Treatment Of Thoracic Aortic Disease Research Articles

Multicentre experience of antegrade thoracic endovascular aortic repair for the treatment of thoracic aortic diseases.

The goal of this multicentre retrospective cohort study was to evaluate technical success and early and late outcomes of thoracic endovascular repair (TEVAR) with grafts deployed upside down through antegrade access, to treat thoracic aortic diseases. Antegrade TEVAR operations performed between January 2010 and December 2021 were collected and analysed. Both elective and urgent procedures were included. Exclusion criteria were endografts deployed in previous or concomitant surgical or endovascular repairs. Fourteen patients were enrolled; 13 were males (94%) with a mean age of 71 years (interquartile range 62; 78). Five patients underwent urgent procedures (2 ruptured aortas and 3 symptomatic patients). Indications for treatment were 8 (57%) aneurysms/pseudoaneurysms, 3 (21%) dissections and 3 (21%) penetrating aortic ulcers. Technical success was achieved in all procedures. Early mortality occurred in 4 (28%) cases, all urgent procedures. Median follow-up was 13 months (interquartile range 1; 44). Late deaths occurred in 2 (20%) patients, both operated on in elective settings. The first died at 19 months of aortic-related reintervention; the second died at 34 months of a non-aortic-related cause. Two patients (14%) underwent aortic-related reinterventions for late type I endoleak. The survival rate of those having the elective procedures was 100%, 84% and 67% at 12, 24 and 36 months, respectively. Freedom from reintervention was 92%, 56% and 56% at 12, 24 and 36 months, respectively. Antegrade TEVAR can seldom be considered an alternative when traditional retrograde approach is not feasible. Despite good technical success and few access-site complications, this study demonstrates high rates of late type I endoleak and aortic-related reinterventions.

Midterm Outcomes of Multicenter Castor Single-Branch Stent Graft Use in the Treatment of Thoracic Aortic Diseases.

The aim of this study was to evaluate the midterm efficacy and safety of a single-branch Castor stent graft in the treatment of thoracic aortic disease. Clinical data of 106 patients with thoracic aortic disease treated with Castor single-branch stent graft at 3 centers were collected between May 2018 and June 2023. The indicators included technical success, stent-related complication, reintervention, retrograde dissection, endoleak, distal stent graft-induced entry (dSINE), branch patency, and mortality. The outcomes of the Castor stent graft for multibranch reconstruction above the arch was also analyzed. The technical success was 98.1% (104/106), while the surgical success was 93.4% (99/106). The reintervention was 2.8% (3/106), consisting of a case of retrograde type A dissection, an endoleak, and a dSINE. The retrograde dissection was 1.9% (2/106), while type I endoleak was 1.9% (2/106). The new dSINE was 2.8% (3/106), and the branch patency rate was 100%. The mortality was 1.9% (2/106). The mean follow-up time was 29.1±17.7 months. The 2-year post-surgery cumulative survival rate was 91.0%±3.1%, while the cumulative branch patency rate was 96.2%±2.2%. In addition, the cumulative freedom from stent-related reintervention rate was 93.2%±2.8%. A comparison showed no significant difference in the stent-related complication, branch patency, endoleak, reintervention, and mortality when the proximal end of the Castor stent graft was anchored to zones 1 or 2 of the aorta. Castor single-branch stent graft showed favorable early and midterm outcomes in the treatment of thoracic aortic disease. In addition, it was feasible to combine Castor stent graft with other advanced techniques for multibranch aortic arch reconstruction. The Castor single-branch stent graft was approval by the Chinese Food and Drug Administration in 2017. However, there were few studies on the mid-term outcomes for thoracic aortic disease after launching, which mainly focused on small single-center retrospective study. In the study, we assessed the mid-term outcomes of Castor stent graft through multi-center cases, Castor stent graft combined with other advanced techniques (such as fenestration and hybrid) for multi-branch reconstruction of aortic arch were also conducted. We found Castor single-branch stent graft showed favorable early and mid-term outcomes in the treatment of thoracic aortic disease. Additionally, it was feasible to combine Castor stent graft with other advanced technique for multi-branch aortic arch reconstruction. As an off-the-shelf branched stent graft with a wide range of models, it could be also used in most emergent situation. The Castor stent graft was expected to become more widely used in the future.

Endovascular treatment for thoracic aortic disease from the Global Registry for Endovascular Aortic Treatment

ObjectiveGlobal Registry for Endovascular Aortic Treatment (GREAT) is an international prospective multicenter registry collecting real-world data on performance of W. L. Gore thoracic and abdominal aortic endografts. This analysis evaluated the long-term differences in patient survival and device performance in patients undergoing thoracic endovascular aortic repair (TEVAR) for any thoracic aortic pathology. MethodsFrom August 2010 to October 2016, 5014 patients were enrolled in GREAT. The population of interest was comprised of only patients treated for thoracic aortic pathologies. Through 5 years, primary outcomes were all-cause and aortic-related mortality, stroke, aortic rupture, endoleaks, migration, fracture, compression, paraplegia, and any reintervention through 5 years, grouped by pathology. Secondary outcomes were reintervention rate and freedom from serious device- and aortic-related events. ResultsThe 578 patients with thoracic aortic pathologies enrolled in GREAT and identified for this analysis were categorized by common pathologies: thoracic aneurysm (n = 239), thoracic dissection (n = 203), arch (n = 26), and other (n = 110). The mean age of this population was 66.1 ± 12.8 years, and 64.7% were male. Procedure survival was 99.7%. In the overall group, at index procedure to 30 days and 31 days to 5 years, Kaplan-Meier estimates of freedom from all-cause mortality were 99.6% and 66.4%, respectively, and for aortic-related mortality were 97.7% and 94.6%, respectively. Aortic rupture rate was 0.5% (n = 3) at 30 days and 1.4% (n = 8) through 5 years. Stroke and spinal cord ischemic events were 1.9% (n = 11) and 1.6% (n = 9) at 30 days and at 5 years were 3.6% (n = 20), 0.5% (n = 3), respectively. Reinterventions were required in 7.3% (n = 42) at 30 days and 12.4% (n = 69) through 5 years. The number of patients with endoleaks at 30 days was 2.1% (n = 12): n = 3 (1.1%) for each of types IA, 1B, and II; n = 2 (0.3%) for type III; and n = 4 (0.7%) for unspecified. Through 5 years, the percentage of patients was 8.3% (n = 40): n = 15 (3.1%) for type IA; n = 10 (2.1%) for type IB; n = 11 (2.3%) for type II; and n = 9 (1.9%) for unspecified. One patient (0.2%) had stent migration at 30 days (aneurysm group); none were reported through 5 years. There were no incidents of stent compression or fracture from index procedure through 5 years. ConclusionsData herein demonstrates durability and support for treatment of thoracic aortic disease with the GORE TAG conformable thoracic stent graft, including no incidents of stent compression/fracture and high freedom from aortic-related mortality. The planned analysis of follow-up to 10 years in GREAT will be beneficial.

A Lethal Late Complication: Aortoesophageal Fistula after TEVAR

AbstractThoracic endovascular aortic repair (TEVAR) has been performed in the treatment of thoracic aortic disease since the mid-1990s. Complications associated with TEVAR are increasing rapidly due to its widespread use. One of these complications is late lethal aortoesophageal fistula (AEF). The aim of this study was to describe the diagnosis of AEF in a 64-year-old woman 8 months after TEVAR. The AEF was diagnosed on a computed tomography angiography with oral and intravenous contrast. The patient underwent open surgical repair and died of sepsis 12 days after surgery.

Endovascular repair of thoracic aortic disease with isolated left vertebral artery and unfavorable proximal landing zone using fenestrated castor stent-graft.

The main purpose of this study was to evaluate the safety and efficacy of Castor single-branched stent-graft combined with fenestrated technique in treatment of thoracic aortic disease (TAD) with unfavorable proximal landing area (PLZ) and isolated left vertebral artery (ILVA). From January 2018 to March 2022, 8 patients with TAD (6 patients with type B aortic dissections, 1 patient with type B intramural hematomas, and 1 patient with thoracic aortic aneurysm) underwent thoracic endovascular aortic repair with fenestrated Castor stent-graft due to the existence of ILVA and unfavorable PLZ. Demographic characteristics, surgical details, postoperative complications, follow-up and postoperative CTA imaging results were collected and analyzed. The primary technical success rate was 100%. The mean operation time was 115 min (range, 70-180 min). All the left subclavian arteries (LSAs) and ILVAs of the eight patients were revascularized by fenestrated Castor stent-grafts. During the follow-up period, no deaths and complications were observed. No internal leakage, aortic rupture, retrograde type A dissection were found on computed tomography angiography. All of the LSAs and ILVAs maintained patency without stenosis. Castor single-branched stent-graft implantation combined with fenestration technique may be safe and feasible for TAD patients with ILVA and unfavorable PLZ.

Machine learning and artificial intelligence in the prediction, diagnosis and treatment of thoracic aortic diseases (literature review). Part 1

Despite their relatively low prevalence compared to cardiac valve lesions and coronary heart disease, thoracic aortic aneurysm and dissection are potentially fatal and represent serious public health problems. The indications for surgical treatment in most thoracic aortic diseases are predominantly based on the maximum aortic diameter in a particular area. Congenital connective tissue disorder, thoracic aortic anomalies (e.g., coarctation), family history of aneurysms, aortic dissections, and sudden deaths are considered as additional risk factors of aortic-related complications influencing the “stricter” indications and lowering the “threshold” aortic diameter. At the same time, a certain proportion of patients with aortic diseases develop aortic dissection and rupture in normal or near-normal thoracic aortic diameter in certain section. Many factors influence the development of aortic diseases and complications, and assessing the contribution to the aetiology and pathogenesis of each factor is difficult. Machine learning and mathematical modeling using artificial intelligence is an actively developing area of computer science, which also finds application in medicine, in particular in the study, diagnosis, and treatment of thoracic aortic aneurysms and dissections. This article discusses modern methods of data analysis, prediction of thoracic aortic aneurysms and dissections, treatment planning in thoracic aortic diseases, and prediction of complications using machine learning and artificial intelligence.

Machine learning and artificial intelligence in the prediction, diagnosis and treatment of thoracic aortic diseases (literature review). Part 2

Despite their relatively low prevalence compared to cardiac valve lesions and coronary heart disease, thoracic aortic aneurysm and dissection are potentially fatal and represent serious public health problems. The indications for surgical treatment in most thoracic aortic diseases are predominantly based on the maximum aortic diameter in a particular area. Congenital connective tissue disorder, thoracic aortic anomalies (e.g., coarctation), family history of aneurysms, aortic dissections, and sudden deaths are considered as additional risk factors of aortic-related complications influencing the “stricter” indications and lowering the “threshold” aortic diameter. At the same time, a certain proportion of patients with aortic diseases develop aortic dissection and rupture in normal or near-normal thoracic aortic diameter in certain section. Many factors influence the development of aortic diseases and complications, and assessing the contribution to the aetiology and pathogenesis of each factor is difficult. Machine learning and mathematical modeling using artificial intelligence is an actively developing area of computer science, which also finds application in medicine, in particular in the study, diagnosis, and treatment of thoracic aortic aneurysms and dissections. This article discusses modern methods of data analysis, prediction of thoracic aortic aneurysms and dissections, treatment planning in thoracic aortic diseases, and prediction of complications using machine learning and artificial intelligence.

Resultados a longo prazo após tratamento endovascular da aorta em pacientes com doenças da aorta torácica

Abstract Background Endovascular treatments for thoracic aortic diseases have been adopted rapidly, and long-term studies are relevant for durability evaluation. Objective To evaluate the long-term results of a prospective observational study of endovascular treatment in patients with thoracic aortic diseases who underwent percutaneous implantation of self-expandable endoprostheses. Methods Procedural success was defined as the absence of endoleak into the aneurysm or dissection-induced false lumen, no migration, and no conversion to open surgery. Intraoperative, postoperative, and late postoperative outcomes were evaluated in terms of complications, mortality, and evolution of the endoprosthesis over a follow-up of up to 179 months (median: 46 months). Results A total of 150 endoprostheses were implanted in 112 patients. Primary success was observed in 100 (82.14%) patients. Immediate mortality occurred in 7 patients (6.25%). Late mortality occurred in 31 patients (27.68%), 10 (8.93%) of whom died from cardiovascular causes, 12 (10.71%) from non-cardiovascular causes, and 2 (1.78%) from natural causes, while 7 (6.25%) had no diagnosis for cause of death. Types I, II, and IV endoleaks occurred during hospitalization in 4 (3.57%), 5 (4.46%), and 3 (2.68%) patients, respectively. Late types I and IV endoleaks occurred in 5 (4.46%) and 3 (2.68%) patients respectively. Twenty-two patients (19.64%) had clinical complications in the immediate postoperative period. Actuarial survival free from death from cardiovascular causes was 79.3% (95% confidence interval, 67.0-91.7%) at 132 months. Conclusions The low levels of intraoperative and postoperative complications demonstrate that endovascular treatment is safe and effective. The high rate of late survival for these critically ill patients indicates that the endovascular technique is beneficial for treatment of thoracic aortic diseases in terms of long-term outcomes.

Effect of Aortic Stent Implantation in the Treatment of Thoracic Aortic Disease

Objective: To explore the effect of aortic stent implantation on patients in the treatment of thoracic aortic diseases. Methods: Selected patients from Yunnan Fuwai Cardiovascular (YFC) Hospital as a sample group to carry out the study, the main participants were thoracic aortic aneurysm patients admitted from June 2020 to June 2021. The number of patients involved were 80. The patients are divided into two groups and different treatment methods were adopted. A comparative analysis of the effects of aortic stent placement on patients was conducted. Results: Before treatment, there was no significant difference in the levels of various inflammatory factors between the two groups of patients, P>0.05. After treatment, the data indicators of the two groups were significantly different, as there were significant differences in the surgical indicators among the two groups of patients, P<0.05. As a result, the experimental group had shorter operation time, less intraoperative blood loss, shorter ICU observation time, lower levels of inflammatory factors, and better results. Conclusion: In the treatment of patients with thoracic aortic disease, the application of aortic stent implantation has significant clinical effects and are more conducive to the recovery of patients. It can be promoted and used in clinical trials.

When is extra-anatomical bypass for the left subclavian artery required to prevent ischaemia after thoracic endovascular stent grafting?

Thoracic endovascular aortic repair (TEVAR) has become an accepted treatment for thoracic aortic disease. However, the principal complications relate to coverage of the thoracic aortic wall and deliberate occlusion of aortic branches over a potentially long segment. Complications include risk of stroke, spinal cord ischaemia (SCI) and arterial insufficiency to the left arm (left arm ischaemia (LAI)). This study specifically scrutinised the development of SCI and LAI after TEVAR for interventions for thoracic aortic disease from 1999 to 2020. In particular, those who underwent extra-anatomical bypass (both immediate and late) were compared to the length of thoracic aortic coverage by the stent graft. Ninety-eight patients underwent TEVAR. The presenting symptoms, pathology, procedural and follow-up data were collected prospectively with particular evidence of stroke, SCI and LAI both immediate onset and after 48 h of graft placement. Fifty underwent TEVAR for an aneurysm (thoracoabdominal aortic aneurysm), 22 for dissection, 19 for acute transection and 7 for intramural haematoma/pseudoaneurysm of the thoracic aorta. Twenty-nine (30%) required a debranching procedure to increase the proximal landing zone (1 aorto-carotid subclavian bypass, 10 carotid/carotid subclavian bypass and 18 carotid/subclavian bypass). Ten patients (10%) died within 30 days of TEVAR. Twenty-four grafts covered the left subclavian artery origin without a carotid/subclavian bypass. Five required a delayed carotid/subclavian bypass for LAI (4) and SCI (1). Six developed immediate signs of SCI after TEVAR and these 11 (group i) had a mean (SD) length of coverage of the thoracic aorta of 30.2 (10.6) cm compared to 21.5 (11.2) cm (group g) in those who had no LAI or SCI post TEVAR, p < 0.05. In this series, delayed carotid/subclavian bypass may be required for chronic arm ischaemia and less so for SCI. The length of coverage of thoracic aorta during TEVAR is a factor in the development of delayed SCI and LAI occurrence. Carotid subclavian bypass is required for certain patients undergoing TEVAR (particularly if greater than 20 cm of thoracic aorta is covered).

Impact of obesity on early postoperative outcomes after frozen elephant trunk procedure

Despite the great interest in the issue of obesity in cardiac surgery patients, its effect on the outcomes surgical treatment of thoracic aortic diseases has hardly been studied. Aim. To assess the effect of obesity on the results of the aortic arch reconstruction using the frozen elephant trunk (FET) technique. Material and methods . In the period from March 2012 to May 2020, 84 patients with thoracic aortic diseases were operated on. All patients underwent surgical aortic arch reconstruction using the FET technique. Interventions were performed under moderate hypothermic circulatory arrest (25-28° C) and unilateral cerebral perfusion via innominate artery. In accordance with the body mass index, all patients were divided into 2 groups: 30 kg/m 2 (group 2, n=28). Results . Neurological complication rates did not differ between the groups. Respiratory failure requiring tracheostomy and dialysis rate due to acute kidney injury occurred in 28,5% vs 35,7% (p=0,626) and 28,5% vs 17,9% (p=0,273), in patients with obesity and normal body weight, respectively. The reoperation rates due to bleeding was nonsignificantly higher in obese patients (14,3% vs 3,6%, p=0,092). The short-term mortality rate was 9,5% without significant differences in studied groups. Conclusion . Aortic arch surgery using FET technique has comparable early results in obese and normal body weight patients.

Single-center midterm results with the low-profile Zenith Alpha thoracic endovascular stent graft

ObjectiveThe analysis of endovascular treatment of thoracic aortic diseases using new low-profile stent grafts in large series is crucial to understanding the durability of these devices. The present study reports the midterm outcomes of a single-center experience using the Zenith Alpha thoracic endovascular stent graft. MethodsThe outcomes of 270 procedures performed on 262 patients (197 men; mean age, 70.5 ± 9.5 years) using the Zenith Alpha thoracic endovascular stent graft from November 2013 to December 2019 for different thoracic aortic diseases were analyzed. The primary endpoints were 30-day clinical success and midterm (5-year) clinical success. The secondary endpoints were the adverse event rate at 30 days and midterm and access- and device-related complications. The follow-up of surviving patients was performed using computed tomography angiography and office visits at 1, 6, and 12 months and annually thereafter. Kaplan-Meier analysis was performed for overall survival, and freedom from thoracic aortic endovascular repair–related mortality and related reinterventions. ResultsThe overall 30-day mortality was 5.2% (2.5% for elective and 30.8% for nonelective cases). Type I endoleaks were identified in six patients. The 30-day primary technical and clinical success rates were 97.8% and 92.6%, respectively. Femoral cutdown was used in 41.1% of cases and percutaneous access in 58.5%. The rate of femoral artery complications after the percutaneous approach was 5.1%, with the need for surgical conversion in 1.9%. The stroke rate was 4.1% (major stroke, 2.2%), and the spinal cord ischemia rate was 3.7% (permanent paraplegia, 0.7%). Of the 248 survivors, 239 complied with the follow-up protocol with adequate computed tomography angiograms available images. Overall follow-up survival was 94.0% at 1 year, 91.6% at 2 years, 88.9% at 3 years, and 88.5% at 5 years. The unplanned secondary endovascular procedure rate was 5.3%. No stent fractures or new-onset type I endoleaks due to stent graft migration were observed in the study cohort. ConclusionsThe midterm outcomes of this new generation of low-profile devices were satisfactory. The reported low incidence of secondary procedures and the absence of migrations are promising for the long-term durability of these devices.

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

Follow-up results of aortic arch cervical debranching performed with the help of a temporary crossover external carotid artery bypass for cerebral protection followed by endovascular thoracic aortic aneurysm repair.

Treating aortic arch aneurysms with conventional open surgical and endovascular stent graft procedures is challenging due to the complex anatomy of the arch and the arteries arising from it that nourish the brain. Cerebral protection is of the utmost importance during the treatment of thoracic aneurysms involving the aortic arch. Between May 2014 and November 2018, 7 patients with thoracic aortic aneurysms involving the aortic arch who underwent aortic arch cervical debranching with our technique were reviewed retrospectively. Because all the patients being considered for conventional surgical aortic arch replacement had serious comorbidities, they were selected to receive hybrid therapy. The mean age of the patients was 71.2 ± 9.4 years. One patient was a woman and 6 patients were men. One patient was given general anaesthesia; the remaining 6 patients had a regional block. A crossover temporary bypass was performed between the external carotid arteries with a 6-mm polytetrafluoroethylene graft for cerebral protection in all patients. Thoracic endovascular aortic repair (TEVAR) was successfully performed in all patients except 1 following debranching. Neurological complications did not occur during the procedures. Patients were followed for a mean of 18.3 ± 4.9 months. One female patient died of exacerbating chronic obstructive pulmonary disease within the first follow-up year. Three other patients died: 1 died of natural causes; 1 died of pneumonia followed by multiorgan failure; and 1 died of myocardial infarction during the mid-term follow-up period. The remaining patients are still being followed and are event free. Endovascular treatment of thoracic aortic diseases involving the aortic arch is facilitated when the aortic arch is debranched. Our cerebral protection method with a temporary crossover bypass between the external carotid arteries provides continuous pulsatile blood flow to the brain; hence, neurologically, it is a reliable procedure. The follow-up results of the patients who underwent aortic arch cervical debranching followed by TEVAR depended on their comorbidities.

Off-the-Shelf Devices for Treatment of Thoracic Aortic Diseases: Midterm Follow-up of TEVAR With Chimneys or Physician-Made Fenestrations

Purpose: To evaluate the midterm outcomes of thoracic endovascular aortic repair (TEVAR) using chimney grafts (ch-TEVAR) or thoracic stent-grafts with fenestrations made on the back table (f-TEVAR) to treat thoracic aortic dissection (TAD) and thoracic aortic aneurysm (TAA). Materials and Methods: A retrospective analysis was conducted of 474 consecutive patients (mean age 62.3±10.7 years; 346 men) treated with either f-TEVAR (n=110) or ch-TEVAR (n=364) for 352 TADs (81 f-TEVAR and 271 ch-TEVAR) or 122 TAAs (29 f-TEVAR and 93 ch-TEVAR) from 2008 to 2016. The primary endpoints at 30 days and during follow-up were overall mortality, aorta-related mortality, and major complications. The secondary endpoints were endoleak and reintervention. The patency of the target branches, cost of hospitalization, and the use of antiplatelet drugs were also analyzed. Results: Intraoperative type I endoleaks were treated in 69 (14.6%) cases (4 f-TEVAR and 65 ch-TEVAR, p<0.01) to achieve 100% technical success. Four (0.8%) patients died within 30 days [1 (0.9%) f-TEVAR and 3 (0.8%) ch-TEVAR]. Perioperative cerebral ischemia (1 fatal stroke) occurred in 9 (1.9%) patients: (1 f-TEVAR and 8 ch-TEVAR, p=0.39). During the mean follow-up of 50.6±20.0 months (49.5±18.3 months in f-TEVAR and 50.9±20.6 months in ch-TEVAR), 11 (2.3%) patients died of an aorta-related event. Type I endoleak was present in 40 (8.4%) patients (1 f-TEVAR and 39 ch-TEVAR, p<0.01). Eleven (2.3%) patients experienced stent-graft migration and 13 (2.7%) had a retrograde dissection. One hundred (16.9%) of the 593 branch stents occluded (4/75 in the f-TEVAR group and 96/518 in the ch-TEVAR group, p<0.01). The branch reintervention rate was 7.2% (34/474). The f-TEVAR group had a significantly higher probability of freedom from branch occlusion (92%) than the ch-TEVAR group (83%, p=0.007). Conclusion: Off-the-shelf techniques employing chimney grafts and homemade fenestrations are both suitable options for TAD and TAA involving the supra-aortic branches, with a low incidence of reintervention. Fenestrated TEVAR seems to have more favorable short- and midterm outcomes. Further study of these off-the-shelf techniques for aortic arch repair is warranted.

Six years' experience of thoracic endovascular aortic repair in patients with thoracic aortic diseases: A single-center study

Aim: Thoracic endovascular aortic repair (TEVAR) is evolving as a gold standard therapy for treating complex thoracic aortic diseases (TAD). It has evolved as first-line therapy for descending thoracic aortic aneurysms (DTAA) and Type B aortic dissection (TBAD) with reduced morbidity and mortality. The aim of this study is to evaluate clinical profiles, treatment variation, results, and complications of TEVAR. We have also highlighted the feasibility of performing complex procedures under mobile C-arm with certain innovative methods. Materials and Methods: A total of 43 patients (34 men and 9 women), mean age 59 years; age range 23–81 years, with TBAD and DTAA, who underwent TEVAR at tertiary care center from July 2012 to April 2019 were included in the study. Management strategies applied as per existing recommendations requiring TEVAR with or without debranching. The primary endpoints were technical success, 30-day mortality. The secondary endpoints were death, stroke, or spinal cord ischemia (SCI) and graft-related complications such as endoleak, migration, kinking, or thrombosis. Follow-up was done at 1, 3, 6, and 12 months and thereafter yearly. Follow-up events included death from all causes, neurological deficits, malperfusion syndrome, and reintervention. Results: Of 43 patients, 14 had TBAD and 29 had DTAA. Sixteen required hybrid repair and rest underwent TEVAR alone. Primary technical and assisted primary clinical success was 96% and 100%, respectively. Three patients developed Type I endoleak, covered with thoracic extender. The mortality rate was 9.5%. One had minor stroke and no SCI. Conclusion: TEVAR is reliable, stable, and safe for the treatment of TAD. It continues to evolve rapidly and will likely establish itself as the first-line procedure with reduced perioperative morbidity and mortality. Utility of hybrid theaters cannot be overemphasized, and the possibilities of performing TEVAR in with portable C-arm will enable the procedure to be performed in the smaller center also.

Management of the Proximal Anchoring of Stentgrafts in the Treatment of Thoracic Aortic Diseases: Results of the Hybrid Procedures

Hybrid treatment is an alternative to conventional surgery to treat the pathologies of the aortic arch. The objective of this study was to describe the short and medium term results of the hybrid treatment of the diseases of the thoracic aorta, for which the proximal anchoring of the endoprothèse is in the aortic arch.

LATE OUTCOMES OF PATIENTS WITH THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR) IN A LARGE SINGLE CENTER COHORT: ARE WE DOING THE RIGHT THERAPY?

Since its introduction, thoracic endovascular aortic repair (TEVAR) has gained widespread acceptance for treatment of thoracic aortic diseases. While early benefits in terms of mortality and morbidity are well documented, reports of late outcomes after TEVAR are limited. We herein report the late outcomes of a large cohort of patients treated with TEVAR in a single large institution. Since 2001, 330 patients were treated by TEVAR; 6,4% (21/330) died perioperatively. All 309 surviving patients were followed prospectively by chest tomography (CT) in a dedicated thoracic aortic clinic; mean FU 5.2± 4.0 years, mean CT/pt: 5.4± 2.9. At operation, mean age was 63.0± 15.6; 76.3% male. Operative indication was: aneurysm 43.4%, dissection 17.5%, complicated penetrating ulcer /intramural hematoma 18.1%, traumatic rupture 14.2%, other indications in 6.2%; 36.6% of procedures were emergent. Proximal landing zone was in zone 0-1 in 22,6% of cases, zone 2 in 34,3% and zone 3 in 43.1%. Late death occurred in 79 pts; with five year overall survival, five-year freedom from aortic and TEVAR related deaths of respectively 78.5%, 98.3% and 93.3%. Predictors of late deaths by multivariate analysis were: COPD OR: 3.46 (1.25-9.59) p=0.02, age OR 1.1 (1.04-1.11) p<0.0001 and TEVAR infection: OR: 23.66 (2.56-218.86) p=0.005. Forty-four patients presented a type I endoleak at a mean of 2.2± 2.9 years after TEVAR implant; five-year freedom of type I endoleak of 74.3%. Type I endoleak was significantly increased in patients with dissection mainly owing to distal septal perforation. An aorto-bronchial or esophageal perforation was observed in 7 patients (2.3%) at a mean of 2.7± 2.3 years (mortality rate 57,1%); while a TEVAR infection was diagnosed in 9 patients (2.9%) at a mean of 1.2 ± 1.6 years (mortality rate 77.8%). Freedom from reintervention (open surgery or redo-TEVAR) was 83.9% at 5-years. Overall survival of TEVAR is good with acceptable TEVAR related deaths mainly owing too infectious and fistula complications. Late complications such as endoleak, infection and fistula mandate rigorous clinical and imaging follow-up for early detection and prompt reintervention in good risk patients.

Outcomes of thoracic endovascular aortic repair for chronic aortic dissections

BackgroundOpen surgical repair remains the “gold standard” treatment for chronic type B aortic dissection (cTBD) with aneurysm. Thoracic endovascular aortic repair (TEVAR) has gained popularity in recent years for the treatment of thoracic aortic diseases, including cTBD. We assessed the effectiveness of TEVAR in the treatment of cTBD using the Vascular Quality Initiative (VQI) database. MethodsThe VQI registry identified 4713 patients treated with TEVAR from July 2010 to November 2015, including 125 repairs for cTBD. We analyzed TEVAR outcomes in this cohort per the Society for Vascular Surgery reporting standards for TEVAR. ResultsMedian age was 65.0 years (interquartile range [IQR], 56.0-72.0 years), and 85 (68.0%) were male. Median aneurysm diameter was 5.5 cm (IQR, 4.8-6.3 cm). Sixty-two (49.6%) patients were asymptomatic on presentation, 57 (45.6%) were symptomatic, and 6 (4.8%) presented with rupture. Median length of stay was 8.0 days (IQR, 4.0-11.0 days). Fluoroscopy time was 17.3 minutes (IQR, 10.5-25.6 minutes). The distal landing zone was aortic zone 4 in 27 (21.6%) and aortic zone 5 and distal in 98 (78.4%) patients. Successful device delivery occurred in 123 (98.4%) patients. Conversion to open repair occurred in one (0.8%) patient. A type IA endoleak was present in 2 (1.6%), type IB endoleak in 2 (1.6%), and type II endoleak in 2 (1.6%) patients. Perioperative complications included stroke in 1 (0.8%), respiratory complications in 6 (4.8%), and spinal cord ischemia symptoms present at discharge in 3 (2.4%) patients. In-hospital mortality occurred in three (2.4%) patients. Reintervention was required in two (1.6%) patients for false lumen perfusion and in two (1.6%) patients for extension of the dissection. Follow-up was available for 43 patients at a median time of 239 days (IQR, 38-377 days). Median change in sac diameter was −0.2 cm (IQR, −0.5 to 0.1 cm). Sac shrinkage of 0.5 cm was noted in 12 (27.9%), with sac growth >0.5 cm in four (9.3%) patients. Extent of stent graft coverage did not affect sac shrinkage (P = .65). Patients with aneurysms ≥5.5 cm compared with <5.5 cm were more likely to demonstrate shrinkage (−0.6 cm vs 0.0 cm; 95% confidence interval, 0.3-11.7; P = .04). ConclusionsTEVAR for cTBD may be performed with acceptable rates of morbidity and mortality. Changes in sac diameter in the midterm are promising. Long-term data are needed to determine whether this approach is durable.

Current status of cardiovascular surgery in Japan, 2013 and 2014: a report based on the Japan Cardiovascular Surgery Database 5. Thoracic aortic surgery.

Although open aortic repair (OAR) is still considered to be a standard treatment for thoracic aortic diseases, the indications for thoracic endovascular treatment (TEVAR)/hybrid aortic repair (HAR) have expanded in recent years. The purpose of this study was to review the current status of treatment of thoracic aortic diseases in Japan. Data for 2013 and 2014 concerning surgery for diseases of the thoracic/thoracoabdominal aorta were extracted from the Japan Cardiovascular Surgery Database (JCVSD). The number of cases and operative mortality were evaluated in terms of pathologic diagnosis (acute dissection, chronic dissection, ruptured aneurysm, unruptured aneurysm), treatment modality (OAR, HAR, TEVAR), JapanSCORE (JS; <5%, 5-10%, 10-15%,≥15%), and their correlations. There were 30,271 total cases in this study and the overall operative mortality was 5.9%. Among the three types of treatment, 73.2% of patients underwent OAR (root 98.3%; ascending 97.4%; root to arch 95.5%; arch 81.7%; descending 34.2%; thoracoabdominal 64.4%). While the rate of OAR was negatively correlated with JS for the treatment of the thoracoabdominal region (JS<5, 80.4%; 5%≤JS<10, 67.6%; 10%≤JS<15, 58.8%; JS≥15, 55.7%), a correlation was not observed in other anatomic regions. The operative mortality associated with OAR was well reflected by JS (JS<5, 2.1%; 5%≤JS<10, 5.5%; 10%≤JS<15, 10.2%; JS≥15, 20.3%); however, the operative mortality associated with TEVAR/HAR was less than that with JS. The distribution of treatment differs depending on the site of disease and is not markedly influenced by JS. It is clear that JS is a reliable tool for estimating operative mortality in OAR. However, the observed operative mortality was lower than the JS in TEVAR/HAR, and a new risk score for TEVAR/HAR should be established.