Frozen Elephant Trunk in Right Aberrant Subclavian Artery

Endovascular single-branched stent graft to treat complicated type B aortic dissection involving aortic arch anomalies

BACKGROUND

The optimal treatment of complicated type B aortic dissection (cTBAD) involving arch anomalies remain unclear.

METHODS

We consecutively enrolled patients with cTBAD involving arch anomalies who underwent endovascular repair using a single-branched stent graft (SBSG) at our medical center between January 2020 and January 2023. The demographics, clinical manifestation, operation detail, and follow-up outcomes of these patients were retrospectively collected and analyzed.

RESULTS

A total of 16 patients (14 men; 55.8 ± 11.7 years) were enrolled, including isolated left vertebral artery (ILVA) (n = 6), aberrant right subclavian artery (ARSA) (n = 7), and right aortic arch and aberrant left subclavian artery (ALSA) with Kommerell's diverticulum (KD) (n = 3). Among them, six patients with multi-branched arch anomalies. The endovascular management strategies of patients were diverse based on their aortic morphology. The early outcome demonstrated that one patient experienced an immediate intraoperative type Ia endoleak, which was resolved by balloon dilation, and two patients exhibited bird-beak configuration. After a median of follow-up of 910 (743-1023) days, the long-term outcome revealed that two patients developed endoleak. No death, retrograde type A aortic dissection (RTAD), paraplegia, stent graft-induced new entry tear (SINE), or branch section stenosis of SBSG were observed during the follow-up.

CONCLUSION

Our limited experience suggests that endovascular repair with a SBSG appears to be a relatively safe, feasible, and effective treatment option for patients with cTBAD and arch anomalies.

Thoracic endovascular aortic repair for type B aortic dissection with aberrant right subclavian artery: a single-center retrospective study

Objective

To evaluate the outcomes of thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) with aberrant right subclavian artery (ARSA).

Methods

A retrospective analysis was conducted on patients with TBAD and ARSA who underwent TEVAR between the period of January 2017 and December 2022. Patient demographics, computed tomography angiography (CTA) measurements, surgical procedures, and postoperative outcomes were reviewed.

Results

A total of 9 patients (6 males and 3 females) were included in the study. 4 ARSA were reconstructed, 3 by periscope technique and 1 by in vitro fenestration technique. 3 left subclavian arteries (LSA) were reconstructed, 1 by the chimney technique and 2 by the single-branched stent technique. 2 patients underwent reconstruction of both ARSA and LSA. The overall technical success rate was 100%, with no occurrences of stroke, paraplegia, or mortality within 30 days. 1 patient experienced immediate type Ia endoleak, which resolved after 3 months. 1 patient developed weakness in the right upper limb, while 1 patient presented mild subclavian steal syndrome (SSS); both cases showed recovery during follow-up. The average follow-up duration was 35.6 ± 11.1 months, during which no reinterventions, deaths, or strokes were observed.

Conclusion

Our limited experience involving 9 patients demonstrates that early and mid-term outcomes of TEVAR for the treatment of TBAD with ARSA are satisfactory.

Aberrant right subclavian artery: a novel approach and an overview of operative techniques

An aberrant right subclavian artery (ARSA) is a rare variation of normal anatomy occurring in 0.5% to 1.8% of the population. No current guidelines are available regarding ARSA management, and surgical intervention should be evaluated carefully. Moreover, symptomatic patients with a dominant left arch and aberrant ARSA require a surgical approach from the right side of the chest for ligation and division of the aberrant artery at its origin on the aorta. The ARSA can then be reimplanted onto the right common carotid artery via a supraclavicular incision. The extensive mobilization in the chest allows for easy reimplantation in the supraclavicular region and eliminates reliance on the collateral circulation. Postoperative monitoring is reliable and easy with radial pulse examinations.

Zone proximalization in frozen elephant trunk: what is the optimal zone for open intervention? A systematic review and meta-analysis

INTRODUCTION

The treatment of complex aortic lesions involving the ascending, arch, and proximal descending aorta, remains challenging for surgeons despite the evolution of surgical techniques and aortic prostheses over decades. The frozen elephant trunk (FET) approach offers a one-stage repair of this entity of aortic pathologies. The main scope of this systematic review and meta-analysis is to evaluate the clinical outcomes and effectiveness of FET.

EVIDENCE ACQUISITION

In a systematic review, multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE were searched from inception to June 2021 to identify relevant studies reporting on outcomes of total arch replacement (TAR) with FET.

EVIDENCE SYNTHESIS

Eighty-five studies met inclusion criteria, encompassing 10960 patients. Meta-analysis was conducted using the R-studio (RStudio, Boston, MA, USA) and STATA software (StataCorp LLC, College Station, TX, USA). The pooled in-hospital mortality rate was 7% (95% CI 0.05-0.09; I²=76%) and 12% for renal failure (95% CI 0.09-0.15; I²=88%), while the rates for paraplegia and cerebrovascular accidents were 3% (95% CI 0.02-0.04; I²=0%) and 6% (95% CI 0.05-0.08; I²=73%), respectively. Lower heterogeneity was attained after the stratification by the aortic pathologies, except for the renal failure. The distal anastomosis of the stent in zone 2 was significantly correlated with a lower renal failure development compared to zone 3 (odds ratio 0.52; 95% CI 0.33-0.82; P=0.069; I²=0%).

CONCLUSIONS

Our results indicate that the morbidities and mortality following TAR with FET were acceptable. We also associated the distal anastomosis in zone 2 with fewer renal failure development compared to that in zone 3.

Frozen Elephant Trunk in Aortic Arch Disease: Different Devices for Different Pathologies

The frozen elephant trunk technique (FET) requires the use of a pre-assembled hybrid prosthesis consisting of a standard Dacron vascular portion to replace the aortic arch and a stent graft component, which is placed into the proximal descending thoracic aorta (DTA) anterogradely in the proximal descending thoracic aorta. In Europe, two hybrid prostheses are available: the E-evita Open Plus hybrid stent graft system provided by JOTEC (Hechingen, Germany) and the ThoraflexTM Hybrid (Vascutek, Inchinnan Scotland). Recommendations for use are extensive pathologies of the arch in case of acute and chronic aortic dissection, degenerative aneurysm and intramural hematoma. The FET approach allows the replacement of the whole arch in one stage with the option of direct treatment of the proximal descending thoracic aorta based on the stent component, creating a safe landing zone for further endovascular treatment more distally. The remarkable feature of this technique is the possibility to perform more proximally (from zone 3 to zone 0) the distal anastomosis in to the arch. This allows for an easier distal anastomosis, reduced hypothermic circulatory arrest time and decreased risk of paraplegia (<5%). Early results are promising and according to the most recent series the rate of developing post-operative renal insufficiency ranges from 3 to 10%, the risk of stroke from 3% to 8% and mortality from 8-15%. The aim of the article will be to provide some knowledge about the use and application of FET procedures in different aortic situations.