Aortic Arch Research Articles

Surgical management protocol for disk battery ingestion.

Disk battery (DB) ingestion in children can lead to severe complications and mortality. This study details our experience in managing DB ingestion and its complications. We analyzed data from all patients treated for DB ingestion at our hospital from June 2010 to January 2024. A protocol established in 2010 requires angio-CT scans for esophageal DB cases and a multidisciplinary approach involving gastroenterologists, otolaryngologists, pediatric and airway surgeons, and cardiac surgeons. We treated 22 patients. In June 2010, following the tragic death of a patient from an undiagnosed DB ingestion that led to an aortoesophageal fistula, our protocol was established. All DBs were removed endoscopically. Four patients needed additional surgery: two had tracheal resection/anastomosis and esophageal repair for large tracheoesophageal fistulas; one required aortic wall reinforcement with a patch; one underwent endoscopic removal with a sternal split to explore the aortic arch. All 22 patients survived and recovered clinically. One developed bilateral vocal cord palsy as a complication. Effective management of DB ingestion complications necessitates a collaborative, multidisciplinary approach. Our protocol has improved management strategies and patient outcomes.

Hybrid repair of complicated acute aortic arch intramural haematoma with the Castor single-branch stent graft.

We report the off-label application of the Castor single-branch stent graft for a complicated acute intramural haematoma involving the aortic arch. The endograft was deployed in zone 1 with the single branch in the left common carotid artery through a surgical left carotid and percutaneous right femoral artery access. The procedure was completed with the construction of a left carotid-subclavian bypass followed by plug embolization of the left subclavian artery.

Chemoradiotherapy treatment increases cardiac and aortic [18F]FDG uptake ratios in lung cancer patients

[18F]Fluorodeoxyglucose (FDG) positron emission tomography (PET) is an indispensable non-invasive imaging tool to aid diagnosis, prognostication, and therapeutic monitoring in oncology, but it can also evaluate cardiovascular inflammation1,2. Previously, cardiac metabolic changes using [18F]FDG with chemoradiotherapy have been explored3 but changes in the rest of the cardiovascular system remain undetermined. To investigate the cardiovascular metabolic changes pre- and post-chemoradiotherapy in stage 3b non-small cell lung cancer (NSCLC) patients. A retrospective analysis of 26 patients (43-82 years) with stage 3b NSCLC from the American College of Radiology Imaging Network (ACRIN 6668) trial was performed3. All available pre- and post-treatment imaging were retrieved from the Cancer Imaging Archive (TCIA)4 and regions of interest for the left ventricle and calcified large arteries were contoured on all PET-CT scans using PMOD version 4.0 software. The mean, maximum standard uptake value (SUVmean and SUVmax) and target-to-background ratio (TBR) were quantified on PMOD. At approximately 14 weeks post-chemoradiotherapy, there was a higher SUVmean (mean difference 0.81, p=0.01) and SUVmax (mean difference 2.20, p=0.006) in the left ventricle compared with pretreatment scans. TBR for aorta was higher post-treatment (mean difference 0.06, p=0.005). However, SUVmean for carotid arteries and right brachiocephalic artery was reduced post-chemoradiotherapy (mean difference 0.15, p=0.008 and mean difference 0.28, p=0.03). A reduction in SUVmax was also seen for aortic arch (mean difference 0.58, p=0.03) and right brachiocephalic artery (mean difference 0.42, p=0.03 and mean difference 0.42, p=0.03). Cardiovascular glucose metabolism is selectively increased in the left ventricle and aorta post-chemoradiotherapy. Changes in glucose metabolism of atherosclerotic plaques vary across different vessels throughout the body. Please click on the 'PDF' for the full abstract!

Calculation of Aortic Arch Calcification Degree in Hemodialysis Patients Using Deep Learning

Abdominal Aortic Calcification (AAC) is a common form of vascular calcification closely associated with atherosclerosis and serves as an important marker for measuring increased risk of cardiovascular, cerebrovascular, and peripheral vascular diseases. Particularly in patients with Chronic Kidney Disease (CKD) and those undergoing dialysis, the risk of AAC significantly increases due to a combination of traditional and non-traditional risk factors. Therefore, developing a rapid and accurate method to assess the extent of AAC is crucial for preventing the progression of vascular calcification and the associated risk of cardiovascular diseases. Dialysis patients are required to undergo an abdominal X-ray annually, and the degree of calcification of the abdominal aorta is assessed manually through these X-ray images. However, these methods have limitations in identifying subtle calcifications in the abdominal aorta and the assessment process is time-consuming and depends on the experience and subjective judgment of physicians. To overcome these limitations, we propose a new method that incorporates deep learning technology to improve the accuracy of assessing the extent of AAC. Our method utilizes CNN models and attention modules to enhance the model's ability to recognize features of abdominal aortic calcification.

Cardiac CT vs Echocardiography for Intracardiac Thrombus Detection in Ischemic Stroke: A Systematic Review and Meta-Analysis of 43 Studies.

Ischemic stroke, a leading cause of mortality, necessitates understanding its mechanism for effective prevention. Echocardiography, especially transesophageal echocardiography (TEE), is the gold standard for detection of cardiac sources of stroke including left atrial thrombus, although its invasiveness, operator skill dependence, and limited availability in some centers prompt exploration of alternatives, such as cardiac CT (CCT). We conducted a systematic review and meta-analysis assessing the ability of CCT in the detection of intracardiac thrombus compared with echocardiography. We searched 4 databases up through September 8, 2023. Major search terms included a combination of the terms "echocardiograph," "CT," "TEE," "imaging," "stroke," "undetermined," and "cryptogenic." The current systematic literature review of the English language literature was reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. We assessed risk of bias using the QUADAS-2 tool and used random-effects meta-analysis to calculate different diagnostic metrics. The meta-analysis investigating CCT vs echocardiography for intracardiac thrombus detection yielded a total of 43 studies of 9,552 patients. Risk-of-bias assessment revealed a predominantly low risk of bias in the flow and timing, index test, and patient selection domains and a predominantly unclear risk of bias in the reference standard domain. The analysis revealed an overall sensitivity of 98.38% (95% CI 89.2-99.78) and specificity of 96.0% (95% CI 92.55-97.88). Subgroup analyses demonstrated that delayed-phase, electrocardiogram-gated CCT had the highest sensitivity (100%; 95% CI 0-100) while early-phase, nongated CCT exhibited a sensitivity of 94.31% (95% CI 28.58-99.85). The diagnostic odds ratio was 98.59 (95% CI 44.05-220.69). Heterogeneity was observed, particularly in specificity and diagnostic odds ratio estimates. CCT demonstrates high sensitivity, specificity, and diagnostic odds ratios in detecting intracardiac thrombus compared with traditional echocardiography. Limitations include the lack of randomized controlled studies, and other cardioembolic sources of stroke such as valvular disease, cardiac function, and aortic arch disease were not examined in our analysis. Large-scale studies are warranted to further evaluate CCT as a promising alternative for identifying intracardiac thrombus and other sources of cardioembolic stroke.

Aberrant Right Subclavian Artery with Retroesophageal Course as a Reason of Dysphagia: A Case Report

The most prevalent vascular anomaly of the aortic arch is the aberrant right subclavian artery, which is a rare embryological aberration. It is an anatomical variation of the right subclavian artery, emerging as the last branch of aortic arch. A surgical operation involving the esophagus should take this abnormality into account. Any inadvertent damage to this artery while undergoing surgery has a high risk of death. Even though aberrant right subclavian artery can be difficult to treat during an esophagectomy, if it is identified beforehand, careful dissection of the retroesophageal area during the procedure can help avoid damaging the abnormal artery and its related consequences.

Unraveling aortic hemodynamics using fluid structure interaction: biomechanical insights into bicuspid aortic valve dynamics with multiple aortic lesions.

Aortic lesions, exemplified by bicuspid aortic valves (BAVs), can complicate congenital heart defects, particularly in Turner syndrome patients. The combination of BAV, dilated ascending aorta, and an elongated aortic arch presents complex hemodynamics, requiring detailed analysis for tailored treatment strategies. While current clinical decision-making relies on imaging modalities offering limited biomechanical insights, integrating high-performance computing and fluid-structure interaction algorithms with patient data enables comprehensive evaluation of diseased anatomy and planned intervention. In this study, a patient-specific workflow was utilized to biomechanically assess a Turner syndrome patient's BAV, dilated ascending aorta, and elongated arch. Results showed significant improvements in valve function (effective orifice area, EOA increased approximately twofold) and reduction in valve stress (~ 1.8-fold) following virtual commissurotomy, leading to enhanced flow dynamics and decreased viscous dissipation (~ twofold) particularly in the ascending aorta. However, increased viscous dissipation in the distal transverse aortic arch offset its local reduction in the AAo post-intervention, emphasizing the elongated arch's role in aortic hemodynamics. Our findings highlight the importance of comprehensive biomechanical evaluation and integrating patient-specific modeling with conventional imaging techniques for improved disease assessment, risk stratification, and treatment planning, ultimately enhancing patient outcomes.

4D-Flow MRI and Vector Ultrasound in the In-Vitro Evaluation of Surgical Aortic Heart Valves - a Pilot Study.

The aim of this study was the initial investigation of 4D-Flow MRI and Vector Ultrasound as novel imaging techniques in the in-vitro analysis of hemodynamics in anatomical models. Specifically, by looking at the hemodynamic performance of state-of-the-art surgical heart valves in a 3D-printed aortic arch. The mock circulatory loop simulated physiological, pulsatile flow. Two mechanical and three biological aortic valves prostheses were compared in a 3D-printed aortic arch. 4D magnetic resonance imaging and vector flow Doppler ultrasound served as imaging methods. Hemodynamic parameters such as wall shear stress, flow velocities and pressure gradients were analyzed. The flow analysis revealed characteristic flow-patterns in the 3D-printed aortic arch. The blood-flow in the arch presented complex patterns, including the formation of helixes and vortices. Higher proximal peak velocities and lower flow volumes were found for biological valves. The mock circulatory loop in combination with modern radiological imaging provides a sufficient basis for the hemodynamic comparison of aortic valves.

ACCESS: ACtive Catheterization for EndovaScular TreatmentS-A First-in-Human, Single-Center, Nonrandomized, Open Clinical Study of the G60 Active Device for Endovascular Neurointerventions.

The catheterization of supra-aortic vessels during neuroendovascular interventions may be challenging in the setting of complex aortic arch anatomy. Evaluation of a new mechatronic controllable directional device in conjunction with different sheath and guide catheters to ease the cannulation of the supra-aortic vessels was conducted in the setting of a first-in-human clinical study. The evaluation assessment included access to the aortic arch, the technical success of the device in terms of time to target vessel, target vessel catheterization, adverse events, and clinical outcome. Ten subjects were enrolled at 1 site for treatment. Successful access, target vessel catheterization, and correct positioning of the catheter into the target vessel with the G60 device were achieved for all 10 procedures (7 from femoral access, 3 from radial access). One procedural complication, unrelated to the G60 device, was recorded during the investigation. The G60 is a polyvalent active device that facilitates guide catheter navigation in neuroendovascular interventions.

Patients undergoing emergent surgery for type A intramural hematomas or type A aortic dissections have similar outcomes

ObjectiveDespite key differences in pathological processes, both Intramural Hematomas and Aortic Dissections are Acute Aortic Syndromes repaired with similar surgical technique. The objective of this study was to determine differences in surgical outcomes between patients with Intramural Hematoma versus Type A Aortic Dissection undergoing Ascending Aortic Arch repair.MethodsThis retrospective review of prospectively collected data included all patients with acute Intramural Hematoma or Type A Aortic Dissection who underwent emergent Ascending- or Arch Repair from January 2018 to May 2023 at a single academic institution. Primary outcomes included intraoperative mortality, 30-Day mortality, and postoperative stay. Secondary outcomes included postoperative complications. Outcomes were analyzed using Chi-squared, Fisher’s Exact, and t-tests, with significance set at p < 0.05.ResultsA total of 107 patients were included, 27 of whom (25%) had Intramural Hematoma and 80 (75%) had Type A Aortic Dissection. There were no differences in preoperative characteristics such as age, gender, and comorbidities, and no differences in perioperative characteristics such as case length, cardiopulmonary bypass, aortic cross-clamp, and circulatory arrest times. When comparing postoperative outcomes, there was a higher rate of postoperative pericardial effusions requiring pericardial window in the Intramural Hematoma cohort compared to the Aortic Dissection cohort (15% [n = 4] vs. 3% [n = 2]; p = 0.02). There were no differences in other primary outcomes such as intraoperative mortality, 30-Day mortality, and postoperative length of stay. There were also no differences in the rates of postoperative complications such as bleeding requiring reoperation, cerebrovascular accident, atrial fibrillation, pleural effusion requiring thoracentesis, and surgery-related Emergency Department visits.ConclusionsOur analysis demonstrates similar outcomes for patients undergoing Ascending Aortic Arch repair between patients with Intramural Hematoma and Type A Aortic Dissection. Despite the higher rate of required postoperative pericardial windows in the Intramural Hematoma cohort, the overall primary outcomes remained comparable. These findings better elucidate the standard of care for patients with acute Intramural Hematoma undergoing Ascending Aortic Arch repair.

The novel and slowest arterial pressure waves: clinical implications in children with congenital heart disease following cardiovascular surgery.

Certain rhythmic arterial pressure waves in humans and animals have been noticed for over one century. We found the novel and slowest arterial pressure waves in children following surgical repair for CHD, and examined their characteristics and clinical implications. We enrolled 212 children with 22 types of CHD within postoperative 48 h. We monitored haemodynamics (blood pressure, cardiac cycle efficiency, dP/dTmax), cerebral (ScO2), and renal (SrO2) oxygen saturation every 6 s. Electroencephalogram was continuously monitored. Mean blood flow velocity (Vm) of the middle cerebral artery was measured at 24 h. We found the waves with a frequency of ∼ 90 s immediately following surgical repair in 46 patients in 12 types of CHD (21.7%), being most prevalent in patients with aortic arch abnormalities (Aorta Group, n = 24, 42.3%) or ventricular septal defect (Ventricular Septal Defect Group, n = 12, 23.5%). In Aorta and Ventricular Septal Defect Groups, the occurrence of the waves was associated with lower blood pressures, dP/dTmax, cardiac cycle efficiency, ScO2, SrO2, Vm, worse electroencephalogram background abnormalities, higher number of electroencephalogram sharp waves, and serum lactate (Ps <0.0001-0.07), and were accompanied with fluctuations of ScO2 and SrO2 in 80.6% and 69.6% of patients, respectively. The waves observed in children following cardiovascular surgery are the slowest ever reported, occurring most frequently in patients with aortic arch abnormalities or ventricular septal defect. While the occurrence of the waves was associated with statistically worse and fluctuated ScO2 and SrO2, worse systemic haemodynamics, and electroencephalogram abnormalities, at present these waves have no known clinical relevance.

Successful occluder removal and reocclusion of an atrial septal defect after occluder immigration to aortic arch: a case report

BackgroundAtrial septal defect (ASD) is a common congenital heart disease, and currently, transcatheter intervention is the most common clinical treatment method. However, certain complications still occur during the percutaneous process, among which occluder loss and displacement are rare but serious complication. Although the probability of occluder loss and displacement is low, severe cases can endanger life.Case presentationHere, we report the case of a patient who underwent ASD closure in which the occluder fell off into the aortic arch, the detached occluder was recovered through catheter intervention, and the patient underwent ASD closure again.ConclusionsIn this case report, we highlight that although percutaneous closure of an ASD is regarded as a routine procedure, clinicians should remember the possibility of complications, especially occluder loss and displacement. Therefore, interventionist should carefully evaluate the situation before intervention closure, establish standardized interventional treatment procedures, and provide timely treatment follow-up.

Safety of adjuvant open axillary access during complex thoracoabdominal aortic endovascular procedures.

Endovascular treatment of aortic diseases with complex anatomy may require an additional upper extremity arterial access (like axillary access) for support during aortic navigation and allowing the use of larger sheaths for thoracoabdominal antegrade access. The objective of this study is to evaluate the safety of the open axillary approach as adjuvant access in complex thoracoabdominal aortic endovascular interventions. A monocentric retrospective study was performed, including all patients with a complex aortic endovascular procedure (fEVAR, bEVAR, chEVAR or TEVAR), elective or urgent, with open surgical exposure of the axillary artery as adjuvant access, between 2012 and 2022. Demographic data, diagnosis and urgency criteria, type of aortic intervention, size of axillary sheath, use of through-and-through maneuver, and features by computed tomography angiography (CTA) of the axillary artery and aortic arch were recorded. The appearance of local and aortic postoperative complications were described, and possible prognostic factors were analyzed. Forty-eight patients (38 men) were included, median age 78 years (range 50-87), 33 with intact thoracoabdominal aneurysms, eight previous EVAR endoleaks and seven aortic aneurysm ruptures. 28 fEVAR/bEVAR, 17 chEVAR and three TEVAR procedures with axillary access were performed. Left infraclavicular axillary access was the most common approach (94%), along with a 12 French (F) median sheath (range 7-20). Eight (16.7%) local complications were identified: three bleedings, one hematoma, three focal dissections in the subclavian artery, and one brachial embolism, all successfully resolved. The only factor related to local complications was small axillary diameter (median 10.7 vs. 14.6 mm; P<0.001), a subclavian/sheath ratio less than one was associated to more local complications (P=0.02). Regarding aortic complications, two (4.1%) type B asymptomatic aortic dissections with left juxta-subclavian tear were found, attributed to local manipulation, occurring only in urgent procedures (P=0.032). The use of open axillary access as an adjuvant approach in complex aortic endovascular surgery, although it is very useful and usually safe, can be associated with subclavian or even aortic complications (not reported until now), especially in cases with small subclavian diameters and urgent cases.

Cardiovascular Ultrasound Predictors for Brain Alterations in Fetuses With Heart Disease: An Exploratory Review of the Literature.

To identify cardiovascular ultrasound predictors for brain anomalies in fetuses with heart disease. A literature search was performed in the following databases: MEDLINE through OVID, EMBASE, Cochrane Registry Center for Controlled Trials (CENTRAL), and LILACS, from their inception until May 2023. Clinical studies, cross-sectional studies, case-control studies, cohorts, and systematic reviews were included. Data extraction was performed, and the risk of bias was assessed using the QUADAS-2 tool. Among 2705 studies evaluated, after filtering information, 10 articles were selected that met the inclusion criteria. These studies noted the following outcomes: a decrease in fetal head circumference, changes in brain maturation measured in days, decreased depth of brain fissures, and a decrease in total brain volume. The studies show a statistically significant correlation with the presence of the following cardiovascular predictors: low or mixed oxygen content in the ascending aorta (p < 0.001), retrograde flow in the aortic arch (p < 0.001), lower z values of the MCA-PI (p < 0.05), higher UA-PI z values (p < 0.01), and lower CPR (p < 0.05). In addition, lower values of left ventricular flow (p < 0.01), ductus arteriosus (p < 0.0001), and combined cardiac output index (p < 0.01) were reported. This review describes the most relevant evidence correlating the effects of hemodynamic changes that lead to states of chronic hypoxia related to the aforementioned changes in the central nervous system.

Sternotomy or thoracotomy for neonatal repair of coarctation of the aorta with aortic arch hypoplasia

ObjectiveFor neonatal repair of coarctation of the aorta, patients may either undergo thoracotomy with extended end-to-end anastomosis or sternotomy for aortic arch reconstruction with cardiopulmonary bypass. The objective of this study was to evaluate the comparative effectiveness of the 2 approaches in patients with arch hypoplasia. MethodsThis is a single-center retrospective cohort study from July 2005 through May 2022 of patients who underwent neonatal repair for isolated coarctation of the aorta with additional arch hypoplasia. Inverse probability of treatment weighting is a statistical method for creating comparable pseudopopulations and was used to account for baseline differences in population. The primary outcome was aortic reintervention, and secondary outcomes were vocal cord dysfunction, length of stay, chylothorax, and phrenic nerve palsy. ResultsThere were 130 patients who met inclusion criteria. After weighting, the interaction between distal transverse arch size and operative approach (sternotomy vs thoracotomy) was statistically significant, P < .05 for interaction. Among patients with a distal arch z score <−3.5, patients undergoing thoracotomy with extended end-to-end anastomosis had an increased hazard for reintervention. Sternotomy was associated with an increased length of stay in the intensive care unit by 4.7 days, P < .001, and odds of vocal cord dysfunction were also greater, odds ratio 7.1 (95% confidence interval, 1.66 to 41.26; P = .01). ConclusionsAmong patients with a distal arch z score smaller than −3.5, the hazard of reintervention was increased for patients undergoing thoracotomy with extended end-to-end anastomosis. However, length of stay and risk of vocal cord paresis was reduced in patients undergoing thoracotomy.

Energy barriers govern catheter herniation during endovascular procedures: a 2.5D vascular flow model analysis.

Endovascular procedures rely on navigating guidewires, catheters and other devices through tortuous vasculature to treat disease. A critical challenge in these procedures is catheter herniation, in which the device deviates from its intended path, often irrecoverably. To elucidate the mechanics of herniation, we developed a physical flow model of the aortic arch that enables direct measurement of device curvature during experimentally simulated neuroendovascular procedures conducted from an upper arterial access. Combined with measurements of initial, unstressed device shapes and flexural rigidities, the method enables the experimental estimation of the device bending energies during these simulated procedures. Characteristic energy profiles revealed distinct stages in both herniation and successful navigation, governed by the interplay between device properties and vascular anatomy. A deterministic progression from successful navigation to herniation was identified, with catheter systems following paths determined by measurable energy barriers. Increasing guidewire stiffness or decreasing catheter stiffness reduced the energy barrier for successful navigation while increasing that for herniation. This framework enables the prediction of endovascular herniation risk and offers unique insight into improved device design and clinical decision-making.

Changes in stent-graft orientation after frozen elephant trunk treatment in aortic arch aneurysm.

Changes in stent graft (SG) orientation after frozen elephant trunk (FET) treatment for aortic arch aneurysms are not well understood. This study investigated changes in SG orientation and their effects on aortic events after FET for aortic arch aneurysms. This study included 57 patients with true aneurysms who underwent elective total arch replacement using FET between 2016 and 2023. Postoperative SG angle, descending aortic (DA) diameter at the end of the SG, and the DA angle were measured retrospectively by using enhanced computed tomography (CT). Median patient age was 74 years. The median stent size was 33 mm, and the stent length was 12 cm (range, 23-37 mm and 6-15 cm). Enhanced CT showed that all the patients had completely thrombosed aneurysms after the procedure. Aortic events (dissection or type Ib leaks) were observed in four patients during the follow-up period. The diameter of the DA at the end of the SG and the DA angle increased in recent periods (P=0.04 and P=0.01, respectively). The SG angle changed to an obtuse angle in the recent periods (P<0.0001). The probability of postoperative aortic events did not correlate with changes in SG orientation but with the ratio of recent postoperative descending diameter to preoperative descending diameter (P=0.04). The descending aorta into which the SG was inserted showed flattening and widening movements owing to the spiring back force. One of the factors related to aortic events was dilation of the postoperative DA due to oversizing of the SG.

Correlation Between Intraoperative Near-infrared Spectroscopy Values and Neurologic Outcomes in Patients Undergoing Total Aortic Arch Replacement Using the Frozen Elephant Trunk Technique

ObjectiveTo correlate intraoperative near-infrared-spectroscopy (NIRS) values to neurologic outcome in patients undergoing total aortic arch replacement using the frozen elephant trunk (FET) technique. DesignRetrospective, single centre registry study using a two-way repeated measures ANOVA. SettingBetween 11/2013 and 12/2023, 427 patients were treated for acute and chronic aortic pathologies using FET procedure. ParticipantsOne-hundred sixty-six patients who had complete NIRS data at all predefined timepoints were included and retrospectively divided into two groups: patients with stroke diagnosed by experienced radiologists and clinicians and patients without stroke after FET. MeasurementsBilateral NIRS values were recorded continuously and at seven critical timepoints in each patient a correlation was made between left- and right-sided NIRS values and stroke. Main Results23 patients (13.9%) were diagnosed with a stroke. There was a significantly higher in-hospital mortality in patients with stroke (21.7%) compared to patients without stroke (7.7%) (p = 0.037). Left sided regional cerebral oxygenation (rSO2) did not show any significant difference in patients with stroke versus patients without stroke (p = 0.550). There were differences detected in right sided rSO2 trends (p < 0.001) and the inter-hemisphere NIRS at the specified timepoints (p = 0.009). The interaction Time x Stroke, however, did not show any significant results in all our analyses (p > 0.05). ConclusionNIRS is a reliable tool to monitor intraoperative frontal lobe cerebral oxygen saturation. However, its use to predict postoperative stroke remains limited. Further refinements are needed to develop the technique to a prediction tool.

New Territory Unlocked: Crossing the Mechanical Aortic Valve During Endovascular Aortic Arch Repair

New Territory Unlocked: Crossing the Mechanical Aortic Valve During Endovascular Aortic Arch Repair

Midterm Morphological Change of Kommerell's Diverticulum after Hybrid Thoracic Endovascular Aortic Repair

Kommerell's diverticulum (KD) is associated with a high incidence of right-sided aortic arch (RAA). Hybrid thoracic endovascular aortic repair (TEVAR) is an effective and less invasive alternative to open repair. However, the long-term results regarding KD diameter regression or symptom improvement remain inadequately described. Nine patients underwent TEVAR for KD associated with RAA between January 2016 and September 2023 at our university hospital and affiliated institutions. A hybrid procedure was performed to exclude KD by blocking the proximal blood flow with TEVAR and distal blood flow with embolization of the aberrant subclavian artery. Simultaneously, extra-anatomical bypass surgery was performed to revascularize the covered supraarch vessels. The patients' mean age was 65.2years, and 6 patients were men. Two patients presented with dysphagia, whereas the rest were asymptomatic. The mean diameter and distance to the opposite aortic wall (OAW) of KD were 32.1mm and 56.2mm, respectively. For revascularization of the covered supraarch vessels, 6 and 2 patients underwent total debranching with sternotomy and extra-thoracic bypass (bilateral common carotid artery-axial artery bypass), respectively. The 30-day and in-hospital mortality rates were 0%, with no instances of cerebral infarction or spinal cord ischemia. The mean follow-up period was 3.2years. The survival and avoidance rates of aortic events were 100% at 1 and 3years. Follow-up computed tomography scans showed no endoleaks; however, 1 (11.1%) type 2 endoleak from the aberrant left subclavian artery occurred 1week postoperatively, necessitating additional coiling. Seven patients were followed up for more than 1year, with 5 experiencing reductions of more than 3mm in KD diameter, distance to the OAW, or both. Although further follow-up and investigations are needed, TEVAR may be a safe and effective surgical treatment for KD associated with RAA.