Endovascular Repair of Aortic Dissection Involving the Left Subclavian Artery by Castor Stent Graft: A Multicentre Prospective Trial

Preclinical Evaluation of a Modular Inner-Branched Stent Graft to Reconstruct the Left Subclavian Artery in Thoracic Endovascular Aortic Repair: Experimental Study in Pigs

PURPOSE

In approximate 40% of thoracic endovascular aortic repair (TEVAR) procedures, the left subclavian artery (LSA) needs to be covered to obtain sufficient proximal sealing zone. To preserve the LSA during the TEVAR for type B aortic dissection (TBAD) adjacent to LSA, our team designed a modular single inner-branched stent graft. This study was performed to evaluate the safety and feasibility of deploying a modular single inner-branched stent graft in a porcine model.

MATERIALS AND METHODS

Modular inner-branched stent grafts were implanted in 14 pigs via right femoral and right carotid arterial access. Computed tomography angiography (CTA) and angiography were performed in all pigs to appraise the morphological characteristics of the stent grafts at the end of follow-up. The pigs were then euthanized, and tissues were collected for gross and histological examination.

RESULTS

The technical success rate was 100% (14/14). One pig suddenly died 5 hours after operation, and 1 pig died after completing the follow-up CTA. During the follow-up period, all surviving pigs showed good mental state, normal diets and activities. Computed tomography angiography examinations showed that all stent grafts were intact without fracture. All bridging covered stents were patent. Angiography showed that the position, shape, and adhesion of the stent grafts were good, and no obvious endoleaks were found. Histological examination showed that the biocompatibility of the stent grafts was good.

CONCLUSIONS

This study's outcomes demonstrate that it is safe and feasible to deploy a modular single inner-branched stent graft in a porcine model.

CLINICAL IMPACT

This device is the first modular device designed to treat TBAD adjacent to LSA in China. This device is a modular two-component system consisting of a thoracic aortic stent graft with a retrograde inner branch and a bridging covered stent. The modular design and the retrograde inner branch are the two important innovations of this device. Theoretically, the device could make it easier and safer for clinicians to treat TBAD adjacent to the LSA.

Treatment for Stanford type B aortic dissection with insufficient anchoring region using castor integrated branched aortic stent graft

Background

To investigate the clinical efficacy of Castor integrated branched aortic stent graft for the treatment of Stanford type B aortic dissection with insufficient anchoring area.

Methods

Retrospective analysis of clinical data of 26 patients with Stanford type B aortic dissection with insufficient anchoring region (<15 mm) treated by Castor branched aortic stent graft from September 2018 to June 2022 at Ganzhou People's Hospital, including 23 acute cases and 3 chronic cases.

Results

Surgical procedures were successfully performed in all 26 patients, and during the perioperative period no complications occurred, such as cerebrovascular accident, stenosis or occlusion of left subclavian artery, progression of reverse avulsion of aortic dissection, and paraplegia. During the operation 2 patients had a small amount of type I endoleak, which disappeared during the postoperative follow-up. The other patients had good postoperative follow-up results. Review of the aortic CTA indicated good stent morphology with patency of the left subclavian artery.

Conclusions

The Castor integrated branched aortic stent graft expanded the indications for endoluminal treatment for Stanford type B aortic dissection, which can avoid open surgery and has good clinical outcomes.

Initial Outcomes of the Gore TAG Thoracic Branch Endoprosthesis for Endovascular Repair of Blunt Thoracic Aortic Injury

OBJECTIVE

Endovascular repair of blunt thoracic aortic injury (BTAI) has dramatically reduced the morbidity and mortality of intervention. Injuries requiring zone 2 coverage of the aorta traditionally require left subclavian artery (LSA) sacrifice or open revascularization. Furthermore, these injuries are associated with increased risk of in-hospital mortality and long-term morbidity. Here we report 1-year outcomes of total endovascular repair of BTAI with the GORE® TAG® Thoracic Branch Endoprosthesis for LSA preservation.

METHODS

Across 34 investigative sites, 9 patients with BTAI requiring left subclavian artery coverage were enrolled in a nonrandomized, prospective study of a single branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for LSA perfusion.

RESULTS

This initial cohort included 8 male and 1 female patient with a median age of 43 (22, 76) and 12 months of follow-up. Five total years of follow-up is planned. All participants had grade 3 BTAI. All procedures took place between 2018-2019. The median injury severity score was 2 (0, 66). The median procedure time was 109 minutes (78, 162). All aortic injuries were repaired under general anesthesia and with heparinization. A spinal drain was used in one patient. Post-deployment balloon angioplasty was conducted in one case at the distal landing zone. There was one asymptomatic LSA branch occlusion 6 months after repair. It was attributed to purposeful proximal deployment of the branch stent to accommodate an early vertebral takeoff. The occlusion did not require revascularization. There were no strokes, mortalities, or aortic adverse events (migration, endoleak, native aortic expansion, dissection or thrombosis) through 12 months of follow-up.

CONCLUSIONS

Initial cohort outcomes suggest that endovascular repair of zone 2 BTAI is feasible and has favorable outcomes using the thoracic branch device with LSA preservation. Additional cases and longer-term follow-up are required for definitive assessment of the device safety and durability in traumatic aortic injuries.

Outcome of Revascularizing the Left Subclavian Artery via Carotid-Subclavian Bypass

BACKGROUND

 Endovascular thoracic aortic treatment frequently requires extending the proximal landing zone up into the aortic arch with consecutive covering of the left subclavian artery orifice. Our aim was to report on our outcome of left subclavian artery revascularization using carotid-subclavian bypass via lateral access to the subclavian artery.

METHODS

 Patients' charts in our aortic center were screened for all those who had undergone carotid-subclavian bypass during endovascular thoracic aortic repair procedures. We analyzed perioperative complications such as cervical plexus nerve or phrenic nerve injury, bleeding, and primary and follow-up graft patency.

RESULTS

 Between 2001 and 2020, 118 patients underwent carotid-subclavian bypass implantation. Postoperative complications included left-sided stroke in 3% and axillary, phrenic, and recurrent laryngeal nerve palsy in 3, 2, and 3%, respectively. Carotid-subclavian bypass-related death rate was 0%. Bypass patency was 92 ± 7% at 5 years. We documented nine (8%) bypass late occlusions with one left upper extremity ischemia and one late stroke due to an embolized thrombus formed at the bypass anastomosis. All others were asymptomatic.

CONCLUSION

 Carotid-subclavian bypass surgery is associated with very low risk of death, stroke, or any nerve palsy. Lateral access to the left subclavian artery reduces the risk of phrenic nerve injury.

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

PURPOSE

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

CLINICAL IMPACT

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 repair of an intrathoracic subclavian artery aneurysm with a single-branched thoracic endograft in a hostile anatomy

OBJECTIVE

Subclavian artery aneurysms (SAA) are rare and usually involve the proximal segment of the artery. In this setting traditional surgical treatment or hybrid procedures are associated with significative morbidity rate so that new endovascular solutions are preferred.

METHODS

Authors report a case of a patient with an intrathoracic left SAA involving the aortic arch's outer curve. Patient's comorbidities contraindicated open surgical treatment while anatomical issues were not favourable to hybrid or standard endovascular solutions. Thus a single-branched custom-made thoracic stent-graft (Castor, MicroPort Medical, Shanghai, China) was implanted.

RESULTS

Technical success was achieved with no intra-operative complications and technical steps of the procedure are accurately described.A pre-discharge CT scan showed the correct position of the endograft, complete aneurysm exclusion and branch patency.

CONCLUSION

Single-branched thoracic stentgrafts could be a good option in unfavourable anatomies with supra-aortic vessels disease involving the aortic arch, with good results in terms of morbidity and early outcomes.

Efficacy of Endovascular Repair Using Single Left Common Carotid Artery Stent Combined with Castor Single-Branched Stent-Graft in the Treatment of Regional Diseases of Zone 2 of the Aorta

PURPOSE

To observe the short-term efficacy of thoracic endovascular aortic repair (TEVAR) using a single left common carotid artery chimney stent combined with a Castor single-branched stent-graft (SC-TEVAR) in the treatment of zone 2 (Z2) aortic diseases.

MATERIALS AND METHODS

To conduct a retrospective analysis of 20 patients with Z2 aortic diseases who were treated in our department from June 2021 to April 2022. The lesions included true aortic degenerative aneurysms with diameter ≥5.0 cm and penetrating aortic ulcers with depth >1.0 cm or basal width >2.0 cm. All 20 patients accepted the SC-TEVAR treatment, which was a new hybrid method to assure the flow of the left common carotid artery (LCCA) and left subclavian artery (LSA). This method was defined as a concomitant chimney stent for LCCA and a Castor single-branched stent graft for the aorta and LSA. The baseline data and intraoperative data were collected to evaluate the safety and efficacy of this method. The patency of the target blood vessel and any associated complications were evaluated at 1 and 6 months postoperatively, to analyze the safety and efficacy of this new method.

RESULTS

After discharge from the hospital, all patients were followed up by a specific follow-up team. At 6 monthly follow-up period, there were no cardiac events, stroke, hemiplegia, type I endoleak, type II endoleak, proximal stent graft-induced new entries, distal stent graft-induced new entries, wound infection, or bleeding. Only 1 patient developed an inguinal wound hematoma and got conservative treatment. Importantly, no patients developed stenosis or occlusion of the LCCA or LSA. The patency of branched arteries was 100%. The technical success rate was 90%.

CONCLUSION

SC-TEVAR appears to be a new and relatively simple, safe, and effective treatment for Z2 aortic diseases.

CLINICAL IMPACT

This was a single-center retrospective cohort study. A total of 20 patients with zone 2 aortic diseases accepted a new hybrid surgical method named SC-TEVAR. This method was not complicated and could be finished with only 3 peripheral artery exposure. The result showed no mortality, 100% patency of the branch artery, and 90% of technical success in 6 months of follow-up time. SC-TEVAR showed a satisfactory result in this retrospective study and could be promoted as an easy method to treat zone 2 aortic diseases.

Surgical treatment for right-side aortic arch concomitant with Kommerell's diverticulum: techniques selection and follow-up results

BACKGROUND

Right-side aortic arch concomitant with Kommerell's diverticulum (KD) is a rare and complex ailment, and there is no consensus on the optimal strategy to deal with this congenital anomaly. We retrospectively analyzed and summary of the cases treated in our center with individual treatment methods for different situations.

METHODS

Between September 2018 and December 2021, 10 patients experienced surgical therapy at our institution who presented with a Kommerell's diverticulum arising from an aberrant subclavian artery from the right-side aortic arch. Four main surgical techniques were applied to those patients: 1. total arch replacement with frozen elephant trunk implantation (n = 2); 2. hybrid procedure combining open arch repair and endovascular intervention (n = 1); 3. total endovascular repair using thoracic endovascular aortic repair (TEVAR) with or without left subclavian artery (LSCA) revascularization (n = 6); 4. direct repair underwent endoaneurysmorrhaphy. Clinical characteristics and outcomes were collected.

RESULTS

The mean age of these 10 patients was 56.5 years (range 29-79 years) and only 1 woman. The pathology includes aortic dissection (n = 6) and aneurysm (n = 4). The mean diverticulum size was 41.4 [24.2-56.8] mm. There were no in-hospital deaths, and the median hospital stay was 22 [15-43] days. During the follow-up period (21.4 months, 1-44 months), one died of an unknown cause and one died of esophageal fistula. Two patients underwent second-stage endovascular intervention for distal lesion. And none of the patients had endoleak during the follow-up period.

CONCLUSIONS

Each of the procedures we have mentioned here has its advantages and disadvantages; individualized treatment should meet the appropriate indications. A single-branched stent graft is feasible and effective in the treatment of aortic disease combined with Kommerell's diverticulum.

Mid-term efficacy of castor stent and in situ fenestration stent in the treatment of type B aortic dissection involving the left subclavian artery: A retrospective single-center study

To evaluate the midterm efficacy of the Castor stent (CS) versus in situ fenestration (ISF) for reconstructing the left subclavian artery (LSA) in patients with type B aortic dissection (TBAD). Between July 2017 and July 2022, a total of 247 patients with TBAD were enrolled. One hundred thirty-seven patients were treated using CSs (group A), while the remaining 110 patients received ISFs (group B). Data of the two groups were retrospectively analyzed. The success rates of surgery were 99.3% and 95.5% in groups A and B (p = .053), There were no deaths during hospitalization. During surgery, group B showed a longer surgical duration [68.0 (66.0, 77.0) vs. 62.0 (59.0, 66.0) min, p < .001] and intraoperative fluoroscopy time [18.0 (16.0, 20.0) vs. 16.0 (14.0, 18.0) min, p < .001] than group A. The follow-up duration was similar for both groups (44.0 vs. 43.0 months, p = .877), and no patient died. Stent-related complications were significantly lower in group A than in group B (1.5% vs. 8.4%, p = .009). Group A had fewer instances entry flow (0.7% vs. 4.7%, p = .048) and stent stenosis (0.7% vs. 2.8%, p = .206) than group B. All reintervention cases (4.7%) were from group B (p = .011). The rate of false aortic lumen thrombosis was significantly higher in group A than in group B (84.6% vs. 72.9%, p = .024). Both CSs and ISFs are evidently safe, feasible, and effective in achieving positive early outcomes in patients undergoing treatment for TBAD. Notably, at midterm follow-up, CSs appeared to be superior to ISF in terms of reducing stent-related complications and minimizing the need for reintervention.

Bibliometric analysis of the top 100 most-cited articles on branch reconstruction in endovascular aortic repair

With the global acceptance of endovascular aortic repair (EVAR) for aortic diseases, one of the most common issues in EVAR is the preservation of critical aortic branches. Despite the fact that many studies on EVAR-assisted endovascular branch reconstruction techniques have been published. There were few bibliometric analyses that focused on branch rebuilding in endovascular aortic repair. In this study, we aim to analyze the characteristics of the 100 most-cited articles on branch reconstruction in Endovascular Aortic Repair. The most popular articles retrospectively searched on the Web of Science were published between 1999 and 2018, with 10480 citations in total (an average of 551.58 citations per year). The top-cited article was 281 citations. The peak years of citations was 2019 (1051 citations). Journal of Vascular Surgery published the most articles (46 articles) and was the most-cited journal (5055 citations), and the United States was the country with the greatest number of publications (43 articles). Cleveland Clinic was the most influential institution with 20 articles. Fenestration technique was the major topic area of interest and trend (63 articles mentioned). Customised device was the most widely used endograft (52 articles mentioned). Renal artery was the most frequently reconstructed branch of aorta (70 articles mentioned). Our analysis showed the endovascular branch reconstruction in EVAR developed rapidly over the past 20 years. Continued exploration and cooperation between specialties and manufacturers on endograft design and modifications will further enhance knowledge of disease intervention and treatment.

Anatomic Feasibility of In-Situ Fenestration for Isolate Left Subclavian Artery Preservation during Thoracic Endovascular Aortic Repair Using an Adjustable Needle Puncturing System

OBJECTIVES

To evaluate the feasibility of thoracic endovascular aortic repair (TEVAR) using the Ankura™ device (Lifetech Scientific, Shenzhen, China) with left subclavian artery (LSA) in-situ fenestration (ISF) using an adjustable puncture device system.

METHODS

It is a single center, retrospective, financially unsupported cohort study of TEVAR performed from 16 February 2007 to 10 January 2023. Inclusion criteria were isolate LSA revascularization for elective or urgent/emergent "zone 2" TEVAR, and the availability of the preoperative computed tomography angiography.

RESULTS

Post-hoc analysis identified 52 TEVARs. There were 39 (75.0%) males, and 13 (25.0%) females: median age was 74.5 years (IQR, 65.5-78). Index TEVAR was performed for atherosclerotic aneurysm in 27 (51.9%) cases, dissection-related diseases in 18 (34.6%), penetrating aortic ulcer in 5 (9.6%), and blunt traumatic aortic injury in 2 (3.8%). Access-vessel feasibility rate of TEVAR using the Ankura™ device would have been 98.1% (51/52). Considering the morphology of the aortic arch, ISF TEVAR feasibility would have been 61.5% (32/52). Binary logistic regression analysis identified LSA angulation (OR: 1.1, 95%CI: 1.03-1.14, p = 0.003) to be associated with ISF feasibility using this endograft and a self-centering adjustable needle-based puncture device.

CONCLUSIONS

Potential feasibility of TEVAR using the Ankura™ endograft with ISF using a self-centering adjustable needle system was 61.5%. Left subclavian artery angulation seems to be the most important and limiting anatomical constraint.

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.

Chimney Technique and Single-Branched Stent Graft for the Left Subclavian Artery Preservation During Zone 2 Thoracic Endovascular Aortic Repair for Type B Acute Aortic Syndromes

PURPOSE

The purpose of this study was to evaluate the efficacy and safety of zone 2 thoracic endovascular aortic repair assisted by the chimney technique or single-branched stent graft for the preservation of the left subclavian artery, and summarize our single-center experience with the techniques.

MATERIALS AND METHODS

From February 2017 to June 2020, 137 patients who underwent left subclavian artery revascularization during zone 2 thoracic endovascular aortic repair were enrolled. Patients had acute type B aortic dissection and penetrating aortic ulcer associated with intramural hematoma. The chimney technique was performed in 68 patients (group A), and single-branched stent graft was deployed in 69 patients (group B). All procedures were performed during the acute phase. Primary technical success, immediate postoperative endoleak, neurologic complications (stroke or spinal cord ischemia), 30-day mortality, 1-year technical success, all-cause mortality, patency of the left subclavian artery, and reintervention were analyzed. Comparing the occurrence of the Bird-Beak Configuration, defined as a gap between the aortic wall and the sent graft with stent protrusion into the aortic lumen more than 5 mm, was also performed.

RESULTS

Primary technique success was achieved in 66 and 67 patients in groups A and B, respectively. The incidence of immediate postoperative endoleak, neurologic complications (stroke or spinal cord ischemia), and 30-day mortality were 5.9%, 1.5%, and 4.4% in group A, and 2.9%, 2.9%, and 2.9% in group B, respectively. During follow-up, the 1-year technical success rate was similar in both groups. All-cause mortality was similar in both groups (3.1% in group A and 4.5% in group B). The patency of the left subclavian artery was not significantly different between the 2 groups with 2 and 3 occlusions in groups A and B, respectively. The rate of reintervention was higher in group B (3.1% vs 1.6%, p=0.536), with a non-significant difference. Bird-Beak Configuration was more prominent in group B with the incidence of 59.42%.

CONCLUSIONS

Acting as minimally invasive alternatives, both techniques are feasible for left subclavian artery preservation during zone 2 thoracic endovascular aortic repair for type B acute aortic syndromes with encouraging mid-term outcomes. Long-term follow-up is required to confirm these findings.

Outcomes of Castor Single-Branched Stent Graft for Reconstruction of Multiple Supra-Aortic Branches in Aortic Arch Disease

PURPOSE

To report the outcomes of a combination of Castor single-branched stent grafts with other techniques for the reconstruction of multiple supra-aortic branches in aortic arch disease.

MATERIALS AND METHODS

Between December 2019 and December 2021, 20 patients with aortic arch disease underwent thoracic endovascular aortic repair (TEVAR) at our institution using a Castor single-branched stent graft combined with the fenestration, chimney, or bypass techniques. Thoracic endovascular aortic repair is indicated for complicated or acute type B aortic dissection (TBAD), nonruptured aneurysms with a maximum aneurysm diameter >5.5 cm or showing rapidly expanded, ruptured, or threatened aneurysms, and penetrating aortic ulcers (PAUs) with a maximal aortic diameter >5.5 cm or with PAUs >10 mm deep or >20 mm in diameter. Preoperative, intraoperative, and postoperative clinical data were recorded.

RESULTS

The median age of the patients was 56 (range=52-69 years) years, and 19 patients were men. Seven patients underwent the Castor single-branched stent graft and left common carotid artery (LCCA) chimney technique, 8 patients underwent the Castor single-branched stent graft and fenestration technique, and 5 patients underwent the Castor single-branched stent graft and bypass technique. The technical success rate was 100%. Major adverse events included 2 endoleaks, 1 spinal cord ischemia, and 1 early-stage retrograde type A aortic dissection. No cerebral stroke-related complications were observed. The mortality rate was 10% (2/20 patients). One patient with thoracic aortic aneurysm (TAA) died because of a sudden decrease in oxygen saturation and blood pressure after surgery. Relatives declined autopsy, and the cause of death was not determined. Another patient died of a retrograde type A dissection after surgery. The median follow-up period was 6 months (range=3.5-12 months). During follow-up, 1 patient with type I endoleak underwent thoracotomy again after a year. The remaining patients recovered well.

CONCLUSIONS

The combination of a Castor single-branched stent graft with fenestration, chimney, or bypass techniques may be an effective treatment for preserving multiple supra-aortic branches in aortic arch disease.

CLINICAL IMPACT

This study introduced three methods of reconstruction of multiple supra-aortic branches using a Castor single-branched stent graft (Castor single-branched stent graft combined with fenestration, chimney, or bypass technique) and analysed their advantages and shortcomings to provide experience for the future treatment of aortic arch diseases.

Mid-term Outcomes of Endovascular and Hybrid Procedures to Treat Complex Aortic Arch Pathologies

PURPOSE

To compare the mid-term outcomes of endovascular and hybrid procedures in treating aortic arch pathologies with an unfavorable proximal landing zone, and analyze the different indications of the 2 methods.

METHODS

We collected the clinical data from 59 patients with complex aortic arch pathologies who underwent endovascular or hybrid surgery from March 2018 to April 2020 at a single center. Among the patients, 45 were treated by branched or fenestrated surgery and 14 by hybrid surgery. The clinical data of preoperative, perioperative, and postoperative results were retrospectively analyzed and compared. The main study indexes were the branch patency rate and endoleakage rate during the follow-up period. The secondary study indexes included the operation success rate, operative time, hospital expenses, complication incidence, freedom from reintervention rate, mortality, etc.

RESULTS

The operation success rate of all the groups was 100%. The hospital expenses of the hybrid group were lower than those of the endovascular group (p<0.05). The operative time of the hybrid group was longer than that of the endovascular group (p<0.05). The incidence of anatomic variants in the hybrid group was 28.6%, which was significantly higher than that in the endovascular group (2.2%, p=0.011). However, there were no significant differences in operative bleeding, ventilator use duration, and treatment time in intensive care units between the 2 groups (p>0.05). Follow-up was conducted for a period of 12 to 34 months. Four patients of the hybrid group experienced numbness of the upper limb (28.57%); the proportion was higher than the endovascular group (0%, p=0.002). There were no significant differences in the occurrence of endoleaks, retrograde aortic dissection, target lesion, secondary operation, branch patency rate, paraplegia, cerebral apoplexy, renal failure, or other complications in either group (p>0.05). The mortality of the endovascular group was 6.67% (3/45). Overall cumulative survival at 1 year was 100% in the hybrid group and 93.3% in the endovascular group. There was no statistical difference in the increase of the true lumen between the 2 groups for vascular remodeling (p>0.05).

CONCLUSION

The hybrid surgery costs less and proves more suitable for treating variants of the aortic arch. The endovascular treatment still has limitations due to anatomical conditions.

Single branch arch stent graft combined with laser fenestration in the treatment of a zone two penetrating thoracic aortic ulcer

We present the case of a 75-year-old man with a symptomatic penetrating aortic ulcer located in zone 2 on the arch inner curve between the left subclavian artery and left carotid artery treated using a single branch thoracic endovascular aortic repair combined with in situ laser fenestration. The patient underwent a successful procedure with no neurologic impairment and was discharged on the second postoperative day. The postoperative follow-up showed a well-excluded penetrating aortic ulcer.

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

Objective

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).

Methods

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.

Results

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.

Conclusion

Castor single-branched stent-graft implantation combined with fenestration technique may be safe and feasible for TAD patients with ILVA and unfavorable PLZ.

Advanced Endovascular Treatment of Complex Aortic Pathology

Endovascular aortic aneurysm repair and thoracic endovascular aortic repair have been shown to reduce blood loss, operative time, length of hospital stay, mortality, and morbidity compared with open surgical repair for abdominal aortic aneurysms and thoracic aortic aneurysms. However, there are anatomical constraints that limit the application of the endovascular approach in 30% to 40% of patients, including those with short necks, excessive angulation, or aneurysms with the involvement of aortic side branches such as supra-aortic trunks, arch aneurysms, visceral arteries, or internal iliac arteries.

Avoiding Stroke in Patients Undergoing Endovascular Aortic Arch Repair: JACC Review Topic of the Week

As the bottleneck of endovascular aortic arch repair, early postoperative stroke remains a devastating complication in high-risk patients and a critical concern for the development of optimal endovascular techniques and devices. The incidence of early postoperative stroke varies widely among currently available endovascular techniques and devices, with reported rates ranging from 0.0% to 42.9%, and is significantly influenced by the severity of the patient's preexisting aortic atherosclerotic burden, air released from the endovascular device, and a variety of factors leading to cerebral perfusion insufficiency. Currently, preidentification of high-risk patients and careful perioperative management appear to play a critical role in reducing stroke incidence. Specific intraoperative prevention methods are still lacking, but embolic protection devices and carbon dioxide or high-volume saline flushing of endovascular devices appear promising. Detailed preoperative stroke risk stratification and screening for optimal endovascular techniques and devices for aortic arch treatment are unmet clinical needs.

Endovascular Options for the Ascending Aorta and Aortic Arch - A Scoping Review

The gold standard for aneurysmal repair of the ascending aorta and the aortic arch has been open surgery with an established track record of good results in suitable patients. In recent years, with innovations in the endovascular field alternative endovascular solutions for pathologies of the aortic arch and ascending aorta became available. At first reserved only for highly selected patients unfit for open surgery, endovascular aortic arch repair is now being offered to patients with suitable anatomy in high volume referral centers after discussion in an interdisciplinary team. The present scoping review aims at providing an overview on indications, available devices, technical aspects and feasibility studies of endovascular arch repair both in elective and emergent situations, including also experiences and considerations from our center.

Gore TAG thoracic branch endograft for treatment of a subacute type B aortic dissection complicated by rupture

An 80-year-old man presented with a subacute zone 3-5 type B aortic dissection complicated by rupture and visceral and lower extremity malperfusion. He underwent emergent zone 2 repair with a Gore TAG thoracic branch endograft with inclusion of the left subclavian artery for a dominant left vertebral artery. The patient's postoperative course was uncomplicated. Type B aortic dissections can be anatomically complex, and rupture is a rare complication in the subacute phase. We report the novel use of a Gore TAG thoracic branch endograft for the management of type B aortic dissection complicated by rupture and demonstrate its feasibility for patients with type B aortic dissection complicated by rupture.

Homemade fenestration and chimney techniques for the left subclavian artery revascularization during zone 2 thoracic endovascular aortic repair

Background

To investigate the safety and efficacy of homemade fenestration and chimney techniques for the left subclavian artery (LSA) revascularization during zone 2 thoracic endovascular aortic repair (TEVAR).

Methods

From February 2017 to February 2021, 41 patients undergoing fenestration technique (group A) and 42 patients undergoing chimney technique (group B) to preserve the LSA during zone 2 TEVAR were enrolled in the present study. The procedure was indicated for dissections with unsuitable proximal landing zone with refractory pain and hypertension, rupture and malperfusion, and high-risk radiographic features. The baseline characteristics, peri-procedure, and follow-up clinical and radiographic data were recorded and analyzed. The primary endpoint was clinical success, and the secondary endpoints were rupture-free survival, LSA patency, and complications. Aortic remodeling, defined as patency, partial and complete thrombosis of the false lumen, was also analyzed.

Results

Technical success was achieved in 38 and 41 patients in groups A and B, respectively. Four intervention-related deaths were confirmed, two in each group. Immediate post-procedural endoleaks were detected in two and three patients in group A and B, respectively. No other major complications were found in either group, except for one retrograde type A dissection in group A. During follow-up, the initial clinical success rates were 90.24% and 92.86% in groups A and B, respectively. The primary and secondary mid-term clinical success rates were 87.5% and 90% in group A, and both of them were 92.68% in group B. Rupture-free survival and LSA patency were not significantly different between the two groups. The incidence of complete thrombosis in the aorta distal to the stent graft was 67.65% and 61.11% in groups A and B, respectively.

Conclusions

Apart from the lower clinical success rate of fenestration technique, both physician-modified techniques are available for LSA revascularization during zone 2 TEVAR and significantly promote favorable aortic remodeling.

Mid-term outcomes of left subclavian artery revascularization with Castor stent graft in treatment of type B aortic dissection in left subclavian artery

Background

Here we analyzed mid-term data of thoracic endovascular aneurysm repair (TEVAR) surgery with Castor single-branched stent graft placement for the management of Stanford type B aortic dissection (STBAD) involving the left subclavian artery (LSA).

Methods

Between April 2014 and February 2019, 32 patients with STBAD involving a Castor single-branched stent graft were included. We analyzed their outcomes, including technical success rate (TSR), surgical duration (SD), presence of ischemia, perioperative complications, LSA patency, and survival rate (SR), using computed tomography angiography and clinical evaluation during mid-term follow-up.

Results

The mean patient age was 54.63 ​± ​12.37 years (range, 36-83 years). The TSR was 96.88% (n ​= ​31/32). The mean SD was 87.44 ​± ​10.89 with a mean contrast volume of 125.31 ​± ​19.30 ​mL. No neurological complications or deaths occurred during the study period. The patients had a mean hospital stay of 7.84 ​± ​3.20 days. At a mean follow-up of 68.78 ​± ​11.26 months, four non-aortic deaths (12.5%) were observed. The LSA patency rate was 100% (n ​= ​28/28). There was only one case of type I endoleak immediately after surgery (3.12%) (type I from LSA). However, none of the patients experienced type II endoleaks, and there were no cases of retrograde type A aortic dissection or stent graft-driven new distal entry. Finally, all patients exhibited good LSA patency.

Conclusion

TEVAR using a Castor single-branched stent graft may be a highly feasible and efficient procedure for the management of STBAD involving the LSA.

Single branched endografts for the preservation of left subclavian artery in the treatment of zone II thoracic aortic lesions a systematic review and meta-analysis

BACKGROUND

We investigated the safety and feasibility of single branched endografts in the treatment of zone II thoracic endovascular aortic repair (TEVAR).

METHODS

We performed a systematic research on Medline, Scopus and EMBASE for articles published up to February 2023. Primary endpoints included technical success, thirty-day mortality, stroke and spinal cord injury (SCI) as well as unassisted left subclavian artery (LSA) branch patency by the end of follow-up. Secondary endpoints included early thirty-day and persistent endoleaks, new onset dissection and reintervention by the end of follow-up.

RESULTS

Fourteen studies, three prospective case series and eleven retrospective case series comprised of 727 patients were finally included. The pooled technical success and thirty-day mortality rates were 94.86 % (95% CI: 90.95-97.86) and 0.14% (95% CI: 0.00-0.87). The thirty-day stroke and SCI rates were 0.45% (95% CI: 0.00-1.39) and 0.08% (95% CI: 0.00-0.99) respectively, while the unassisted LSA branch patency estimate was 99.12% (95% CI: 97.97-99.86). The early thirty-day and persistent endoleak rates were 5.19% (95% CI: 2.45-8.65) and 2.57% (95% CI: 0.36-6.02), whereas new onset dissections and reinterventions estimates were 0.94% (95% CI: 0.17-2.11) and 2.40% (95% CI: 0.41-5.42).

CONCLUSION

While we have displayed the safety and feasibility of single branched endografts in the treatment of zone II thoracic aortic lesions, physicians should be aware of the persistency displayed by early type I endoleaks eventually requiring re-intervention. The variations in device and lesion characteristics accompanied by the short-term follow-up presented in our review do not allow for definite conclusions to be drawn, necessitating further research through high-quality randomized controlled trials.

Surgical treatment patterns and clinical outcomes of type B aortic dissection involving the aortic arch

OBJECTIVE

In the present report, we have described the outcomes of endovascular repair, hybrid arch repair, and open surgical repair for type B dissection involving the aortic arch (B_{1-2, D}).

METHODS

Cases of endovascular repair, hybrid arch repair, and open surgical repair performed between January 2015 and December 2019 for aortic dissection designated as B_{1-2, D} by the Society for Vascular Surgery/Society of Thoracic Surgeons classification were retrospectively analyzed. The primary end point was all-cause mortality at follow-up. The secondary end points included early mortality, early morbidities, and aortic-related late events. Kaplan-Meier curves were created to analyze survival from all-cause mortality and freedom from aortic-related late events in the endovascular, hybrid, and open groups. Propensity score matching and stratification (stratified by proximal dissection extension: B_{1, D} and B_{2, D}) were performed as sensitivity analyses to compare the outcomes among the three treatment patterns after controlling for major confounders.

RESULTS

The present study included 151 patients (men, 79.5%; mean age, 47.3 ± 10.5 years), with 72 (47.7%) in the endovascular group, 46 (30.5%) in the hybrid group, and 33 (21.8%) in the open group. No significant difference was noted in early mortality between the endovascular, hybrid, and open groups (1.4% vs 2.2% vs 3.0%; P = .791). The incidence of early endoleak was significantly greater (33.3% vs 13.0% vs 6.1%; P = .002) and the incidence of renal function deterioration was less (4.2% vs 26.1% vs 24.2%; P = .001) after endovascular repair vs hybrid arch repair and open surgery. After a median follow-up of 40.0 months (range, 0-84.0 months), no significant differences were found in all-cause mortality (5.6% vs 4.3% vs 3.0%; P = 1.0), aortic-related late events (16.7% vs 15.2% vs 12.1%; P = .834), or late endoleak (9.7% vs 4.3% vs 6.1%; P = .630) after endovascular, hybrid, and open surgery. The propensity score matching and stratification analyses displayed consistent outcomes for early mortality, all-cause mortality, and aortic-related late events among the three groups.

CONCLUSIONS

The mid- to long-term outcomes after endovascular repair, hybrid arch repair, and open surgical repair for type B dissection involving the aortic arch (B_{1-2, D}) were favorable and comparable in selected patients. Extensive experience and multidisciplinary teamwork are prerequisites for individualized strategies for repair of B_{1-2, D}.

Triple-Branched Stent Graft Implantation for Acute Non-A-non-B Aortic Dissection

BACKGROUND

The optimal treatment for acute non-A-non-B aortic dissection remains controversial. Triple-branched stent graft (TBSG) implantation has been used to treat acute type A aortic dissection. This study aimed to evaluate the safety and efficacy of TBSG as a treatment for acute non-A-non-B aortic dissection.

METHODS

Fifty patients with non-A-non-B dissection received TBSG implantation in our center between January 2014 and December 2019. Early mortality, morbidity, and dissected aorta remodeling during follow-up were calculated.

RESULTS

There were no deaths in-hospital or within 30 days. Postoperative complications included pneumonia (n = 12), acute kidney injury (n = 6; preoperative renal malperfusion, n = 4), transient cerebral injury (n = 6; preoperative cerebral malperfusion, n = 4), pleural effusion (n = 4), and pericardial effusion (n = 2). During follow-up, 1 patient experienced a stroke, and 2 patients required secondary interventional therapy for residual dissection below the level of the TBSG. All implanted TBSGs had good positioning, and all sidearm stent graft grafts were fully patent. No retrograde aortic dissection or type I endoleak was detected.

CONCLUSIONS

TBSG implantation for acute non-A-non-B aortic dissection had a low incidence of mortality and morbidity, featuring good remodeling of the dissected aortic wall during follow-up. The early outcomes of this technique were satisfactory.

Systematic review and meta-analysis of type B aortic dissection involving the left subclavian artery with a Castor stent graft

OBJECTIVE

Despite the rapid development of thoracic endovascular aortic repair (TEVAR), it is still a challenge to maintain the blood flow of the branch arteries above the aortic arch in Stanford type B aortic dissection involving the left subclavian artery (LSA). The Castor stent graft is an integrated, customized, single-branch stent that enables reconstruction of the LSA. The purpose of this systematic review and meta-analysis was to assess the efficacy of the Castor stent graft for type B aortic dissection.

MATERIALS AND METHODS

An extensive electronic literature search (PROSPERO registration number: CRD42022322146) was undertaken to identify all articles published up to August 2022 that described thoracic aortic repair with branch stents in the treatment of type B aortic dissection involving the LSA. The quality of the included studies was analyzed using the MINORS criteria. The primary outcome measures were the technical success rate, early mortality rate, endoleak rate, and 1-year survival rate. The secondary outcome measures were the stroke rate, left upper extremity ischemia rate, and target vessel patency rate.

RESULTS

Eleven studies involving 415 patients were eligible for this meta-analysis. The LSA was successfully preserved in all procedures. The technical success rate was 97.5% (95% CI: 0.953-0.991); the intraoperative endoleak rate was 0.1% (95% CI: 0.000-0.012); the intraoperative LSA patency rate was 99.52%; the intraoperative LSA stent deformation and stenosis rate was 0.15% (95% CI: 0.000-0.051); the early type I endoleak rate was 1.6% (95% CI: 0.003-0.035); the 30-day mortality rate was 0.96%; the early reintervention rate was 0.9% (95% CI: 0.000-0.040); and the perioperative stroke rate was 0% (95% CI: 0.000-0.005). The 1-year survival rate was 99.7% (95% CI: 0.976-1.000). The half-year LSA patency rate was 99.3%, the 1-year LSA patency rate was 97.58%, and the 2-year LSA patency rate was 95.23%. During the follow-up period, the leakage rate was 0.3% (95% CI: 0.000-0.017), the incidence of left upper extremity ischemia rate was 0.5% (95% CI: 0.000-0.035), and the deformation and stenosis rate of the LSA stent was 2.2% (95% CI: 0.06-0.046).

CONCLUSION

This meta-analysis shows that endovascular repair of type B aortic dissection using the Castor stent-graft may be technically feasible and effective. However, this conclusion needs to be interpreted with caution, as the quality of evidence for all outcomes is between low and very low.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022322146].

Single-branched stent-graft with on-table fenestration for endovascular repair of primary retrograde type A aortic dissection: A multicenter retrospective study

Objective

This study aims to evaluate the feasibility, efficacy, and safety of a single-branched stent-graft with on-table fenestration for primary retrograde type A aortic dissection (RTAD) during thoracic endovascular aortic repair (TEVAR).

Materials and methods

From January 2019 to December 2021, 36 patients with primary RTAD from five tertiary hospitals received medical management in the acute phase. They underwent TEVAR with a proximal zone 1 landing for aortic arch reconstruction in the subacute phase, using a fenestration technique on a single-branched stent-graft. Nearly 2 weeks after admission, computed tomography angiography (CTA) was re-examined to evaluate the thrombosis status of retrograde false lumen (FL). The primary outcomes were technical success, patency of the target branch arteries, and absence of type Ia endoleaks. The second outcomes were stent-graft-related complications and all-cause mortality.

Results

The mean age was 56.2 ± 11.3 years, and 29 (80.6%) were male. After a median interval of 18.0 [interquartile range (IQR), 17.0–20.3] days of medical treatment, the partial and complete thrombosis of proximal FL rates increased to 52.8% and 47.2%, respectively. One patient (2.8%) experienced postoperative type Ia endoleaks, and was successfully re-treated using coli and Onyx glue. The median hospital stay was 20.5 (IQR, 18.0–23.0) days. The overall technical success rate was 100%. The median follow-up time was 31.5 (IQR, 29.8–34.0) months. There was one death (2.8%) due to gastrointestinal bleeding. Distal aortic segmental enlargement (DASE) occurred in two (5.6%) patients. No major complications or recurrent dissections in the proximal landing zone were recorded during follow up.

Conclusion

The retrograde FL in primary RTAD could realize partial or complete thrombosis after medical management in the acute phase, and it might be regarded as a valid proximal landing zone for endovascular repair. The single-branched stent graft with on-table fenestration performed in the subacute phase may be feasible strategy in selective primary RTAD patients.

A review: Single and multi-branch devices for the treatment of aortic arch pathologies with proximal sealing in Ishimaru Zone 0

Recently published experience has shown that endovascular management of the aortic arch, including sealing in the proximal zones, can be a viable option for patients considered unfit for conventional open repair. Endograft designs vary and include single or multibranch devices, with or without the addition of surgical debranching. Initial reports show that both techniques can be performed with high technical success and acceptable perioperative morbidity and mortality rates in high volume centers. Single branch devices, available off-the-shelf, may provide a treatment option for emergent presentations where patients cannot wait for the design and manufacture of a customized endograft. Double or triple branched endografts are now increasingly implanted in high-volume aortic centers. The purpose of this review is to describe the single and multibranched endovascular devices currently available for aortic arch repair, their associated published outcomes, and to discuss their relative advantages and disadvantages.

Single-center experience with a unibody single-branched stent graft for zone 2 thoracic endovascular aortic repair

To provide an adequate proximal landing zone, left subclavian artery (LSA) reconstruction has become an important part of thoracic endovascular aortic repair (TEVAR). This study evaluates the short and medium term efficacy of a novel unibody single-branched stent graft for zone 2 TEVAR. Fifty-two patients (mean age, 56 ± 10.9 years; 42 men) with distal aortic arch lesions requiring LSA reconstruction received unibody single-branched stents from September 2019 to March 2021. Computed tomography angiography was performed 6, 12, and 24 months after surgery to observe stent morphology, branch patency, endoleaks, stent-related adverse events, and changes in the diameter of true and false lumens. All stents were deployed adequately, and the technical success rate was 100%. The mean operation time was 121.8 ± 47.0 min. The mean postoperative hospital stay was 6.2 ± 3.7 days, and the mean follow-up was 16.8 ± 5.2 months (range, 12–24 months). During follow-up, there were no deaths and complications such as stent displacement or fracture, stenosis, fracture, occlusion, and type Ia endoleaks. The patency rate of the branched segment was 100%. In 42 patients with aortic dissection (AD), the true lumen diameter of the aortic isthmus was 29.4 ± 2.9 mm after surgery, significantly larger than before surgery (20.6 ± 5.4 mm, P < 0.05). Postoperative aortic isthmus false lumen diameter was significantly smaller than that before operation (6.1 ± 5.2 mm vs. 16.0 ± 7.6 mm, P < 0.05). The new unibody single-branched stent for zone 2 TEVAR is safe and accurate, and its efficacy is good in the short and medium term.

Outcomes of Endovascular Repair of Aortic Aneurysms with the GORE® Thoracic Branch Endoprosthesis for Left Subclavian Artery Preservation

OBJECTIVE OR BACKGROUND

Thoracic endovascular aortic repair has emerged as the dominant paradigm for treatment of patients with descending thoracic aortic aneurysms. For aneurysms involving the aortic arch in the region of the left subclavian artery (LSA), branch vessel preservation to maintain blood flow to the LSA is recommended. Branched aortic endografts are an alternative to surgical revascularization of the LSA.

METHODS

Across 34 investigative sites, 84 patients with Zone 2 aneurysm were enrolled in a nonrandomized, prospective study of a single branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for left subclavian perfusion.

RESULTS

Over half of the patients were male (63%). Their average age was 70 (±11) years. The aneurysm morphology was fusiform in 43 and saccular in 41 patients. The mean aneurysm diameter at screening was 56.2 mm. The mean follow up was 30 months (range 2.6 to 50.7 months). Reported here are the patient outcomes at 1 and 12 months. Pre-defined technical success with implantation of the device in landing Zone 2 was achieved in 92% (n=77) of patients. There were no cases of aortic rupture, lesion-related mortality, or new onset renal failure. There was no peri-operative (30-day) mortality. A single case each of permanent paraplegia and paraparesis occurred. Three patients experienced a procedure-related stroke. Through 12 months, four patients died; none of the deaths were adjudicated as related to the device or procedure. One aortic reintervention was required. A single case of aortic enlargement (core laboratory) was reported at 6 months. Type 1 (n=3) and III (n=5) endoleaks occurred in 9.8% of patients of which one (Type III) required reintervention.

CONCLUSIONS

Results from this device study in patients with Zone 2 aneurysm demonstrate that early safety and efficacy outcomes are maintained up to 12 months after the endovascular procedure with low mortality and reintervention rates and an acceptable frequency of procedural complications, including neurologic complications.

Penetrating Aortic Ulceration Treated with Castor Branched Aortic Stent Graft—A Case Series

Penetrating aortic ulceration (PAU) is an acute aortic syndrome similar to aortic dissection and intramural hematoma. It is the result of a tunica intima ulceration due to atherosclerotic disease. This clinical condition can lead to serious complications and a poor short-term prognosis, especially in high-surgical-risk patients. We report three cases of patients referred to “Ospedale del Cuore” of Massa (Italy) with PAU at the aortic arch-proximal descending aorta level who could not undergo surgical intervention. For the first time in Italy, we successfully treated these patients with a full percutaneous implantation of a Castor branched aortic stent graft. Our case series shows that this type of endovascular graft is an effective, safe, and feasible treatment for PAU involving a distal aortic arch and avoiding surgery and related complications.

The Mini-Cross Prefenestration for Endovascular Repair of Aortic Arch Pathologies

Objective: To examine the feasibility, integrity, efficacy, and safety of endovascular repair of the aortic arch pathologies with the mini-cross prefenestration (MCPF) on stent grafts.

Methods: First, to prove the feasibility of the MCPF, an in-vitro prefenestration experiment was conducted. Second, to examine the integrity of the MCPF stent grafts, a fatigue test was conducted. Then, the membranes and metal structures of stent grafts were examined by light microscopy and scanning electron microscopy (SEM). Third, a clinical experiment was conducted to investigate the efficacy and safety of this novel technique (ClinicalTrials.gov Identifier: NCT04544579).

Results: All the 12 branch stents were successfully implanted and flared in vitro. After the fatigue test stimulating a 5-year cardiac cycle, no obvious disintegration or fracture was found in light microscopy or SEM. From December 2017 to February 2020, 26 patients with left subclavian arteries and/or left common carotid arteries involved received the novel technique. The endovascular repair with the MCPF was successfully performed on all the 26 (100%) patients. Eighteen (69.2%) patients underwent the reconstruction of the left subclavian artery (LSCA) only. The fenestrations of both the LSCA and left common carotid artery (LCCA) were conducted in 8 (30.8%) patients. Median operative time was 120 [interquartile range (IQR), 95–137.5] min and median revascularization time of the LSCA and LCCA was 30.5 (IQR, 22.8–42.0) s and 20.0 (IQR, 18.0–32.0) s separately. During the median follow-up duration of 38.9 (range, 18.8–44.2) months, one case needed an open surgery because of retrograde type A aortic dissection 3 months after implantation and no other complications or mortality occurred. The maximum aortic diameters were significantly decreased in patients with thoracic aortic dissection and thoracic aortic aneurysm (p < 0.05).

Conclusion: The existing evidence demonstrated the safety, rapid branch artery revascularization, and positive aortic remodeling of the novel technique. Long-term observation is warranted to prove the durability.

Hybrid Arch Repair with Supra-Aortic Debranching and Using Castor Stent-Graft

Background  The management of aortic lesions involving the aortic arch in patients who cannot tolerate thoracotomy is a challenge.

Case Description  A 32-year-old woman who underwent a giant aneurysm at the proximal end of the descending aorta with significant vascular wall calcification. The patient underwent Castor single-branched stent-grafting in the brachiocephalic trunk combined with surgical supra-aortic debranching, which avoided surgical aortic arch replacement and stent fenestration.reopening. The patient was followed up for 9 months, and surgery-related complications were not observed.

Conclusion  Hybrid arch repair with supra-aortic debranching and using Castor single-branched stent can be used to treat aortic lesions involving the aortic arch.

The End of Wire Wrapping: A Technique to Avoid Intertwining Preloaded Guidewires for Endovascular Aortic Arch Repair

PURPOSE

The purpose of this study was to present a new technique for endovascular aortic arch repair for 1, 2, or 3 vessels using preloaded wires and precannulated target vessels without wire wrapping.

TECHNIQUE

This technique uses a prototype catheter with 2 parallel lumens to position through-and-through guidewires in the supra-aortic branches and an extra-stiff guidewire in the ascending aorta with no wrapping. This allows the introduction and advancement of the device with the already precannulated target vessels. The endograft is advanced to the aortic arch without twisting or wrapping. Covered stents are deployed to align the graft and target vessels.

CONCLUSION

To our knowledge, a technique that avoids wire wrapping has not been previously described. This technique allows safer and faster endovascular arch procedures and opens up new possibilities by enabling multi-vessel endovascular aortic arch repair with all precannulated target vessels.