Fenestrated endovascular repair for diseases involving the aortic arch

Abstract

ObjectiveExtension of aortic disease to the aortic arch is common, frequently requiring cervical debranching procedures to maintain patency of supra-aortic branches. Endovascular aortic arch repair is an attractive alternative in the treatment of aortic arch disease for high-risk patients with thoracoabdominal diseases encroaching on the arch. The aim of our study was to report our experience of fenestrated endovascular repair in the aortic arch. MethodsA retrospective review of prospectively collected data involving consecutive patients in a single tertiary center treated with custom-made fenestrated endografts for the aortic arch (Cook Medical, Bloomington, Ind) was undertaken. End points included technical success, perioperative mortality and morbidity, reintervention, and late survival. ResultsBetween 2011 and 2017, there were 44 patients with a mean age of 67 ± 9 years (27 male [61%]) who were treated with fenestrated endografts for arch aneurysm (n = 11 [25%]), arch penetrating aortic ulcer (n = 6 [14%]), thoracoabdominal aneurysm with arch involvement (n = 11 [25%]), postdissection false lumen aneurysm (n = 13 [29%]), or lusorian artery aneurysm (n = 3 [7%]). The proximal landing zone was at Ishimaru zone 0 in 12 cases (27%), zone 1 in 27 cases (62%), and zone 2 in 5 cases (11%). Nine patients (20%) underwent a unilateral carotid-subclavian bypass, two (5%) a bilateral carotid-subclavian bypass, and four (9%) a subclavian transposition. In total, of the 73 target supra-aortic vessels (average of 1.7 target vessels per patient), 37 were treated with fenestrations and 36 with scallops. The mean operation time, fluoroscopy time, and contrast material volume were 215 ± 152 minutes, 33 ± 23 minutes, and 114 ± 45 mL, respectively. Technical success was 95% (42/44). The median intensive care unit and hospital stays were 3 ± 1 days and 7 ± 6 days, respectively. The 30-day mortality was 9% (4/44; one graft displacement and stroke, one retrograde type A dissection, one access complication and stroke, and one death of unknown cause). Major stroke occurred in three (7%), minor stroke in one (2%), temporary spinal cord ischemia in three (7%), and renal injury in three (7%) patients, whereas three (7%) patients required early reintervention. With mean follow-up of 18 ± 17 months, 10 more patients required secondary interventions, most of which (90%) were planned distal intervention to complete the repair of thoracoabdominal diseases. Overall survival rates were 78% ± 7% and 72% ± 8% at postoperative years 1 and 2, respectively. ConclusionsFenestrated endograft repair of aortic arch disease is a feasible technique with a high technical success rate and acceptable rates of stroke and paraplegia. A high number of secondary interventions were needed to complete the treatment of underlying diseases.