Thoracic type Ia endoleak: direct percutaneous coil embolization of the aortic arch at the blood entry site after TEVAR and double-chimney stent-grafts

Comparison of the Outcomes of Total Endovascular Aortic Arch Repair Between Branched Endograft and Chimney Endograft Technique in Zone 0 Landing

PURPOSE

Zone 0 landing in thoracic endovascular aortic repair (TEVAR) has recently gained increasing attention for the treatment of high-risk patients. The aim of this study was to compare the outcomes of total endovascular aortic arch repair between branched TEVAR (bTEVAR) and chimney TEVAR (cTEVAR) in the landing zone (LZ) 0.

MATERIALS AND METHODS

This was a single-center, retrospective, and observational cohort study. From January 2010 to March 2020, 40 patients (bTEVAR, n=25; cTEVAR, n=15; median age: 79 years) were enrolled in this study, with a median follow-up period of 4.1 years. These patients were considered unsuitable for open surgical treatment.

RESULTS

All procedures were successful and no cases of conversion to open repair were noted during the 30-day postoperative period. The 30-day mortality was 2.5% (n=1; bTEVAR [0 of 25, 0%] vs cTEVAR [1 of 15, 6.7%]; p=0.375), the perioperative stroke rate was 10.0% (n=4; bTEVAR [4 of 25, 16.0%] vs cTEVAR [0 of 15, 0%], p=0.278), and type 1a endoleak rate was 15.0% (n=6; bTEVAR [0 of 25, 0%] vs cTEVAR [6 of 15, 40.0%], p=0.001). The risk factor for stroke was atheroma grade of ≥2 in the brachiocephalic artery (p<0.001). The risk factor for type 1a endoleak was cTEVAR (p=0.001). The 8-year survival rate was 49.9%. The aorta-related death-free rate and aortic event-free rate at 8 years were 94.4% (bTEVAR: 95.5% vs cTEVAR: 93.3%, p=0.504) and 60.7% (bTEVAR: 70.7% vs cTEVAR: 40.0%, p=0.048), respectively.

CONCLUSIONS

Total endovascular aortic arch repair using bTEVAR and cTEVAR is feasible for the treatment of aortic arch diseases in high-risk patients who are unsuitable for open surgery. However, as the rate of stroke is high, strict preoperative evaluation to prevent stroke is needed. No rupture of the aneurysm was observed in cTEVAR, but patients should be selected carefully because of the high incidence of type 1a endoleak.

Chimney Graft Technique Combined With Embolization for Treating Ruptured Aortic Arch Lesions

Background: This study aimed to share the experience in applying the chimney graft technique combined with embolization for treating aortic arch rupture under emergency conditions and evaluating early-term results in these patients. Methods: This study retrospectively included patients with ruptured aortic arch lesions who received the chimney graft technique combined with embolization between March 2016 and March 2021. The primary endpoint was a technical success, deemed as successful stent graft deployment to the planned location, patency of the target branch vessel, and absence of significant type I endoleak. The secondary endpoint was clinical success defined with the size of false lumen in follow-up remaining unchanged or decreasing over time, 30-day mortality, complication, and primary patency of chimney graft. Results: This study included 12 patients (age, 61 ± 12 years; male, 83%). Five patients (42%) received single chimney, one patient (8%) received double chimney, and six patients (50%) received triple chimney. Intraoperative type I endoleak occurred in six patients (50%) who underwent endovascular embolization in the primary operation. Post-operative type I endoleak, evaluated by computed tomography angiography examination following the primary operation, occurred in seven patients (58%), including one patient who received endovascular embolization two times. All patients with post-operative type I endoleak were successfully re-treated using coil and Onyx glue within 1 week, and the median length of stay was 22 ± 11 days (range: 7-44 days). Overall technical success was 100%. Eleven patients had completed their follow-up (median, 12 months, range: 1-34 months), and one patient was out of contact. The 30-day mortality was 9% (1/11, post-operative death of a patient with cerebral hemorrhage). No major complications and no chimney compression, migration, occlusion, or stenosis were recorded during follow-up. Seven patients (58%) have ≥6 months of clinical follow-up time with appropriate imaging. In four (57%) of these patients, diameter stabilization was detected, whereas three (43%) experienced significant reduction (≥5 mm). Conclusion: The patients in this study had satisfactory early-term outcomes. The chimney graft technique combined with coil and Onyx glue embolization may be a safe and effective treatment for ruptured aortic arch lesions under emergency conditions.

A technique for creating an experimental type Ia endoleak model in the thoracic aorta of swine

PURPOSE

This study aimed to create an animal model of type Ia endoleak that creates persistent problems after thoracic endovascular aortic repair.

MATERIALS AND METHODS

In six swine, thoracic aortic aneurysms were created using the harvested jugular vein. We created a type Ia endoleak using a composite stent-graft comprising the first stent-graft (reverse-tapered: thicker part, 16 mm; thinner part, 10 mm) and the second stent-graft (tapered: thicker part, 18-20 mm; thinner part, 16 mm). This double-component stent-graft was deployed in the abdominal aorta and then moved upward to the proximal entry site of the thoracic aneurysm using the inflated balloon for precise positioning. After the surgical procedure and on postoperative day 8, aortography was performed to detect residual endoleak, and then the swine were euthanized.

RESULTS

A stable aneurysm (mean size of all aneurysms, 16.8 ± 1.72 mm × 11.8 ± 2.32 mm) and type Ia endoleak were successfully observed in all swine. A single stent-graft was sufficient in one of the six swine.

CONCLUSION

A novel technique to create a type Ia endoleak model can be successfully developed in swine.

Secondary Endoleak Management Following TEVAR and EVAR

Endovascular abdominal and thoracic aortic aneurysm repair and are widely used to treat increasingly complex aneurysms. Secondary endoleaks, defined as those detected more than 30 days after the procedure and after previous negative imaging, remain a challenge for aortic specialists, conferring a need for long-term surveillance and reintervention. Endoleaks are classified on the basis of their anatomic site and aetiology. Type 1 and type 2 endoleaks (EL1 and EL2) are the most common endoleaks necessitating intervention. The management of these requires an understanding of their mechanics, and the risk of sac enlargement and rupture due to increased sac pressure. Endovascular techniques are the main treatment approach to manage secondary endoleaks. However, surgery should be considered where endovascular treatments fail to arrest aneurysm growth. This chapter reviews the aetiology, significance, management strategy and techniques for different endoleak types.

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

Background

Zone 0 landing hybrid thoracic endovascular aortic repair (TEVAR) includes a few moderately invasive surgical procedures. To reduce invasiveness, TEVAR with a branched aortic arch stent-graft can be considered. This study aimed to elucidate the effectiveness of performing TEVAR using a Bolton (Bolton Medical, Inc, Sunrise, Fla) branched endograft by analyzing early and midterm results.

Methods

We enrolled 28 patients (mean age, 78.4 years) who underwent TEVAR with the Bolton branched endograft in Osaka University Hospital between October 2012 and June 2018 with a mean follow-up period of 4.0 years. Double-side and single-side branched devices were used in 24 (85.7%) and 4 (14.3%) patients, respectively.

Results

All procedures were successful; no cases of endoleak or conversion to open repair were noted during the 30-day postoperative period. The perioperative stroke rate was 14.3% (4 out of 28); midterm stroke was not detected. All patients with perioperative stroke had atheroma grade ≥2 in the brachiocephalic artery. No type 1a endoleak was reported during the early or midterm results. The cumulative survival rate, aorta-related death-free rate, and aortic event-free survival rate at 5 years were 80.8%, 95.8%, and 81.6%, respectively.

Conclusions

We achieved satisfactory early and midterm results by using a Bolton branched endograft for high-risk patients with arch pathologies except for high postoperative stroke. Although this treatment method is associated with postoperative stroke, performing strict evaluation of atheroma may prevent such complication. By preventing intraoperative stroke, TEVAR with this custom-made Bolton branched endograft may be considered a less-invasive treatment.

Repair of Type Ia Endoleaks Involving the Distal Arch Using Left Subclavian Artery-Left Common Carotid Artery Transposition with a Stented Elephant Trunk

BACKGROUND

Type Ia endoleaks are common after thoracic endovascular aortic repair (TEVAR). However, the repair of type Ia endoleaks involving the distal arch is challenging because of the presence of the interventional endografts, potential damage to the aortic arch vessels, and the location and size of the aneurysmal body. We retrospectively reviewed our experience of the surgical treatment of type Ia endoleaks with distal arch involvement using left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition with a stented elephant trunk.

METHODS

Sixteen patients (male = 16; mean age, 47 ± 9 years, range 31-63 years) with type Ia endoleaks involving the distal arch underwent LSCA-LCCA transposition with a stented elephant trunk from July 2010 to July 2018. TEVAR failure occurred in 12 patients, re-TEVAR was performed in two patients, hybrid aortic arch repair in one patient, and the chimney technique in one patient.

RESULTS

There were no in-hospital deaths. Fourteen patients required mechanical ventilation for <24 h and one for <48 h. One patient required reintubation after mechanical ventilation for 19 h and continuous renal replacement therapy because of renal failure. One patient received pericardial drainage, and recurrent laryngeal nerve injury occurred in one patient. Three patients died during follow-up.

CONCLUSIONS

The LSCA-LCCA transposition with a stented elephant trunk can produce satisfactory results in patients with a type Ia endoleak involving the distal arch. Using this technique, it is possible to exclude the aneurysm sac distal to the LCCA origin and seclude the failed interventional endograft. These encouraging outcomes suggested that this technique could be a suitable surgical treatment for this type of lesion.

Treatment of Type I Endoleak after Thoracic Endovascular Aortic Repair and Stent Extension via False Lumen Catheterization and Coil Embolization

Thoracic endovascular aortic repair (TEVAR) is a minimally invasive alternative to conventional open surgical reconstruction for the treatment of thoracic aortic dissection. However, the possibility of a type I endoleak may contribute to false lumen enlargement and rupture. Here, we present a case of successful treatment of type I endoleak after TEVAR and endograft extension for a complicated descending thoracic aortic dissection that was embolized by coils via a false lumen channel through the distal entry tear. This endovascular technology might offer a new option to treat thoracic type I endoleak by embolizing the blood entry site of the endoleak through the distal entry site and false lumen.

Persistent Type I Endoleak after Endovascular Treatment with Chimney Technique

Thoracic endovascular aortic repair (TEVAR) is increasingly used in the treatment of acute type B aortic dissection. Type Ia endoleaks are a common complication of the procedure, but its clinical significance and the best treatment strategy remain poorly defined. We present a case of a type Ia endoleak following TEVAR in the treatment of acute type B aortic dissection. Chimney technique approach was used in an attempt to seal the endoleak. Although technical success was suboptimal, the patient remained clinically stable and event free. Data regarding the natural course and management of type Ia endoleaks following TEVAR for aortic dissection are sparse. Future research is required to establish the clinical and technical determinants of the need to treat these endoleaks and the best treatment strategy.