Adequate Proximal Landing Zone Research Articles

Computed tomography-based anatomic suitability of an Endo-Bentall prosthesis for ascending aortic aneurysms

IntroductionThis study aimed to evaluate the suitability of a coronary-branched ascending aortic endograft, paired with aortic valve (AV) prosthesis (Endo-Bentall), for the endovascular repair of ascending aortic aneurysms. MethodsPre-operative ≤1mm computed tomography angiographies of consecutive patients managed with Bentall procedure or ascending aortic replacement and AV reconstruction/replacement, in a single institution (01.01.2008-31.12.2023), were retrospectively analyzed. Dedicate software was used to assess: (1) vascular access, (2) proximal landing zone, (3) coronary artery anatomy and (4) distal landing. Eligibility criteria for Endo-Bentall were: ≥8mm iliac arteries, without severe calcification/tortuosity, proximal landing with 18-29mm aortic annulus diameter, ≥10mm annulus-coronary ostium distance, no mechanical AV, absence of coronary grafts in the ascending aorta, no left ventricle thrombus, coronary arteries ≥3mm wide and ≥10mm long, with no anatomic abnormalities, ostial stent or stenosis and ≥20mm long and ≤38mm wide distal landing zone within the ascending aorta or applicability of branched endovascular arch repair. ResultsTwenty-nine patients (55.2% females) were included. All patients had adequate proximal landing zone in terms of annulus diameter (median: 25mm, IQR: 5mm). Two (6.8%) had inadequate iliac access (external iliac artery <8mm). Two patients (6.8%) had a mechanical AV. Twenty-six patients (89.6%) had adequate landing zone for stenting of the left main coronary artery (LMCA; median diameter: 5.2mm, IQR: 1.8mm) and 28 (96.6%) had adequate right coronary artery (RCA) landing (median diameter: 4.1, IQR: 1mm). The LMCA and RCA were located at 5:00' and 10:50’ clock positions, respectively. Three patients (20.7%) had an adequate distal landing zone within the ascending aorta. The remaining were suitable for extension with a branched arch device. According to the predefined criteria, 75.9% of patients were anatomically suitable for Endo-Bentall. ConclusionThree out of four patients with ascending aortic aneurysms may be considered as anatomically eligible for endovascular treatment with an Endo-Bentall prosthesis.

Type III aortic arch angulation increases aortic stiffness: Analysis from an ex vivo porcine model

ObjectiveThe relationship among increased aortic arch angulation, aortic flow dynamics, and vessel wall stiffness remains unclear. This experimental ex vivo study investigated how increased aortic arch angulation affects aortic stiffness and stent-graft induced aortic stiffening, assessed by pulse wave velocity (PWV). MethodsPorcine thoracic aortas were connected to a circulatory mock loop in a Type I and Type III aortic arch configuration. Baseline characteristics and blood pressures were measured. Proximal and distal flow curves were acquired to calculate PWV in both arch configurations. After that, a thoracic stent-graft (VAMF2626C100TU) was deployed in aortas with adequate proximal landing zone diameters to reach 10% t0 20% oversizing. Acquisitions were repeated for both arch configurations after stent-graft deployment. ResultsTwenty-four aortas were harvested, surgically prepared, and mounted. Cardiac output was kept constant for both arch configurations (Type I: 4.74 ± 0.40 and Type III: 4.72 ± 0.38 L/minute; P = .703). Compared with a Type I arch, aortic PWV increased significantly in the Type III arch (3.53 ± 0.40 vs 3.83 ± 0.40 m/second; P < .001), as well as blood pressures. A stent-graft was deployed in 15 aortas. After deployment, Type I arch PWV increased (3.55 ± 0.39 vs 3.81 ± 0.44 m/second; P < .001) and Type III arch PWV increased although not significantly (3.86 ± 0.42 vs 4.03 ± 0.46 m/second; P = .094). Type III arch PWV resulted the highest and significantly higher compared with the Type I arch after stent-graft deployment (3.81 ± 0.44 vs 4.03 ± 0.46 m/second; P = .023). ConclusionsIncreased aortic arch angulation—as in a Type III arch—is associated with higher aortic PWV and blood pressures and this may negatively influence cardiovascular health.

Simultaneous aortoiliac kissing Endovascular stenting for management of isolated monolateral common iliac artery aneurysm with no proximal landing zone.

Isolated iliac artery aneurysm (IIAA) is an uncommon finding. It, accounts for 0.03% of all patients and 2% of all abdominal aneurysm. Endovascular approach represents the treatment of choice for most patients with IIAA. We reported our experience on iliac aneurysm with no proximal landing zone by simultaneous aortoiliac kissing endovascular (S.A.K.E.) covered stenting. This is a retrospective analysis of nine consecutive patients with IIAA with no proximal landing zone, who underwent endovascular kissing covered stenting (Gore®Viabahn®VBX) The median aneurysm diameter was 4.1cm, with a median 3-mm proximal neck length. In 3/9 aneurysms involving the internal iliac arteries the origin of the internal iliac artery was covered after its embolization and a stent graft extending to the external iliac artery (EIA) was placed. All stents were flared with semi-compliant balloon. Iliac aneurysm exclusion was obtained in all cases (100%), no graft migration or endo-leak were recorded. The median operative time was 28min; the median fluoroscopy time was 9min and a median 70mL of contrast was used. At a median 24-month follow-up, all patients are alive, and no endo-leak or migration, infection, distal embolization, limb loss were observed. Moderate buttock claudication was experienced in 1/9 patients with internal iliac artery embolization. In 6/9 patients a shrinkage of the aneurysmal sac was recorded after 1year. Endovascular management of IIAAs cases has been reported in literature and it was confirmed to be safe and successful. The IAA usually progresses into expansion which eventually leads into rupture. Adequate long proximal and distal landing zones were the most important feature related to better outcomes. Short proximal neck (˂10mm) represents a real challenge for iliac aneurysm treatment and, nowadays, a classical bifurcated aortoiliac endograft deployment represents the treatment of choice. Endovascular repair of isolated CIA aneurysms with no proximal neck is safe and successful using the SAKE stenting technique with VBX adequately flared and it represents effective and minimally invasive alternative to aortobiliac endograft implantation in the treatment of these aneurysms. To the best of our knowledge, this is the first report which describes this approach in the treatment of IIAA with no adequate proximal landing zone. Our approach overcomes the need to aortic bifurcation graft implantation and reduces procedure time, contrast dose and radiation exposure. It also preserves relevant collaterals vessels thanks to inferior mesenteric artery and lumbar arteries sparing. A proximal aortic bifurcation endograft allows proximal sealing to be regained. Large population study with longer follow-up are needed to establish this approach as a new standard.

Physician–Modified Endovascular Graft for Left Subclavian Artery Fenestration during Thoracic Endovascular Aortic Repair

This study aimed to evaluate the safety and efficacy of physician-modified endovascular graft for preservation of left subclavian artery during thoracic endovascular aortic repair. From June 2019 to October 2022, 66 patients with a variety of thoracic aortic pathologies were treated with thoracic endovascular aortic repair using physician-modified endovascular graft left subclavian artery fenestration to achieve adequate proximal landing zone. The details of surgical techniques were described. The perioperative morbidity, mortality, and the outcomes of mid-term follow-up were analyzed. Of the 66 patients (men: women, 53:13; age, 55.18 [55.18±10.62] years), 53 (80.30%) presented with type B aortic dissection, 10 (15.15%) with thoracic penetrating aortic ulcer, 2 (3.03%) with thoracic aortic aneurysm, and 1 (1.52%) with left subclavian artery aneurysm. All of them underwent thoracic endovascular aortic repair using physician-modified endovascular graft left subclavian artery fenestration on the sterile back table. The technique success rate was 96.97% (n=64). Total operation time was 92min (interquartile range, 86-118), graft modification time was 19min (interquartile range, 17-21), fluoroscopy time was 49min (interquartile range, 41-62), and contrast agent dosage was 165mL (interquartile range, 155-185). 30-day perioperative morbidities were 3 (4.55%) strokes, 1 (1.52%) retrograde type A aortic dissection, 1 (1.52%) aortic intimal intussusception, 1 (1.52%) left arm ischemia, and 3 (4.55%) type Ia endoleaks. Postoperative 30-day mortality and reintervention rates were 1.52% and 4.55%, respectively. Among the 63 patients included in the follow-up of 17months (interquartile range, 7.75-18.25), the primary patency of left subclavian artery fenestration stents was 100%. Late complications were 1 (1.59%) distal stent graft-induced new entry and 1 (1.59%) death due to retrograde type A aortic dissection during the follow-up. The stent graft-induced new entry patient was observed with stable false lumen. Thoracic endovascular aortic repair with physician-modified endovascular graft for left subclavian artery revascularization is a safe, feasible, and efficacious technique associated with high success rate. Further study is needed for long-term outcome investigation.

Single-center experience with a unibody single-branched stent graft for zone 2 thoracic endovascular aortic repair.

To provide an adequate proximal landing zone, left subclavian artery (LSA) reconstruction has become an important part of thoracic endovascular aortic repair (TEVAR). This study evaluates the short and medium term efficacy of a novel unibody single-branched stent graft for zone 2 TEVAR. Fifty-two patients (mean age, 56 ± 10.9 years; 42 men) with distal aortic arch lesions requiring LSA reconstruction received unibody single-branched stents from September 2019 to March 2021. Computed tomography angiography was performed 6, 12, and 24 months after surgery to observe stent morphology, branch patency, endoleaks, stent-related adverse events, and changes in the diameter of true and false lumens. All stents were deployed adequately, and the technical success rate was 100%. The mean operation time was 121.8 ± 47.0 min. The mean postoperative hospital stay was 6.2 ± 3.7 days, and the mean follow-up was 16.8 ± 5.2 months (range, 12–24 months). During follow-up, there were no deaths and complications such as stent displacement or fracture, stenosis, fracture, occlusion, and type Ia endoleaks. The patency rate of the branched segment was 100%. In 42 patients with aortic dissection (AD), the true lumen diameter of the aortic isthmus was 29.4 ± 2.9 mm after surgery, significantly larger than before surgery (20.6 ± 5.4 mm, P < 0.05). Postoperative aortic isthmus false lumen diameter was significantly smaller than that before operation (6.1 ± 5.2 mm vs. 16.0 ± 7.6 mm, P < 0.05). The new unibody single-branched stent for zone 2 TEVAR is safe and accurate, and its efficacy is good in the short and medium term.

Endovascular aortic repair of endoleaks : Diagnosis, treatment, and outcomes

Sämtliche Patienten nach endovaskulärer Versorgung eines Aortenaneurysmas bedürfen einer regelmäßigen Nachkontrolle, zumeist in jährlichem Abstand. Der kontrastmittelverstärkte Ultraschall und die Computertomographie-Angiographie (CTA) sind die wichtigsten diagnostischen Modalitäten für die Erkennung von Endoleaks. Die (CTA) erlaubt eine bessere Unterscheidung der verschiedenen Endoleak-Typen. Sogenannte Hochdruck-Endoleaks (Typ I und Typ III) stellen, wenn sich nicht kurzzeitig ein Spontanverschluss zeigt, eine absolute Indikation zur Nachbehandlung dar. Typ-II-Endoleaks weisen in der Mehrzahl einen benignen Verlauf auf. Wenn kein Wachstum des Aneurysmasacks erfolgt, kann eine Nachkontrolle im gewohnten Intervall durchgeführt werden. Typ-II-Endoleaks mit assoziiertem Wachstum des Aneurysmasacks können durch Embolisation der verantwortlichen Gefäße behandelt werden. Ob eine Behandlung immer durchgeführt werden muss, ist umstritten. Eine Behandlungsindikation von einem Typ-II-Endoleak mit wachsendem Aneurysmasack ist jedoch gegeben, wenn durch eine Verkürzung des Aneurysmahalses ein sekundäres Typ-I-Endoleak droht. Typ-I-Endoleaks stellen die Hauptlimitation der Stentgraft-Therapie dar. Die beste Prävention eines Typ-I-Endoleaks ist die Bereitstellung einer adäquaten proximalen Landezone. Dies kann durchaus bedeuten, dass fenestrierte Stentgrafts verwendet werden müssen. Die Verwendung von Schrauben oder anderen Fixationsinstrumenten zur sicheren Behandlung auch kurzer Hälse ist derzeit noch in der Studienphase.

Endovascular management of iliac artery aneurysms

Purpose: The aim is to evaluate the role of endovascular interventions in treatment of iliac artery aneurysms with one year follow up. Patients and methods: our study included 20 patients with iliac artery aneurysms defined as (iliac artery with a diameter &gt;3cm) with adequate proximal and distal landing zone. Patients with anastomotic aneurysms, infected aneurysms or with severe renal impairment (GFR &lt;30ml/min/1.73m2) were excluded. FOR ISOLATED ILIAC ANEURYSM: access used through either: 1) Retrograde ipsilateral common femoral artery puncture. 2) Contralateral femoral puncture and performing a crossover technique. Under fluoroscopy, the stent graft devices were advanced into the iliac axis up to the planned graft deployment site, Embolization of the IIA was performed in cases where backflow from the IIA was expected to result in a type II endoleak. For Aorto-Iliac Aneurysms: Bilateral femoral access is needed to place endografts and can be performed via surgical femoral cut down. Once vascular access is established and landmarks for positioning the device are obtained with aortography, the main device is positioned with particular attention paid to the location of the opening for the contralateral iliac limb ("contralateral gate").

Penetrating Atherosclerotic Aortic Ulcer with Pseudoaneurysm

We present a case of penetrating atherosclerotic aortic ulcer with pseudoaneurysm which was managed by a hybrid partial debranching thoracic endovascular aneurysm repair (d-TEVAR) procedure. A 68-year-old professional singer with multiple comorbidities presented with mid-chest pain radiating to the back for the past 2 months. Computed tomography aortogram revealed a penetrating atherosclerotic ulcer near the summit of the left subclavian artery (LSA) at the distal aortic arch. In view of the high risk of an open-heart surgery, TEVAR procedure with partial debranching of the aortic arch vessel was proposed. As the aneurysm was close to the origin of the LSA, an adequate proximal landing zone was not available. Hence, a bypass from the left common carotid artery to the LSA was done. Following this, an endovascular procedure was performed and the stent graft was placed covering the origin of the LSA. Check aortograms after the procedure revealed patent stent and complete obliteration of the pseudoaneurysm. There was no endoleak noted and the left carotid to subclavian artery bypass was functioning well. The postoperative period was uneventful. Follow-up over a 6-month period was satisfactory. The key elements of a successful thoracic endovascular aneurysm repair are appropriate patient selection, thorough planning, and careful procedural execution. This case demonstrates that a hybrid procedure with partial debranching and thoracic endovascular repair of penetrating aortic ulcers is a safe and less-invasive alternative for elderly, high-risk patients.

Outcomes of thoracic endovascular aortic repair for penetrating aortic ulcers involving the left subclavian artery with the Castor single-branched stent graft.

To acquire adequate proximal landing zones for penetrating aortic ulcers in the proximal descending aorta or aortic arch, the left subclavian artery (LSA) is usually covered during thoracic endovascular aortic repair. The Castor single-branched stent graft is used to treat aortic disease involving LSA. Our goal was to evaluate the efficiency and safety of the Castor device in treating penetrating aortic ulcers (PAUs) involving the LSA. Between January 2019 and December 2020, we enrolled 25 patients with PAUs requiring LSA revascularization using Castor devices during thoracic endovascular aortic repair (TEVAR). Outcomes including surgical results, 30-day and follow-up deaths and morbidity and aortic computed tomography angiography data were analyzed. In total, 24 patients (96.0%) underwent successful surgical procedures: 1 patient (4.0%) had a type I endoleak and 1 patient (4.0%) had a stroke. Stent migration occurred in 1 patient (4.0%) and paraplegia in 1 patient (4.0%). Two stents were deployed in 2 patients (8.0%). After a mean follow-up period of 15.7 months, 2 cases of branch occlusions and 1 death related to myocardial infarction were noted. Aortic computed tomography angiography demonstrated that the diameters and depths were reduced significantly whereas complete thrombosis of the lumens of the PAUs occurred in all cases during the 12-months follow-up period. These preliminary results justify the efficiency and safety of the Castor single branched stent graft in the treatment of PAUs requiring LSA revascularization.

Antegrade Hybrid Chimney TEVAR Endograft in a Patient with Blunt Aortic Injury: A Challenging Case with Technical Success but Unfavorable Result

Thoracic Endovascular Aortic Repair (TEVAR) has modified aortic medicine, particularly in patients with traumatic aortic injury (TAI). Conventional repair of TAI in the aortic arch is technically demanding as it requires cardiopulmonary bypass and deep hypothermic arrest with still a significant number of complications. Despite recent improvements in endovascular techniques, many patients have been excluded from endovascular repair due to unfavorable anatomy. To increase the feasibility of endovascular repair, adjunctive open extra-anatomical bypasses may be required to provide an adequate proximal landing zone. Several methods, for instance, chimney technique, hybrid technique, and fenestrated or branched stent-grafts, have been proposed as options to preserve the supra-aortic branches, each with its own advantages and disadvantages. We herein present a patient with complex anatomical features and blunt aortic injury, who underwent antegrade chimney stent-graft deployment through the ascending aorta, not otherwise amenable to standard retrograde delivery because of severe peripheral artery disease. The remarkable aspect, in this case, is that both stents were placed antegrade, through the ascending aorta.

Hybrid Repair With Endovascular Debranching of the Aberrant Right Subclavian Artery for Complicated Type B Aortic Dissection in Patients With Kommerell’s Diverticulum

Purpose: Aberrant right subclavian artery (ARSA) associated with Kommerell’s diverticulum (KD) is a common congenital arch anomaly. It can be complicated by type B aortic dissection (TBAD) or aneurysmal formation at its ostium. Recently, hybrid repair with thoracic endovascular aortic repair (TEVAR) has appeared to be more favorable. Due to the normal anatomic proximity of the ARSA to the left subclavian artery (LSA) orifice in KD, coverage of the bilateral subclavian arteries (SCAs) to obtain an adequate proximal landing zone (PLZ) is usually required, and double cervicotomy for SCA revascularization potentially increases the risk of complications. Technique: This technique was demonstrated on a 50-year-old man presenting with progressive aneurysmal formation of KD with ARSA after chronic TBAD. A 3-step technique, namely left cervical debranching with a left common carotid artery to LSA bypass graft, TEVAR, and an LSA-to-ARSA endovascular debranching with a self-expanding covered stent by a through-and-through wire from the right brachial artery to the bypass graft, was performed in a 1-stage repair to cover the primary tear of TBAD and preserve the bilateral SCAs. The postoperative course was uneventful. Conclusion: This technique can prevent complications from double cervicotomy and achieve an adequate PLZ with preservation of the bilateral SCAs for TEVAR.

A deep learning-based and fully automated pipeline for thoracic aorta geometric analysis and TEVAR planning from computed tomography

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Publich Health - Ricerca Corrente Introduction Thoracic endovascular aortic repair (TEVAR) represents a well-established alternative to open repair in selected patients. Its preoperative feasibility assessment and planning requires a computational tomography (CT)-based analysis of the geometric aortic features to identify an adequate proximal and distal landing zone (LZ) for endograft deployment. Yet, controversies persist on the definition and methods of measurement of specific geometric features of the LZs, including angulation and tortuosity, which are associated with an increased risk of postoperative endograft failure. In this respect, the development of a preoperative image processing method that provides an automatic and highly reproducible 3D identification of critical geometric features and specific anatomical landmarks, thus reducing the time and uncertainties related to manual segmentation, remains a largely unmet clinical need. In this study, we developed and applied a fully automated pipeline embedding a convolutional neural network (CNN), which feeds on 3D CT images to automatically segment the thoracic aorta, recognize the relevant anatomical landmarks and LZs, and quantifies the geometry of the aortic arch in each proximal LZ s (i.e. 0 to 3). Methods Ninety CT scans of healthy aortas were retrieved, being the study conceived as a proof of concept analysis. The thoracic aorta was manually segmented by five independent and expert operators. 72 scans with the corresponding ground truth segmentations were randomly selected and used to train the CNN, which was based on a 3D U-Net architecture. The other 18 scans were used to test the CNN-based segmentations. The fully automated pipeline was obtained by integrating the CNN, 3D geometry skeletonization, and processing of the aortic centerline and wall via computational geometry (Figure). The resulting metrics included aortic arch centerline radius of curvature, proximal landing zones (PLZs) maximum diameters, angulation and tortuosity calculated according to previously published work. These parameters were statistically analyzed to compare standard arches vs. arches with a common origin of the innominate and left carotid artery (CILCA), and the different landing zones in each arch type. Results The CNN segmentation yielded a mean Dice score of 0.94 with respect to manual ground truth segmentations. Standard arches were characterized by significantly larger radius of curvature (p = 0.002) and lower tortuosity in zone 3 (p = 0.004) vs. CILCA arches. For both standard and CILCA arches, comparisons among PLZs revealed statistically significant differences in maximum zone diameters (p &amp;lt; 0.0001), angulation (p &amp;lt; 0.0001) and tortuosity (p &amp;lt; 0.0001). Conclusions We developed a CNN-based automated pipeline for the automated, and reliable geometric quantification of standard and CILCA aortic arches. This tool has the potential to support TEVAR pre-procedural planning in a real clinical setting. Abstract Figure. Automatic pipeline scheme

Carotid-Axillary Bypass as an Alternative to Carotid-Subclavian Bypass Following Coverage of Left Subclavian Artery During TEVAR

Thoracic Endovascular Aortic Repair (TEVAR) has become the procedure of choice for pathology involving the descending thoracic aorta since its approval by the FDA in 2005. Left subclavian artery (LSA) coverage is commonly required to facilitate an adequate proximal landing zone for the endograft. The traditional revascularization procedure of choice is carotid-subclavian bypass, however recent studies report complication rates as high as 29%-specifically phrenic nerve palsy in 25% of patients undergoing this procedure. Our aim is to present our experience using carotid-axillary bypass as a safe alternative to carotid-subclavian bypass. All patients undergoing carotid-axillary bypass for TEVAR with LSA coverage between June 2016 and September 2019 at a tertiary medical center were retrospectively identified. Short-term and long-term complications were identified and analyzed including: phrenic nerve, recurrent laryngeal nerve, and axillary nerve injuries, as well as local vascular complications requiring re-intervention. All perioperative chest radiographs were reviewed for new hemidiaphragm elevation to assess for phrenic nerve injuries. 35 patients underwent carotid-axillary bypass in conjunction with TEVAR during this time period. The majority of bypasses were performed concurrently with TEVAR (80.0%, 28/35) utilizing GORE PROPATEN 8 mm externally supported vascular graft (91.4%, 32/35). The complication rate specific to carotid-axillary bypass was 14.3% (5/35). We observed a significantly lower (0%, 0/35, P < 0.01) rate of phrenic nerve palsy for carotid-axillary bypass compared to the previously reported 25% (27/107) for carotid-subclavian bypass. For patients with available follow-up imaging (85.7%, 30/35), there was a 100% patency rate at time intervals ranging from 0-1066 days (IQR = 3-37.8). Carotid-axillary bypass can be performed as a safe alternative to carotid-subclavian bypass for LSA coverage during TEVAR involving a more superficial anatomic course of dissection. Phrenic nerve palsy, a well-described complication of the traditional carotid-subclavian bypass, was not observed in this retrospective series.

Endovascular Repair of Aortic Dissection Involving the Left Subclavian Artery by Castor Stent Graft: A Multicentre Prospective Trial

The left subclavian artery (LSA) origin can be intentionally covered by stent grafts, to provide adequate proximal landing zones during thoracic endovascular repair for Stanford type B aortic dissections (TBADs). To preserve the LSA, a novel single branched stent graft, named “Castor” was designed and a clinical trial conducted to investigate its suitability. From April 2013 to March 2015, 73 patients with TBAD were treated by Castor stent grafts at 11 Chinese tertiary hospitals as part of a single arm prospective clinical trial. There were 50 acute (<2 weeks [68.5%]) and 23 chronic aortic dissections (>2 weeks [31.5%]). The technical success rate was 97% (n = 71/73). The two failures were caused by occlusion of the branch section of the stent graft. There were four intra-operative endoleaks (two type Ia, two type B from the LSA). The endoleak rate was 5% (n = 4/73). There was one in hospital death and no major complications. The median follow up time was 61 months (range 48–72 months). The mortality was 5% (n = 4/73) within one year and 7% within six years (n = 5/73). Two deaths were of unknown cause and three were not related to the aorta. Two new entry tears were found on the proximal or distal edge of the stent graft and were retreated endovascularly. Six occlusions of the branch section of the Castor stent graft were found, and the follow up patency rate of the branch section was 93% (n = 63/68). Two intra-operative endoleaks were left during follow up and eventually disappeared according to the latest computed tomography angiograms. For patients with TBADs needing anchoring proximal to the origin of LSA, the Castor single branched stent graft may provide an easily manipulated, safe, and effective endovascular treatment.

Endovascular Repair of Aortic Dissection Involving the Left Subclavian Artery by Castor Stent Graft: A Multicentre Prospective Trial

The left subclavian artery (LSA) origin can be intentionally covered by stent grafts, to provide adequate proximal landing zones during thoracic endovascular repair for Stanford type B aortic dissections (TBADs). To preserve the LSA, a novel single branched stent graft, named "Castor" was designed and a clinical trial conducted to investigate its suitability. From April 2013 to March 2015, 73 patients with TBAD were treated by Castor stent grafts at 11 Chinese tertiary hospitals as part of a single arm prospective clinical trial. There were 50 acute (<2 weeks [68.5%]) and 23 chronic aortic dissections (>2 weeks [31.5%]). The technical success rate was 97% (n=71/73). The two failures were caused by occlusion of the branch section of the stent graft. There were four intra-operative endoleaks (two type Ia, two type B from the LSA). The endoleak rate was 5% (n=4/73). There was one in hospital death and no major complications. The median follow up time was 61 months (range 48-72 months). The mortality was 5% (n=4/73) within one year and 7% within six years (n=5/73). Two deaths were of unknown cause and three were not related to the aorta. Two new entry tears were found on the proximal or distal edge of the stent graft and were retreated endovascularly. Six occlusions of the branch section of the Castor stent graft were found, and the follow up patency rate of the branch section was 93% (n=63/68). Two intra-operative endoleaks were left during follow up and eventually disappeared according to the latest computed tomography angiograms. For patients with TBADs needing anchoring proximal to the origin of LSA, the Castor single branched stent graft may provide an easily manipulated, safe, and effective endovascular treatment.

Carotid-Axillary Bypass as an Alternative to Carotid-Subclavian Bypass Following Coverage of Left Subclavian Artery During Thoracic Endovascular Aortic Repairs

Thoracic endovascular aortic repairs (TEVAR) have become the procedure of choice for aneurysms of the descending thoracic aorta and type B aortic dissection since their approval by the US Food and Drug Administration in 2005. Coverage of the left subclavian artery (LSA) is commonly required when TEVAR is performed in zone 3 of the descending thoracic aorta to allow for an adequate proximal landing zone for the endograft. Practice guidelines from the Society for Vascular Surgery suggest routine revascularization following LSA coverage in several categories of patients.

Stenting the Upper/Cervical Oesophagus with a Proximal Deployment Cervical Oesophageal Stent: Technique and Outcomes.

Proximal oesophageal stent deployment continues to provide challenges due to the proximity of the upper oesophageal sphincter and the associated subsequent complications such as globus sensation and stent migration. Patients with cervical oesophageal cancer have previously had limited stenting options available to them with a paucity of the literature describing the radiological technique for successfully placing these high-risk stents. In this paper, we present our experience using the Taewoong Niti-S CERVICAL Oesophageal Stent. We describe our method for stent deployment highlighting the importance of pre-procedural planning in ensuring an adequate proximal landing zone for the short proximal flare of the stent. Furthermore, we outline how we have adapted our placement technique to incorporate a routine pre-dilatation stage which has optimised retrieval of the proximal to distal deployment system. We have placed eight cervical oesophageal stents within our institution. Contrast swallows in all the patients following stent deployment have demonstrated free flow of contrast to the stomach with all patients reporting symptomatic relief and no foreign body/globus sensation. There has been one episode of stent migration but no incidence of oesophageal perforation or haemorrhage. Evolution of stenting technique and the properties of the stents themselves are improving accuracy of stent placement in relation to the important landmark of the upper oesophageal sphincter. Stenting of cervical oesophageal malignancy has proved successful in our institution and provided symptom relief for a subset of palliative patients who were previously unable to benefit from oesophageal stenting.

Aortic events and reoperations after elective arch surgery: incidence, surgical strategies and outcomes.

The true incidence of aortic events (AEs) and reoperations (REDO) following elective total aortic arch replacement remains unknown. The aim of this study was to review the incidence of AEs and surgical REDO, and its respective outcomes after 1232 elective arch repairs at 11 European aortic centres. Retrospective chart review (in the absence of prospective data collection) was performed for statistical analysis. Follow-up was conducted during routine clinical examination or in a telephone interview with patients and/or their respective physicians. One hundred fifty-five (12.6%) patients were identified (median follow-up time 48.7 months). The recorded AEs comprised aortic dilatation (62.6%), rupture (15.5%), endoleak (11%), false aneurysm (3.9%), dissection (3.2%), infection (2.6%) and others (1.3%). REDO (open/endovascular) were performed in 85.8% of patients (n = 133). Intraoperative and in-hospital mortality in the REDO patients were 7.5% and 17.3%, respectively. Postoperative neurological complications comprised paraplegia (6.0%) and stroke (1.5%). Survival rates after REDO at 1, 3 and 5 years were 81.2%, 79.0% and 76.7%, respectively. Univariate analysis identified 'rupture' and 'diameter progression', 'older age at REDO' and the REDO strategies 'frozen elephant trunk' and 'no elephant trunk' as predictors of increased in-hospital mortality. Multivariate analysis identified 'older age at REDO' (P = 0.008) as the only independent risk factor for in-hospital mortality. AEs after elective arch surgery are not irrelevant and mostly involve the distal aspects of the adjoining aorta. In accordance with the underlying pathology, open or endovascular REDO may be performed with an acceptable outcome. Preparation of an adequate proximal landing zone at the time of primary arch surgery is advisable.

Feasibility and Technical Aspects of Proximal Nellix-in-Nellix Extension for Late Caudal Endograft Migration

Purpose: To describe the feasibility and technical aspects of a proximal Nellix-in-Nellix extension to treat caudal stent-graft migration after endovascular aneurysm sealing (EVAS) in the in vitro and in vivo settings. Methods: In vitro studies were designed (1) to assess inner diameters of Nellix-in-Nellix extensions after postdilation with 12-mm balloons and (2) to test wall apposition in tubes with different diameters using a Nellix-in-Nellix stent-graft that extended out of the original Nellix stent-graft lumen by 10, 20, 30, and 40 mm. Simulated-use experiments were performed using silicone models in conjunction with a pulsatile flow pump. In the clinical setting, 5 patients (median age 74 years, range 73–83) presented at 2 centers with type Ia endoleak secondary to caudal Nellix stent-graft migration measuring a median 9 mm (range 7–15) on the left and 7 mm (range 0-11) on the right. Median polymer fill volume at the initial EVAS procedure was 42.5 mL (range 25–71). The median time to reintervention with a proximal Nellix extension was 15 months (range 13–32). Results: In vitro, the inner diameters of the Nellix-in-Nellix extensions were consistent after postdilation. Cases with 10 and 20 mm of exposed endobag resulted in a poor seal with endoleak, while cases with 30 and 40 mm of exposed endobag length exhibited angiographic seal. Fill line pressures of the second Nellix were higher than expected. In the 5 clinical cases, chimney grafts were required in each case to create an adequate proximal landing zone. The Nellix-in-Nellix procedure was successful in all patients. There were no procedure-related complications, and no endoleaks were observed during a median 12-month follow-up. Reinterventions were performed in 2 patients because of in-stent stenosis and chimney graft compression, respectively. Conclusion: Proximal Nellix-in-Nellix extension can be used to treat caudally migrated Nellix stent-grafts and to treat the consequent type Ia endoleak, but the technique differs from primary EVAS. The development of dedicated proximal extensions is desirable.

Inner-Branched Endografts for the Treatment of Aortic Arch Aneurysms After Open Ascending Aortic Replacement for Type A Dissection

The development of a postdissection aortic arch aneurysm after open ascending aortic replacement for type A dissection places the patient at increased risk for an open operation due to the need for redo sternotomy and total arch replacement. We conducted a computed tomography-based feasibility study to assess what proportion of these patients would be anatomically suitable for branched endograft repair of an arch aneurysm. We also aimed to identify ways to tailor the index operation to increase suitability for future endovascular repair. Our study was conducted at the Aortic Centre, Lille University Hospital, Lille, France. Postoperative images were assessed for patients after open replacement of the ascending aorta for acute type A dissection in this center between 2009 and 2015 to determine suitability for use of an aortic arch inner-branched device. The assessment found 52 of 73 patients (71.2%) were anatomically suitable for treatment with the aortic arch inner-branched device. The only cause for absolute exclusion from suitability was the absence of a proximal landing zone in the ascending aorta. Reasons for this were the ascending aortic graft being too short (71.4%), the presence of a major kink in the graft (23.8%), and the graft diameter being too large (4.8%). Approximately 70% of patients with arch aneurysm formation after open ascending aortic replacement for type A dissection are anatomically suitable for treatment with the aortic arch inner-branched device. In the future, surgeons will be able to fashion the prosthetic graft at the time of the index operation to ensure it fulfills criteria for an adequate proximal landing zone.