Long-term outcomes for hybrid aortic arch repair

Comparative analysis of arch vessel revascularization techniques in proximal arch thoracic endovascular aortic repair

OBJECTIVE

Endovascular stent grafting extending into the ascending aorta (zone 0) is increasingly used in the treatment of aortic arch disease. This study aims to evaluate the risk of stroke in patients undergoing zone 0 arch thoracic endovascular aortic repair (TEVAR) based on the technique used for head vessel revascularization.

METHODS

Patients undergoing zone 0 arch TEVAR covering all the aortic arch vessels were identified in the Vascular Quality Initiative between 2014 and 2023. Patients treated for aortic rupture or trauma were excluded. Head vessel revascularization techniques were classified into three groups: open revascularization (OR), endovascular revascularization (ER), and hybrid revascularization (HR). Multivariate logistic regression analysis was used to evaluate the association of head vessel revascularization technique with the primary outcomes of perioperative mortality and stroke.

RESULTS

A total of 409 patients underwent zone 0 arch TEVAR covering all the aortic arch vessels, of which 50% (207/409) underwent OR, 20% (80/409) underwent ER, and 30% (122/409) underwent HR of the head vessels. The in-hospital mortality and stroke rates were 9% and 12%, respectively. Survival at 30 days, 1 year, and 2 years were 88%, 79%, and 74%, respectively. Patients undergoing ER of the head vessels had significantly higher stroke compared with those undergoing OR and HR (OR 11%, ER 21%, HR 8%; P = .02). ER was associated with a two-fold higher risk of perioperative stroke compared with OR (odds ratio, 2.16; 95% confidence interval, 1.08-4.30; P = .03), whereas no difference in perioperative stroke was observed between OR and HR (P = .40). Although OR and HR of the head vessels had a significantly lower rate of perioperative stroke compared with ER in 2017-2020 (OR 10% vs ER 30% vs HR 10%, P = .02), this difference diminished over time with no significant difference observed in the most recent interval (2021-2023) studied (OR 9% vs ER 12% vs HR 8%; P = .76). Trends revealed an increase in the use of HR (from 4% in 2014 to 57% in 2023) alongside a significant decrease in ER (from 39% in 2020 to 14% in 2023).

CONCLUSIONS

Stroke remains a significant concern during zone 0 arch TEVAR. Total endovascular repair of the aortic arch is associated with a greater than two-fold higher risk of stroke compared with OR and HR of the head vessels. However, advances in ER techniques and increased use of hybrid strategies highlight an ongoing evolution toward safer and less invasive approaches resulting in a decrease in perioperative stroke rates over time.

Challenging Proximal Control for Open Thoracoabdominal Repair

Proximal control of the thoracic aorta during the open repair of thoracoabdominal aorta can be challenging. Various techniques have been developed to address these challenges, including the use of deep hypothermic circulatory arrest and staged procedures, such as the conventional as well as frozen elephant trunk procedures. This paper is a brief review of the challenges and rationale behind some approaches.

Hybrid Aortic Arch Replacement with Frozen Elephant Trunk (FET) Technique: Surgical Considerations, Pearls, and Pitfalls

The involvement of the aortic arch in thoracic aortic aneurysms (TAA), or acute aortic dissections (AAD), represents a challenging clinical entity, mandating a meticulous surgical plan, tailored to each individual case. The advent of endovascular techniques and the introduction of modern arch protheses have led to the implementation of the frozen elephant trunk (FET) technique. This one-step hybrid operation consists of a total aortic arch replacement combined with an antegrade delivery of a stent-graft for the descending aorta, which acts as a proximal landing zone facilitating a potential distal endovascular reintervention. In this manner, this technique addresses acute and chronic arch disease with an acceptable morbidity and mortality. Several FET prosthetic devices are available on the global market and have exhibited favourable outcomes, although with some disadvantages in complex cases; similarly, the hybrid procedure described in this review has also been associated with complications, such as coagulopathy and neurological and graft-related events. The purpose of this review is to thus provide key insights into successful hybrid aortic arch replacements and to discuss useful tips and relevant considerations regarding its use.

Endovascular aortic arch repair under monitored anaesthesia care: maximizing microinvasiveness

Patients with aortic arch pathologies after surgery for type-A acute aortic dissection represent a challenging population since open surgery is associated with a non-negligible rate of mortality and complications. Microinvasive endovascular aortic arch repair Arch-Thoracic EndoVascular Aortic Repair (Ar-TEVAR) has shown promising results in high-risk patients. Ar-TEVAR is usually performed under general anaesthesia. We report the case of an 83-year-old man with a history of ascending aorta replacement for type-A acute aortic dissection who was referred for an anastomotic pseudoaneurysm. Ar-TEVAR using an off-the-shelf single-branch aortic arch stent graft was chosen. In order to further minimize procedural invasiveness, monitored anaesthesia care (local anaesthesia with sedation and analgesia) was performed since it provides less stress on the cardiovascular and respiratory systems and overall leads to a faster recovery especially in elderly patients.