Arch Stent Research Articles

Total aortic arch stenting - hemodynamical impact of carotid artery perfusion

The aim of this experimental study is to evaluate the feasibility and the outcome of total endovascular stent implantation in the aortic arch. Indications for this operation-technique would be acute or chronic dissection of the aortic arch (non-A-non-B dissection) or type B dissection with retrograde extension. Four pigs were canulated via the distal abdominal aorta and a retrograde placement of a Djumbodis arch stent (4-9 cm) was controlled by using intravascular ultrasound and intracardiac ultrasound by the inferior cava vein and under radioscopic control. Cerebral perfusion, by using a flow meter placed on one prepared carotid artery, were controlled before, immediate post-procedural (<1 min), and in the early follow-up after aortic arch stent implantation. During the implantation process, especially during balloon inflation and deflation, mean carotid perfusion decreases slightly. A reactive increase of carotid perfusion after stent placements indicates transitory cerebral hypo-perfusion. Non-covered aortic arch stent implantation is technically feasible and could be a potential treatment option in otherwise inoperable arch dissections. The time required for balloon inflation and deflation causes an important risk of cerebral ischemia. The latter can be reduced by transaxillary perfusion.

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.

Hybrid Treatment for Complex Aortic Problems Combining Surgery and Stenting in the Integrated Operating Theater

Conventional surgical treatment of complex aortic pathologies involving several thoracoabdominal aortic segments necessitates extended incisions or subsequent surgeries, resulting in significant mortality and morbidity rates. The combination of surgery and simultaneous stenting in the operating theater may reduce the surgical trauma. A total of nine patients (62 +/- 10 years, range 44-70) underwent a combined surgical and endovascular treatment of thoracic or thoracoabdominal aortic aneurysms or chronic dissection. Five patients were treated with viscero-renal artery translocation followed by transfemoral stenting of the entire thoracoabdominal aorta. Two patients underwent debranching of the supraaortic vessels followed by immediate transfemoral stenting of the aortic arch, and two patients with a history of an ascending aortic aneurysm repair were treated with open surgical debranching of the supraaortic trunks and repair of the ascending aorta and aortic arch with elephant trunk technique. Preoperatively, magnetic resonance imaging was used to check supraaortic and intracranial vessels as well as the completeness of the Circle of Willisi prior to arch stenting and/or supraaortic vessel surgery. Cerebrospinal fluid drainage and induced mild hypertension have been used for one-step thoracoabdominal aortic stenting. Thirty-day mortality rate and incidence of paraplegia was 0%. There was a single reversible perioperative stroke after aortic arch stenting. One patient required temporary renal replacement therapy using continuous arterio-venous hemofiltration. There was one early reoperation at the superior mesenteric artery after viscero-renal translocation. Four type I endoleaks occurred in three patients requiring two interventions. All patients have been discharged to home. The innovative combination of simultaneous conventional surgery and stenting reduces the operative burden for patients with complex aortic pathologies involving several segments of the thoracic and thoracoabdominal aorta. Arch debranching and viscero-renal artery translocation may avoid the use of thoracoabdominal incisions, cardiopulmonary bypass techniques, deep hypothermia, and circulatory arrest.

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.

Assembly and Deployment of a Branched Arch Stent Graft Using the Transaortic Approach

Transaortic stent grafting is an alternative method for treating distal arch aneurysms. Total arch grafts are too bulky to be inserted into a sheath catheter during usual stent grafting methods. An assembling method that uses a chain stitch enables the deployment of any type of stent graft into the distal aorta without the need for a sheath catheter. We describe how to safely assemble and use a branched arch stent graft. We consider this method to be beneficial in selected cases involving extensive distal arch aneurysms or in patients with highly calcified aortas.