Fenestrated Endovascular Repair for Pathologies Involving the Aortic Arch

Abstract

Introduction - Extension of aortic pathologies to the aortic arch is very common, requiring often cervical debranching procedures. Endovascular aortic arch repair is an attractive alternative to the treatment of aortic arch pathology in high-risk patients as well as patients with thoracoabdominal pathologies encroaching the arch. The aim of our study was to report our experience of fenestrated endovascular repair in the aortic arch. Methods - A 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, IN) was undertaken. Endpoints included technical success, 30-day mortality and major morbidity, endoleaks and late outcomes. Results - Between 2011 and 2016, 36 patients with mean age of 67±9 years old (23 male, 60%,) were treated with fenestrated endografts for an aortic arch pathology. Most of the patients were asymptomatic (33/36; 92%) while, over half of them (22/36; 61%) were categorized as >3 ASA. Eleven (31%) had a previous aortic reconstruction (3 abdominal, 5 thoracic and 3 both abdominal and thoracic aortic). The proximal landing zone was in Ishimaru zone 0 in 9 cases (25%), zone I in 23 cases (72%) and in zone II in 4 (11%). Ten patients (28%) underwent a carotid-subclavian bypass and 3 (8%) a subclavian interposition. In total, of the 59 supra-aortic target vessels (1.6 target vessels/patient), 33 were treated with fenestrations and 26 with scallops. The mean operation time, fluoroscopy time and contrast volume were 221±31 minutes, 35±9 minutes and 119±22 ml respectively. Technical success rate was 97% (35/36). The mean ICU and hospital stay were 3±1.2 and 7±3.1 respectively. The 30-day mortality was 11% (4/36; 1 graft displacement and stroke, 1 retrograde type A dissection, 1 access complication and 1 unknown cause). Major stroke occurred in 3 (8%), paraplegia in 2 (5%) and renal failure in 3 (8.3%) patients, while 5 (14%) patients were diagnosed with endoleak (3 Ib, 1 Ia, 1 III). The mean follow-up was 12±4 months and the secondary intervention rate to complete the repair of thoracoabdominal pathologies was 27% (10/36) Late death occurred in 2 cases suggesting a 12-month survival rate of 83.4%. Conclusion - Fenestrated endograft repair of aortic arch disease is a feasible technique with high technical success rate and relatively low rates of stroke and paraplegia. Mid-term outcomes showed a good survival rate but high number of secondary interventions needed to complete treatment of the underlying pathogies.