Total Endovascular Aortic Arch Repair Research Articles

Multicenter Global Early Feasibility Study to Evaluate Total Endovascular Arch Repair Using Three-vessel Inner Branch Stent-grafts for Aneurysms and Dissections

To evaluate the outcomes of endovascular repair using three-vessel inner branch aortic arch stent-grafts for aneurysms and chronic dissections. We reviewed the clinical data and outcomes of consecutive patients treated by total endovascular aortic arch repair at eight academic centers using three-vessel inner branch stent grafts (William Cook Europe, Bjaeverskov, Denmark) between 2016 and 2019. All patients received patient-specific stent designs with two antegrade and one retrograde inner branch, which was used to incorporate the innominate, left common carotid, and left subclavian arteries. The antegrade inner branches were accessed via axillary or carotid artery access. A preloaded catheter was used for access to the retrograde left subclavian artery branch via femoral approach (Fig). End points were technical success, mortality, major adverse events, any stroke (minor or major) or transient ischemia attack, secondary interventions, target vessel patency, target vessel instability, aneurysm-related mortality and patient survival. There were 39 patients (31 male patients [79%], mean age 70 ± 7 years) treated for 14 (36%) degenerative and 25 (64%) chronic postdissection arch aneurysms. Clinical characteristics included American Society of Anesthesiologists classification of >3 in 37 patients (95%) and prior median sternotomy for ascending aortic repair in 33 patients (85%). Technical success rate was 100%. There were two in-hospital or 30-day deaths (5%) and two strokes (one minor). Combined mortality/any stroke rate was 8% (n = 3). Major adverse events occurred in 10 patients (26%), including respiratory failure in 4 patients (10%) and estimated blood loss of >1 L, myocardial infarction and acute kidney injury in two patients each (5%). Mean follow-up was 8 ± 10 months. Twelve patients (31%) required secondary interventions to treat vascular access complications in five patients, endoleak in six patients (three type II, one type IC, one type IB, one type IIIA) and target vessel stenosis in one patient. At 1 year, primary and secondary patency rates and freedom from target vessel instability were 95% ± 5%,100%, and 92% ± 5%, respectively. Freedom from aortic-related mortality and patient survival were 94% ± 4% and 90% ± 6%, respectively. This multicenter global experience demonstrates the technical feasibility and safety of total endovascular aortic arch repair for aneurysms and chronic dissections using three-vessel inner branch stent grafts. Mortality and stroke rates compare favorably to reported outcomes of total open surgical arch replacement, particularly among higher risk patients who had prior median sternotomies and ascending aortic repairs. A limitation remains the high rate of secondary reinterventions (31%), emphasizing need for larger experience and longer follow-up.

Aortic Arch Anatomy Pattern in Patients Treated Using Double Homemade Fenestrated Stent-Grafts for Total Endovascular Aortic Arch Repair

Purpose: To analyze the structural variation of the aortic arch and the supra-aortic arteries and establish an average spatial configuration that would be a pattern for a “universal double fenestration” design for physician-modified endovascular grafts (PMEGs) used in total thoracic endovascular aortic repair (TEVAR). Materials and Methods: Aortic arch morphology was retrospectively analyzed by reviewing the preoperative thoracic computed tomography angiography scans in 33 consecutive patients (mean age 68 years; 27 men) treated between January 2017 and March 2019 using double-fenestrated PMEGs for zone 0 TEVAR. Image analysis was completed according to a standardized technique on a vascular workstation with center lumen line reconstruction for all measurements. Variations in branching pattern of the aortic arch were classified into 8 types. Results: The arch trunk configuration was type I in 26 patients (79%), type II in 5 (15%), type III in 1, and type IV in 1. Mean aortic diameters at the level of mid ascending aorta, innominate artery (IA), left common carotid artery (LCCA), and left subclavian artery (LSA) were 35.7±3.7, 34.2±4.5, 33.3±6.7, and 33.7±4.7 mm, respectively. Mean diameters of the trunk were 12.2±1.7, 7.5±1.4, and 8.0±0.8 mm, respectively. Mean longitudinal center to center lengths were 15.9±2.5 mm between the LSA and LCCA and 12.1±3.0 mm between the LCCA and IA. Mean clock positions using the LSA as reference were 12:50 for the IA and 12:05 for the LCCA. In 32 patients (97%) all the supra-aortic branch vessels fit perfectly inside two delimited areas defined by a proximal common square area of 30×30 mm for the IA and LCCA and a second distal 8-mm-diameter circle for the LSA. Conclusion: Variations of the aortic arch anatomy are numerous and common. A general morphological pattern is described that delimits the aortic area where these variations occur. This information can be utilized for the design of an off-the-shelf double-fenestrated stent-graft for zone 0 TEVAR.

Endovascular management of chronic post-dissection aneurysms of the aortic arch.

This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.

Externalized transapical guidewire technique after artificial aortic valve replacement during complete endovascular aortic arch repair.

An externalized transapical guidewire (ETAG) technique has been used for safe delivery of high-profile devices through a tortuous aorta to zone 0, which is currently precluded after mechanical artificial aortic valve replacement (AVR). The aim of the study was to report one center’s experience (based on 3 cases) of a unique modification to the ETAG technique used for the first time during total endovascular aortic arch repair after AVR.This report contains technical notes regarding a new method of steering the guidewire from the apex inside the artificial aortic valve during total endovascular aortic arch repair after AVR and the details crucial in preparation for this mini-invasive procedure.As a conclusion, the ETAG technique could be performed after mechanical AVR with active positioning of the guidewire carried out under the control of transesophageal echocardiography.

Total Endovascular Repair of the Aortic Arch: Initial Experience in the Netherlands

We report procedural and early results in the Netherlands of the Relay Branch device (Terumo Aortic, Sunrise, FL) for total endovascular repair of the aortic arch. Between 2014 and 2018, all consecutive patients who received the Aortic Relay double-branched stent graft in the Netherlands were included in a multicenter, retrospective registry. The Relay Branch device was used in 11 patients to treat saccular (n= 4), fusiform (n= 5), or false aneurysms (n= 2) in the aortic arch. Patients were deemed unfit or extreme high-risk for open (redo) surgery. The brachiocephalic trunk and left common carotid artery were branched using a retrograde approach in all cases. Additional surgical left subclavian artery revascularization was performed in 8 patients. The main device and the branches were successfully introduced, positioned, and deployed with complete exclusion of the aortic pathology in all patients (100% technical success). There was no retrograde type A dissection or conversion to open surgery. Two procedure-related deaths occurred, both caused by perioperative or postoperative strokes. There were 2 minor strokes with full recovery. One patient recovered from transient paraplegia after spinal fluid drainage. No permanent paraplegia was observed. Follow-up imaging showed persistent adequate exclusion of aortic arch pathology. Mean follow-up was 17 months (range, 3-42 months). Total endovascular aortic arch repair using the Relay Branch device is technically feasible and effective in excluding aortic arch pathology. The observed stroke rate in the initial experience, however, was considerable. Although appealing, this new less-invasive technique should be carefully introduced and its progress thoroughly evaluated.

Homemade Fenestrated Stent-Grafts for Complete Endovascular Repair of Aortic Arch Dissections

Purpose: To evaluate outcomes of homemade fenestrated stent-grafts for complete endovascular aortic repair of aortic arch dissections. Materials and Methods: From July 2014 through September 2018, 35 patients (mean age 66±11 years; 25 men) underwent homemade fenestrated stent-graft repair of acute (n=16) or chronic (n=10) complicated type B aortic dissections (n=16) and dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections (n=9). Nineteen (54%) procedures were emergent. Results: Zone 2 single-fenestrated stent-grafts were used in 25 cases; the remaining 10 were double-fenestrated stent-grafts deployed in zone 0. Median time for stent-graft modification was 18 minutes (range 16–20). Technical success was achieved in all cases. An immediate distal type I endoleak was treated intraoperatively. Among the double-fenestrated stent-graft cases, the left subclavian artery fenestration could not be cannulated in 2 patients and revascularization was required. Partial coverage of the left common carotid artery necessitated placement of a covered stent in 3 cases. One (3%) patient had a stroke without permanent sequelae. Two type II endoleaks required additional covered stent placement at 5 and 7 days postoperatively, respectively. The 30-day mortality was 6% (2 patients with ruptured aortic arch aneurysm). During a mean follow-up of 17.6±13 months, there was no aortic rupture or retrograde dissection. One late type I endoleak was treated with additional proximal fenestrated stent-graft placement. One type II endoleak is currently under observation. One additional patient died (unrelated to the aorta); overall mortality was 9%. All supra-aortic trunks were patent. Conclusion: The use of homemade fenestrated stent-grafts for endovascular repair of aortic arch dissections is feasible and effective for total endovascular aortic arch repair. Durability concerns will need to be assessed in additional studies with long-term follow-up.

Total Endovascular Aortic Arch Repair with Branched Graft.

In selected cases, the utilization of branched endografts for the treatment of aortic arch aneurysms could be a safe and advantageous alternative to high-risk procedures such as open total aortic arch replacement or hybrid arch repair. We present the case of a 70-year-old man with saccular aneurysm of a bovine aortic arch which was endovascularly treated using a double-branched custom-made aortic endoprosthesis based on the Relay NBS (Non-Bare Stent) Plus platform intended for zone 0 deployment. The postoperative clinical course was uneventful. The postoperative computed tomography scan showed a good result of the implant. The patient was discharged 6 days after the procedure.

Double homemade fenestrated stent graft for total endovascular aortic arch repair

ObjectiveThe aim of this retrospective analysis was to evaluate the outcomes of physician-modified double fenestrated stent grafts for total endovascular aortic arch repair: one proximal large fenestration for the brachiocephalic trunk and the left common carotid artery and one distal fenestration for the left subclavian artery (LSA). MethodsFrom January 2017 through February 2018, 17 patients (88.2% elective) underwent thoracic endovascular aortic repair (TEVAR) with double homemade fenestrated stent graft for total endovascular aortic arch repair to maintain supra-aortic trunk patency. Indications were degenerative aortic arch aneurysm (n = 7), dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections (n = 6), chronic complicated type B aortic dissection (n = 3), and acute complicated type B aortic dissection (n = 1). Routine postoperative follow-up imaging with computed tomography angiography was performed to assess TEVAR and supra-aortic trunks patency and endoleak. ResultsThe median time for stent graft modification was 19 minutes (range, 16-20 minutes). Endovascular exclusion of the aortic arch was achieved in all the cases. One LSA catheterization failed and LSA revascularization was performed by carotid axillary bypass and coverage of the LSA fenestration by additional stent graft placement. Additional planned endovascular procedures were required in three patients: closure of supra-aortic trunks re-entry tears in two cases of dissecting aortic arch aneurysms and one transcatheter aortic valve replacement for severe native aortic valve regurgitation. One stroke, with no long-term deficit, was observed. No patients died. All left supra-aortic trunks are patent. No type I endoleak was observed. We only observed one patient with a type II endoleak. During a mean follow up of 7 ± 2 months, there were no conversions to open surgical repair, aortic rupture, paraplegia, or retrograde dissection. ConclusionsDouble homemade fenestrated TEVAR is both feasible and effective for maintaining the patency of the supra-aortic trunks and allows total endovascular aortic arch repair. Durability concerns will need to be assessed in additional studies with long-term follow-up.

Physician-Modified Thoracic Stent Grafts for the Arch After Surgical Treatment of Type A Dissection

This study evaluated the outcome of physician-modified thoracic stent grafts for the treatment of dissecting aortic arch aneurysms after surgical treatment of acute type A dissection. From August 2016 through February 2018, 13 patients (8 men and 5 women) underwent thoracic endovascular aortic repair in which physician-modified thoracic stent grafts were used to treat dissecting aortic arch aneurysms after surgical treatment of acute type A dissection. Patients were a mean age of 70.7 ± 10 years (range, 43 to 82 years). Four patients were treated in an emergent setting for a symptomatic aortic arch aneurysm. The aneurysmal disease involved zone 0 in 10 patients and zone 2 in 3. Seven patients (48%) were treated using an aortic arch stent graft with a single fenestration, combined with cervical debranching in 4 patients. Six patients underwent total endovascular aortic arch repair using a double-fenestrated stent graft. Additional planned endovascular procedures were performed in 3 patients. Median time for stent graft modifications was 18 minutes (range, 14 to 21 minutes). All the proximal entry tears in the arch were successfully excluded. The 30-day mortality rate was 0%. One patient (7.6%) had a stroke without permanent sequelae. The median length of stay was 5 days (range, 1 to 17 days). During follow up of 8 ± 6 months, there were no conversions to open repair, aortic rupture, paraplegia, or retrograde dissection. The use of physician-modified thoracic stent grafts for the treatment of dissecting aortic arch aneurysm after surgical treatment of acute type A dissection is feasible and effective. Durability concerns will need to be assessed in future studies.