Failed Proximal-zone Anchoring in Two Cases with Complex Aortic Arch: A Challenge for Vascular Surgeons in the Endovascular Era.

Abstract

Introduction: In the past, surgical replacement of the thoracic aorta was the only effective treatment, involving complex surgeries associated with high-level morbi-mortality. Since the first endografting of the thoracic aorta in 1994, a large number of publications have demonstrated the safety and efficacy of the thoracic endovascular aortic repair (TEVAR). But the progressive population aging is associated with more complex and challenging anatomies, which difficult the optimal technical success of the endovascular procedures. Methods: We present two cases with failed anchoring of the endovascular devices at the proximal aortic area. Case 1: a 50-year-old man with a post-traumatic false aneurysm of the thoracic aorta treated with TEVAR in 2011 and 2013, in another centre. At the follow-up, CT scan showed the devices positioned in zone 3 of the aortic arch and a collapse of the proximal edge of the second endoprothesis. Case 2: a 52-year-old man admitted to the Intensive Care Unit (ICU) of our hospital with an acute aortic syndrome. The CT scan demonstrated an aneurismatic type B dissection (diameter 58x65 mm) with complex aortic arch. Results: Case 1: the intraoperative angiogram confirmed the discoveries previously described. An angioplasty with balloon was done and finally, a more proximal aortic stent (Jotec 28x24x130 mm) was deployed adjusted to the origin of the left common carotid artery (LCCA), covering the left subclavian artery (LSA). The final angiogram showed an optimal result, with a patent LCCA and without leaks depending on the LSA. At the follow-up, no evidence of collapse or wrinkle have been demonstrated. Case 2: after the optimal medical treatment in the ICU, the intraoperative angiogram showed an aortic arch with several angulated curves and a large entry tear in the thoracic aorta, just distal to the left subclavian artery with a false lumen down to celiac trunk. Once the supra-aortic trunks were marked, two overlapped endoprothesis EVITA (Jotec) 24x130 mm and 33x170 mm (for proximal and distal areas) were deployed covering the LSA and an Amplatzer was placed previous to the vertebral artery. The final angiography and transesophagic ecocardiography (TEE) evidenced no contrast inside the false lumen without leaks dependent on the subclavian artery. The left vertebral artery was patent. After one month, the partial patency of the false lumen and a rectification of the proximal portion of the endoprothesis was demonstrated in the CT scan. Conclusion: The population aging involves more complex anatomies that challenge the skills of the vascular surgeons and the adaptability of the endovascular devices. High-resolution computed tomography (CT) scanning from the supra-aortic vessels to the common femoral arteries and multiplanar reconstructions are very useful for the preoperative plan. In patients with complex arch the probability of TEVAR failure is higher. Therefore, we consider that the proximal landing zone should be as long as possible to ensure a perfect anchoring. In the case 1, the wrinkle edge of the prosthesis could have been avoided, placing the second stent more proximally, at the zone 2 of the aortic arch. In the case 2, probably, a carotid-carotid cross-over bypass was necessary prior to repair the dissection to obtain a longer healthy proximal landing area.