Aortic Remodeling Following Hybrid Arch Repair for Complex Arch and Proximal Descending Thoracic Aortopathies

Abstract

Hybrid aortic arch repair involves debranching of the great vessels to create a zone 0 proximal landing zone for simultaneous or staged thoracic endovascular aortic repair (TEVAR) as a less invasive therapy for complex arch and descending thoracic aortopathies. Data on thoracoabdominal aortic remodeling following hybrid arch repair remains scarce. We aimed to evaluate short-term remodeling of the thoracoabdominal aorta following hybrid arch repair. All patients (n = 38) undergoing hybrid arch repair with planned zones 0 to 5 TEVAR from January 2020 to March 2022 were retrospectively reviewed. Computed tomography angiography scans preoperatively, after TEVAR, and at the 3- to 6-month follow-up were analyzed for thoracoabdominal aorta remodeling. Aortic true lumen diameter (TLD) for dissections and full lumen diameter for aneurysms were recorded at 12 anatomical levels: left subclavian artery, tracheal carina, left inferior pulmonary vein, inferior left atrium, diaphragm, celiac trunk, superior mesenteric artery, renal arteries, aortic bifurcation, and common iliac arteries. Visceral vessel origin from true/false lumen and extent of false lumen thrombosis were assessed. Mean change in aortic TLD was calculated at every level and paired-samples t test was used to compare means. Of 38 patients, 37 had follow-up imaging at a mean duration of 6 months (mean age, 57.9 ± 10.0 years; 30 males [78.9%]) and one (2.6%) mortality (Table). Four (10.5%) presented with aneurysms (0, 3), 26 (68.4%) with type A aortic dissection (0, 3), and 8 (21.1%) with type B aortic dissection (1, 10). In aneurysm patients (n = 4), there was one postoperative death (2.6%) due to cardiac arrest before staged TEVAR; the remaining three had stable aneurysm sacs without endoleak at last follow-up. For dissection patients, at a mean follow-up of 6 months, there was significant increase in the mean TLD at each level (P < .05), except zones 9 and 10. The largest increase in mean TLD was observed at the left subclavian artery (+5.19 mm; 95% confidence interval [CI], 2.63-7.76), tracheal carina (+6.78 mm; 95% CI, 3.04-10.53), and lower left atrium (+4.49 mm; 95% CI, 2.01-6.97). The left renal artery was the most common vessel originating from the false lumen (14 [36.8%] pre- and post-TEVAR); followed by the right renal artery (7 [18.4%] pre-TEVAR and 5 [13.2%] post-TEVAR). Visceral perfusion remained intact following TEVAR in all patients. False lumen thrombosis to distal zone 5 was observed in 100% of the dissection patients. Hybrid arch repair with zone 0 to 5 TEVAR provides adequate aneurysm exclusion and positive aortic remodeling down to zone 8 in the short term with improved TLD and high rate of false lumen thrombosis. When involved, zones 9 to 11 may require adjunctive or alternative branched or fenestrated strategies for total aortic remodeling and complete false lumen obliteration.TableSummary of included patients and measurements at various anatomic levelsVariableNo. of patients (%); n = 38Patient characteristics Age, years57.9 ± 10.0 Male30 (78.9) Diabetes mellitus11 (28.9) Hypertension35 (92.1) Dyslipidemia19 (50.0) Cerebrovascular disease4 (10.5) Dialysis1 (2.6) Chronic obstructive pulmonary disease7 (18.4) Smoking history22 (57.9) Prior coronary artery bypass grafting3 (7.9) Aortic aneurysm4 (10.5) Type A aortic dissection26 (68.4) Type B aortic dissection8 (21.1) Prior valve surgery10 (26.3) Mortality1 (2.6)Aortic remodeling dataLevelPreoperative true lumen measurements, mmPost-TEVAR true lumen measurements (mean follow-up 6 months), mmRemodeling over mean follow-up of 6 monthsMinMaxMean ± SDVessel origin from false lumenFalse lumen partial thrombosisFalse lumen full thrombosisMinMaxMean ± SDVessel origin from false lumenFalse lumen partial thrombosisFalse lumen full thrombosisMean Change (95% CI) [% change]P valueLeft subclavian artery11.248.322.25 ± 8.83---15.938.427.44 ± 5.33---5.19 (2.63-7.76) [+23.3%].001*Carina3.460.919.78 ± 11.05---3.340.126.59 ± 7.28---6.78 (3.04-10.53) [+34.3%].001*LIPV6.567.317.45 ± 10.61---7.93623.16 ± 6.31---4.27 (0.85-7.69) [+24.5%].016*Left atrium4.966.216.89 ± 11.03---5.461.221.33 ± 9.30---4.49 (2.01-6.97) [+26.6%].001*Diaphragm6.634.715.75 ± 7.15---6.549.119.03 ± 8.22---3.28 (1.53-5.04) [+20.9%].001*Celiac trunk2.828.113.92 ± 6.574 (10.5)25 (65.8)0 (0.0)5.928.915.49 ± 6.204 (10.5)14 (36.8)2 (5.3)2.57 (0.86-4.27) [+18.4%].005*SMA3.427.113.77 ± 5.963 (7.9)24 (63.2)0 (0.0)6.330.114.94 ± 5.673 (7.9)17 (44.7)1 (2.6)1.17 (0.20-2.15) [+8.5%].020*RRA3.126.313.08 ± 6.147 (18.4)24 (63.2)0 (0.0)6.728.614.46 ± 5.645 (13.2)13 (34.2)1 (2.6)1.38 (0.18-2.58) [+10.6%].025*LRA3.130.712.78 ± 6.4714 (36.8)22 (57.9)0 (0.0)6.328.613.80 ± 5.4614 (36.8)13 (34.2)2 (5.3)1.02 (0.02-2.02) [+8.0%].046*Aortic bifurcation7.328.114.06 ± 5.83---7.830.114.45 ± 4.99---0.39 (−0.83 – 1.62) [+2.8%].518RCIA3.517.510.82 ± 3.76---2.717.710.44 ± 3.46---−0.38 (−1.36 – 0.61) [-3.5%].443LCIA3.315.610.28 ± 3.72---3.616.410.67 ± 3.63---0.28 (−0.29 – 0.86) [+2.8%].317LCIA, left common iliac artery; LIPV, left inferior pulmonary vein; LSCA, left subclavian artery; RRA, right renal artery; LRA, left renal artery; RCIA, right common iliac artery; SD, standard deviation SMA, superior mesenteric artery; TEVAR, thoracic endovascular aortic repair. 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