Single vs Multibranched/Fenestrated Endovascular Aortic Arch Repair

Abstract

To evaluate results of single vs multibranched/fenestrated endovascular aortic arch repair at a single institution. A retrospective review was performed of all endovascular aortic arch endografts at a single institution. Demographics, clinical records, and imaging were evaluated. Outcomes reviewed included debranching complications and early (within 30 days) and late (>30 days) procedural complications including death, stroke, myocardial infarction, spinal cord ischemia, endoleak, infection, and any return to the operating room. Patient were divided into two cohorts based on number of cervical vessel branches/fenestrations: group A (0 or 1 branch/fenestration) and group B (2 or 3 branches/fenestrations). Between March 2014 and May 2022, 24 patients underwent endovascular aortic arch repair. All procedures were elective. Technical success was achieved in 23 (95.8%) patients; one patient in group A had migration of the ascending Nexus module. Indications for surgery were arch aneurysm (58.3%) and proximal landing zone creation for descending thoracic aortic aneurysm repair (41.2%). The Cook CMD endograft was most commonly use overall (group A 53.8%, group B 100%), while the Nexus arch endograft was used in nearly one-half of all group A procedures (46.2%). The majority of grafts were landed in zone 0 (group A 69.2%, group B 100%) (Table). Debranching procedures were most frequently performed in group A; in particular, carotid-carotid bypass was necessary in all group A patients with proximal landing in zone 0 (53.8%). This led to graft infection in two patients requiring explant. Additional debranching complications included one carotid-subclavian bypass graft explant and one Amplatzer plug migration in a subclavian artery resulting in false lumen expansion (all group A). Overall 30-day mortality was 8.3% and stroke rate was 12.5% with no significant difference between the two groups. There were no instances of spinal cord ischemia. Early type Ia endoleaks were noted in three (12.5%) patients. There were two retrograde type A dissections on postoperative imaging; one required ascending/hemiarch replacement and partial graft explant at 3 months (group A); the other was managed nonoperatively (group B). One type III endoleak at 3 years required TEVAR (group A). Median follow-up was 6 months (interquartile range, 4-18). Endovascular aortic arch grafts have high technical success rate with acceptable morbidity and mortality. Single-branched/fenestrated grafts designed to land in zone 0 are more likely to require more in-hospital days and are prone to debranching complications without any added mortality or stroke benefit. Multibranched grafts are preferable for zone 0 landings when anatomically feasible.TableSingle vs multibranched/fenestrated endovascular aortic arch repairGroup A (n = 13) (0-1 branched/fenestrated)Group B (n = 11) (2-3 branched/fenestrated)P valueAge72 (65-77)79 (73-82).08Female sex6 (46.2)4 (36.4).95Indication for surgery.08 Arch aneurysm5 (38.5)9 (81.8) Create proximal landing zone8 (61.5)2 (18.2)Proximal landing zone.131 09 (69.2)11 12 (15.4)0 22 (15.4)0Endograft.03 Nexus6 (46.2)0 Cook CMD7 (53.8)11 (100)Technical success12 (92.3)11 (100)1Total hospital days (including debranching)7 (2-15)8 (7.5-9.5).43Debranching Carotid-carotid bypass7 (53.8)0.02 Carotid-to-subclavian bypass7 (53.8)3 (27.3).37 Carotid-to-subclavian transp1 (7.7)1 (9.1)1 Subclavian-to-carotid bypass2 (15.4)3 (27.3).83Debranching complications Infection requiring explant2 (15.4)0.54Complications (<30 days) Death1 (7.7)1 (9.1)1 StrokeDisabling02 (18.2).39Nondisabling01 (9.1).93Myocardial infarct01 (9.1).93Spinal cord ischemia00Reintervention Access-related1 (7.7)3 (27.3).46 Other01 (9.1).93Early endoleak IA2 (15.4)1 (9.1)1 IB00 III00Retrograde type A1 (7.7)1 (9.1)1Values are median (interquartile range) or number (%). Open table in a new tab