Aortic Arch Pathology Research Articles

Impact of Arch Disease Pathology on Outcomes of Zone 0 Branched Thoracic Endovascular Arch Repair.

Zone 0 branched thoracic endovascular arch repair (Z0BTEVAR) has emerged as an alternative to open repair for high-risk patients with aortic arch pathology. However, it is unclear how disease characteristics in this population impacts clinical outcomes. The study aimed to compare Z0BTEVAR according to arch disease pathology and to identify potential predictors of post-operative outcomes. From 2011 to 2023, patients who underwent Z0BTEVAR for chronic aortic dissection (C-AD) or for non-aortic dissection (N-AD) etiology at 3 European centers were included. The primary outcome was a composite of in-hospital mortality and disabling stroke. Multivariable logistic analyses were conducted to identify independent predictors of the outcomes. Overall, 213 patients underwent Z0BTEVAR, including 111 patients treated for C-AD and 102 patients treated for N-AD. The median age was 72 years old. Overall composite outcome was 10.3%, higher for N-AD patients compared to C-AD patients (15.7% vs. 5.4%; p=0.01). Similarly, N-AD patients had more post-operative strokes (17.7% vs. 4.5%; p<0.01). On multivariable analysis, previous type A aortic dissection was protective for the composite outcome (OR 0.2; C.I. 0.1-0.6), while degenerative aneurysm with zone 0 or 1 involvement was predictive of post-operative stroke (OR 3.7; CI 1.2-11.8). At 4 years, survival for the N-AD group was 71.8±6.6%, and for the C-AD group was 71.5±6.5% (p=0.81). Z0BTEVAR could be performed with satisfactory short- and mid-term outcomes for high-risk patients, particularly those with previous dissection. Patient selection is important, and continued effort should be placed on minimizing post-operative stroke.

Multi-center experience with an off-the-shelf single retrograde thoracic branch endoprosthesis for acute aortic pathology.

The thoracic branch endoprosthesis (TBE®, WL Gore, Flagstaff AZ) offers an off-the-shelf single option for thoracic endovascular aortic repair (TEVAR) of aortic arch pathology with sealing in zones 0-2. This study reports the early outcomes of TBE®-TEVAR for acute indications. Clinical data, imaging, and outcomes of patients treated with TBE®-TEVAR at seven institutions were retrospectively reviewed (March 2017- March 2024). Patients treated for complicated aortic dissection, symptomatic aneurysm/pseudoaneurysm (PSA), or blunt traumatic aortic injury (BTAI) by urgent/emergent repair were included. End-points were 30-day mortality, major adverse events (MAEs: mortality, myocardial infarction, prolonged intubation, stroke, paraplegia, dialysis, or bowel ischemia), and technical success. Of 356 patients treated by TBE®-TEVAR, 107 (69.0% male, mean 60±15 years-old) underwent repair for acute indications including 70 (65%) dissections, 21 (20%) symptomatic aneurysms/PSA and 16 (15%) BTAIs. Eight (8%) patients had repair immediately after open ascending repair of a Type A dissection. Proximal sealing was in zone 2 in 91 patients (89%) and zone 0-1 in 11 patients (11%) who required cervical debranching. Technical success was achieved in all (99%) except one patient with acute dissection and aneurysmal degeneration requiring staged repair. At 30-days, two (2%) patients died and 19 (18%) developed MAEs, including stroke in 6 (6%) and paraplegia in 6 (6%). Five patients (5%; all Zone 2) had retrograde dissections, all treated for acute or subacute dissection, with no mortality. Mean follow up was 55±171 days and 96 (94%) patients had follow-up imaging. Type IA or III endoleak occurred in seven patients (7%), retrograde branch occlusion in one (1%), and eleven (10%) required re-intervention. Cumulative aortic-related mortality was three (3%) from aortic rupture. Urgent/emergent TEVAR with the Gore TBE® device in acute pathology offers low mortality, stroke and paraplegia risk. Longer follow up is needed to assess effectiveness of the repair.

Anatomic feasibility of a novel modular triple-branched endograft for patients with aortic arch pathologies.

This study aimed to assess the anatomical feasibility of a novel modular triple-branched endograft for aortic arch diseases. A cross-sectional study was conducted on 314 patients with aortic arch pathologies treated at a single center from January 2018 to December 2023. Preoperative computed tomography angiography images were analyzed with three-dimensional reconstruction to quantify anatomical features. Feasibility was based on endograft anatomical criteria, and logistic regression identified risk factors for unsuitability. Out of 132 patients included in the study, 67.4% were deemed anatomically suitable for the triple-branched device. A total of 36 (27.3%) patients were deemed inapplicable due to a large diameter of the proximal landing zone, 12 (9%) patients due to a small diameter of the left common carotid artery, and 1 (0.8%) patient due to a small diameter of the left subclavian artery. Logistic regression identified large proximal landing zone diameter and small left common carotid artery diameter were significant factors for unsuitability (p < 0.001 and p = 0.002, respectively). The novel triple-branched endograft demonstrated promising anatomical feasibility in two-thirds of patients. However, anatomical constraints limited its applicability. Future device iterations should focus on accommodating a broader range of anatomical variations.

Endovascular Repair of Aortic Arch Zones 0 to 2 Using Physician-Modified Endografts: A Systematic Review and Meta-Analysis.

The purpose of this study was to collect all the available evidence concerning technical success and early and mid-term clinical outcomes of physician-modified endografts (PMEGs) for the treatment of aortic arch pathologies in zones 0 to 2. We performed a systematic review to identify all the eligible studies that reported outcomes to the PMEGs for aortic arch pathologies in zones 0 to 2 and then conducted a qualitative synthesis and meta-analysis of the results. The main outcomes were technical success, mortality, stroke rate, bridging stents' complications, and reintervention rate. We estimated pooled proportions and 95% confidence intervals (CIs). A total of 134 study titles were identified by the initial search strategy, of which 14 (zone 0 n=6; zone 1 n=1; zones 1 t o2: n=7) were considered eligible for inclusion in the meta-analysis. A total of 777 patients (80% male; 62±6 years) were identified among the eligible studies. The pooled technical success for the PMEG in zone 0 was 96.6% (95% CI=93.9%-98.2%), whereas in zones 1 to 2 was 95.9% (95% CI=92.9%-97.6%). The pooled 30-day mortality was 4.6% (95% CI=2.0%-10%) and 4.3% (95% CI=2.2%-8.2%) for zones 0 and 1 to 2, respectively, whereas the prevalence of late mortality was 8.2% (95% CI=4.7%-14%) and 3.4% (95% CI=1.9%-6%). The pooled stoke rate was 3.7% (95% CI=2.1%-6.4%) in zone 0 and 2.7% (95% CI=1.4%-5%) in zones 1 to 2. The early reintervention rate was 3.5% (95% CI=1.5%-8.0%) and 4.2% (95% CI=2.4%-7.2%) for zones 0 and 1 to 2, respectively, whereas during the mean follow-up of 26 months was 8.5% (95% CI=3.0%-21%) and 1.9% (95% CI=0.8%-4.3%). The pooled bridging's stent instability was 3.9% (95% CI=1.1%-12.9%) in zone 0 and 3.2% (95% CI=1.8%-5.8%) in zones 1 to 2. Endovascular repair of aortic arch pathologies using PMEGs seems to present a satisfactory level of technical success and a low mortality rate. To attain clearer conclusions, further research employing randomized controlled trials, longer-term follow-up, and consistent reporting of results is warranted. This systematic review and meta-analysis of observational studies analyzed the short- and mid-term outcomes of aortic arch aneurysm and/or dissection using physician-modified endografts. It separately examined the outcomes from zones 0 and 1-2 of the aortic arch. Fourteen studies (n=777 patients) were included. Overall technical success rates were 96.6% for zone 0 and 95.9% for zone 1-2. Regarding early mortality and stroke rates, no significant differences were observed, while late mortality was higher in patients in zone 0. The late reintervention rate favored patients treated with PMEGs in zone 1-2. The physician-modified technique appears to be an excellent and rapidly available alternative for the treatment of aortic arch diseases.

Anesthetic Considerations for Endovascular Repair of the Thoracic Aorta.

Thoracic aorta pathologies, especially those of the ascending aorta and aortic arch, were traditionally approached via open surgical repair. This carries risk of ischemic end-organ damage and other complications. Endovascular repair of ascending aorta and aortic arch pathologies is becoming more successful and widespread, thereby posing numerous challenges to the anesthesiologist. This article reviews the anesthesia-pertinent pathophysiology, repair techniques, preoperative evaluation, intraoperative management, and postoperative care of patients presenting for endovascular repair of thoracic aorta pathologies.

Arch Branch Devices and Clinical Trials in Treatment of Aortic Arch Pathology

Aortic arch endografting will undoubtedly expand the population suitable for aortic arch repair. Currently, there are four endografts under investigation to treat aortic arch pathology including Gore's Thoracic Branch Endoprosthesis, Endospan's NEXUS Aortic Arch Stent Graft System, Terumo's RelayBranch Thoracic Stent-Graft System, and Cook's Zenith Arch Branched Graft. Despite advances in deployment technique, self-aligning features to mitigate aortic arch manipulation, and distal embolic protection, perioperative stroke continues to be high, limiting the devices from commercial availability. Here we discuss current devices under trial in the United States, limitations of aortic arch endografting, and future directions.

Predictors of Type 1a Endoleak After Hybrid Thoracic Endovascular Aortic Repair for Aortic Arch Diseases.

This study analyzed the risk factors for type 1a endoleak after hybrid thoracic endovascular repair (TEVAR) for aortic arch diseases based on preoperative patient characteristics and multidetector computed tomography measurements. In all, 213 patients who underwent proximal landing zone 1 and 2 hybrid TEVAR for aortic arch pathologies (zone 1, n=82 [38.5%]; zone 2, n=131 [61.5%]; median age 72 years) between May 2008 and February 2020 were enrolled in this study; the median follow-up period was 6.0 years. The rates of type 1a endoleak at 1, 3, 5, and 10 years were 1.4%, 1.4%, 4.1%, and 4.1%, respectively. Multivariate Cox proportional hazard regression analysis revealed that the angle of the aortic arch was a significant risk factor for type 1a endoleak (hazard ratio 1.08; 95% confidence interval 0.85-0.99; P=0.045). The estimated area under the curve in receiver operating characteristic curve analysis was 0.76, and the cut-off value of the aortic arch angle was 95°. It is essential to prevent type 1a endoleak, the most severe complication of hybrid TEVAR. The risk factor for type 1a endoleak in this study was a sharper angle of the aortic arch (≤95°). For patients at high risk of type 1a endoleak, it is necessary to consider alternative procedures depending on a patient's surgical risk.

The Use of Short Dilator Tip in Endovascular Branched Arch Repair: A Case Series.

The aim of the study was to investigate the safety and feasibility of branched endovascular arch repair (b-TEVAR) with a custom-made double or triple inner branched arch endograft using a short dilator tip (35 mm) in patients with aortic arch pathologies. Retrospective analysis of all consecutive patients undergoing b-TEVAR with a short dilator tip for the treatment of aortic arch pathologies in a high-volume tertiary center between January 2019 and July 2023. The combined primary endpoint was technical success and perioperative complications caused by the endograft, including tip-induced cardiac injury and trackability issues. Secondary endpoints were major adverse events (MAE), including morbidity, mortality, and reinterventions within 30 days. During a 4-year period, 22 patients (median age 72 years, 16 males) were treated with a custom-made double or triple inner-branched TEVAR for different aortic arch pathologies using a short dilator tip (35 mm). After initial exclusive treatment of patients with previous valve replacement, the use of a short dilator tip became standard. Eighteen patients received a triple- and 4 patients received a double-branched endograft. Seventeen patients (77.3%) underwent elective treatment, while 5 patients underwent urgent repair due to contained rupture or symptomatic aneurysms. The technical success was 100%. No tip-induced cardiac mortality and morbidity occurred perioperatively. The trackability of the device was in no case affected by the short tip. Within 30 days, the MAE rate was 45%, including one death. No re-intervention had to be performed. Endovascular aortic arch repair with inner-branched arch endografts using a short dilator tip (35 mm) appears to be safe and technically feasible and could potentially reduce the risk of fatal myocardial injuries. Due to safe and stable maneuverability and deployment of endograft in zone 0 the use of short dilator tip might have the potential to become standard in endovascular branched arch repair. This is one of the first reports on the use of short dilator tip and associated complications in endovascular branched arch repair.

Physician-Modified and In Situ Fenestrated Stent Grafts in Zone 0 for Aortic Arch Pathology After Ascending Aortic Replacement.

We sought to describe our experience and outcomes of a zone 0 landing physician-modified aortic stent for the treatment of aortic arch pathologies late after open ascending aortic replacement. This study included consecutive patients with aortic arch diseases treated with total endovascular repair using different techniques. The indication for endovascular repair was agreed on in a multidisciplinary discussion. Study end points were technical success, early and late outcomes. From November 2018 to May 2022, 16 consecutive patients underwent total endovascular repair of aortic arch pathologies. Median time for surgery was 4.8 hours (range, 2.6-6.6 hours). All the new-onset aortic arch pathologies were successfully treated. The 30-day mortality rate was 0%. Two patients had endoleak. The median length of postoperative stay was 4 days (range, 3-6 days). During follow-up, 1 patient underwent reintervention for type II endoleak. There were no conversions to retrograde dissection, aortic rupture and stroke. Our experience of using different total endovascular techniques for selective patients with arch pathologies who may be unfit or too risky for reopen surgery revealed favorable initial results. In addition, these techniques are promising options for urgent arch pathologies without availability of custom-manufactured devices. Durability concerns will need to be assessed in additional studies with long-term follow-up. The use of physician-modified and in situ fenestrated stent grafts in zone 0 landing for aortic arch pathologies in patients with prior open ascending aortic replacement is effective in endovascular therapy. This innovation enables clinicians to offer an alternative option to high-risk patients, potentially reducing morbidity and mortality. It underscores the feasibility of tailored endovascular therapy in complex aortic diseases, where customized devices may not be available.

Patient-Tailored Therapy for Complex Aortic Arch Anatomy: An Evolving Research Field with Custom-Made Solutions.

The treatment of complex aortic pathologies requires specialized techniques and tailored approaches due to each patient's unique anatomical and clinical challenges. The European Association for Cardiothoracic Surgery (EACTS) and the Society of Thoracic Surgeons (STS) new guidelines identify the aorta as the body's 24th organ and reiterate that multidisciplinary aortic teams are recommended for shared decision-making to determine optimal treatment strategies. Patients treated for conditions such as aneurysms, dissections, intramural hematomas, or penetrating aortic ulcers may develop complex forms over time, necessitating careful follow-up and timely corrective actions. Endovascular solutions can be favorable for older patients with complex anatomies and multiple comorbidities. However, when endovascular treatment is not feasible, hybrid treatments or open surgery must be considered if the patient's condition allows it. The risk-benefit ratio of each procedure must be carefully evaluated; choosing the best intervention or deciding not to intervene becomes a critical and challenging decision. At our Cardiac Surgery Center in Verona, a multidisciplinary team with over 20 years of experience in treating complex aortic arch pathologies extensively discussed different cases of complex aortic pathologies treated with endovascular, hybrid, or surgical approaches, emphasizing the importance of considering both anatomical and patient-specific characteristics. The decisions and treatments were often challenging, and unanimity was not always achieved, reflecting the complexity of finding the best solutions.

A Scoping Review of Definitions of Success in Endovascular Aortic Arch Repair.

The present standard of care to treat aortic arch pathologies is open surgical repair with cardiopulmonary bypass and deep hypothermic arrest. With approaches for total endovascular and extra-anatomic cervical debranching hybrid arch repair becoming more diverse, understanding what is considered a successful operation is prerequisite for a rigorous comparison of techniques. This review describes the specific outcomes reported, the rates of success, and the definitions of technical and clinical success in total endovascular and extra-anatomic cervical debranching hybrid aortic arch repair. A comprehensive search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was performed. Studies with patients undergoing total endovascular or hybrid extra-anatomic cervical debranching repair of the aortic arch were included. Any publications including only patients with Ishimaru zone 2 or distal repairs were excluded from this review. Studies with less than 5 patients were excluded. Data extraction was performed by one author. Data items included were study design, procedure type, procedural details, underlying pathology, type of cervical debranching, type of endograft repair, surgical outcomes, definition of cerebrovascular events, technical success, and the definition of technical success. Of 1754 studies screened for review, 85 studies with 5521 patients were included. By frequency, the included studies examined the following interventions: fenestrated devices, branched devices, parallel grafting. Most studies were retrospective single-institution studies. There were no randomized controlled trials. Short-term mortality and cerebrovascular events were nearly universally reported, present in 99% and 95% of studies reviewed, respectively. Only 27% of studies provided an explicit definition for cerebrovascular events. While 75% of studies reported a technical success rate, only 45% of those studies provided explicit criteria. Clinical success rates were infrequently reported, present in only 5.9% of studies reviewed. The definitions of technical success that were provided fell short of analogous defined reporting standards in nearly all studies, inflating technical success rates. Definitions of cerebrovascular events and technical success require stringent criteria to uniformly compare various methods of endovascular aortic arch repair. A societal consensus document for reporting standards of endovascular aortic arch repair would allow for higher-quality outcomes research. Total endovascular and extra-anatomic cervical debranching hybrid operations are being increasingly utilized for complex aortic arch repair. These techniques, however, can be associated with serious complications. Currently, there is no accepted metric to define technical or report clinical outcomes. Due to the paucity of high-quality data, use of these approaches may be limited in clinical practice. This study emphasizes the need for the development of standards for reporting outcomes in endovascular aortic arch repair. Future studies can then utilize these benchmarks, whcih will allow for improved efficacy and safety in these techniques.

Systematic Review and Meta-Analysis With Reconstructed Time-To-Event Data of Frozen Elephant Trunk and Conventional Aortic Repair.

Frozen elephant trunk (FET) has gained popularity since its inception. Nevertheless, the optimal approach for managing aortic arch pathologies remains subject of debate. This meta-analysis compared outcomes between patients undergoing FET and those undergoing conventional aortic repair. Systematic searches were conducted up to February 2024. Pooled results of short and long-term outcomes were computed. A systematic review identified 21 non-randomized studies encompassing 3240 patients. Short-term mortality was lower in FET recipients than in those undergoing conventional repair (OR [95% CI] = 0.58 [0.44-0.78], P < .01). Postoperative paraplegia incidence was higher in the FET cohort (OR = 1.85 [1.02-3.34], P = .04), while subgroup analysis showed no difference between the two groups in patients with acute aortic dissection. Long-term all-cause mortality was lower among FET recipients. Subgroup analysis showed FET was associated with reduced all-cause mortality (HR = 0.55 [0.39-0.79], P < .01) and aortic re-intervention (HR = 0.62 [0.39-0.99], P = .05) in acute aortic dissection patients. This meta-analysis underscores the favorable association between the utilization of FET and improved short and long-term outcomes compared with conventional repair, while paraplegia incidence was higher in the FET group. FET appears to offer superior benefits, particularly evident in patients with acute aortic dissection.

Technical Aspects of Exclusive Transfemoral Route for Total Endovascular Arch Repair: A Custom-Made Device With Only Upward-Facing Inner Branches for Aortic Arch Treatment.

The purpose was to demonstrate a new arch endograft configuration to allow total endovascular aortic arch repair exclusive from transfemoral approach. The custom-made multi-branched arch endograft (Cook Medical, Bloomington, Indiana) features 3 inner branches (IBs) for supra-aortic vessels incorporation and complete endovascular arch repair. Traditionally, the innominate and left carotid branches are anterograde IBs, requiring upper access for incorporation of these vessels, and the left subclavian branch is an upward-facing IB that can be incorporated from transfemoral access. We report a novel device configuration with only upward-facing IBs, allowing exclusive transfemoral route for total endovascular arch repair. Technical aspects, implantation technique, and limitations are described thoroughly. Herein is described an arch endograft configuration that simplifies endovascular aortic arch repair, allowing supra-aortic vessel incorporation through a transfemoral route only. This innovative design may serve as another alternative in selected patients. This innovative endograft design, with only upward-facing inner branches, simplifies the total endovascular aortic arch repair by allowing for a exclusively transfemoral approach. This may reduce procedural complexity and minimizes risks associated with multiple access points. It provides another alternative, particularly beneficial for selected high-risk patients for open repair, potentially expanding the applicability of endovascular treatments for aortic arch pathologies.

Six-Year Outcomes of Total Arch Replacement vs Debranching With TEVAR for Aortic Arch Pathologies: Meta-Analysis of Kaplan-Meier-Derived Data From Propensity Score-Matched Studies.

Total arch replacement (TAR) and debranching plus thoracic endovascular aortic repair (TEVAR) serve as significant therapeutic options for aortic arch pathologies. It remains unclear whether one of these approaches should be considered preferable. Our study aimed to compare the long-term outcomes of these 2 approaches. We carried out a pooled meta-analysis of time-to-event data extracted from studies published by December 2023. Eligibility criteria included populations with any aortic arch pathology who underwent debranching plus TEVAR or TAR, propensity score-matched (PSM) studies (prospective/retrospective; single-center/multicentric), and the outcomes included follow-up for overall survival/mortality and/or reinterventions. Eleven PSM studies met our eligibility criteria, including a total of 1142 patients (571 matched pairs). We did not observe any statistically significant difference in the risk of all-cause death between the groups (hazard ratio [HR]=1.20, 95% confidence interval [CI]=0.91-1.56, p=0.202), but patients who underwent TAR had a significantly lower risk of late aortic reinterventions compared with patients who underwent debranching plus TEVAR (HR=0.38, 95% CI=0.23-0.64, p<0.001). Our meta-regression analyses for all-cause mortality identified statistically significant coefficients for age (coefficient=-0.047; p=0.012) and type A aortic dissections (coefficient=0.012; p=0.010). Debranching plus TEVAR and TAR demonstrate no statistically significant differences in terms of survival in patients with aortic arch pathologies, but TAR is associated with lower risk of late aortic reinterventions over time. Although older patients may benefit more from debranching plus TEVAR rather than from TAR, patients with dissections may benefit more from TAR. Although the 2 strategies seem to be equally valuable in terms of survival, total aortic arch replacement (when compared with debranching plus TEVAR to treat patients with aortic arch pathologies) is associated with reduction of late aortic reinterventions over time in patients with and without aortic dissections. However, we should consider debranching plus TEVAR in older patients as it is associated with lower risk of death in this population. The novelty of our study lies in the fact that, instead of comparing study-level effect estimates, we analyzed the outcomes with reconstructed time-to-event data. This offered us the opportunity of performing our analyses with a mathematically appropriate model which consider events and time; however, these findings might be under the influence of treatment allocation bias.

Branch Thrombus after Endovascular Treatment with Arch Branched Devices for Aortic Arch Pathologies

The aim of this study was to describe the occurrence of branch thrombosis following endovascular treatment of aortic arch pathology using an arch branched device (ABD) and to determine whether this is influenced by clinical and geometric parameters. In this retrospective observational study of patients treated with an ABD in three centres, the primary endpoint was thrombus formation within a branch during follow up. Secondary endpoints were technical success, serious adverse events (SAEs), early and late death, stroke, and re-interventions. Geometric measurements (tortuosity index and curvature) were determined on pre-operative and post-operative computed tomography angiographies. Thirty nine patients were treated and 68 antegrade branches were analysed (innominate artery, n = 27; common carotid artery [CCA], n = 40; left subclavian artery [LSA], n = 1). Thrombus was identified within seven branches (10%) on surveillance imaging (innominate artery, n = 6; CCA, n = 1; LSA, n = 0; p = .021) and was associated with a wider distal bridging stent diameter (median 14.0 mm [interquartile range {IQR} 2.0] vs. 8.7 mm [IQR 5.9]; p = .026), a higher degree of reversed tapering (4.3 mm [IQR 1.4] vs. 1.2 mm [IQR 2.8]; p = .023), use of polyethylene terephthalate (Dacron) covered (vs. expanded polytetrafluoroethylene) bridging stents (23% vs. 2%; p = .011), and higher body mass index (BMI) (32.1 kg/m2 [IQR 7.5] vs. 25.7 kg/m2 [IQR 5.4]; p = .029), but not with pre-operative or post-operative tortuosity index or curvature or alterations. Regarding secondary outcomes, the technical success rate was 97%, SAEs occurred in 15 patients (38%), early and late death rates were 8% and 23%, respectively, and early and late stroke rates were 5% and 23%, respectively. The risk of developing branch thrombosis after endovascular intervention with an ABD is considerable, especially of innominate artery branches, characterised by Dacron covered large diameter bridging stents, and in patients with a high BMI. Large prospective studies are required to analyse factors associated with branch thrombosis.

Evaluation of custom-made Relay® stent-grafts for aortic arch landing zones 0 and I: experience from two high-volume aortic centres.

To report experience with a Relay® stent-graft custom-made platform in treating different aortic arch pathology in 2 high-volume aortic centres. A retrospective analysis of all patients treated between July 2016 and July 2023 with custom-made Relay® stent-graft (custom-made device). Underlying aortic arch pathology was an aneurysm, penetrating aortic ulcer, and dissection. Three custom-made device designs were used: proximal scallop, fenestrations, and inner branches. The endpoints were technical success, perioperative stroke, death, and reintervention rate. Thirty-five patients (89% males) with a mean age of 70 ± 11 years were treated.Indication for treatment was penetrating aortic ulcer in 14 patients (40%), aneurysm in 11 patients (31%) and aortic dissection in 10 patients (29%). The technical success rate was 100%. Twenty-eight patients (80%) had proximal sealing in zone 0, and 7 (20%) had proximal sealing in zone 1. Nine patients (25.6%) had proximal scallops, 9 (25.6%) had 1 big fenestration and 17 (48.8%) had a branched device; 1 with single branch, 15 with double branches and 1 with triple branches. Thirty patients (86%) had previous or simultaneous left subclavian artery revascularization. No patient died during 30 days. Two patients (5.7%) had stroke postoperatively; both recovered without disabling deficits. The mean follow-up was 35 ± 26 months. Six patients (17.1%) died during follow-up. One patient required reinforcement of the bridging stent in the left common carotid artery and one additional vascular plugging of the left subclavian artery. Three patients received distal extension. The Relay® stent-graft custom-made platform showed a good performance in our study with a high technical success rate, low perioperative stroke and mortality, and low reintervention rates during the follow-up.

Proximal sealing in the aortic arch for inner curve disease using the custom Relay scalloped and fenestrated stent graft

ObjectiveThis study aimed to analyze early and midterm results of custom-made proximal scallop and fenestrated stent grafts for thoracic endovascular aortic repair (TEVAR) with a proximal landing zone (PLZ) in the aortic arch. MethodsAll consecutive patients treated with the custom made proximal scalloped and fenestrated Relay stent grafts (Terumo Aortic Bolton Medical Inc.) in 10 Italian centers between January 2014 and December 2022 were included. The primary end points were technical success, incidence of intraoperative major adverse events, deployment accuracy, and rate of early neurological complications, endoleaks (ELs) and retrograde aortic dissection. ResultsDuring the study period, 49 patients received TEVAR with Relay custom-made endograft in Italy were enrolled. The median patient age was 70.1 years (interquartile range, 23-86 years) and 65.3% were male. The indication for treatment was atherosclerotic aneurysms in 59.2% of cases and penetrating aortic ulcer in 22.4%. The endograft configuration was proximal fenestration in 55.1% and scallop in 44.9%. The proximal landing zone was zone 0 in 25 cases (51%), zone 1 in 14 cases (28.6%), and zone 2 in 10 cases (20.4%). The supra-aortic debranching procedures were 38 (77.5%). Technical success was 97.9% (48/49) owing to one case (2.0%) of inaccurate deployment. Intraoperatively, one (2.0%) type Ia and one (2.0%) type III EL were detected. There were no cases of in-hospital mortality, major adverse events, or retrograde dissection. Three minor strokes (6.1%) (National Institutes of Health Stroke Scale score of ≤4) were observed. At a mean follow-up time of 36.3 ± 21.3 months the rate of types I to III ELs and reintervention was 4.1%, respectively. Four patients (8.2%) died during the follow-up period, one (2.1%) from abdominal aortic rupture and three (6.1%) from nonaortic causes. ConclusionsOur early and midterm outcomes suggest that scalloped and fenestrated TEVAR may provide an acceptable alternative treatment option for aortic arch pathologies. Large-scale studies are needed to assess the long-term durability of this technique.

Two-stage hybrid surgical repair for aortic arch pathology with a shaggy aorta: a case report

BackgroundThe surgical treatment strategy for aortic arch pathology with a shaggy aorta must be determined on a case-by-case basis because of the risk of catastrophic complications, such as brain infarction and spinal cord injury.Case presentationThis report describes the surgical case of two saccular aneurysms of the arch and abdominal aorta associated with a shaggy aorta in a 63-year-old man who underwent total arch replacement and secondary thoracic endovascular aortic repair. Considering the risk of embolization during endovascular therapy, graft replacement for the abdominal aortic aneurysm was initially performed. On postoperative day 28, total arch replacement with the conventional elephant trunk was performed using the functional brain isolation technique, which involves manipulating places far from the atherosclerotic burden, such as arterial inflow for cardiopulmonary bypass and unclamping of neck vessels. On postoperative day 7 after total arch replacement, thoracic endovascular aortic repair was performed across the conventional elephant trunk in the nondiseased descending aorta. No postoperative complications, such as cerebrovascular failure, paraplegia, or embolization to abdominal viscera or lower extremities, occurred. The patient remained asymptomatic.ConclusionsThe present case suggests that total arch replacement with the conventional elephant trunk and secondary thoracic endovascular aortic repair may be an effective alternative for aortic arch pathology with a shaggy aorta. The strategy for surgical treatment in patients with aortic arch pathologies with a shaggy aorta must be judged on a case-by-case basis, considering patient characteristics, comorbidities, and preoperative evaluation using transesophageal echocardiography and computed tomography angiography, to eliminate potential determinants of intraoperative stroke.

Editor's Choice – Sex Related Anatomical Differences in Patients With Aortic Arch Pathology and Their Impact on the Feasibility of Double and Triple Branched Endografts

To evaluate sex based differences in ascending aorta and arch anatomy in patients with underlying proximal aortic disease and to evaluate their impact on feasibility for total endovascular repair with custom made, branched arch devices. This was a retrospective cross sectional review of all patients undergoing open and or total endovascular arch repair due to distal ascending aorta and or aortic arch pathologies in a single high volume aortic centre between 2012 and 2022. Anatomical ascending aorta and aortic arch parameters were analysed on a flow centreline on a dedicated 3D workstation. Sex related differences of the ascending aorta, aortic arch, and supra-aortic vessels were evaluated. Subsequently, four endovascular devices were assessed for feasibility: double and triple branched devices both for the Zenith (Cook Medical) and Relay (Terumo Aortic) platforms, first in accordance with the instructions for use and then considering the possibility of adjunctive cervical debranching. The primary endpoints were sex specific differences in aortic anatomy, while secondary endpoints included sex based feasibility of branched endograft devices. During the study period, 395 patients underwent total aortic arch repair, of whom 152 (51 female, 33.5%) had high quality computed tomography angiograms available and were included in the study. Female patients had a shorter proximal landing zone than males (22 mm vs. 47 mm; p < .001). Left subclavian artery dissection was more frequent in men (24.8% vs. 3.9%; p < .001). Other anatomical parameters showed a similar distribution between sexes. Female patients presented a lower feasibility for double branched devices (35.3% vs. 58.4%; p= .015) as well as a tendency for lower feasibility rates for triple branched devices (31.4% vs. 47.5%; p= .081). Although most ascending aortic and arch parameters showed similar trends in both sexes, the availability of a suitable proximal landing zone was lower in female patients. Consequently, female patients had lower feasibility rates for double arch branched endografts and, to lesser extent, for triple arch branched endografts.

Clinical outcomes of the type II hybrid procedure for the repair of extensive aortic arch pathology.

Type II hybrid arch repair (HAR) has been used for the repair of extensive aortic arch pathology. The aim of this study was to retrospectively analyze single-stage hybrid treatment involving replacement of the ascending aorta, arch debranching, and zone 0 stent graft deployment. We retrospectively analyzed clinical data from 41 patients with acute and chronic aortic disease who underwent a type II hybrid arch procedure at Beijing Anzhen Hospital and Beijing Chaoyang Hospital from January 2020 to August 2022. The femoral arteries and right axillary arteries were used as cannulation sites to decrease the risk of malperfusion. During surgery, the nasopharyngeal temperature was lowered to 30 ℃. Demographic, perioperative, and late results data were retrieved and analyzed. The mean age of the patients was 54.9±11.1 years, and 31 patients (75.6%) were men. In all cases, zone 0 stent graft deployment was successful, with no in-hospital mortality. The median follow-up time was 10.5 [interquartile range (IQR), 4.8-17.6] months, and the survival rate was 94.9% during follow-up. Complications included cerebral infarction (3 patients, 7.3%) and renal failure requiring dialysis (3 patients, 7.3%). There were no occurrences of paraplegia, and no stent-related complications occurred during the follow-up period. The single-stage hybrid arch procedure achieved satisfactory early results and represents a less invasive approach for treating complex diffuse aortic disease that affects the arch. This strategy is an important technical advance in the treatment of high-risk patients with extensive aortic arch pathology.