Thoracic Endograft Research Articles

STS Adult Cardiac Surgery Database: 2021 Update on Outcomes, Quality, and Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It has been the foundation for quality measurement and improvement activities in cardiac surgery, facilitated the generation of accurate risk adjusted performance benchmarks and serves as a platform for novel research. Recent enhancements have added to the database's functionality, ease of use, and value to multiple stakeholders. This report is the sixth in a series of annual reports that provide updated volumes, outcomes, database-related developments, quality improvement initiatives, and research summaries using the Adult Cardiac Surgery Database in the past year.

High Energy Blunt Thoracic Trauma Requiring Endovascular Reinforcement

A 72 year old man was admitted after a road traffic accident. He was conscious and clinically stable, though presenting with acute flaccid paraplegia. (A) Computed tomography angiography revealed severe fracture dislocation through T8. A fractured and bevelled vertebral body was compressing the descending thoracic aorta, without aortic rupture. (B) A tapered thoracic endograft (Zenith Alpha; Cook Aortic Interventions, Bloomington, IN, USA) was deployed with the patient on the radiolucent spinal board, reinforcing the aortic wall, and allowing safe patient mobilisation. In ventral decubitus, the dislocation was reduced and a posterior stabilisation performed. The patient is alive and well at the 20 month follow up.Image 1

Valiant NAVION stent graft system application: First Asian case-series analysis.

The Valiant NavionTM stent graft system is a third-generation low profile thoracic endograft designed for thoracic endovascular aortic repair. In this population analysis, we report on the first Asian all-comers experience and outcomes who underwent thoracic endovascular aortic repair with the use of this new stent graft system. Between May 2019 and October 2020, 21 patients with different aortic pathologies were prospectively recruited and retrospectively analyzed. Important clinical and device-related outcomes were evaluated. The endpoints included short-term survival, technical success, access failures, major vascular and clinical complications, endoleaks, and hospital stay. The commonest indication of stenting was penetrating aortic ulcers (28.6%) and six (28.6%) patients had emergency stenting performed for aortic transection or rupture. 30 days of survival postprocedure was recorded and complete. There were no major vascular complications. Deployment accuracy was 100%, and the technical success rate was 94.7% (18/19) with one patient having a Type 2 endoleak on follow-up imaging. No neurological complications were noted. The mean operative time was 95 ± 73.6 min and the mean fluoroscopy time was 16.2 ± 10.8 min. Mean hospital stay for elective zone 2, 3, and 4 stenting was 5.3 ± 3.8 days, and only one patient postzone 1 thoracic endovascular aortic repair required a brief (0.5 days) ICU stay. All procedures were performed via the percutaneous transfemoral route with 100% success in percutaneous closure. This first reported Asian case series demonstrated versatility, safety, and efficacy of the Valiant NavionTM stent in Asian patients with different aortic pathologies.

Management of arch aneurysms with a single-branch thoracic endograft in zone 0.

BackgroundWe present preliminary data from a patient cohort undergoing thoracic endovascular aortic repair for Ishimaru zone 0 and 1 using a novel branched arch endograft.MethodsThis US multicenter early feasibility investigational device exemption clinical trial treated 9 patients with a mean age 72.8 ± 8.0 years (77.8% male). The endograft was designed with a single side branch designed to facilitate aortic coverage proximal to the innominate or left carotid artery while maintaining branch vessel patency. Pathology treated included fusiform (n = 2) or saccular (n = 7) aneurysm, with a maximum aortic diameter of 6.3 ± 0.7 cm. Treatment was into zone 0 in 8 patients, and zone 1 in 1 patient.ResultsAll patients underwent initial successful first-stage supra-aortic trunk revascularization using a variety of techniques, without the occurrence of stroke. For the second thoracic endovascular aortic repair stage, median total treatment length was 20 cm. The primary end point of device delivery and branch vessel patency was achieved in 100% of patients, without 30-day mortality or spinal cord ischemia. Cerebrovascular events were observed in 2 patients through 30 days. No type I or III endoleaks were reported and all side branches were patent at 12-month imaging follow-up.ConclusionsEndovascular repair of Ishimaru zone 0 or 1 arch aortic aneurysms can be achieved with a novel branched arch endograft. Future studies will evaluate the mid-term outcomes with this device in other pathologies and further define the occurrence of postoperative neurologic events.

Spinal Anesthesia and Outcomes After Thoracic Endograft Placement

Spinal Anesthesia and Outcomes After Thoracic Endograft Placement

Impact of Thoracic Endografting on the Hemodynamics of the Native Aorta: Pre- and Postoperative Assessments of Wall Shear Stress and Vorticity Using Computational Fluid Dynamics

Purpose To quantify the hemodynamic consequences of thoracic endovascular aortic repair (TEVAR) by comparing the preoperative and postoperative wall shear stress (WSS) and vorticity profiles on computational fluid dynamics (CFD) simulations. Materials and Methods The pre- and postoperative computed tomography (CT) scans from 20 consecutive patients (median age 69 years, range 20–87) treated for different thoracic aortic pathologies (11 aneurysms, 5 false aneurysms, 3 penetrating ulcers, and 1 traumatic aortic rupture) were segmented to construct patient-specific CFD models using a meshless code. The simulations were run over the cardiac cycle, and the WSS and vorticity values measured at the proximal and distal landing zones were compared. Results The CFD runs provided 4-dimensional simulations of blood flow in all patients. WSS and vorticity profiles at the proximal landing zone (located in zones 0–3 in 15 patients) varied in 18 and 20 of the cases, respectively; WSS was increased in 11 cases and the vorticity in 9. Pre- and postoperative WSS median values were 4.19 and 4.90 Pa, respectively. Vorticity median values were 40.38 and 39.17 Hz, respectively. Conclusion TEVAR induces functional alterations in the native thoracic aorta, though the prognostic significance of these changes is still unknown. CFD appears to be a valuable tool to explore aortic hemodynamics, and its application in a larger series would help define a predictive role for these hemodynamic assessments.

Utility of Single-Branched Thoracic Endograft in Patients Requiring Zone 2 Seal During Thoracic Endovascular Aortic Repair

Single-branched thoracic endografts (SBTEs) are under investigation for treatment of thoracic aortic disease that requires zone 2 seal during thoracic endovascular aortic repair (TEVAR). A variety of anatomic criteria must be met for their effective implantation. Our aim was to analyze anatomic suitability for SBTE. We performed a retrospective review of 103 TEVAR procedures in 88 patients at our academic referral center between 2017 and 2019. Proximal seal was achieved in zone 3 or zone 4 (n = 37 [36%]), zone 2 (n = 30 [29%]), or zone 0 or zone 1 (n = 36 [35%]). We analyzed the zone 2 group’s operative angiograms and preoperative computed tomography angiograms using centerline software to measure arterial diameters and length in relation to the left common carotid artery, left subclavian artery (LSA), and proximal extent of aortic disease to determine whether patients met anatomic criteria using the instructions for use (IFU) of the Navion Mona LSA (Medtronic, Santa Rosa, Calif; Table I). Average age in the zone 2 group was 64 years (range, 26-85 years); 17 were male (57%). Indications (Table II) were acute type B dissection (ATBD; n = 13 [43%]), aneurysm (n = 15 [50%]), and blunt aortic injury (n = 2 [7%]). The LSA was revascularized in 20 (67%): carotid subclavian bypass or transposition, n = 17; laser fenestration, n = 3. Overall, 14 (47%) of the zone 2 patients met the IFU. Reasons for failure are listed in Table I. Of the 16 who did not meet IFU, 9 had multiple exclusion criteria. Inadequate aortic diameter excluded only the two blunt aortic injury patients. The proportion of patients who met IFU criteria by indication are listed in Table II. Fewer ATBDs (5/13 [38%]) met IFU than aneurysms (9/15 [60%]), but this was not statistically significant (P = .26). Of the eight ATBD patients who failed to meet criteria, seven had dissection at or into the origin of the LSA. If dissection into the LSA origin was allowed in ATBD, three of the seven would have otherwise qualified. Approximately half of patients who require TEVAR seal in zone 2 meet criteria for this SBTE. The device may offer the ability to provide flow to the LSA without the need for adjuvant revascularization procedures. Patients with aneurysms more often met the IFU than those with acute dissection. A modification to the IFU to allow dissection up to the LSA origin would increase eligibility in ATBD by >50%. Clinical efficacy data, however, are needed to determine whether this would be effective.Table IAnatomic criteria for the Navion Mona LSAAnatomic criteriaCriteria to meet IFUMean ± SD, mmNo. (%) failing to meet criteriaAortic diameter at proximal seal zoneDissection: 28-44 mm Aneurysm/PAU: 25-42 mm30.2 ± 3.82 (7)LSA diameter8-13 mm9.47 ± 1.30 (0)Distance between orifices of LCCA to LSA≥10 mm10.9 ± 6.012 (40)Distance of LCCA to aortic disease≥20 mm22.1 ± 10.111 (37)Distance of LSA to aortic disease≥0 mm (presence of nondiseased aorta distal to LSA)5.6 ± 6.311 (37)IFU, Instructions for use; LCCA, left common carotid artery; LSA, left subclavian artery; PAU, penetrating aortic ulcer; SD, standard deviation. Open table in a new tab Table IIThoracic endovascular aortic repair (TEVAR) indications and proportion that met the instructions for use (IFU)IndicationNo.No. (%) meeting criteriaAcute type B dissection135 (38)Aneurysm or penetrating ulcer96 (67)Aneurysm in chronic dissection63 (50)Blunt aortic injury20 (0) Open table in a new tab

Is a “petticoat” just cosmetic or like a “belt and suspenders”?

Although it is clear that proximal thoracic endografting has improved the management of dissections involving the descending thoracic aorta, there remain significant challenges with the management of this condition. In the acute setting, excluding patients with impending or frank rupture, it is the treatment of malperfusion that takes first priority. In the chronic phase, aneurysmal degeneration in the uncovered visceral and infrarenal aorta occurs in 30% to 50% of patients and represents the Achilles heel of current endovascular management strategies.

Floating Stent-Graft as a Support to Bridge an Unfavorable Renal Artery During Postdissection TAAA Repair Using a Multibranched Thoracoabdominal Endograft

Purpose: To report an unusual endovascular technique to manage unfavorable renal artery anatomy encountered in an urgent case of symptomatic postdissection thoracoabdominal aortic aneurysm (TAAA) treated with an off-the-shelf multibranched device. Technique: The technique is demonstrated in a 77-year-old woman who had a history of previous open abdominal aortic aneurysm repair and an emergent procedure to implant a thoracic endograft and an aortic bare Z-stent (PETTICOAT) for acute Stanford type B dissection 7 years prior. The patient presented with a symptomatic, rapidly growing, postdissection TAAA. Endovascular treatment with a Zenith t-Branch was planned. After standard catheterization techniques failed in the left renal artery, a bailout maneuver was utilized to place a “floating” Viabahn stent-graft in the aneurysm sac to create sufficient support to deliver the bridging stent-grafts through the bare stent to the target left renal artery. The procedure was successful in excluding the TAAA and preserving perfusion to all target vessels. No neurological complications occurred. Six-month imaging follow-up confirmed the patency of the bridging stents. Conclusion: Remodeling changes after complex endovascular TAAA procedures often require the use of innovative techniques and materials during secondary procedures. In this case, the presence of a post-PETTICOAT bare aortic stent and hostile target artery anatomy increased the technical difficulty of t-Branch implantation. A “floating” stent-graft could be useful to reach challenging target vessels by providing additional support to bridging stent advancement and deployment.

Procedure-Associated Costs and Midterm Outcomes of Endovascular Zone 0 and Zone 1 Aortic Arch Repair

Thoracic endovascular aortic repair (TEVAR) of proximal aortic arch disease provides a less invasive treatment option for high-risk patients who are not candidates for open arch reconstruction. However, the fiscal impact of these techniques remains unclear. Therefore, our objective was to characterize the midterm outcomes after zone 0 and zone 1 TEVAR and to describe the associated technical costs, technical revenues, and net technical margins at a single tertiary medical center. We examined all patients who underwent TEVAR between April 2011 and August 2019 by retrospective chart review at a single tertiary medical center. Patients were categorized by proximal thoracic endograft extent to identify those with zone 0 or zone 1 landing zones. Procedural characteristics and outcomes were described. Total technical costs, technical revenues, and net technical margins were obtained from the hospital finance department. We identified 10 patients (6 zone 0, 4 zone 1) who had been turned down for open surgical arch reconstruction. Patients were predominantly female (n = 8 [80%]), and the mean age was 72.8 ± 5.5 years. Repair was performed in five asymptomatic patients, urgently in three symptomatic patients and emergently in two ruptured patients. Aortic disease and procedural details are described in the Table. Great vessel debranching with chimney stent grafting was performed in four patients, debranching with branched thoracic endografting in one patient (investigational device exemption clinical trial), and traditional surgical debranching alone in four patients. In situ fenestration was performed in one patient. Within the 30-day postoperative period, one patient experienced a stroke and one patient died. Bypass and branch vessel patency were 100% through the duration of follow-up (mean, 19.3 months). Mean total technical cost associated with all procedures or stages of repair was $105,164 ± $59,338, whereas mean net technical margin was −$25,055 ± $18,746. The net technical margin was negative in the treatment of nine patients. Endovascular repair of the proximal aortic arch is associated with good midterm outcomes in patients considered too high risk for open repair. However, reimbursement does not adequately cover the cost of treatment, with net technical margins being negative in nearly all cases. To remain financially sustainable, efforts should be made to optimize aortic arch TEVAR delivery as well as to advocate for reimbursement commensurate with associated costs.TableProcedural details, outcome measures, and associated technical costs and net technical margins for Zone 0 (n = 6) and Zone 1 (n = 4) TEVARPatientIndication for repairProximal extent of coverageGreat vessel reconstructionNumber of procedures/stagesStroke or deathBypass/Branch patencySurvivalTechnical cost (USD)Net technical margin (USD)1Ruptured aneurysmZone 1Carotid-carotid bypass, LSA embolization1No100%Alive at 31 months; follow-up ongoingN/AN/A2Asymptomatic aneurysmZone 0Carotid-carotid bypass, LSA to L carotid transposition, Gore TSSB branched device to innominate artery3No100%Died of MI 15 months after repair$141,688-$29,5493Type IA endoleak after Zone 2 TEVAR for acute type B dissectionZone 0Carotid-carotid bypass, carotid-LSA transposition, innominate chimney2Death-Died in hospital 4 days after TEVAR$153,668-$45,5984Asymptomatic aneurysmZone 1LSA to carotid transposition, L CCA chimney2No100%Alive at 37 months; follow-up ongoing$115,223-$31,7485Symptomatic aneurysmZone 0Carotid-carotid-LSA bypass, innominate chimney, LSA embolization2Stroke100%Died 18 months after repair$101,317-$20,9286Ruptured dissectionZone 0Carotid-carotid bypass, chimney to innominate, snorkel to LSA2No100%Alive at 34 months; follow-up ongoing$185,613-$54,6227Asymptomatic aneurysmZone 0L carotid to R carotid transposition, L carotid to LSA bypass, LSA embolization2No100%Alive at 23 months; follow-up ongoing$97,579-$18,8878Chronic type B dissection with asymptomatic aneurysmZone 1Carotid-carotid-LSA bypass2No100%Alive at 2 months; follow-up ongoing$48,068-$26,2809Penetrating aortic ulcerZone 0Carotid-carotid-LSA bypass at OSH2 (debranching at OSH)No100%Died 6 months after repair of unknown causes$42,813$4,90210Chronic type B dissection with asymptomatic aneurysmZone 1Left carotid and LSA in situ branched fenestrations1No100%Alive at 8 months; follow-up ongoing$60,505-$2,784CCA, Common carotid artery; LSA, left subclavian artery; MI, myocardial infarction; OSH, outside hospital; TSSB, thoracic single side branch; USD, United States dollars. Open table in a new tab

Mid-Term Outcomes of Complex Endografting for Chronic Post-Dissection Thoracoabdominal Aortic Aneurysms.

To report early and mid-term results of post-aortic dissection thoracoabdominal aneurysms (pD-TAAA) treated by complex endografting in three tertiary referral hospitals. A review of all patients with pD-TAAA unfit for open surgery treated with complex endovascular repair from 2012 to 2018 was performed. Simple thoracic endografts (TEVAR) were excluded. Staged procedures in case of extensive aortic coverage were always planned. In total, 21 patients (16 males, mean age 63 ± 10years) with pD-TAAA underwent aortic repair by fenestrated or branched thoracoabdominal endografts for visceral vessels. Mean TAAA diameter was 61 ± 6.2mm. Spinal cord drainage was performed in all patients. A staged approach was used in 12 (57%) cases. Technical success was achieved in 18 (86%) patients. No in-hospital deaths occurred. Two patients experienced transient post-procedural spinal cord ischemia. At 30days, six type II endoleaks (29%), two type Ic endoleak (9.5%) and one type IIIc endoleak (5%) were reported. At a mean follow-up of 23 ± 13months, no late aortic-related deaths occurred. Three patients underwent reintervention for type Ic and IIIc endoleaks. No visceral vessel occlusion was observed. Estimated freedom from reintervention at 12 and 24months was 85.7 ± 0.7%. In 13 cases, TAAA diameter decreased at least 5mm, while increased > 5mm in only one case. Complete false lumen thrombosis was achieved in 18 patients (86%). Complex endografting for pD-TAAA showed favorable mid-term results. Staged and carefully planned endovascular procedures may represent a safe and effective therapeutic option in patients deemed at high risk of open repair.

Kommerell diverticulum – rare complications of a rare disease

Incidence of anomalies of the aortic arch is estimated 1-2 per cent in newborn babies. Lusory artery may arise either from left sided aortic arch in 0.7–2 per cent, or from right sided aortic arch in 0.4 per cent. Leading symptoms develop from compression of the oesophagus or trachea, or both. If lusory artery dilates conically over the time reaching 3 cm or more we call it Kommerell diverticulum. Very rare complications of this are the Type B aortic dissection, which may turn into chronic thoracoabdominal aneurysm, or its shaggy inner surface can be the source of upper extremity embolism. Rupture is extremely rare complication. In our report we focus on five cases of the mentioned complications with their clinical workups and technical solutions. In a female patient with right sided arch transection of the lusory artery was followed by transposition into the right common carotid artery. The central stump 10 years later gradually expanded and the saccular aneurysm indicated intervention. After complete arch debranching thoracic endograft was implanted. In this group of patients with variable surgical and hybrid procedures neither complication nor mortality occurred.

Outcome comparison of thoracic endovascular aortic repair performed outside versus inside proximal landing zone length recommendation

ObjectiveSuccess of thoracic endovascular aortic repair (TEVAR) relies heavily on the proximal landing zone (PLZ) sealing. Most instructions for use of thoracic endografts recommend a PLZ length of at least 2 cm. Because of the complex aortic anatomic features, TEVAR landing in zone 1 to zone 3 may not meet this requirement. The aim of this study was to examine whether 2-cm PLZ nonadherence was related to adverse outcomes after TEVAR. MethodsA retrospective review was performed of patients who underwent zone 1, zone 2, and zone 3 landing TEVAR at a single institution between November 2013 and October 2018. Preoperative and postoperative computed tomography angiography images were analyzed using three-dimensional reconstruction. The patients were categorized into two groups: PLZ ≥2 cm (adherence group) and PLZ <2 cm (nonadherence group). Collected data included patient and anatomic characteristics. Primary outcomes were type IA endoleak, retrograde dissection, and graft migration. ResultsThe cohort comprised 63 patients (18 in the adherence group and 45 in the nonadherence group) with a mean age of 53.3 ± 20.6 years. Indications for TEVAR were blunt thoracic aortic injury (65.1%), thoracic aneurysm (23.8%), penetrating ulcer (9.5%), and type B dissection (1.6%). Mean PLZ length was significantly shorter for the nonadherence group (8 ± 7 mm for the nonadherence group vs 34 ± 15 mm for the adherence group; P < .0001). PLZ location (2 zone 1, 15 zone 2, 46 zone 3) and oversizing (19.4% ± 8.3% for the adherence group; 20.3% ± 10.2% for the nonadherence group; P = .7) were similar between the groups. The mean PLZ aortic diameter of the adherence group was significantly larger than that of the nonadherence group (29 ± 5 mm for the adherence group; 25 ± 5 mm for the nonadherence group; P = .004). Mean follow-up time was 126.7 days (range, 0-644 days) for the adherence group and 233.8 days (range, 0-1750 days) for the nonadherence group (P = .2). During the study period, no primary outcome was observed in the adherence group, whereas 12 adverse events occurred in 10 patients in the nonadherence group (type IA endoleak, n = 10; graft migration, n = 1; retrograde dissection, n = 1). Of 10 type IA endoleaks, five were immediate (4 resolved spontaneously, 1 remained persistent) and five were delayed (1 resolved spontaneously, 1 remained persistent, 1 ruptured causing death, 2 required total arch replacement). ConclusionsAchieving recommended sealing zone of 2-cm centerline length is paramount to avoid device-related adverse outcomes. We recommend careful surveillance in patients undergoing urgent TEVAR with <2-cm PLZ.

Survival after endovascular therapy in patients with ruptured thoracic aortic diseases: Results from the Global Registry for Endovascular Aortic Treatment Registry

ObjectiveThe Global Registry for Endovascular Aortic Treatment is a prospective observational multicenter cohort registry of all Gore aortic endografts for a variety of aortic pathologies. The purpose of this study was to evaluate the outcome of the Conformable GORE TAG Thoracic Endoprosthesis and GORE TAG Thoracic Endoprosthesis devices for ruptured thoracic aortic syndromes. MethodsBetween December 2010 and October 2016, a total of 5018 patients were enrolled from 114 international sites in this registry. The database was queried for patients with at least one of the following pathologies: descending thoracic aortic aneurysm with rupture, thoracoabdominal aortic aneurysm rupture, descending aortic dissection rupture, and aortic arch aneurysm rupture. Patient demographics, operative details, and clinical outcomes were analyzed. ResultsA total of 40 patients were treated with a ruptured thoracic aortic disease (62.5% male; mean age, 67.5 ± 14.1 years). Nineteen patients were treated for descending thoracic aneurysm rupture, 9 for thoracoabdominal aneurysm rupture, 7 for descending aortic dissection rupture, and 5 for aortic arch aneurysm rupture. Technical success was achieved in 40 of 40 patients (100%). There were no intraoperative mortalities and no conversions to an open procedure. A total of 12 patients (30.0%) required intervention for involvement of at least one aortic branch vessel (4 covered, 5 surgically debranched, 1 stented, and 6 chimney technique). The 30-day mortality was four patients (10.0%). Early reintervention (≤30 days) was required in seven patients (17.5%), five of which were device related. There was a total of five endoleaks and all five required a reintervention. The median follow-up duration was 14.7 months (range, 1-57 months). Freedom from device-related intervention at 1 year was 87.1% (95% confidence interval, [CI], 0.716-0.944), at 2 years was 81.3% (95% CI 0.607-0.917) and at 3 years was 73.1% (95% CI, 0.47-0.878). Freedom from all-cause mortality at 1 year was 65.0% (95% CI, 0.474-0.780), at 2 years was 61.2% (95% CI, 0.431-0.751), and at 3 years was 56.1% (95% CI, 0.369-0.715). ConclusionsThe Conformable GORE TAG Thoracic Endoprosthesis and GORE TAG Thoracic Endoprosthesis thoracic endografts provide an effective treatment for ruptured thoracic aortic diseases. Adjunctive coverage or revascularization of an aortic branch vessel may be necessary. Longer follow-up and larger studies are needed to determine durability of these repairs.

Applicability of a standardized thoracic endograft with a single branch for the left subclavian artery to treat aortic disease involving the distal arch

ObjectiveCoverage of the left subclavian artery (LSA) origin during thoracic endovascular aortic repair (TEVAR) is associated with increased neurologic complications. Our group is involved in the development of an off-the-shelf (OTS) thoracic endograft incorporating a left common carotid artery (LCCA) scallop and a retrograde inner branch for LSA perfusion. This study aimed to evaluate the arch morphology of patients treated by TEVAR and requiring LSA coverage to determine the applicability of this OTS device. MethodsThe preoperative anatomy of consecutive patients from three separate cohorts treated with TEVAR with LSA coverage was studied. High-quality preoperative computed tomography angiography images were analyzed on an imaging workstation. Location of the origin of the supra-aortic trunks and their anatomic relationship were depicted in all patients; the LCCA origin was set as reference point. We determined the proportion of arch morphology in our cohort of patients eligible for this OTS device configuration. ResultsThere were 196 patients included in this study, 132 in the dissection cohort and 64 in the aneurysm cohort. The median length from the lower margin of the LCCA to the proximal aspect of the pathologic process was 25.0 mm (18.2-35.2 mm), with 68.4% (n = 134) of our cohort presenting with a proximal sealing zone length >20 mm. The median LCCA-LSA distance was 20.8 mm (16.6-25.4 mm). The median clock position of the LSA from the LCCA was −10 minutes (−30 to 0 minutes). In total, 127 patients (64.8%) could have been treated with the current OTS branched TEVAR configuration; 59 were excluded for proximal neck length distal to the LCCA <20 mm and 10 because of the clock position of the LCCA, and 9 first required a vertebral artery transposition. ConclusionsThe low variability of LSA and LCCA locations in patients with distal aortic arch disease offers wide applicability of a new standardized thoracic branched endograft.

4:03 PM Abstract No. 98 Type Ia endoleak treated with excluded sac embolization after thoracic and abdominal aortic endograft repair

4:03 PM Abstract No. 98 Type Ia endoleak treated with excluded sac embolization after thoracic and abdominal aortic endograft repair

Chimney stent graft for left subclavian artery preservation during thoracic endograft placement

ObjectiveCarotid to subclavian artery bypass (CSB) has been the standard for revascularizing the left subclavian artery during coverage by thoracic endovascular aortic repair (TEVAR). The purpose of this study is to determine if a chimney stent graft (CSG) offers similar outcomes as an alternative to open bypass. MethodsA retrospective review of a single vascular surgery registry between February 2011 and September 2017 was performed of all left subclavian revascularization during elective TEVAR. Arch reconstructions involving more than just the left subclavian artery were excluded. Indications, demographics, procedural details, and outcomes were analyzed using standard statistical analysis. ResultsEighty-one patients with a mean age of 68 years (range, 32-87 years) had left subclavian revascularization (64 [79%] CSB vs 17 [21%] CSG) during TEVAR. Median follow-up for CSG was 8 months (range, 0-52 months) and for CSB was 14.5 months (range, 3-72). Demographics between the groups were similar except for more males in both groups (43 [67%] in CSB vs 10 [59%] in CSG; P = .28). The CSB group had significantly more aneurysms than dissections compared with CSG (45 [70%] vs 6 [35%]; P = .008). There were no perioperative occlusions or ischemic issues for either group in the perioperative period. Postoperative hematoma rates trended higher in the CSB (7.11% vs 1.6%; P = .53) with three (4.6%) of the CSB requiring evacuation of hematoma. Left hemispheric strokes were 6% in the CSB with none occurring in the CSG group. Perioperatively, the CSB group had one recurrent laryngeal nerve and one graft infection. Length of stay was similar in both groups (CSB, 8.4 days vs CSG, 9.1 days). Perioperative mortality was not statistically significant between both groups with two deaths (3%) in the CSB and none in the CSG group. No gutter leaks were identified on follow-up computed tomography scan during long-term follow-up. Patency rates were similar with only one occlusion in the CSB group at 23 months. ConclusionsLeft common carotid to subclavian artery bypass has been the standard for revascularization of the left subclavian artery during coverage by TEVAR. Chimney stent grafting to perfuse the left arm appears to offer equivalent results as a minimally invasive alternative.

Successful two-step treatment of a ruptured giant thoracoabdominal aortic aneurysm

Treatment of thoracoabdominal aortic aneurysms is one of the most difficult challenges of vascular surgery. Endovascular options for complex aneurysms in urgent situation are limited. Thoracoabdominal giant aortic aneurysms are especially rare phenomena, each of them requires patient-specific treatment. Staged-fashion reconstructions may offer lower rate, especially for spinal cord injury. In our case report, we present a male patient, who had a 19.2 cm maximum diameter modified Crawford type V thoracoabdominal aortic aneurysm with contained rupture. The patient underwent an acute open repair and later a staged endovascular repair successfully. A 64-year-old male patient was admitted to our institution with complaints of chest and lower back pain in stable hemodynamic state. After evaluation, computer tomography angiography revealed a 19.2 cm maximum diameter thoracoabdominal aortic aneurysm, compression signs and hemothorax. Based on the anatomy, the serious compression symptoms and hemothorax associated with the gigantic aneurysm, we decided to perform open aortic repair. To reduce risk of spinal cord ischemia, intraoperatively we chose finishing the full reconstruction in a staged fashion. First, we performed an open repair with a Dacron interpositum distally using an oblique patch involving the visceral orifices. Later we implanted a thoracic endograft. At one-year follow-up, the patient was symptom-free, with no sign of endoleak. Giant aortic aneurysms are rare conditions, especially in the thoracoabdominal region. In the presence of compression symptoms, hemothorax and unsuitable aneurysm anatomy, open repair should be done. Staged repair offers a less invasive approach decreasing the risk of spinal cord ischemia. Orv Hetil. 2020; 161(7): 269-274.

Assessment of Pull-out Forces in TEVAR and ANACONDA FEVAR Combination and Early Clinical Results: Creation of a Proximal Landing Zone for FEVAR in Patients with Extent I and Extent IV TAAAs

Although recent data on the treatment of thoracoabdominal aortic aneurysms (TAAAs) are promising, in some cases, the paravisceral segment of the aorta may not be suitable for a branched endograft due to space restrictions. A combination of a fenestrated aneurysm repair (FEVAR) with a thoracic aneurysm repair (TEVAR) may represent a feasible treatment option. The current investigation was performed to assess the stability of a fenestrated Anaconda device implanted into a set of thoracic endografts from different manufacturers. We then assessed our clinical results with the FEVAR/TEVAR combination. Pull-out forces were measured invitro after docking a fenestrated Anaconda graft within the distal end of different TEVAR devices. Anaconda devices were implanted in 28- or 30-mm thoracic tube grafts (oversizing of at least 2mm: 13.3-21.4; minimum overlap of 15mm). Continuously increasing longitudinal pull forces of up to 100N were applied on an Instron Tensile Tester. Initial break point and damage to the endografts were documented. Clinical results of patients treated with such an FEVAR/TEVAR combination at our institution are presented as a second part of this study. Median pull-out forces ranged from 2.38N to 55.0N. The highest stability was achieved with 34-mm Anaconda devices in 28-mm thoracic tube grafts. Grafts with either thinner Dacron material or those featuring a polytetrafluorethylene membrane seemed especially vulnerable to punctures and tears caused by the downward-looking hooks of the Anaconda device. Between April 1, 2013 and December 31, 2018, in 28 of 172 patients treated with a fenestrated Anaconda device, prior implantation of a thoracic tube graft was necessary to create a sufficient proximal landing zone. In 25 cases (89.3%), the aneurysm was successfully treated. Although the 30-day reintervention rate in this subgroup was relatively high at 28.6%, none of these was due to a failure of the FEVAR/TEVAR combination. Upon an average follow-up of 15months, no failure of the graft connection and no type III endoleak due to membrane damage were observed. The combination of a thoracic tube graft and a fenestrated Anaconda device is a viable option for the treatment of patients with Extent I or IV TAAAs with no adequate landing zone above the celiac trunk. Although pull-out testing has shown good stability with most assessed grafts, the thoracic devices with thicker Dacron membranes seemed to be especially suitable.

Thoracic Endovascular Aortic Repair (TEVAR): A Case Report

Thoracic aortic aneurysm (TAA) is generally a disease of the elderly which remains mostly asymptomatic. It is often detected incidentally with imaging studies of the chest done for other reasons. We present a 55year-old smoker, normotensive and non-diabetic male patient who was diagnosed as a case of TAA and treated by endovascular means with thoracic endovascular aortic repair (TEVAR) technique. Due to small caliber femoral artery, thoracic endograft was deployed through a Dacron graft conduit of 10 mm diameter which was anastomosed to the common iliac artery. It was a hybrid procedure done in cardiac catheterization laboratory under general anesthesia. Completion angiogram revealed good technical success with no endoleak or neurological deficit. Patient improved symptomatically after TEVAR.&#x0D; Bangladesh Heart Journal 2019; 34(2) : 146-150