Thoracic Endovascular Aortic Repair for Challenging Aortic Arch Diseases Using Fenestrated Stent Grafts From Zone 0

Abstract

Although previous reports have described the repair of distal aortic arch aneurysms through debranching and chimney techniques, these methods invariably involve surgical management of the carotid artery. We report clinical results of thoracic endovascular aortic repair (TEVAR) using fenestrated stent grafts in the treatment of aortic arch aneurysms located less than 15 mm from the left common carotid artery. A semi-custom-made fenestrated stent graft designed to fit aortic arch tortuosity and preserve blood flow at least into the brachiocephalic and left common carotid arteries was placed from zone 0. From 2007 through 2013, TEVAR from zone 0 was performed on 37 high-risk patients for open surgery (mean age 78.2 years). The mean length between the left common carotid artery and aortic aneurysm was 11.1 mm (range, 5 to 15 mm). The left subclavian artery was preserved for 26 patients (70.3%) through surgical reconstruction (n = 19) and graft fenestration (n = 7). The early mortality rate was 0%. Postoperative strokes and spinal cord ischemia occurred in 2 (5.4%) and 3 (8.1%) patients, respectively. Although type I endoleaks at discharge were noted in 12 (32.4%) patients, aneurysm enlargement was noted during follow-up in 6 (16.2%). Four patients (10.8%) underwent secondary interventions consisting of 3 coil embolization procedures; 2 re-TEVARs and 1 open conversion. There were no aorta-related late deaths. Survival and aorta-related event-free rates at 2 years were 86.3% and 88.8%, respectively. Thoracic endovascular aortic repair using fenestrated stent graft from zone 0 can be considered as one of therapeutic options for high-risk patients with aortic arch diseases.