Endovascular Repair of Aortic Arch Aneurysm with Surgeon-Modified Fenestrated Stent Graft

Feasibility and safety of Stanford A aortic dissection complete endovascular repair system in a porcine model

BACKGROUND

Acute type A aortic dissection (ATAAD) is a catastrophic disease with high morbidity and mortality. Although open surgery is still the gold standard for the treatment of ATAAD, some patients, with advanced age and multiple comorbidities, can only receive medical management alone. Nowadays, thoracic aortic endovascular repair (TEVAR) provides a potential treatment option for the patient with ATAAD, but traditional stent grafts (SGs), which are not designed for the ATAAD, are inapplicable to the unique anatomy of the aortic arch. Therefore, we innovatively created the BRIDGE system (Chuangxin Medical, Shenzhen, China), a complete endovascular reconstruction system designed to treat ATAAD. This study aimed to evaluate the feasibility and safety of the novel Stanford A aortic dissection complete endovascular reconstruction system in a porcine model.

METHOD

The BRIDGE system consists of the type A stent system and the type C stent system. Between November 2020 and March 2021, three white swine were utilized in the study. The BRIDGE system was deployed via the transcatheter approach under angiographic guidance. The swine(n = 3) treated with our system were evaluated using angiography before sacrifice 1-month after implantation, which was followed by gross specimen evaluation and histological examination of harvested tissues.

RESULT

The acute procedure success rate was 100% (3/3). The immediate post-procedural angiography showed that both type A SGs and type C SGs were deployed in satisfactory locations, with patency of the supra-aortic trunk and no endoleak. The cumulative mortality of 30-day was 0% without any adverse events. No device migration or leakage was observed angiographically, before sacrifice. The gross observation confirmed a type A SG covered part of the entry of anonyma. Favorable endothelialization, no thrombogenesis, and slight inflammatory infiltration of the tissues around the device were confirmed by microscopic examinations in all pigs.

CONCLUSION

It was feasible and secure to use Stanford A aortic dissection complete endovascular reconstruction system to implement a transcatheter endovascular repair in a porcine model. With this novel system, treating acute type A aortic dissection may be more efficient and secure in human.

Early Clinical Outcomes of Retrograde In-Situ Branched Stent Grafting for Complex Aortic Arch Aneurysms

OBJECTIVE

To evaluate the early outcomes of retrograde in-situ branched stent grafting (RIBS) using the gutter balloon technique for complex aortic arch aneurysms (CAAs).

METHODS

The RIBS technique is an in-situ needle fenestration procedure during thoracic endovascular aortic repair (TEVAR) with the reconstruction of cervical branches. The Double-RIBS (D-RIBS) for the reconstruction of the left common carotid artery and the brachiocephalic artery using the gutter balloon technique was performed in 30 high-risk patients. We describe the early clinical results of the D-RIBS technique for CAAs. Primary endpoints were technical success and 30-day mortality. Secondary endpoints were postoperative complications, rates of endoleaks, overall survival, aneurysm-related death, and re-interventions.

RESULTS

The mean age was 77.1±6.6 years and the mean maximum minor-axis aneurysmal diameter was 65.9±8.9 mm. Twenty six patients underwent D-RIBS for elective arch aortic aneurysm and four patients were for reintervention after Zone 2 TEVAR failure. Stent graft puncture was performed 60 times from the common carotid arteries and technical success was achieved in all cases (100%). Postoperative complications included cerebral infarction in 2 patients (6.7%), recurrent nerve palsy in one patient (3.3%). The 30-day mortality was 0%. During the median follow-up period of 14 months (6-56), overall survival at 12 months was 92.3% without any aneurysm-related death. Type 1b and type 2 endoleaks were observed in one each and no reintervention was encountered.

CONCLUSION

Early clinical outcomes of the D-RIBS for high-risk patients with CAAs are acceptable. The gutter balloon method enables safe and reliable fenestration. Further studies and dedicated devices are warranted.

Clinical application and technical details of cook zenith devices modification to treat urgent and elective complex aortic aneurysms

Purpose

To describe technical details of modifying four different Cook Zenith devices to treat complex aortic aneurysms.

Material

In the first three cases, the modification process involved complete stent graft deployment on a sterile back table. Fenestrations were created using an ophthalmologic cautery and reinforced with a radiopaque snare using a double-armed 4–0 Ethibond locking suture based on measurements obtained on centerline of flow. In each instance, a nitinol wire was withdrawn and redirected through and through the fabric and used as a constraining wire. In the fourth patient, modification involved partial stent graft deployment and creation of additional two fenestrations to accommodate renal arteries. The devices are resheathed and implanted in the standard fashion.

Results

Four patients underwent exclusion of their aneurysms, including thoracoabdominal aneurysms (n = 2), a contained ruptured juxtarenal aneurysm (n = 1), and a ruptured failed previous endovascular repair (n = 1). Fifteen fenestrations were successfully bridged with Atrium iCAST stent grafts. Average graft modification time, operative time, contrast volume, radiation dose, estimated blood loss, and hospital length of stay were 89 min, 155.25 min, 58.8 mL, 2451 mGy, 175 mL, and 4.3 days, respectively. One patient required a secondary intervention to treat a type Ib endoleak. During an average follow-up of 25 months, aneurysm sacs progressively shrank without additional intervention.

Conclusion

Physician-modified fenestrated/branched endografts are a safe alternative to custom made devices, especially in urgent cases and should be part of the armamentarium of any complex aortic program.

Hoarseness Due to Aortic Arch Aneurysms

OBJECTIVE

To give an overview of the Ortner's syndrome caused by an aortic arch aneurysm.

METHODS

By comprehensive retrieval of the pertinent literature published in the past two decades, 75 reports including 86 patients were collected and recruited into this study along with a recent case of our own.

RESULTS

The aortic arch aneurysms causing hoarseness were most commonly mycotic aneurysms. In this patient setting, in addition to the left recurrent laryngeal nerve, trachea was the most commonly affected structure by the aortic arch aneurysm. Surgical/interventional/hybrid treatments led to a hoarseness-relieving rate of 64.3%, much higher than that of patients receiving conservative treatment. However, hoarseness recovery took longer time in the surgically treated patients than in the interventionally treated patients.

CONCLUSION

The surgical and interventional treatments offered similar hoarseness-relieving effects. Surgical or interventional treatment is warranted in such patients for both treatment of arch aneurysms and relief of hoarseness.

Systematic Review on the Use of Physician-Modified Endografts for the Treatment of Aortic Arch Diseases

BACKGROUND

The total endovascular approach is in current evolution, and many series have described variable outcomes for branched technology, chimney techniques, or fenestrated repair; and even a combination of some of them. We aim to describe the current outcomes on physician-modified endograft for the treatment of arch diseases.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for this systematic review. The search was applied to MEDLINE, EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials. We used the following search terms in all possible combinations: home-made, physician-modified, surgeon-modified, on-table modification, hand-made, endograft, endovascular, aortic arch, and TEVAR: a thorough search of the English-language literature published until March 2020 was performed to identify studies using physician-modified endograft for the treatment of arch diseases. Only studies with treatment of 3 patients or more and with a minimum of 6-month follow-up were enrolled in the systematic review, whereas case reports were excluded from the analysis.

RESULTS

Six articles participated in the systematic review after the exclusions, including a total of 239 patients for analysis. Four high-volume centers provided data including a high rate of single fenestrations in zone 2, accounting for nearly 70% of the cases. About 80.3% were males, and 67.4% received urgent treatment mainly for acute/subacute dissection (64.4%). Thoracic aortic aneurysm and/or postdissection arch aneurysm was the second leading cause of treatment with 25.9%. There was a technical success of 93.7% reaching up to 98.3% when additional procedures were performed. The 30-day mortality, stroke/transient ischemic attack, paraplegia, and stent-induced new entry rates were 2.9%, 2.1%, 0.4%, and 0.4%, respectively; whereas, overall mortality of the study was 4.6% at a mean follow-up of 33.2 ± 14.8 months.

CONCLUSIONS

Endograft modification for aortic arch diseases' treatment demonstrates to be safe and highly effective, especially for aortic dissections needing single zone 2 fenestrations. Although outcomes achieved in the study seem encouraging, these are achieved at high-volume experienced centers, thus, they need to be judiciously evaluated, whereas proctoring may be a good alternative if one patient may benefit from the technique in an unexperienced center.

Follow-up results of aortic arch cervical debranching performed with the help of a temporary crossover external carotid artery bypass for cerebral protection followed by endovascular thoracic aortic aneurysm repair

OBJECTIVES

Treating aortic arch aneurysms with conventional open surgical and endovascular stent graft procedures is challenging due to the complex anatomy of the arch and the arteries arising from it that nourish the brain. Cerebral protection is of the utmost importance during the treatment of thoracic aneurysms involving the aortic arch.

METHODS

Between May 2014 and November 2018, 7 patients with thoracic aortic aneurysms involving the aortic arch who underwent aortic arch cervical debranching with our technique were reviewed retrospectively. Because all the patients being considered for conventional surgical aortic arch replacement had serious comorbidities, they were selected to receive hybrid therapy. The mean age of the patients was 71.2 ± 9.4 years. One patient was a woman and 6 patients were men. One patient was given general anaesthesia; the remaining 6 patients had a regional block. A crossover temporary bypass was performed between the external carotid arteries with a 6-mm polytetrafluoroethylene graft for cerebral protection in all patients. Thoracic endovascular aortic repair (TEVAR) was successfully performed in all patients except 1 following debranching.

RESULTS

Neurological complications did not occur during the procedures. Patients were followed for a mean of 18.3 ± 4.9 months. One female patient died of exacerbating chronic obstructive pulmonary disease within the first follow-up year. Three other patients died: 1 died of natural causes; 1 died of pneumonia followed by multiorgan failure; and 1 died of myocardial infarction during the mid-term follow-up period. The remaining patients are still being followed and are event free.

CONCLUSIONS

Endovascular treatment of thoracic aortic diseases involving the aortic arch is facilitated when the aortic arch is debranched. Our cerebral protection method with a temporary crossover bypass between the external carotid arteries provides continuous pulsatile blood flow to the brain; hence, neurologically, it is a reliable procedure. The follow-up results of the patients who underwent aortic arch cervical debranching followed by TEVAR depended on their comorbidities.

Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

Background

Endovascular rescue of failed infrarenal repair (EVAR) has emerged as an attractive option to stent graft explantation. The procedure, however, is underutilized due to limited devices accessibility and the challenges associated with their implantation in this patient population. The purpose of this study was to report our outcomes and discuss our approach to rescuing previously failed infrarenal endovascular aneurysm repairs (EVAR) with fenestrated/branched endografts (f/b-EVAR).

Methods

A retrospective analysis of prospectively collected data of consecutive patients with failed EVAR rescued with f/b-EVAR at our institution from November 2013 to March 2019 was conducted. The study primary end point was technical success; defined as the implantation of the device with no type I a/b or type III endoleak or conversion to open repair. Secondary endpoints included major adverse events (MAEs), graft patency and reintervention rates.

Results

During this time, 202 patients with complex aortic aneurysms were treated with f/b-EVAR. Of these, 19 patients (Male: 17, mean age 79 ± 7 years) underwent repair for failed EVAR. The median time from failed repair to f/b-EVAR was 48 (30, 60) months. Treatment failure was attributed to stent graft migration in 9 (47.4%) patients, disease progression in 5 (26.3%), short initial neck in 3 (15.8%) and unable to be determined in 2 (10.5%). Three patients were treated urgently with surgeon modified stent graft. Technical success was achieved in 18 patients (95%), including two who had undergone emergent repair for rupture. Seventy-two targeted vessels (97.3%) were successfully incorporated. Sixteen (84.2%) patients required a thoracoabdominal repair to achieve a durable seal. Major adverse events (MAEs) occurred in 3 patients (15.7%) including paralysis and death in one (5.3%), compartment syndrome and temporary dialysis in another and laparotomy with snorkeling of one renal and bypass of the other in the third patient. Median (IQR) hospital length of stay was 3 (2, 4) days. Late reintervention, primary target vessel patency and primary assisted patency rates were 5.3%, 98.6% and 100%, respectively.

Conclusion

Implantation of f/b-EVAR in patients with failed previous EVAR is a challenging undertaking that can be performed safely with a high technical success and low reintervention rates.