Outcomes of Fenestrated and Branched Endografts for Partial and Total Endovascular Repair of the Aortic Arch - A Systematic Review and Meta-Analysis

TEVAR with fenestrations of all supra-aortic branches for traumatic aortic pseudoaneurysm: Case report and systematic review

ObjectivesBlunt thoracic aortic injuries (BTAIs) involving the aortic arch are a challenging condition. Thoracic endovascular aortic repair (TEVAR) with fenestration, which expands the proximal landing zone, is able to exclude the injury while preserving blood flow in supra-aortic branches.MethodsHere we report a case of TEVAR with fenestrations of all supra-aortic branches for traumatic aortic pseudoaneurysm and perform a systematic review.ResultsA 24-year-old man suffering a blunt thoracic injury and a left femoral fracture was sent to our hospital. A pseudoaneurysm was found in the aortic arch between the brachiocephalic artery and the left common carotid artery. The patient underwent emergent TEVAR with fenestrations of all supra-aortic branches, which excluded the pseudoaneurysm and preserved the patency of all branches. The orthopedic team then treated the femoral fracture. The patient's recovery was unremarkable. We performed a systematic review on TEVAR with fenestrations for BTAI. Six patients (75%) received TEVAR with single fenestration, 1 patient (12.5%) received TEVAR with two fenestrations, and 1 patient (12.5%) had fenestrations of all supra-aortic branches. Except one patient died in the perioperative, other patients survived without stent-related complications in the short-term follow-up.ConclusionsTEVAR with fenestration is feasible for treating BTAI involving the aortic arch in selected patients.

Proximal Landing Zone's Impact on Outcomes of Branched and Fenestrated Aortic Arch Repair

Background/Objectives: The impact of the proximal landing zone has not been investigated in fenestrated and branched endovascular aortic arch repair (f/bTEVAR). This study aimed to analyze the f/bTEVAR outcomes in patients with non-native (nNPAL) vs. native proximal aortic landing (NPAL). Methods: The STROBE statement was followed in order to conduct a single-center retrospective analysis of patients with nNPAL vs. NPAL managed, from 1 September 2011 to 30 June 2022, with f/bTEVAR. The primary outcomes were technical success, 30-day mortality and stroke. Results: A total of 83 patients with nNPAL vs. 126 patients with NPAL were included. Among the nNPAL group, 34 (39.7%) underwent previous aortic arch replacement and the remaining underwent an ascending aortic replacement. The nNPAL patients were more commonly treated for chronic dissections (nNPAL: 70.6% vs. NPAL: 21.6%, p < 0.001), presented a more proximal disease (zone 0: nNPAL: 27.7% vs. NPAL: 7.1%, p < 0.001; zone 1: nNPAL: 50.6% vs. NPAL: 10.2%, p < 0.001) and received more triple-branch devices (nNPAL: 16.9% vs. NPAL: 3.2%, p < 0.001), with a higher rate of Ishimaru zone 0 landing (nNPAL: 86.8% vs. NPAL: 51.6%, p < 0.001). Technical success (nNPAL: 98.8% vs. NPAL: 94.4%, p = 0.07) and 30-day mortality (nNPAL: 6.0%, vs. NPAL: 11.9%, p = 0.16) were similar. Stroke was lower among nNPAL patients (nNPAL: 4.8% vs. NPAL: 13.5%, p = 0.04). A multivariate regression analysis confirmed nNPAL as an independent protector for stroke (p = 0.002). Survival (log rank: p = 0.02) was higher within the nNPAL group at 24 months. Conclusions: f/bTEVAR in patients with nNPAL zone showed encouraging outcomes. Despite more proximal landing in zone 0, stroke was significantly lower when compared to NPAL patients.

Thoracic Endovascular Aortic Repair with Left Subclavian Artery Revascularization for Type B Aortic Dissection: Outcomes of Fenestrated Physician-Modified Stent-Graft Versus Unibody Single-Branched Stent-Graft

BACKGROUND

To evaluate the outcomes of thoracic endovascular aortic repair (TEVAR) with fenestrated physician-modified stent-grafts (f-PMSG) or Castor unibody single-branched stent-graft to revascularize left subclavian artery (LSA) in type B aortic dissection (TBAD) patients.

METHODS

A retrospective analysis was conducted of TBAD patients treated f-PMSG (n = 37) or Castor unibody single-branched stent-graft (n = 43) from January 2019 to July 2022. The primary endpoints at 30 days and during follow-up were overall mortality, aortic-related mortality, and major complications. The secondary endpoints were endoleak, reintervention, and branch artery patency.

RESULTS

Technical success was 100% in both groups. No patient had early mortality in f-PMSG group, and 1 (2.3%) patient died of multiorgan failure during hospitalization in Castor group. The median follow-up was 53.6 months (range, 34-60 mouths) and 41 months (range, 24-42 months) in f-PMSG and Castor group, respectively. In f-PMSG group, 4 (10.8%) patients died, including 1 aortic-related mortality. In Castor group, 4 (9.3%) patients died of unknown reason. At 1 year after the operation, the branch artery patency rate was 92.0% and 88.4% in f-PMSG and Castor group, respectively.

CONCLUSION

For patients with TBAD, TEVAR with Castor single-branched stent-graft or f-PMSG is optimal treatment option when proximal landing zone is insufficient. Compared with f-PMSG, Castor single-branched stent-graft was an off-the-shelf product indicated for TBAD and revascularization.

Right Atrial Inflow Occlusion for Zone Zero Thoracic Endovascular Repair and Its Safety, Efficacy, and Predictors of Response

BACKGROUND

Landing in the ascending aorta (zone 0) demands more precise and significant reductions of the cardiac pulsatility induced motion. Right atrial inflow occlusion with an inferior vena cava (IVC) balloon offers an alternative to traditional rapid ventricular pacing for cardiac output control during deployment of thoracic endografts. We aim to evaluate the safety and efficacy of IVC balloon occlusion and determine the predictors of the blood pressure response in patients who underwent arch-branched endovascular repair.

METHODS

Consecutive patients who underwent endovascular repair of arch pathologies using custom-made inner side branch aortic endografts landing in zone 0 were studied. IVC balloon occlusion was used routinely for blood pressure reduction with a systolic target of 70 mm Hg, which is set as a balance between the risks of stent graft migration due to cardiac pulsatility-induced motion, and risks of hypotension. Primary outcomes were the safety and efficacy of IVC balloon occlusion. Secondary outcomes include the predictors of the blood pressure response during induction, deployment, and recovery phases of induced hypotension.

RESULTS

A total of 23 patients were included (91.3% male, mean age 75.7 years). The median duration of IVC balloon occlusion was 60 sec (range 35-109 sec, interquartile range [IQR] 26 sec). Graft deployment took a median time of 16 sec (range 5-30 sec, IQR 16 sec). A target systolic blood pressure (SBP) lower than 70 mm Hg could be achieved in 95.7% of patients within 60 sec (with a median of 55 mm Hg). The median recovery time was 32 sec (range 25-45 sec, IQR 5 sec). A target SBP of 70 mm Hg or lower could be achieved in 95.7% of patients in our cohort with IVC balloon occlusion. All stent grafts were deployed in an accurate position. No cardiac complications or other safety issues were reported. On risk factor analysis, induction of hypotension was hastened by a lower mean intraoperative SBP (P = 0.016) which was associated with a lower preoperative SBP (P = 0.001). A shorter balloon occlusion time would lead to faster recovery of SBP (P = 0.021).

CONCLUSION

IVC balloon occlusion is a simple, effective, and predictable method for reduction of aortic impulse for zone 0 thoracic endovascular repairs.

Fenestrated Aortic Arch Endovascular Repair for Aortic Diseases Extending to Ishimaru Zones 2 and 3

INTRODUCTION

Fenestrated endovascular aortic arch repair (fTEVAR) has been successfully used for the exclusion of aortic lesions extending to distal arch. This study aimed to present the outcomes of fTEVAR for the preservation of the left common carotid artery (LCCA) or left subclavian artery (LSA) in lesions extending to Ishimaru zone 2 and 3.

MATERIALS AND METHODS

A single-center retrospective analysis of patients managed with fTEVAR for the preservation of the LCCA or LSA, between September 1st, 2011 and December 31st, 2023, was conducted, following the STROBE guidelines. Only preloaded fenestrated custom-made devices (Cook Medical, Bloomington, IN, USA) were used. Primary outcomes were technical success, mortality, and stroke at 30 days. Survival and freedom from secondary intervention were assessed using Kaplan-Meier estimates.

RESULTS

Seventy-five patients were included [72 years (IQR 13), range 48-86; 66.7% males]; 54 scheduled for LSA and 21 for LCCA preservation. Seven (9.3%) were treated urgently. Twenty-one (28.0%) presented with aortic dissection; 19 type B. Ishimaru zone 2 disease extension was recorded in 44 (58.7%) and zone 3 in 32 (42.7%). Debranching was performed in 22 patients: 81.8% LCCA-LSA bypass. Technical success was 93.3% with proximal landing to zone 0 in 18.7% cases, zone 1 in 70.7%, and zone 2 in 10.6%. Six (8.0%) deaths were recorded at 30-days and 4 (5.3%) strokes; 2 (2.7%) major. All strokes were diagnosed in patients with LCCA preservation. The multivariate analysis showed LCCA bridging (OR 0.2, 95% CI 0.08-0.3, p < 0.001) as independently related to stroke. The median follow-up was 12 months. The survival and freedom from secondary intervention were 85.2% [standard error (SE) 4.7%] and 75.0% (SE 6.5%) at 12 months, respectively.

CONCLUSION

Patients treated by fTEVAR for diseases extending to zones 2 and 3 presented encouraging early outcomes. LCCA bridging seems to be independently related to higher stroke rate. Preservation of the LSA seems safe, without neurological consequences.Clinical ImpactFenestrated endovascular arch repair has been applied with acceptable mortality in distal aortic arch lesions. However, the published experience is limited. This retrospective study of 75 patients with disease extend to zones 2 and 3 showed encouraging early outcomes with 93.3% technical success, 8.0% mortality, and 5.3% strokes. The inclusion of the left common carotid artery to the repair was related to higher stroke rate, while the preservation of the left subclavian seems to have no neurological consequences.

A three-dimensional model of aortic dissection for hybrid surgical simulation and training

Thoracic endovascular aortic repair is widely performed in complicated and uncomplicated type B aortic dissection cases. After the introduction of a stent graft, the use of several types of hybrid approaches has been reported for patients with type A aortic dissection. The procedure is advanced because the complications are fatal; therefore, training is required. However, the surgical simulation of aortic dissection is challenging because no favourable animal model is available. This study aimed to simulate hybrid surgical simulation using a novel three-dimensional aortic dissection model. Three-dimensional polyurethane models of type A and B aortic dissection, both of which have true and false lumens, were manufactured based on computed tomography data. Under fluoroscopy, the entry tear and false lumen flows were visualized using a contrast medium. A stent graft was delivered and deployed under pulsatile conditions in the type B aortic dissection model. Total arch replacement was performed in the type A and B aortic dissection models after thoracic endovascular aortic repair as a hybrid approach. In conclusion, a model with a mock circuit is a useful tool to simulate both open and endovascular aortic repair for aortic dissections as a hybrid approach.

Mid-term outcomes of the fenestration, branched stent-graft, and hybrid techniques in the treatment of thoracic aortic pathologies involving the left subclavian artery

OBJECTIVE

To compare the midterm outcomes of fenestration, branched stent-graft thoracic endovascular aortic repair, and hybrid procedures in treating aortic arch pathologies involving the left subclavian artery.

METHODS

We collected the clinical data from 144 patients with aortic arch pathologies involving and only involving the left subclavian artery (LSA) who underwent fenestration, branched stent-graft thoracic endovascular aortic repair, and hybrid procedures from November 2015 and December 2022 at a single center. Among the patients, 68 were treated by fenestration, 61 by branched stent-grafts, and 15 by hybrid surgery. The clinical data was retrospectively analyzed and compared. The primary outcome indicators included technical success and in-hospital mortality; others included the incidence of endoleaks, spinal cord ischemia, LSA patency, stent-related entry tear, aortic-related reintervention, operative time, blood loss, and aortic remodeling.

RESULTS

The technical success rate was 83.8%, 95.1%, and 100% (p = .046), and the in-hospital mortality rate was 1.5% (n = 1), 0%, and 0% (p = 1.000) in the fenestration, branched stent-graft, and hybrid surgery groups. Type I or III endoleaks occurred in 16.2% (n = 11), 4.9% (n = 3), and 0% of patients, respectively (p = .046). The operative time, blood loss, and hospitalization duration of the hybrid surgery group was significantly higher than those of the other two groups (p < .05). However, the surgery-related costs and total costs in the hybrid surgery group were lower than the other two groups (p < .001). The rate of LSA patency was 100% in the fenestration group and 98.3% in the branched stent-graft group (p = .475). The all-cause mortality rates were 10.9% (n = 7), 6.9% (n = 4), and 0%, respectively (p = .359). Spinal cord ischemia and other complications were not significantly different in each group, both in the perioperative and postoperative periods. In the subgroup analysis of patients with AD, the incidence of endoleaks was 28.9% (n = 13), 7.0% (n = 3), and 0%, respectively (p = .011), and stent-related new entry tears in each group were 2.2% (n = 1), 18.6% (n = 8), and 14.3% (n = 1), respectively, p = .032. The overall cumulative survival rate at 2 years was 90.0%, 92.4%, and 100%, respectively (p = .508). The true lumen area of the aortic arch and descending thoracic aorta in the stent segment was significantly larger postoperatively compared to that preoperatively in both of these three groups.

CONCLUSION

The fenestration technique is sophisticated with long learning curve and is prone to complications such as endoleaks with inexperience. Branched grafts are at greater risk of stent-related entry tears, which result in a higher rate of re-intervention. The hybrid technique broadens the indications for patients with aortic arch vessel variation and generally costs less, but the operative time is longer. Surgeons should select the optimal solution based on each patient's condition to achieve satisfactory results.

Complications after treatment of type B aortic dissection with TEVAR stent-graft deployment in zone 2

OBJECTIVE

To analyze the outcome of 147 cases of type B aortic dissection with thoracic endovascular aortic repair (TEVAR).

METHODS

We systematically reviewed 147 patients of type B aortic dissection with stent graft deployment in zone 2 or zone 3 by TEVAR from January 2012 to December 2022. These patients were observed by computed tomography angiography after the first and third months and annually thereafter during follow-up. Statistical analysis was performed by SPSS.16.

RESULTS

The stent graft of 107 patients was deployed in zone 3, and the stent graft of 40 patients was deployed in zone 2. Severe dissection and surgery-related complications after TEVAR occurred in 19 patients, with complications arising more frequently in zone 2 than in zone 3 (12/40 vs. 7/107, P < 0.005). Endoleak was detected in 10 (6.8%, 10/147) cases, which included 6 cases of endoleak in zone 2, exceeding the 4 cases of endoleak in zone 3 (6/40 vs. 4/107, P < 0.05). Twelve (8.16%, 12/147) cases underwent re-intervention, and the 8 patients who underwent re-intervention in zone 2 exceeded the 4 patients who underwent re-intervention in zone 3 (8/40 vs. 4/107, P < 0.05). One case of subclavian steal in zone 2 (0.68%, 1/147). Two (1.36%, 2/147) cases died after TEVAR. The 1-year, 3-year, and 5-year overall survival rates were 99.3%, 98.6%, and 98.6%, respectively. The re-intervention rates were 5.4%, 7.5%, and 8.2%, respectively. The re-intervention rates in zone 2 were 15%, 20%, and 20%, respectively. The re-intervention rates in zone 3 were 1.9%, 2.8%, and 3.7%, respectively.

CONCLUSION

TEVAR is the major treatment to use if the stent graft can be deployed in zone 3. However, with the higher rate of complications and re-intervention after TEVAR, for patients whose stent graft can only be deployed in zone 2, it is not recommended that TEVAR be chosen as the preferred treatment.

Chronic Post-Traumatic Aortic Isthmus Pseudoaneurysm After Conservative Management of Grade II Injury: Why Is Continuous Follow-Up Mandatory?

Background: Grade I-II blunt traumatic aortic injuries (BTAIs) are typically managed conservatively, but their long-term progression is poorly understood. Chronic pseudoaneurysms may develop years after the injury, often remaining asymptomatic and being incidentally diagnosed. Methods: Two cases of post-traumatic aortic pseudoaneurysms, detected 20 and 25 years following conservatively managed BTAIs, are reported. Additionally, a comprehensive review of all post-traumatic pseudoaneurysms reported in the MedLine (PubMed.gov, U.S. National Library of Medicine, National Institute of Health) database between January 1984 and December 2024 was performed. Results: Both our patients underwent successful hybrid procedures, with no complications at the 1- and 4-year follow-ups. Our literature review identified 37 patients across 22 studies, with 32.4% presenting asymptomatically or incidentally diagnosed through routine imaging, between 1 month and 50 years after the initial trauma. In 37.8% of cases, the patients underwent open or endovascular repair. Conclusions: This case series and literature review emphasize the importance of long-term follow-up for patients with conservatively managed BTAIs, as chronic complications such as aortic pseudoaneurysms can arise decades later. Continuous surveillance is critical to ensure early detection and management.

The Retrograde-Access Gutter Snare (RAGS) Technique: A Bailout Maneuver to Maintain Patency of the Left Subclavian Artery in Fenestrated TEVAR

PURPOSE

The purpose of this study is to describe a new bailout maneuver for use during fenestrated thoracic endovascular aneurysm repair (fTEVAR) in the event of wire wrap or wire entanglement with the proximal graft fabric.

TECHNIQUE

A 68-year-old-man with hypertension and chronic atrial fibrillation underwent elective thoracic endovascular aneurysm repair (TEVAR) with a left subclavian fenestration to treat a residual arch and thoracic aortic aneurysm after previous type A dissection repair. The procedure was challenging due to malrotation of the main body graft, as well as wire entanglement of the precannulated through-and-through wire on the leading edge of the main body fabric. A novel bailout maneuver is described. Through-and-through access was maintained, and a long 8F sheath was delivered through the fenestration from femoral access, and an 8.5F steerable sheath was delivered through upper extremity access. This allowed coaxial snaring of a new through-and-through wire via the gutter between the stent-graft and native aorta in the seal zone, which both reoriented the fenestration, and permitted placement of a bridging stent to the left subclavian artery.

CONCLUSION

The retrograde-access gutter snare (RAGS) technique described above provides a streamlined approach to achieve technical success in challenging fenestrated thoracic endovascular aneurysm repair (fTEVAR) cases.

CLINICAL IMPACT

This technical note describes the retrograde-access gutter snare (RAGS) technique that can provide a successful bailout maneuver for fenestrated TEVAR (fTEVAR) devices. The RAGS technique offers an approach to be used with precannulated custom-made or physician-modified fTEVAR devices in which wire wrap or wire entanglement precludes access through the fenestration after deployment of the main body device. Instead of traditional attempts at de novo cannulation of the fenestration from upper extremity or femoral access, the maneuver offers an approach to maintaining through-and-through access to facilitate snaring a new wire proximal to the leading edge of the main body fabric, which can then be used to deliver a covered stent into the fenestration from either the upper extremity or femoral access. This technique offers an added benefit of potentially realigning malrotated fenestrations via tensioning of the new through-and-through wire.

Safety and validity of extracorporeal fenestration and in situ fenestration in patients with aortic disease involving the left subclavian artery: a prospective, single-center, randomized controlled study

BACKGROUND

Thoracic aortic pathologies involving the aortic arch are a great challenge for vascular surgeons. Maintaining the patency of supra-aortic branches while excluding the aortic lesion remains difficult. Thoracic EndoVascular Aortic Repair (TEVAR) with fenestrations provides a feasible and effective approach for this type of disease. The main purpose of this trial is to assess the safety and validity of extracorporeal fenestration and in situ fenestration in patients with aortic disease involving the left subclavian artery.

METHODS

This is a prospective, single-center, randomized controlled study. A total of 170 eligible patients will be recruited from The Fourth Affiliated Hospital, Zhejiang University School of Medicine in China and randomized on a 1:1 basis either to the group A (extracorporeal fenestration) or the group B (in situ fenestration). The primary outcome will be the all-cause mortality (30 days). The secondary outcomes will include incidence of secondary intervention (30 days, 6 months, 1 year), incidence of endoleak (30 days, 6 months, 1 year), incidence of major adverse events (MAE) (i.e., immediate procedural success and complications) (30 days, 6 months, 1 year), immediate technical success rate, and all-cause mortality (6 months, 1 year).

DISCUSSION

Suppose extracorporeal fenestration non-inferior to in situ fenestration in patients with aortic disease involving the left subclavian artery. This trial aims to demonstrate the safety and validity of extracorporeal fenestration and in situ fenestration in patients with aortic disease involving the left subclavian artery, which is expected to provide a reference for Thoracic EndoVascular Aortic Repair (TEVAR) with fenestrations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06256757. Registered on February 5, 2024. https://clinicaltrials.gov/study/NCT06256757 .

Anatomic feasibility of a novel modular triple-branched endograft for patients with aortic arch pathologies

OBJECTIVES

This study aimed to assess the anatomical feasibility of a novel modular triple-branched endograft for aortic arch diseases.

METHODS

A cross-sectional study was conducted on 314 patients with aortic arch pathologies treated at a single center from January 2018 to December 2023. Preoperative computed tomography angiography images were analyzed with three-dimensional reconstruction to quantify anatomical features. Feasibility was based on endograft anatomical criteria, and logistic regression identified risk factors for unsuitability.

RESULTS

Out of 132 patients included in the study, 67.4% were deemed anatomically suitable for the triple-branched device. A total of 36 (27.3%) patients were deemed inapplicable due to a large diameter of the proximal landing zone, 12 (9%) patients due to a small diameter of the left common carotid artery, and 1 (0.8%) patient due to a small diameter of the left subclavian artery. Logistic regression identified large proximal landing zone diameter and small left common carotid artery diameter were significant factors for unsuitability (p < 0.001 and p = 0.002, respectively).

CONCLUSIONS

The novel triple-branched endograft demonstrated promising anatomical feasibility in two-thirds of patients. However, anatomical constraints limited its applicability. Future device iterations should focus on accommodating a broader range of anatomical variations.

Endovascular Repair of Aortic Arch Zones 0 to 2 Using Physician-Modified Endografts: A Systematic Review and Meta-Analysis

PURPOSE

The purpose of this study was to collect all the available evidence concerning technical success and early and mid-term clinical outcomes of physician-modified endografts (PMEGs) for the treatment of aortic arch pathologies in zones 0 to 2.

MATERIAL AND METHODS

We performed a systematic review to identify all the eligible studies that reported outcomes to the PMEGs for aortic arch pathologies in zones 0 to 2 and then conducted a qualitative synthesis and meta-analysis of the results. The main outcomes were technical success, mortality, stroke rate, bridging stents' complications, and reintervention rate. We estimated pooled proportions and 95% confidence intervals (CIs).

RESULTS

A total of 134 study titles were identified by the initial search strategy, of which 14 (zone 0 n=6; zone 1 n=1; zones 1 t o2: n=7) were considered eligible for inclusion in the meta-analysis. A total of 777 patients (80% male; 62±6 years) were identified among the eligible studies. The pooled technical success for the PMEG in zone 0 was 96.6% (95% CI=93.9%-98.2%), whereas in zones 1 to 2 was 95.9% (95% CI=92.9%-97.6%). The pooled 30-day mortality was 4.6% (95% CI=2.0%-10%) and 4.3% (95% CI=2.2%-8.2%) for zones 0 and 1 to 2, respectively, whereas the prevalence of late mortality was 8.2% (95% CI=4.7%-14%) and 3.4% (95% CI=1.9%-6%). The pooled stoke rate was 3.7% (95% CI=2.1%-6.4%) in zone 0 and 2.7% (95% CI=1.4%-5%) in zones 1 to 2. The early reintervention rate was 3.5% (95% CI=1.5%-8.0%) and 4.2% (95% CI=2.4%-7.2%) for zones 0 and 1 to 2, respectively, whereas during the mean follow-up of 26 months was 8.5% (95% CI=3.0%-21%) and 1.9% (95% CI=0.8%-4.3%). The pooled bridging's stent instability was 3.9% (95% CI=1.1%-12.9%) in zone 0 and 3.2% (95% CI=1.8%-5.8%) in zones 1 to 2.

CONCLUSIONS

Endovascular repair of aortic arch pathologies using PMEGs seems to present a satisfactory level of technical success and a low mortality rate. To attain clearer conclusions, further research employing randomized controlled trials, longer-term follow-up, and consistent reporting of results is warranted.

CLINICAL IMPACT

This systematic review and meta-analysis of observational studies analyzed the short- and mid-term outcomes of aortic arch aneurysm and/or dissection using physician-modified endografts. It separately examined the outcomes from zones 0 and 1-2 of the aortic arch. Fourteen studies (n=777 patients) were included. Overall technical success rates were 96.6% for zone 0 and 95.9% for zone 1-2. Regarding early mortality and stroke rates, no significant differences were observed, while late mortality was higher in patients in zone 0. The late reintervention rate favored patients treated with PMEGs in zone 1-2. The physician-modified technique appears to be an excellent and rapidly available alternative for the treatment of aortic arch diseases.

Proximal sealing in the aortic arch for inner curve disease using the custom Relay scalloped and fenestrated stent graft

OBJECTIVE

This study aimed to analyze early and midterm results of custom-made proximal scallop and fenestrated stent grafts for thoracic endovascular aortic repair (TEVAR) with a proximal landing zone (PLZ) in the aortic arch.

METHODS

All consecutive patients treated with the custom made proximal scalloped and fenestrated Relay stent grafts (Terumo Aortic Bolton Medical Inc.) in 10 Italian centers between January 2014 and December 2022 were included. The primary end points were technical success, incidence of intraoperative major adverse events, deployment accuracy, and rate of early neurological complications, endoleaks (ELs) and retrograde aortic dissection.

RESULTS

During the study period, 49 patients received TEVAR with Relay custom-made endograft in Italy were enrolled. The median patient age was 70.1 years (interquartile range, 23-86 years) and 65.3% were male. The indication for treatment was atherosclerotic aneurysms in 59.2% of cases and penetrating aortic ulcer in 22.4%. The endograft configuration was proximal fenestration in 55.1% and scallop in 44.9%. The proximal landing zone was zone 0 in 25 cases (51%), zone 1 in 14 cases (28.6%), and zone 2 in 10 cases (20.4%). The supra-aortic debranching procedures were 38 (77.5%). Technical success was 97.9% (48/49) owing to one case (2.0%) of inaccurate deployment. Intraoperatively, one (2.0%) type Ia and one (2.0%) type III EL were detected. There were no cases of in-hospital mortality, major adverse events, or retrograde dissection. Three minor strokes (6.1%) (National Institutes of Health Stroke Scale score of ≤4) were observed. At a mean follow-up time of 36.3 ± 21.3 months the rate of types I to III ELs and reintervention was 4.1%, respectively. Four patients (8.2%) died during the follow-up period, one (2.1%) from abdominal aortic rupture and three (6.1%) from nonaortic causes.

CONCLUSIONS

Our early and midterm outcomes suggest that scalloped and fenestrated TEVAR may provide an acceptable alternative treatment option for aortic arch pathologies. Large-scale studies are needed to assess the long-term durability of this technique.

The Use of Short Dilator Tip in Endovascular Branched Arch Repair: A Case Series

OBJECTIVES

The aim of the study was to investigate the safety and feasibility of branched endovascular arch repair (b-TEVAR) with a custom-made double or triple inner branched arch endograft using a short dilator tip (35 mm) in patients with aortic arch pathologies.

METHODS

Retrospective analysis of all consecutive patients undergoing b-TEVAR with a short dilator tip for the treatment of aortic arch pathologies in a high-volume tertiary center between January 2019 and July 2023. The combined primary endpoint was technical success and perioperative complications caused by the endograft, including tip-induced cardiac injury and trackability issues. Secondary endpoints were major adverse events (MAE), including morbidity, mortality, and reinterventions within 30 days.

RESULTS

During a 4-year period, 22 patients (median age 72 years, 16 males) were treated with a custom-made double or triple inner-branched TEVAR for different aortic arch pathologies using a short dilator tip (35 mm). After initial exclusive treatment of patients with previous valve replacement, the use of a short dilator tip became standard. Eighteen patients received a triple- and 4 patients received a double-branched endograft. Seventeen patients (77.3%) underwent elective treatment, while 5 patients underwent urgent repair due to contained rupture or symptomatic aneurysms. The technical success was 100%. No tip-induced cardiac mortality and morbidity occurred perioperatively. The trackability of the device was in no case affected by the short tip. Within 30 days, the MAE rate was 45%, including one death. No re-intervention had to be performed.

CONCLUSION

Endovascular aortic arch repair with inner-branched arch endografts using a short dilator tip (35 mm) appears to be safe and technically feasible and could potentially reduce the risk of fatal myocardial injuries.

CLINICAL IMPACT

Due to safe and stable maneuverability and deployment of endograft in zone 0 the use of short dilator tip might have the potential to become standard in endovascular branched arch repair. This is one of the first reports on the use of short dilator tip and associated complications in endovascular branched arch repair.

Physician-modified endograft for symptomatic zone 2 penetrating ulcer of the aortic arch without bridging stenting of the left subclavian artery for vertebral preservation

We report the case of a 65-year-old male patient who was deemed unfit for open surgery and underwent zone 0 endovascular repair with a physician-modified fenestrated endograft for a symptomatic penetrating ulcer. A thoracic stent graft was modified creating a large fenestration for the innominate artery and the left common carotid artery, and a second small fenestration for the left subclavian artery and the left vertebral artery, which had a common origin. No bridging stent was used for the left subclavian artery to avoid coverage of the left vertebral artery. The postoperative course was uneventful, and no leaks nor other complications were detected on postoperative computed tomography angiography. Although long-term durability needs to be better assessed, our experience suggests that physician-modified fenestrated endografts are a feasible option for the emergent treatment of aortic arch lesions in unfit patients and provide satisfactory results in the short term.

Evaluation of custom-made Relay® stent-grafts for aortic arch landing zones 0 and I: experience from two high-volume aortic centres

OBJECTIVES

To report experience with a Relay® stent-graft custom-made platform in treating different aortic arch pathology in 2 high-volume aortic centres.

METHODS

A retrospective analysis of all patients treated between July 2016 and July 2023 with custom-made Relay® stent-graft (custom-made device). Underlying aortic arch pathology was an aneurysm, penetrating aortic ulcer, and dissection. Three custom-made device designs were used: proximal scallop, fenestrations, and inner branches. The endpoints were technical success, perioperative stroke, death, and reintervention rate.

RESULTS

Thirty-five patients (89% males) with a mean age of 70 ± 11 years were treated.Indication for treatment was penetrating aortic ulcer in 14 patients (40%), aneurysm in 11 patients (31%) and aortic dissection in 10 patients (29%). The technical success rate was 100%. Twenty-eight patients (80%) had proximal sealing in zone 0, and 7 (20%) had proximal sealing in zone 1. Nine patients (25.6%) had proximal scallops, 9 (25.6%) had 1 big fenestration and 17 (48.8%) had a branched device; 1 with single branch, 15 with double branches and 1 with triple branches. Thirty patients (86%) had previous or simultaneous left subclavian artery revascularization. No patient died during 30 days. Two patients (5.7%) had stroke postoperatively; both recovered without disabling deficits. The mean follow-up was 35 ± 26 months. Six patients (17.1%) died during follow-up. One patient required reinforcement of the bridging stent in the left common carotid artery and one additional vascular plugging of the left subclavian artery. Three patients received distal extension.

CONCLUSIONS

The Relay® stent-graft custom-made platform showed a good performance in our study with a high technical success rate, low perioperative stroke and mortality, and low reintervention rates during the follow-up.