Aortic Arch Stent Graft Research Articles

Physician-Modified Thoracic Stent-Grafts for the Treatment of Aortic Arch Lesions

Purpose: To evaluate outcomes of physician-modified thoracic stent-grafts for the treatment of aortic arch aneurysms. Methods: A retrospective dual-center analysis was performed involving 36 patients (mean age 74.7±9 years, range 58–91; 27 men) with an aortic arch lesion who were treated between November 2013 and June 2016 using physician-modified thoracic stent-grafts. Half of the patients had a degenerative aneurysm; the remainder had type B dissection (n=9), traumatic transection (n=3), type Ia endoleak after previous endografting (n=5), or aortoesophageal fistula (n=1). All patients were considered to be at high surgical risk. Patients were treated using an aortic arch stent-graft with a single fenestration (n=24) or a proximal scallop (n=12); zone 0 was involved in 16 patients, zone 1 in 9, and zone 2 in 11. The modified thoracic stent-graft was deployed after supra-aortic branch revascularization in 24 (67%) patients. Results: Mean time required for stent-graft modifications was 18 minutes (range 14–21). Technical success was obtained in all cases with no type I endoleak. One (3%) patient had a stroke without permanent sequelae. The 30-day mortality was 6%. During a mean follow-up of 11.4±6 months (range 2–36), there were no conversions to open repair. The overall mortality was 14%; aorta-related mortality was 6%. Conclusion: Our experience suggests that physician-modified thoracic stent-grafts are feasible for aortic arch lesions and provide encouraging results in the short term. Durability concerns will need to be assessed.

Safety and Efficacy of an Aortic Arch Stent Graft with Window-Shaped Fenestration for Supra-Aortic Arch Vessels: an Experimental Study in Swine.

Background and ObjectivesThoracic endovascular aortic repair exhibits limitations in cases where the aortic pathology involves the aortic arch. We had already developed a fenestrated aortic stent graft (FASG) with a preloaded catheter for aortic pathology involving the aortic arch. FASG was suitable for elective cases.Materials and MethodsAn aortic arch stent graft with a window-shaped fenestration (FASG-W) for supra-aortic arch vessels is suitable for emergent cases. This study aims to test a FASG-W for supra-aortic arch vessels and to perform a preclinical study in swine to evaluate the safety and efficacy of this device. Six FASG-Ws with 1 preloaded catheter were advanced through the iliac artery in 6 swine. The presence of endoleak and the patency and deformity of the grafts were examined with computed tomography (CT) at 4 weeks postoperatively. A postmortem examination was performed at 8 weeks. The mean procedure time for FASG-W was 27.15±4.02 minutes. The mean time for the selection of the right carotid artery was 5.72±0.72 minutes.ResultsMajor adverse events were not observed in any of the 6 pigs who survived for 8 weeks. For the FASG-W, no endoleaks, no disconnection, and no occlusion of the stent grafts were observed in the CT findings or the postmortem gross findings.ConclusionThe procedure with the FASG-W was able to be performed safely in a relatively short procedure time and involved an easy technique. The FASG-W was found to be safe and convenient for use in this preclinical study of swine.

TCTAP A-074 Development of a Fenestrated Window Shape Aortic Arch Stent Graft with a Preloaded Catheter for Protecting Branch Arteries: An Experimental Study in Swine

TCTAP A-074 Development of a Fenestrated Window Shape Aortic Arch Stent Graft with a Preloaded Catheter for Protecting Branch Arteries: An Experimental Study in Swine

Safety and efficacy of a novel, fenestrated aortic arch stent graft with a preloaded catheter for supraaortic arch vessels: an experimental study in Swine.

Thoracic endovascular aortic repair (TEVAR) shows limitations in cases in which the aortic pathology involves the aortic arch. The study aims were to test a fenestrated aortic arch stent graft (FASG) with a preloaded catheter for the supraaortic arch vessels and to perform a preclinical study in swine to evaluate the safety and efficacy of this device. Six FASGs with 1 preloaded catheter and 5 FASGs with 2 preloaded catheters were advanced through the iliac artery in 11 swines. The presence of endoleaks and the patency and deformity of the grafts were examined with computed tomography (CT) at 4 weeks postoperatively. A postmortem examination was performed at 8 weeks. The mean procedure time for the one and two FASG groups was 30.2 (27.9-34.5) min and 43.1 (39.2-53.7) min. The mean time for the selection of the carotid artery was 4.8 (4.2-5.5) min and 6.2 (4.6-9.4) min. Major adverse event was observed in one of 11 pigs. One pig died at 4 weeks likely because of the effects of the high dose of ketamine, while the remaining 10 pigs survived 8-week. For both the one and two FASG groups, no endoleaks, no disconnection, no occlusion of the stent grafts were observed in the CT findings and the postmortem gross findings. The procedure with the FASG could be performed safely in a relatively short procedure time and involved an easy technique. The FASG is found to be safe and convenient in this preclinical study with swine.

PM098 Development of A Novel, Fenestrated Aortic Arch Stent Graft With A Preloaded Catheter For Protecting Branch Arteries: An Experimental Study In Swine

O ST E R A B ST R A C T S conflicting results around whether AF is associated with adverse outcomes after aortic valve replacement (AVR) amongst the few studies that have investigated this. Objectives: We compared the characteristics and outcomes of patients undergoing AVR by history of AF. Methods: Isolated AVR patients at Auckland City Hospital 2005-2012 were divided into those with and without pre-operative AF for comparative analyses. Results: Amongst 620 patients, 19.2% (119) had permanent or paroxysmal AF preoperatively. Patients with AF were significantly older (70.5 vs 63.4 years, p 24 hours 2.48 (1.32-4.69). Conclusion: AF was associated with a number of cardiovascular and cardiac surgery risk factors, but remained independently associated with short and long-term mortality. AF should be incorporated into cardiac surgery risk models and AF ablation be considered when AVR is performed. Disclosure of Interest: None Declared

EndoAnchor Placement in Thoracic and Thoracoabdominal Stent-Grafts to Repair Complications of Nonalignment

To report our early experience in repairing incomplete sealing or nonalignment of thoracic or thoracoabdominal stent-grafts using EndoAnchors. Six patients (5 men; mean age 67 years, range 56-76) with thoracic or thoracoabdominal aortic stent-grafts and persistent type I endoleak (n=4), stent-graft migration (n=2), partial stent-graft infolding (n=2), and/or side branch malperfusion (n=1) were treated using the Heli-FX Aortic Securement System. Stent-graft or uncovered stent extension did not improve alignment in 3 patients prior to the use of EndoAnchors. Intended fixation of the proximal stent-graft in the aortic arch (n=1) and the proximal (n=3) or distal (n=2) descending thoracic aorta was achieved in all 6 patients using 28 EndoAnchors (3-7 per patient). Two to 4 EndoAnchors were placed at the site of the nonalignment and an additional 2 to 4 to fix the entire circumference of the stent-graft. The majority of the EndoAnchors were delivered successfully at the first attempt, but 5 required reapplication during the same intervention (no EndoAnchors were lost). No additional balloon dilation or other adjunctive maneuver was required for improvement of thoracic stent-graft fixation after the deployment of the EndoAnchors. The intraoperative and early postoperative periods were uneventful in 5 patients; however, one TAAA patient with a fenestrated aortic arch stent-graft suffered from multiple visceral and cerebral infarctions and died 4 weeks later. During the mean 11-month follow-up (range 5-22), no stent-graft migration or EndoAnchor dislocation has been observed. There have been no periaortic hematomas or side branch complications. Although the number of patients treated so far is small, the Heli-FX Aortic Securement System seems to be a feasible and safe treatment option for primary or secondary procedures in patients with complications of proximal or distal thoracic stent-graft nonalignment. However, extensive endovascular interventions in the proximal aortic arch should be performed with caution because of an increased risk of severe embolic events.

Development of a Novel, Fenestrated Aortic Arch Stent Graft with Preloading Catheter to Save Branch Arteries: An Experimental Study

Development of a Novel, Fenestrated Aortic Arch Stent Graft with Preloading Catheter to Save Branch Arteries: An Experimental Study

Application of Open Triple-Branched Aortic Arch Stent Graft for Acute Stanford Type A Aortic Dissection

Complete documentation is provided outlining a process for surgical treatment of the ascending aorta using open triple-branched aortic arch stent grafts to treat acute Stanford type A aortic dissection based on clinical observations. A total of 34 patients underwent replacement of the ascending aorta or aortic root in combination with open placement of a triple-branched stent graft. Mean cardiopulmonary bypass, mean myocardial ischemic, and selective cerebral perfusion times were 186 ± 38, 101 ± 27, and 39 ± 11 minutes, respectively. Two deaths occurred during hospitalization. Of the remaining patients, postoperative computed tomography angiography confirmed that all implanted stent grafts were fully opened; however, the dissected aorta and false lumen size showed evidence of reduced thickness. This applies mainly to those who need extensive surgical reconstruction of the thoracic aorta with acute Stanford type A aortic dissection, and it can reduce cardiopulmonary bypass complexities of the traditional surgeries and potential complication.

An Externalized Transseptal Guidewire Technique to Facilitate Guidewire Stabilization and Stent-Graft Passage in the Aortic Arch

To describe a technique to facilitate passage and stable deployment of thoracic stent-grafts in patients with multiple tortuous aortic segments that may hamper endograft delivery or precise placement because of an unstable position in the aortic arch. The technique of a transseptal through-and-through guidewire is demonstrated in a patient with a ruptured thoracic aneurysm with severe tortuosity of the aorta and a right-sided, severely angulated aortic arch. The transseptal through-and-through guidewire stabilization technique allowed successful passage and deployment of a thoracic stent-graft after debranching of the right common carotid and subclavian arteries. The ruptured thoracic aneurysm was excluded, while the proximal graft edge lined up with the origin of the aberrant left innominate artery. An externalized transseptal guidewire can facilitate endograft passage in tortuous aortic anatomies and optimize control in most severely angulated aortic arches. It may obviate the use of proximal bare stents because the proximal stent-graft is actively conformed to the inner curve of the aortic arch by the stabilizing wire. Transseptal access to the ascending aorta has the potential to become an important tool for endovascular treatment, especially for catheterization of branches and fenestrations in aortic arch stent-grafts.

Retrograde Type A Aortic Dissection After Endovascular Stent Graft Placement for Treatment of Type B Dissection

Retrograde type A aortic dissection has been deemed a rare complication after endovascular stent graft placement for type B dissection. However, this life-threatening event appears to be underrecognized and is worth being investigated further. Eleven of 443 patients developed retrograde type A aortic dissection during or after stent grafting for type B dissection from August 2000 to June 2007. Of these 11 patients, 3 had Marfan syndrome. The Kaplan-Meier estimate of the rate of freedom from this event at 36 months is 97.4% (95% confidence interval, 0.95 to 0.99). The new entry was located at the tip of the proximal bare spring of the stent graft in 9 patients, was within the anchoring area of the proximal bare spring in 1, and remained unknown in 1 patient. Eight patients were converted to open surgery, and 2 received medical treatment. One patient suddenly died 2 hours after the primary stent grafting, and 2 died within 1 week after the surgical conversion, so mortality reached 27.3%. During the follow-up from 3 to 50 months, type I endoleak was identified in 1 patient 3 months after the surgical exploration and disappeared at 6 months. Retrograde type A aortic dissection after stent grafting for type B dissection appears not to be rare and results from mixed causes. Fragility of the aortic wall and disease progression may predispose to it, whereas stent grafting-related factors make important and provocative contributions. Avoiding aortic arch stent grafting in Marfan patients, preferably selecting the endograft without the proximal bare spring for patients with a kinked aortic arch or with Marfan syndrome (if endografting is used), improving the device design, and standardizing endovascular manipulation might lessen its occurrence.

The Hybrid Total Arch Repair: Brachiocephalic Bypass and Concomitant Endovascular Aortic Arch Stent Graft Placement

Repair of aortic arch aneurysm is technically demanding, requiring complex circulatory management. Very large atherosclerotic saccular aneurysms of the arch are grave markers of extensive arch and brachiocephalic atheromatous disease and represent high surgical risks for perioperative neurologic complications. Operative morbidity and mortality may be prohibitive with traditional surgical intervention. We described our experience with a hybrid procedure for total arch repair with a brachiocephalic bypass with a trifurcated graft followed by concomitant placement of a stent graft in the arch. Since June 2005, we have performed the hybrid total arch repair in eight patients. A retrospective review was performed to evaluate the new technique. The mean age of the patients was 67 years with a mean aneurysm size of 8 cm (range, 4.4 to 10 cm). Significant comorbidities included carotid stenosis, chronic renal insufficiency, peripheral vascular disease, hypertension, and coronary artery disease. Two patients had previous Abdominal aortic aneurysm (AAA) repairs. Three patients had previous sternotomy for type A dissection, ascending aortic aneurysm repair, and coronary artery bypass grafting. Transesophageal echocardiogram demonstrated grade IV or V atheromatous disease in the arch and ascending aorta. Stent grafts were deployed antegrade directly into the ascending aorta in three patients and retrograde from the femoral artery in five patients. Technical success with complete aneurysmal exclusion was achieved in all patients (100%). At a mean follow-up period of 11.7 months, there was no incidence of endoleak. There was one death resulting from a perioperative myocardial infarction (first patient). Documented perioperative neurologic events (stroke) occurred in two patients, with both patients demonstrating no residual deficit at the time of discharge. Saccular arch aneurysms can be technically treated by total arch repair with brachiocephalic bypass and concomitant aortic arch stent graft placement. Hybrid arch repair provides an alternative to patients otherwise considered prohibitively high risk for traditional open arch repair.

Invited Commentary: The Hybrid Total Arch Repair: Brachiocephalic Bypass and Concomitant Endovascular Aortic Arch Stent Graft Placement

Journal of Cardiac SurgeryVolume 22, Issue 2 p. 103-104 Invited Commentary: The Hybrid Total Arch Repair: Brachiocephalic Bypass and Concomitant Endovascular Aortic Arch Stent Graft Placement Grayson H. Wheatley III M.D., Grayson H. Wheatley III M.D. Arizona Heart Institute, Phoenix, AZSearch for more papers by this author Grayson H. Wheatley III M.D., Grayson H. Wheatley III M.D. Arizona Heart Institute, Phoenix, AZSearch for more papers by this author First published: 02 March 2007 https://doi.org/10.1111/j.1540-8191.2007.00377.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume22, Issue2March/April 2007Pages 103-104 RelatedInformation

Invited commentary

Invited commentary

Acute Type A Dissection Treated with Combined Endovascular Repair of Arch and Surgical Bypass of Arch Vessels from Descending Aorta

We report a case of an endovascular repair of a recurrent dissecting aneurysm of the aortic arch and dissection of carotid vessels, 3 years after surgical repair of aortic valve and ascending aorta for a type A dissection. We performed a bypass from the descending aorta to right, left common carotid artery (CCA), to left subclavian artery with no cardiopulmonary bypass and thereafter, total ascending and aortic arch stent grafting. We suggest considering total aortic arch stent grafting with bypass of arch vessels in cases of complicated acute type A dissection. In cases where the ascending aorta cannot be used as donor site for bypass, we suggest the use of the descending aorta.

Acute Type A Dissection Treated with Combined Endovascular Repair of Arch and Surgical Bypass of Arch Vessels from Descending Aorta

We report a case of an endovascular repair of a recurrent dissecting aneurysm of the aortic arch and dissection of carotid vessels, 3 years after surgical repair of aortic valve and ascending aorta for a type A dissection. We performed a bypass from the descending aorta to right, left common carotid artery (CCA), to left subclavian artery with no cardiopulmonary bypass and thereafter, total ascending and aortic arch stent grafting. We suggest considering total aortic arch stent grafting with bypass of arch vessels in cases of complicated acute type A dissection. In cases where the ascending aorta cannot be used as donor site for bypass, we suggest the use of the descending aorta.

An Experimental Study of a New Pull-through Technique for Aortic Arch Aneurysm in a Porcine Model

A new pull-through technique for placement of the aortic arch stent-graft was developed. Self-expandable curved stents (Matsui-Kitamura stents) were used on 4 pigs. With use of the endoscopic system, the sheath insertion was performed at the ascending aorta. By this pull-through method from the ascending aorta to the femoral artery, the stent was deployed into the aortic arch. All stents were successfully deployed into the correct position, and they fitted into the curvature of the aortic arch wall. By this method, stent-grafting for aortic arch aneurysm is expected to be performed with more accuracy and safety.