A novel modular inner aortic arch stent-graft for localized Stanford type A aortic dissection aneurysm with short healthy proximal ascending aorta

Abstract

Central MessageA novel modular inner aortic arch stent-graft system simplified our procedure and provided a novel therapeutic strategy for ascending and aortic arch lesions with short healthy ascending aorta. A novel modular inner aortic arch stent-graft system simplified our procedure and provided a novel therapeutic strategy for ascending and aortic arch lesions with short healthy ascending aorta. A 53-year-old man was admitted with chronic localized Stanford type A aortic dissection aneurysm (maximum diameter of 60.2 mm) with a 3-year history of hypertension and cerebral infarction. Preoperative computed tomography angiography showed the primary entry tear originated in the ascending aorta (Figure 1, A). The lengths of total ascending aorta and the proximal healthy ascending aorta were 92.1 mm and 24.0 mm, respectively. The diameter of proximal landing zone is 40.0 mm. The orifice diameters of the innominate artery (IA), left common carotid artery (LCCA), and left subclavian artery (LSA) were 14.0 mm, 7.7 mm, and 13.2 mm, respectively. Given the high risk of rupture and cerebral infarction, and the patient's refusal of transfusion for personal beliefs, we performed endovascular repair using a novel modular aortic arch stent-graft system (WeFlow-Arch; Hangzhou Endonom Medtech Co., Ltd.) (Figure 1, E and F). Since the diameter of LCCA was significantly smaller than LSA, IA and LSA were used for revascularization of supra-aortic arteries after LCCA-LSA bypass. Puncture access included: (1) left brachial artery for bridging LSA with one inner branch, (2) right common carotid artery for bridging innominate artery with another inner branch, (3) right femoral artery for implanting the main stent-grafts, and (4) left femoral vein for rapid pacing. A low transverse cervical incision was performed to expose common carotid arteries of both sides and LSA. A bypass between LCCA and LSA was performed and the proximal segment of the LCCA was planned to ligate. The endovascular procedural process is shown in Video 1. The first module, ascending aorta stent-graft (44 × 44 mm in diameter, 50 mm in length, 12 mm in diameter of inner branch), in the precurved delivery system, via femoral artery access was deployed into the ascending aorta under rapid pacing of a preset temporary pacemaker (Figure 1, C). The second modules, bridging covered stents, were deployed for bridging the supra-aortic branches and the 2 inner branches, including one 13-mm × 16-mm × 100-mm covered stent for bridging IA and two 13-mm × 13-mm × 80-mm covered stents for bridging LSA. The third module, aortic arch stent-graft (44 mm × 32 mm in diameter, 200 mm in length), was overlapped with the lumen of the first module via steerable delivery system to avoid iatrogenic migration of the first module (Figure 1, D). Segmental deployment simplified the procedures associated with complicated anatomic matching and avoided the long-time interruption of the supra-aortic blood supply. The patient was free from postprocedural symptomatic cerebral infarction. 12-month follow-up computed tomography angiography confirmed patency of the stent-graft branches, no endoleak or retrograde dissection, and complete thrombosis of false lumen with a maximum aneurysm diameter of 60.0 mm (Figure 1, B). This case indicated that this modular endograft simplified aortic arch repair procedure and provided a novel therapeutic strategy for ascending and aortic arch lesions with short healthy ascending aorta. This case was part of a clinical trial (NCT04764370), namely Guo's Aortic Arch Reconstruction: The First in Man Study of WeFlow-Arch Modular Embedded Branch Stent Graft System. This study was reviewed and approved by Chinese PLA General Hospital Medical Ethics Committee (approval number: S2018-230-01, approval date: February 28, 2019) and informed consent was taken from the patient. https://www.jtcvstechniques.org/cms/asset/59e4aa36-84b1-4a38-86a6-e0f080c88901/mmc1.mp4Loading ... Download .mp4 (27.07 MB) Help with .mp4 files Video 1Endovascular procedure. LCCA, Left common carotid artery; LSA, left subclavian artery; IA, innominate artery; RCCA, right common carotid artery; RAO, right anterior oblique; CAU, caudal oblique. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00347-9/fulltext. Download .jpg (.09 MB) Help with files Video 1Endovascular procedure. LCCA, Left common carotid artery; LSA, left subclavian artery; IA, innominate artery; RCCA, right common carotid artery; RAO, right anterior oblique; CAU, caudal oblique. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00347-9/fulltext.