Repair Of Aortic Arch Disease Research Articles

Open, endovascular or hybrid repair of aortic arch disease: narrative review of diverse strategies with diverse options.

The management of aortic arch disease is complex. Open surgical management continues to evolve, and the introduction of endovascular repair is revolutionizing aortic arch surgery. Although these innovative techniques have generated the opportunity for better outcomes in select patients, they have also introduced confusion and uncertainty regarding best practices. In New York, we developed a collaborative group, the New York Aortic Consortium, as a means of cross-linking knowledge and working together to better understand and treat aortic disease. In our meeting in May 2023, regional aortic experts and invited international experts discussed the contemporary management of aortic arch disease, differences in interpretation of the available literature and the integration of endovascular technology into disease management. We summarized the current state of aortic arch surgery in this review article. Approaches to aortic arch repair have evolved substantially, whether it be methods to reduce cerebral ischaemia, improve haemostasis, simplify future operations or expand options for high-risk patients with endovascular approaches. However, the transverse aortic arch remains challenging to repair. Among our collaborative group of cardiac/aortic surgeons, we discovered a wide disparity in our practice patterns and our management strategies of patients with aortic arch disease. It is important to build unique institutional expertise in the context of complex and evolving management of aortic arch disease with open surgery, endovascular repair and hybrid approaches, tailored to the risk profiles and anatomical specifics of individual patients.

Fenestrated endovascular repair for diseases involving the aortic arch

ObjectiveExtension of aortic disease to the aortic arch is common, frequently requiring cervical debranching procedures to maintain patency of supra-aortic branches. Endovascular aortic arch repair is an attractive alternative in the treatment of aortic arch disease for high-risk patients with thoracoabdominal diseases encroaching on the arch. The aim of our study was to report our experience of fenestrated endovascular repair in the aortic arch. MethodsA retrospective review of prospectively collected data involving consecutive patients in a single tertiary center treated with custom-made fenestrated endografts for the aortic arch (Cook Medical, Bloomington, Ind) was undertaken. End points included technical success, perioperative mortality and morbidity, reintervention, and late survival. ResultsBetween 2011 and 2017, there were 44 patients with a mean age of 67 ± 9 years (27 male [61%]) who were treated with fenestrated endografts for arch aneurysm (n = 11 [25%]), arch penetrating aortic ulcer (n = 6 [14%]), thoracoabdominal aneurysm with arch involvement (n = 11 [25%]), postdissection false lumen aneurysm (n = 13 [29%]), or lusorian artery aneurysm (n = 3 [7%]). The proximal landing zone was at Ishimaru zone 0 in 12 cases (27%), zone 1 in 27 cases (62%), and zone 2 in 5 cases (11%). Nine patients (20%) underwent a unilateral carotid-subclavian bypass, two (5%) a bilateral carotid-subclavian bypass, and four (9%) a subclavian transposition. In total, of the 73 target supra-aortic vessels (average of 1.7 target vessels per patient), 37 were treated with fenestrations and 36 with scallops. The mean operation time, fluoroscopy time, and contrast material volume were 215 ± 152 minutes, 33 ± 23 minutes, and 114 ± 45 mL, respectively. Technical success was 95% (42/44). The median intensive care unit and hospital stays were 3 ± 1 days and 7 ± 6 days, respectively. The 30-day mortality was 9% (4/44; one graft displacement and stroke, one retrograde type A dissection, one access complication and stroke, and one death of unknown cause). Major stroke occurred in three (7%), minor stroke in one (2%), temporary spinal cord ischemia in three (7%), and renal injury in three (7%) patients, whereas three (7%) patients required early reintervention. With mean follow-up of 18 ± 17 months, 10 more patients required secondary interventions, most of which (90%) were planned distal intervention to complete the repair of thoracoabdominal diseases. Overall survival rates were 78% ± 7% and 72% ± 8% at postoperative years 1 and 2, respectively. ConclusionsFenestrated endograft repair of aortic arch disease is a feasible technique with a high technical success rate and acceptable rates of stroke and paraplegia. A high number of secondary interventions were needed to complete the treatment of underlying diseases.

Three-Dimensional Printing to Guide the Application of Modified Prefenestrated Stent Grafts to Treat Aortic Arch Disease

The aim of this study was to summarize the experience and outcomes of total endovascular repair of aortic arch disease using three-dimensional (3D) printing to guide the application of modified prefenestrated/branched stent grafts. From April 2018 to March 2019, 17 patients with aortic arch disease were treated in our department. Five patients had an aortic arch aneurysm and 12 had undergone an aortic arch dissection. Thirteen men and 4 were women, with an average age of 57.82±10.47years. Preoperatively, a 3D-printed model of the aorta was made according to computed tomography data. Then, under the guidance of the 3D-printed aortic model, modified prefenestrated/branched stent grafts were prepared, and the diameter of the stent grafts was reduced intraoperatively by a physician for total endovascular repair. Aortic computed tomography angiography was performed 3 and 6months after the surgery. All procedures were completed in one stage with no conversions to sternotomy. Among all 17 patients, the operation was successful in 16. One patient was treated with a chimney graft and a stent graft fenestrated in situ because of distortion of the stent. The success rate of the technique was 94.18%. The average operation time was 4.18±1.57hr, and no patients died. No neurologic complications, such as cerebral infarction or paraplegia, were observed during the follow-up period. Three-Dimensional printing can be used to help guide the treatment of aortic arch disease using modified prefenestrated/branched stent grafts. This minimally invasive total treatment technique is accurate, allows quick recovery, and has a low complication rate. The short-term follow-up data show the safety and reliability of the method; however, further research and development are needed.

Proximal Landing Zone Influence Early and Late Results After Hybrid Repair of Aortic Arch Disease

Proximal Landing Zone Influence Early and Late Results After Hybrid Repair of Aortic Arch Disease

Fenestrated Endovascular Repair for Pathologies Involving the Aortic Arch

Introduction - Extension of aortic pathologies to the aortic arch is very common, requiring often cervical debranching procedures. Endovascular aortic arch repair is an attractive alternative to the treatment of aortic arch pathology in high-risk patients as well as patients with thoracoabdominal pathologies encroaching the arch. The aim of our study was to report our experience of fenestrated endovascular repair in the aortic arch. Methods - A retrospective review of prospectively collected data involving consecutive patients in a single tertiary center treated with custom-made fenestrated endografts for the aortic arch (Cook Medical, Bloomington, IN) was undertaken. Endpoints included technical success, 30-day mortality and major morbidity, endoleaks and late outcomes. Results - Between 2011 and 2016, 36 patients with mean age of 67±9 years old (23 male, 60%,) were treated with fenestrated endografts for an aortic arch pathology. Most of the patients were asymptomatic (33/36; 92%) while, over half of them (22/36; 61%) were categorized as >3 ASA. Eleven (31%) had a previous aortic reconstruction (3 abdominal, 5 thoracic and 3 both abdominal and thoracic aortic). The proximal landing zone was in Ishimaru zone 0 in 9 cases (25%), zone I in 23 cases (72%) and in zone II in 4 (11%). Ten patients (28%) underwent a carotid-subclavian bypass and 3 (8%) a subclavian interposition. In total, of the 59 supra-aortic target vessels (1.6 target vessels/patient), 33 were treated with fenestrations and 26 with scallops. The mean operation time, fluoroscopy time and contrast volume were 221±31 minutes, 35±9 minutes and 119±22 ml respectively. Technical success rate was 97% (35/36). The mean ICU and hospital stay were 3±1.2 and 7±3.1 respectively. The 30-day mortality was 11% (4/36; 1 graft displacement and stroke, 1 retrograde type A dissection, 1 access complication and 1 unknown cause). Major stroke occurred in 3 (8%), paraplegia in 2 (5%) and renal failure in 3 (8.3%) patients, while 5 (14%) patients were diagnosed with endoleak (3 Ib, 1 Ia, 1 III). The mean follow-up was 12±4 months and the secondary intervention rate to complete the repair of thoracoabdominal pathologies was 27% (10/36) Late death occurred in 2 cases suggesting a 12-month survival rate of 83.4%. Conclusion - Fenestrated endograft repair of aortic arch disease is a feasible technique with high technical success rate and relatively low rates of stroke and paraplegia. Mid-term outcomes showed a good survival rate but high number of secondary interventions needed to complete treatment of the underlying pathogies.

ITalian RegIstry of doUble inner branch stent graft for arch PatHology (the TRIUmPH Registry)

ObjectiveThe objective of this study was to assess early and midterm results after endovascular aortic arch repair using a double inner branch stent graft (DIBSG) in patients with aortic arch aneurysm or dissection unfit for open surgery. MethodsBetween 2012 and 2018, there were 24 patients with aortic arch disease who were treated with a single model of a DIBSG (Terumo Aortic, Glasgow, United Kingdom) in nine Italian cardiovascular centers. We investigated technical success, mortality, occurrence of major complications, and need for reintervention in a multicenter, nonrandomized, retrospective fashion. ResultsThe in-hospital mortality rate was 16.7%. Cerebrovascular events occurred in 25% of patients and major strokes in 12.5%. Two patients experienced a retrograde dissection (8.3%), whereas none reported any type I or type III endoleak. During a mean follow-up of 18 months (range, 1-60 months), one patient died of a nonaortic cause and one reported a nonarch-related major stroke. No late secondary intervention was needed during the follow-up. Excluding from the analysis the first six patients treated until 2014 as part of the learning curve, in-hospital mortality, major stroke, and retrograde dissection rates were 11.1%, 11.1%, and 5.6%, respectively. ConclusionsEndovascular aortic arch repair using this model of DIBSG is feasible, and results are acceptable for a new technique in a high-risk subset of patients. Operative mortality suffers the effect of a learning curve, whereas midterm aorta-related survival is promising. Endovascular repair of aortic arch disease with a DIBSG should always be considered to give high-risk patients a chance of repair. Large-scale studies are needed to assess the long-term durability of this technique.

Conventional Open Versus Hybrid Arch Repair of Aortic Arch Disease: Early and Long-Term Outcomes

It is unclear at present whether conventional open repair or a hybrid technique is preferential in the treatment of aortic arch diseases. Our intent was to compare early and long-term outcomes of both therapeutic strategies. Between January 2002 and December 2017, 238 patients eligible for total arch replacement (TAR; 174) or hybrid arch repair (HAR; 64) qualified for study. A retrospective analysis of clinical outcomes was undertaken, with propensity matching (48 pairs). Mean follow-up duration was 60.2 months. In-hospital mortality rates were 4.6% (8 of 174 patients) and 6.3% (4 of 64 patients) in the TAR and HAR groups, respectively (p= 0.739). The TAR group displayed a lower incidence of permanent stroke (2.9%, 5 of 174 patients) by comparison (HAR: 12.5%, 8 of 64 patients; p= 0.004). Overall survival rates at 5 and 10 years differed significantly by group (TAR: 87.0% ± 5.5% and 81.9% ± 4.8%, respectively; HAR: 69.5% ± 7.4% and 40.8% ± 11.1%, respectively; p= 0.003). After propensity matching, in-hospital mortality (4.2% versus 4.2%, p > 0.99) and patient morbidities showed no statistically significant group differences. For patients undergoing HAR, a tendency for permanent stroke (14.5% versus 2.1%, p= 0.070) was evident. In the TAR (versus HAR) group, 10-year overall survival (74.7% versus 42.6%, p= 0.043) and reintervention-free (93.2% versus 34.0%, p < 0.001) rates were significantly better. In the treatment of aortic arch diseases, HAR showed equivalent short-term outcomes compared with TAR but was limited regarding long-term outcomes beyond 5 years after the procedure. Conventional TAR remains the gold standard of therapy, and our findings suggest that the hybrid approach should be reserved for strictly selected patients with significant comorbidities.

Endovascular arch replacement with a dual branched endoprosthesis.

In the light of current evidence, endovascular repair of aortic arch pathologies with custom-made devices should be considered a valid alternative to decrease operative mortality and morbidity associated with open or hybrid repair. Currently, two double inner branch devices are available on the market. Some papers from multicenter experiences have been published about the use of Cook device. We report our single-center experience with Bolton double branch stent graft in the treatment of aortic arch disease. Between 2013 and 2016, nine high-risk patients with arch pathology were treated in our center with a Bolton custom-made branched device. Among these, two with a single branch model were excluded, leaving a subgroup of seven patients of this study. Out of the seven male patients (mean age, 76; range, 70-85) included in the study, two (28%) died perioperatively after stroke (14%) and retrograde dissection (14%), respectively. No other death, major complications, including aneurysmal diameter evolution and branch related complications, or secondary intervention was recorded at a mean follow up of 24 [6-53] months. Despite the small sample size, our results are in line with the early experiences published on this technique. Endovascular repair of aortic arch disease with custom-made branched devices should always be considered to give high-risk patients a chance of repair.

Endovascular repair of aortic arch disease with double inner branched thoracic stent graft: the Bolton perspective.

In the light of current evidence, endovascular repair of aortic arch pathologies with custom-made devices should be considered a valid alternative to decrease operative mortality and morbidity associated with open or hybrid repair. Today, two double inner branch devices are available on market. We report our single-center experience with Bolton double branch stent graft in the treatment of aortic arch disease. Between 2013 and 2016, 15 high-risk patients with arch pathology were treated in our center with a custom-made branched device. Six of these received a Cook arch branched stent graft. Nine were treated with Bolton device. Among these, 2 with single branch model were excluded leaving a subgroup of 7 patients object of this study. Out of the 7 male patients (mean age 76, range 70-85) included in the study, 2 died in-hospital after stroke and retrograde dissection, respectively. No other death, major complication or secondary intervention was recorded at a mean follow-up of 24 (min-max 6-53) months, neither any aneurysmal diameter evolution nor branch related complications. Despite the small sample size, our results are in line with the early-published experiences about this technique. Endovascular repair of aortic arch disease with custom-made branched devices should always be considered to give high-risk patients a chance of repair.

Comparison of Total Arch and Partial Arch Transposition During Hybrid Endovascular Repair for Aortic Arch Disease

Total arch transposition (TAT) during hybrid endovascular repair for aortic arch disease is believed to allow a better landing zone, but also to be associated with higher peri-operative mortality than partial arch transposition (PAT). Information on this issue is limited. This study was a retrospective analysis. All 53 consecutive patients with aortic arch disease (41 males, mean age 65.0 years) who underwent hybrid endovascular repair with TAT (zone 0, n=20) or PAT (zone 1 or 2, n=33) from 2008 to 2014 were analyzed retrospectively. The peri-operative and late outcomes of these two groups were compared. Baseline characteristics, including EuroSCORE II results, were similar in the two groups. After procedures, peri-operative mortalities and stroke rates were similar in the two groups (5.0% vs. 9.1%, p=1.000, and 10.0% vs. 6.1%, p=.627). Interestingly, all four strokes occurred in patients with a type III aortic arch irrespective of transposition type. Primary success rates (80.0% vs. 69.7%, p=.527) and type I endoleak incidences (20.0% vs. 27.3%, p=.744) were not significantly different. During follow up (mean duration 36.9 months), overall survival (89.7% vs. 87.4% at 1 year and 89.7% vs. 79.3% at 3 years; p=.375) and re-intervention free survival rates (78.6% vs. 92.0% at 1 year; 72.0% vs. 62.2% at 3 years, p=.872) were similar in the two groups. Morbidity and mortality were high within the first year of hybrid endovascular therapy for aortic arch disease, implying that candidates for hybrid procedures need to be selected carefully. Hybrid endovascular repair with TAT was found to have peri-operative mortality, stroke, and long-term survival rates comparable with PAT, so hybrid endovascular repair may be considered, irrespective of type of arch reconstruction, when clinically indicated.

Midterm Outcomes of Carotid-to-Carotid Bypass for Hybrid Treatment of Aortic Arch Disease

The purpose of this study was to compare midterm results of carotid-to-carotid bypass (CCB) after hybrid repair of aortic arch disease. Between October 2001 and April 2012, all patients undergoing hybrid aortic arch repair with CCB were enrolled. CCBs were positioned in the subcutaneous or in the retropharyngeal position. Hybrid aortic arch repair was performed in a single-stage intervention. We treated 19 (82.6%) men and 4 women; mean age was 74 ± 6 years (range, 58-83 years). Subcutaneous tunnelization was performed in 15 (65.5%) cases and the retropharyngeal route in 8 (34.5%). In-hospital mortality was 8.7% (n = 2); causes of death were major stroke (n = 1) and respiratory failure (n = 1). Cranial nerve injuries (transient or permanent), dysphagia, or local problems were not observed. Tracheostomy was never required. Early outcomes did not differ between the 2 types of bypass. Mean follow-up was 44 months (range, 1-118; median 24). Survival rate at 1, 3, and 5 years was 70% ± 9.6%, 55% ± 10.7%, and 50% ± 11.1%, respectively. At the time of the last follow-up control, all bypasses were patent: stenosis and thrombosis were not recorded. Bypass graft or endograft infection were not registered. Shrinkage of the aortic lesion was observed in 15 (71.4%) cases. CCBs are durable at midterm follow-up. No relevant superiority was identified between the 2 types of CCB; subcutaneous and retropharyngeal routes proved to be equally safe.

Trade in the hammer for a power driver-perspectives on the frozen elephant trunk repair for aortic arch disease.

Like a power driver for which the bit can be changed for each screw that is turned, improvement of brain protection strategies and the development of hybrid techniques have provided us with the ability to offer tailored repair options for patients with complex thoracic disease involving the arch. Variations of the frozen elephant trunk operation have been the most versatile of the newer hybrid approaches to repair complex thoracic aortic pathology. The frozen elephant trunk procedure includes the use of circulatory arrest in combination with suturing a stentgraft into the arch, and may reduce the risk of stroke and endoleaks. This article describes various methods of performing the frozen elephant trunk procedure with a focus on preoperative considerations including the etiology of disease, the time and urgency of presentation, and the indications to operate.

Invited Commentary

One of the last surgical domains yet to be addressed in a less invasive fashion is repair of the aortic arch. This is significant because surgical repair of aortic arch disease involves cardiopulmonary bypass and hypothermic circulatory arrest. Although surgical outcomes for aortic arch replacement have improved consistently, many patients are not surgical candidates secondary to multiple medical comorbidities that frequently accompany aortic arch disease. Therefore newer surgical alternatives that incorporate emerging endovascular techniques have the potential to transform the way we address the aortic arch.

Early and Long Term Results of Endovascular Repair for Aortic Arch Disease Combined With Great Vessels Transposition

Early and Long Term Results of Endovascular Repair for Aortic Arch Disease Combined With Great Vessels Transposition