruction techniques.

Initial experience with the new type A arch dissection stent: restoration of supra-aortic vessel perfusion

OBJECTIVES

The goal of the present study is to investigate changes in supra-aortic vessel perfusion after implantation of the non-covered Ascyrus Medical Dissection Stent (AMDS) for surgical treatment of acute type A aortic dissection.

METHODS

From 2017 to 2020, 16 consecutive patients treated with AMDS and involvement (dissection to total occlusion) of at least 1 supra-aortic vessel were included in the study. Centre-line based computed tomography measurements of true, false and total lumen area using Terarecon software were performed before and after surgery. Changes in the true lumen area were indexed to the entire vessel area. The paired sample t-test was used to assess the significance of the observed differences.

RESULTS

Analysis of supra-aortic vessels and the descending aorta showed significant improvement in true lumen perfusion after the AMDS was implanted. The indexed true lumen area increased postoperatively by 72%, 112% and 30% in the innominate, right and left common carotid arteries, respectively. Total occlusions of both common carotid arteries recovered completely after surgical treatment. The proximal- and the mid-descending aorta showed a 78% and 48% improvement of the indexed true lumen area, respectively.

CONCLUSIONS

Arch repair using AMDS shows promising results in the treatment of acute type A aortic dissection. Quantitative measurements of true and false lumen perfusion demonstrated a significant increase in true lumen area and a 100% regression of totally occluded supra-aortic branches. Further examination in a larger cohort of patients and comparison with isolated hemiarch repair are needed to confirm positive vascular remodelling after an AMDS implant.

Hybrid type II and frozen elephant trunk in acute Stanford type A aortic dissections

Objectives. Composite frozen elephant trunk is an increasingly popular solution for complex aortic pathologies. This review aims to compare outcomes of zone 0 type II hybrid (hybrid II) with the composite frozen elephant trunk (FET) technique in managing acute Stanford type A aortic dissections. Methods. PubMed and Embase were systematically searched using PRISMA protocol. 11 relevant studies describing the outcomes of hybrid II arch repair and FET techniques in patients with type A aortic dissection were included in the meta-analysis. The study focused on early post-operative 30-day outcomes analysing mortality, stroke, spinal cord injury, renal impairment requiring dialysis, bleeding and lung infection. Results. 1305 patients were included in the analysis - 343 receiving hybrid II repair and 962 treated with the FET. Meta-analysis of proportions showed Hybrid II was associated with less early mortality [5.0 (CI 3.1-7.8) vs 8.1 (CI 6.5-10.0) %], stroke [2.3 (CI 1.1-4.6) vs 7.0 (CI 5.5-8.8) %], spinal cord injury [2.0 (CI 0.9-4.3) vs 3.8 (CI 2.8-5.3) %], renal impairment requiring dialysis [7.9 (CI 5.5-11.2) vs 11.8 (CI 9.8-14.0) %], reoperation for bleeding [3.9 (CI 1.8-8.4) vs 10.6 (CI 8.1-13.8) %] and lung infection [14.8 (CI 10.8-20.0) vs 20.7 (CI 16.9-25.1) %]. Conclusion. Hybrid II should be considered in favour of FET technique in acute Stanford type A dissection patients who are at higher risk due to age and comorbidities.

Traumatic brachiocephalic trunk dissection of a bovine arch

Aortic dissections after deceleration traumas are mainly located in the region of the proximal descending thoracic aorta. Less common are brachiocephalic trunk ruptures, which are not automatically amenable to an endovascular treatment. We present a poly-traumatized patient with an intimal tear at the origin of the brachiocephalic tunk with intramural haematoma extension to the ascending aorta. In addition, the left common carotid artery originated from the proximal brachiocephalic trunk, forming a 'bovine arch'. Aortic arch and supra-aortic arteries were successfully replaced. The case demonstrates the importance of an individualized treatment in complex intrathoracic vascular injuries in poly-traumatized patients, including a careful risk assessment.

Midterm results of arch augmentation with autologous vascular patch in interrupted aortic arch

OBJECTIVES

Aortic arch reconstruction of interrupted aortic arch remains challenging, and subsequent problems, including arch and airway stenosis, may occur. Thus, we investigated midterm results of an augmentation technique using autologous vascular patch.

METHODS

This retrospective study included 24 patients who underwent arch reconstruction with an autologous vascular patch for interrupted aortic arch with biventricular physiology from 2006 to 2018. The median age and body weight at operation were 10 days (range 4-77 days) and 3 kg (range 2.5-5.1 kg), respectively. The reconstructed arch was supplemented in the lesser curvature with an autologous vascular patch that was harvested from main pulmonary artery (n = 19), left subclavian artery (n = 3) or aberrant right subclavian artery (n = 1). One patient used patches from both the main pulmonary and left subclavian artery.

RESULTS

There was 1 early death due to right heart failure. All survivors were discharged 15 days (range 9-58 days) after surgery without residual arch stenosis. Late death occurred in 1 patient with Cri-du-chat syndrome and airway stenosis. Two reoperations and 1 intervention for arch stenosis were performed. The 1-, 5- and 10-year survival was 92%. Freedom from reoperation or intervention for arch stenosis was 86% 1, 5 and 10 years after surgery. No occurrence of arch aneurysm formation, left main bronchial stenosis and significant hypertension was found during a median follow-up period of 5.5 years (range 0.3-13.3 years).

CONCLUSIONS

Augmenting the lesser curvature with an autologous vascular patch during arch reconstruction resulted in reasonable midterm outcomes.