Hybrid Thoracic Endovascular Aortic Repair Research Articles

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.

Assessment of the Effectiveness of Zone 1-Landing Hybrid TEVAR by Comparing Its Outcomes with Those of Zone 2-Landing Hybrid TEVAR.

Background: Hybrid thoracic endovascular aortic repair (TEVAR) without median sternotomy is increasingly being performed in high-risk patients with aortic arch disease. The outcomes of hybrid TEVAR were reported to be worse with a more proximal landing zone. This study aims to clarify the effectiveness of zone 1-landing hybrid TEVAR by comparing the outcomes of zone 2-landing hybrid TEVAR. Methods: From April 2008 to October 2020, 213 patients (zone 1: zone 1-landing hybrid TEVAR, n = 82, 38.5%; zone 2: zone 2-landing hybrid TEVAR, n = 131, 61.5%) were enrolled (median age, 72 years; interquartile range [IQR], 65-78 years), with a median follow-up period of 6.0 years (IQR, 2.8-9.7 years). Results: The mean logistic EuroSCORE was 20.9 ± 14.8%: the logistic EuroSCORE of the zone 1 group (23.3 ± 16.1) was significantly higher than that of the zone 2 group (19.3 ± 12.4%, p = 0.045). The operative time and hospital stay of the zone 1 group were significantly longer than those of the zone 2 group. On the other hand, the in-hospital and late outcomes did not differ significantly between the two groups. There were no significant differences in cumulative survival (66.8% vs. 78.0% at 10 years, Log-rank p = 0.074), aorta-related death-free rates (97.6% vs. 99.2% at 10 years, Log-rank p = 0.312), and aortic event-free rates (81.4% vs. 87.9% at 10 years, Log-rank p = 0.257). Conclusions: Zone 1- and 2-landing hybrid TEVAR outcomes were satisfactory. Despite the high procedural difficulty and surgical risk, the outcomes of zone 1-landing hybrid TEVAR were equal to those of zone 2-landing hybrid TEVAR. If the surgical risk is high, zone 1-landing hybrid TEVAR should not be avoided.

Effectiveness of Proximal Landing Zone 1 and 2 Thoracic Endovascular Aortic Repair for Type B Aortic Dissection by Comparing Outcomes With Thoracic Arch Aneurysm.

Hybrid thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is a minimally invasive procedure with improved results. This study aimed to clarify the effectiveness and expand the possibilities of zone 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy. This retrospective, single-center, observational cohort study included 213 patients (TBAD, n=69; thoracic arch aneurysm [TAA], n=144; median age, 72 years; median follow-up period, 6 years) from May 2008 to February 2020. The following conditions were satisfied before performing zone 1 and 2 landing TEVAR: TBAD; proximal landing zone (LZ): diameter <37 mm, length >15 mm, and nondissection area, proximal stent-graft: size ≤40 mm and oversizing rate: 10% to 20%, and TAA; proximal LZ: diameter ≤42 mm and length >15 mm, proximal stent-graft: size ≤46 mm and oversizing rate: 10% to 20%. Of the 69 patients in the TBAD group, 34 (49.3%) had patent false lumen (PFL), and 35 (50.7%) had false lumen partial thrombosis (FLPT), including ulcer-like projections. Emergency procedures were performed in 33 (15.5%) patients. There were no significant differences in the in-hospital mortality (TBAD: 1.5% vs TAA: 0.7%, p=0.544) or the in-hospital aortic complications (TBAD: n=1 vs TAA: n=5, p=0.666). Retrograde type A dissection was not observed in the TBAD group. The aortic event-free rates at 10 years were 89.7% (95% confidence interval [CI]: 78.7%-95.3%) and 87.9% (95% CI: 80.3%-92.8%) in the TBAD and TAA groups, respectively (log-rank p=0.636). In the TBAD group, the early and late outcomes were not significantly different between the PFL and FLPT groups. Satisfactory early and long-term results were obtained with zone 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD. This study aimed to clarify the effectiveness and expand the possibilities of zones 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy. Satisfactory early and long-term results in the TBAD and thoracic arch aneurysm (TAA) groups were obtained with zones 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD.

Five-Year Survival and Complications of Thoracic Endovascular Aortic Repair (TEVAR): A Single Tertiary Center Registry for All-Comers Patients

IntroductionStudies on the mid and long-term outcomes of thoracic endovascular aortic repair (TEVAR) are scarce. This study aimed to investigate the long-term outcomes of TEVAR for all-comers patients with various types of thoracic aortic pathologies, predominantly thoracic aortic dissections and thoracic aortic aneurysms. MethodsBetween January 2005 and December 2015, 123 consecutive patients with thoracic aortic pathologies underwent TEVAR. The patients were divided into groups based on aortic pathologies (dissections or aneurysms) and the type of procedure (hybrid TEVAR or non-hybrid TEVAR). Mortality, complications, and reintervention rates were compared between these four groups. The Kaplan–Meier curve and the Cox regression analysis were employed to estimate survivals and factors associated with 5-year mortality. ResultsOne hundred twenty-three consecutive patients with various aortic pathologies undergoing TEVAR were evaluated. Hypertension (79.7 %) and smoking (39 %) were the most common comorbidities in the study population. The patients were followed up for a mean duration of 58.1 ± 7.1 months to evaluate the postprocedural surveillance. Most complications occurred in the dissection and hybrid groups; however, these differences were nonsignificant. The overall 5-year surveillance and reintervention rates were 65 % and 12.1 %, respectively. A significant difference existed in 5-year survival between the patients with aneurysmal and aortic dissection pathologies based on the log-rank test (P = 0.01). On the other hand, no significant differences were observed in 5-year survival between the patients who underwent hybrid and non-hybrid TEVAR. The Cox regression analysis confirmed that chronic kidney disease, previous coronary artery bypass grafting, age >65 years, platelet counts <150∗ 103/μL, aneurysmal aortic pathology, and ejection fraction ≤ 50 % were predictors of 5-year mortality. ConclusionsThe long-term outcomes of TEVAR for various aortic pathologies disclosed that this procedure was well-tolerated in a group of patients with high comorbid conditions. The five-year survival rate of TEVAR for thoracic aortic dissections was more favorable than that for thoracic aortic aneurysms, but there were no significant differences between hybrid and non-hybrid procedures regarding the mortality rate.

Effectiveness and Minimal-Invasiveness of Zone 0 Landing Thoracic Endovascular Aortic Repair Using Branched Endograft.

Background: Zone 0 landing thoracic endovascular aortic repair (TEVAR) for the treatment of aortic arch diseases has become a topic of interest. This study aimed to verify whether branced TEVAR (bTEVAR) is an effective and a more minimally invasive treatment by comparing the outcomes of bTEVAR and hybrid TEVAR (hTEVAR) in landing zone 0. Methods: This retrospective, single-center, observational cohort study included 54 patients (bTEVAR, n = 25; hTEVAR, n = 29; median age, 78 years; median follow-up period, 5.4 years) from October 2012 to June 2018. The logistic Euro-SCORE was significantly higher in the bTEVAR group than in the hTEVAR group (38% vs. 21%, p < 0.001). Results: There was no significant difference the in-hospital mortality between the bTEVAR and hTEVAR groups (0% vs. 3.4%, p = 1.00). The operative time (220 vs. 279 min, p < 0.001) and length of hospital stay (12 vs. 17 days, p = 0.013) were significantly shorter in the bTEVAR group than in the hTEVAR group. The 7-year free rates of aorta-related deaths (bTEVAR [95.5%] vs. hTEVAR [86.9%], Log-rankp = 0.390) and aortic reintervention (bTEVAR [86.3%] vs. hTEVAR [86.9%], Log-rankp = 0.638) were not significantly different. Conclusions: The early and mid-term outcomes in both groups were satisfactory. bTEVAR might be superior to hTEVAR in that it is less invasive. Therefore, bTEVAR may be considered an effective and a more minimally invasive treatment for high-risk patients.

Hybrid Approaches for Aortic Disease–Our Experience

Despite significant technological advancements in endovascular aortic repair, the aortic arch remains a challenge due to anatomic complexity including arch angulation and morphology as well as the location of brachiocephalic vessels in relation to landing zones. Total endovascular solutions are in development and being studied, in the meantime, hybrid thoracic endovascular aortic repair (TEVAR) is a viable alternative to traditional open total arch replacement. A retrospective case series was performed reviewing outcomes of 71 patients who underwent hybrid TEVAR in the aortic arch over the past 12years at our facility. Major morbidity in the first 30days post procedure was experienced by 3 patients (15.7%) and included one patient with stroke (n=1), and another who experienced paraplegia and pulmonary complications (n=1). There was one in-hospital death as a result of respiratory failure in a patient with multiple underlying comorbidities including chronic obstructive pulmonary disease on postoperative day 5 resulting in a 30-day mortality of 5.2%. After a mean follow-up of 30months, the overall mortality remained 5.2%. Major morbidity occurred in one patient who developed retrograde type A dissection. There was no stenosis of bypass grafts identified on follow-up imaging. Endoleak was identified in 2 patients. One patient experienced persistent retrograde perfusion of the false lumen with interval aneurysmal degeneration which was managed with an Amplatz vascular plug at 120months following the initial hybrid TEVAR (5.2%). Single-stage hybrid TEVAR in the aortic arch is technically feasible with a good mid-term survival and a long-term freedom from reintervention.

Zone 2 hybrid thoracic endovascular aortic repair: Is it a good option for all types of thoracic aortic disease?

BackgroundZone 2 thoracic endovascular aortic repair (TEVAR) is performed for the treatment of various thoracic aortic diseases involving the left subclavian artery. This study aimed to analyze the late clinical outcomes of zone 2 hybrid TEVAR according to the various indications.MethodsA total of 48 patients who underwent zone 2 TEVAR at our institution between December, 2010 and July, 2020 were enrolled. The indications were aortic aneurysm (AA, n = 15), acute type B aortic dissection (AD, n = 14), penetrating aortic ulcer (PAU, n = 8), traumatic aortic injury (TAI, n = 8), and others (n = 3). The clinical outcomes including early complications and mid-term aortic measurements were retrospectively reviewed.ResultsThe technical success rate was 100% and in-hospital mortality occurred in one patient. The early postoperative complications included stroke (n = 1), transient spinal cord ischemia (n = 1), neck wound hematoma (n = 1), and left phrenic or vagus nerve injury (n = 9). In patients with AD, positive remodeling was observed in ten patients (76.9%) (false lumen regression in the entire or thoracic aorta [n = 9], false lumen thrombosis in the thoracic aorta [n = 1]). However, in patients with AA, increased aneurysm was found in six patients (40%). Persistent aneurysmal growth was found in patients with a maximal aortic diameter of > 60 mm on initial imaging (4/6, 50%). No aortic expansion was observed in those with TAI or PAU. Endoleak was noted in five patients (10.4%), and among them, aortic reintervention was required only in patients with large AAs.ConclusionsZone 2 hybrid TEVAR was associated with an acceptable early complication rate and provided acceptable mid-term aortic results for patients with AD, PAU, and TAI. However, patients with large AAs were at increased risk of aortic reintervention. In cases of large AA, clinicians should carefully consider whether zone 2 hybrid TEVAR or open surgical repair will be more effective for the patient.

Transposition of Isolated Left Vertebral Artery in Hybrid Thoracic Endovascular Aortic Repair.

Objectives: The aim of this study was to present our experience with the management of isolated left vertebral artery (ILVA) during complex thoracic aortic pathology treated with the hybrid thoracic endovascular aortic repair.Methods: This is a single-center, respective cohort study. Between June 2016 and June 2020, 13 patients (12 men; median age 60 years old, range 42–72 years old) who underwent hybrid procedures were identified with ILVA in our center. Demographics, imaging features, operation details, and follow-up in these patients were collected and analyzed.Results: In this study, all patients received the hybrid procedure, and the primary technical success rate was 100%. There were no in-hospital deaths. Complication occurred in two (15.4%) patients. One patient suffered from contrast-induced acute kidney injury (CI-AKI) and recovered before discharge. Another patient required reintervention for acute left-lower-limb ischemia, which was successfully treated using Fogarty catheter embolectomy. Immediate vagus/recurrent laryngeal never palsy, lymphocele, and chylothorax were not observed. The median duration of follow-up was 22 months (range, 13–29 months). No neurologic deficits, bypass occlusion, or ILVA occlusion or stenosis were observed during the follow-up. No aortic rupture, cerebrovascular accident, or spinal cord ischemia was observed during the follow-up period.Conclusions: Our limited experience reveals that hybrid procedures [thoracic endovascular aortic repair (TEVAR), ILVA transposition, and left common carotid artery-left subclavian artery (LCCA-LSA) bypass] are relatively safe, feasible, and durable for the treatment of thoracic aortic pathology with ILVA. However, further technique durability and larger studies with long-term follow-up periods are warranted.

Effectiveness of Proximal Landing Zones 0, 1, and 2 Hybrid Thoracic Endovascular Aortic Repair: A Single Centre 12 Year Experience

Hybrid thoracic endovascular aortic repair (TEVAR) is being accepted increasingly as a first line treatment for arch repair at the present authors' institution. This study aimed to clarify the effectiveness of zones 0, 1, and 2 landing hybrid TEVAR. This was a retrospective single centre case series. From April 2008 to March 2020, 348 patients (median age 72 years; interquartile range [IQR] 65, 77 years) were enrolled, with a median follow up period of 5.6 years (IQR 2.6, 8.7 years). The procedures included zone 0 in 135 patients (38.8%), zone 1 in 82 patients (23.6%), and zone 2 proximal landing zone (LZ) hybrid TEVAR in 131 patients (37.6%). The pathologies consisted of dissecting aortic aneurysms in 123 (35.3%) patients. Emergency procedures were performed in 39 (11.2%) patients. The 30 day mortality (n= 2, 0.6%) and hospital deaths (n= 6, 1.7%) were registered. The stroke rate was 1.1% (n= 4), while early and late endoleak rates were 4.8% (n= 17) and 1.7% (n= 6), respectively. Type 1a endoleak and retrograde type A dissection occurred in seven (2.0%) and three (0.9%) patients, respectively. The cumulative survival, freedom from aorta related deaths, and freedom from aortic events in 10 years were 75.0%, 97.2%, and 84.1%, respectively. The freedom from aortic events in each landing zone in 10 years was 82.3%, 81.4%, and 87.9% for zones 0, 1, and 2, respectively. The 10 year survival rates were 82.5% and 73.6%; the 10 year aorta related death free rates were 94.9% and 98.6%, and the 10 year aortic event free rates were 82.3% and 85.5% in the zone 0 and zone 1 and 2 TEVAR, respectively. Satisfactory early and long term results of hybrid arch repair at zones 0, 1, and 2 were achieved. To avoid complications and aortic events, the treatment strategy of hybrid arch repair for aortic arch pathologies should be tailored using accurate pre-operative assessment of the ascending aorta and the aortic arch.

Hybrid Transcatheter Thoracic Endovascular Aortic Repair With Total Debranching of Supra-aortic Trunks: A Case Report

Here we report the case of a patient who underwent TEVAR with total debranching of supra-aortic trunks. Thoracic endovascular aortic repair (TEVAR) can be limited by inadequate proximal and distal landing zones. Debranching or hybrid TEVAR has emerged as an important modality to expand landing zones and facilitate TEVAR. The incidence of intraoperative surgical conversion remains low, but late complications and remedial secondary procedures may necessitate complex aortic reconstructions that demand advanced endovascular skills. KEYWORDS: hybrid TEVAR, thoracic aneurysm, debranching of supra-aortic trunks

Early and midterm results of thoracic endovascular aortic repair using a branched endograft for aortic arch pathologies: A retrospective single-center study.

BackgroundZone 0 landing hybrid thoracic endovascular aortic repair (TEVAR) includes a few moderately invasive surgical procedures. To reduce invasiveness, TEVAR with a branched aortic arch stent-graft can be considered. This study aimed to elucidate the effectiveness of performing TEVAR using a Bolton (Bolton Medical, Inc, Sunrise, Fla) branched endograft by analyzing early and midterm results.MethodsWe enrolled 28 patients (mean age, 78.4 years) who underwent TEVAR with the Bolton branched endograft in Osaka University Hospital between October 2012 and June 2018 with a mean follow-up period of 4.0 years. Double-side and single-side branched devices were used in 24 (85.7%) and 4 (14.3%) patients, respectively.ResultsAll procedures were successful; no cases of endoleak or conversion to open repair were noted during the 30-day postoperative period. The perioperative stroke rate was 14.3% (4 out of 28); midterm stroke was not detected. All patients with perioperative stroke had atheroma grade ≥2 in the brachiocephalic artery. No type 1a endoleak was reported during the early or midterm results. The cumulative survival rate, aorta-related death-free rate, and aortic event-free survival rate at 5 years were 80.8%, 95.8%, and 81.6%, respectively.ConclusionsWe achieved satisfactory early and midterm results by using a Bolton branched endograft for high-risk patients with arch pathologies except for high postoperative stroke. Although this treatment method is associated with postoperative stroke, performing strict evaluation of atheroma may prevent such complication. By preventing intraoperative stroke, TEVAR with this custom-made Bolton branched endograft may be considered a less-invasive treatment.

Patch aortoplasty and anatomical lung resection in a patient with aortobronchial fistula due to aortic psuedo-aneurysm

Aortobronchial fistula (ABF) is a rare and devastating complication, if left untreated. Its main clinical manifestation is hemoptysis, and there are no defined guidelines for its treatment yet. Herein, we present the case of a 74-year-old male who complained of back pain and hemoptysis. The patient was diagnosed with pseudo-aneurysm and ABF, and he underwent hybrid thoracic endovascular aortic repair. However, hemoptysis recurred. With patch aortoplasty and anatomical lung resection, successful management of ABF was achieved, with no relapse for 5years.

Hybrid Aortic Arch Debranching and TEVAR Is Safe in a Private, Community Hospital

Hybrid open cervical vessel debranching and thoracic endovascular aortic repair (TEVAR) is a treatment option in the management of aortic arch or proximal descending thoracic aortic aneurysms. However, these patients are often referred to tertiary care academic centers for aneurysm repair. Our study looks to assess the safety and outcomes of open cervical debranching and TEVAR within a private, community hospital setting. A total of 12 patients underwent hybrid open cervical vessel debranch with staged TEVAR from 2015 to 2018 at Riverside Community Hospital (Riverside, California). Three patients underwent open sternotomy with innominate artery bypass; four patients underwent combined carotid-carotid bypass with left carotid-axillary bypass or left subclavian transposition; three patients solely underwent left carotid-axillary bypass or left subclavian transposition. In cases involving multiple cervical bypasses, two surgeons were present. TEVAR was performed in a staged fashion during the same hospitalization. There were no patient deaths, MI, or stroke within the 30-day postoperative period and at 1-year follow-up. One patient suffered a small subdural bleed after ascending aorta to innominate bypass involving redo sternotomy and hypothermic circulatory arrest. The mean aortic zone stented was zone 1. On follow-up imaging, all bypass grafts were patent, all aneurysms demonstrated thrombosis without endoleak. Average follow-up was 20months. Hybrid cervical debranching with staged TEVAR can be safely performed by experienced vascular surgeons in the community setting. Staged repair appears to confer better operative and patient outcomes.

Mortality and Re-operation Risk Following Hybrid Thoracic Endovascular Aortic Repair Versus Open Surgical Arch Replacement at Eight-Year Follow-Up

Purpose: Hybrid thoracic endovascular aortic repair is an emerging treatment modality that combines open and endovascular techniques for the treatment of aortic arch disease. However, there has been limited studies comparing hybrid percutaneous repair versus open surgical aortic arch replacement at eight-year follow-up. This retrospective study aimed to compare hybrid endovascular repair with open surgery to assess early and mid-term outcomes in patients with aortic arch disease.

Open repair of type Ia endoleak in the aortic arch: three tailored approaches.

Endoleaks are an important complication following hybrid thoracic endovascular aortic repair (TEVAR) with an incidence ranging from 20% to 25% (1,2). There are five different types of endoleaks, which are classified based on the source of vessels that cause the inflow into the aneurysm sac (3). Type I endoleaks (EL-I) occur at either the proximal (Ia) or distal (Ib) attachment sites and can be seen during insertion of the initial stent graft or during a follow-up surveillance imaging exam.

Image fusion using the two-dimensional-three-dimensional registration method helps reduce contrast medium volume, fluoroscopy time, and procedure time in hybrid thoracic endovascular aortic repairs

ObjectiveThe objective of this study was to evaluate the effect of image fusion (IF) technology in thoracic endovascular aortic repair (TEVAR) on reducing radiation exposure (dose and time), amount of injected iodinated contrast medium needed, and procedure time. MethodsWe performed a review of our institutional endovascular aortic database of patients who had undergone TEVAR between 2008 and 2016 before and after the installation of a three-dimensional (3D) IF computed tomography system in our hybrid operating room. All patients were operated on using the same radiologic equipment with or without IF. ResultsThe 146 patients who had undergone elective or emergent TEVAR with preoperative computed tomography angiography done in 1-mm-thick slices were divided into two groups: the IF group (98 patients), in which TEVAR was performed using intraoperative IF with the two-dimensional-3D registration method; and 48 controls without the use of IF. The IF group received a significantly reduced dose of contrast material, with a median of 70 mL (interquartile range [IQR], 50-101 mL) compared with controls receiving 104 mL (IQR, 69-168 mL; P < .001).Patients who underwent hybrid TEVAR had a significantly reduced procedure time under IF guidance (n = 25) compared with controls (n = 11; median, 162 minutes [IQR, 139-199 minutes] vs 213 minutes [IQR, 189-298 minutes]; P = .015). In addition, the intraoperative fluoroscopy time was reduced to 9 minutes (IQR, 6-13 minutes) vs 23 minutes (IQR, 12-45 minutes; P < .005). However, the radiation dose (dose-area product) was similar for the two groups (P = .37).In patients who underwent plain TEVAR (n = 74) without a carotid-subclavian bypass, the IF group needed significantly less contrast material (median, 64 mL [IQR, 43-81 mL]) compared with the control group (median, 98 mL [IQR, 60-180 mL]; P = .003), whereas intraoperative radiation exposition, procedure time, and fluoroscopy time did not statistically significantly differ between the two groups. ConclusionsThe IF technology using the two-dimensional-3D registration method was associated with reduced intraoperative contrast material volume in performing TEVAR. IF seemed to shorten the operation and radiation times in the more complicated (hybrid) TEVAR cases. However, a prospective study is needed to look at the dose-area product, fluoroscopy time, and procedure time in a larger cohort of patients.

Ten-year experience of the thoraco-abdominal aortic aneurysm treatment using a hybrid thoracic endovascular aortic repair.

The treatment of thoraco-abdominal aortic aneurysm continues to have a high mortality and paraplegia rate. In superaging societies, the methods of performing less invasive operations remain a major issue. We reviewed our 10-year experience in the treatment of thoraco-abdominal aortic aneurysm using a hybrid procedure of combined visceral reconstruction and thoracic endovascular aortic repair. Sixty patients underwent a hybrid repair for the treatment of the thoraco-abdominal aortic aneurysm between 2007 and 2016. The mean age was 72.7 years. A true aneurysm was found in 43 (72%) patients and a chronic dissection in 17 (28%) patients. The standard operative procedure involved replacing the abdominal aorta with an artificial graft, and the visceral arteries were reconstructed using a quadrifurcated graft. Renovisceral debranching and stent grafting were performed as a 2-stage procedure. The hospital mortality rate was 5%. Two (3%) patients died due to an aneurysmal rupture in the hospital just after renovisceral debranching. The other 2 patients died due to an aneurysmal rupture in the long-term period after preventive renovisceral debranching. Two (3%) patients experienced spinal cord ischaemia after the stenting procedure. Four (7%) patients required additional treatment during the follow-up period. The overall survival was 75.9% at 2 years, 65.2% at 5 years and 43.5% at 8 years. The rates of freedom from aorta-related events were 92.9% at 2 years, 80.5% at 5 years and 72.5% at 8 years. The hybrid repair is considered to be a good option for elderly and high-risk patients. Further long-term follow-up is necessary to extend the indication in younger patients.

The Impact of Distal Stent Graft–Induced New Entry on Aortic Remodeling of Chronic Type B Dissection

In chronic type B aortic dissection, late distal stent graft-induced new entry (SINE) has a possible negative role in long-term aortic remodeling. This study aimed to investigate the impact of SINE occurrence on survival by evaluating true and false lumen remodeling in thoracic and abdominal segments at midterm surveillance. This study enrolled 65 patients with chronic type B aortic dissection (DeBakey type IIIb), who had received hybrid thoracic endovascular aortic repair (TEVAR) and had completed surveillance for at least 3 years. The 3-year survival rate was 84.7%. The patients were classified into non-SINE (n= 47) and SINE (n= 18) groups. Serial computed tomography scans were used to analyze volumetric change, true and false lumens, and thrombus volume from arch to aortic bifurcation level. The SINE event occurred at a median of 22.5 months. In the SINE group, there was a significant interruption of the abdominal true lumen expansion in the second year (median 0.01 [interquartile range (IQR), -0.03 to 0.12] in the non-SINE group versus median -0.04 [IQR, -0.12 to 0.04] in the SINE group; p= 0.014). There was a significantly worse thoracic false lumen remodeling in the SINE group compared with the non-SINE group in the third year after the SINE event occurred (median 0 [IQR, -0.09 to 0.05] in the non-SINE group versus median 0.06 [IQR, 0 to 0.13] in the SINE group; p= 0.038). For chronic aortic dissection, late occurrence of distal SINE could influence abdominal true lumen expansion and thoracic false lumen shrinkage. Early reintervention for distal SINE could improve aortic remodeling in chronic aortic dissection.

Supraclavicular transposition of aberrant left vertebral artery for hybrid treatment of aortic arch aneurysm: a case report

BackgroundVertebral artery variations are common in thoracic aortic patients. If patients have the aberrant left vertebral artery, the more difficult to determine the treatment modality.Case presentationWe report the case of a 63-year-old man with an aberrant left vertebral artery originating from an aneurysmal aortic arch. The patient underwent a successful hybrid thoracic endovascular aortic repair after aortic arch debranching and transposition of the aberrant left vertebral artery to the left common carotid artery through a supraclavicular incision without sternotomy.ConclusionsThe aberrant left vertebral artery originating from the aortic arch can be safely transposed to the left common carotid artery through a supraclavicular approach.

The assessment of collateral communication after hybrid repair for Crawford extent II thoraco-abdominal aortic aneurysms.

The repair of extensive thoraco-abdominal aortic aneurysms (TAAAs) is invasive and carries a high risk for spinal cord injury (SCI). The aim of this study was to assess the early results and collateral circulation to the spinal cord after hybrid repair for Crawford extent II aortic aneurysms. Between 1997 and 2013, we performed 128 thoracic endovascular aortic repair (TEVAR) procedures for TAAAs. This study reviews 12 patients who underwent hybrid TEVAR for a Crawford extent II aortic aneurysm (mean age: 56 years, 6 men, chronic dissection: 10). Aortic arch repair was performed to create a proximal landing zone and visceral debranching bypass was performed to create a distal landing zone at separate stages prior to TEVAR. Subsequently, a stent graft was deployed to cover the residual downstream aorta. TEVAR was generally performed the day after the final debranching procedure. Cerebrospinal fluid drainage was performed, and the mean blood pressure was maintained at >90 mmHg in all cases. The median operation time for TEVAR was 94 min (range: 71-421 min) and the mean blood loss was 300 ml (range: 130-1350 ml). No SCI or in-hospital death was observed after TEVAR. Multidetector computed tomography identified three arteries (subclavian artery, external iliac artery and internal iliac artery) providing collateral circulation to spinal segmental arteries (SAs). In all cases, mid-thoracic SAs (Th5-8) and low lumbar SAs (L2-5) were fed by the subclavian artery and the internal iliac artery, respectively. Additionally, low thoracic to high lumbar SAs (Th9-L1) communicated with the subclavian artery via the lateral thoracic wall and/or the external iliac artery via the abdominal wall. We achieved satisfactory early and mid-term outcomes with hybrid repair for Crawford extent II TAAAs. Furthermore, collateral circulation to SAs was maintained during and after TEVAR regardless of the extent of the aortic repair.