RELAYTM Branched–International Results of Vessel Patency and Reintervention

Endovascular reconstruction of the aortic arch with new-generation dual-branch and triple-branch endograft: design, applicability, indications, outcomes, and future directions

INTRODUCTION

Repair of aortic arch pathologies such as degenerative aneurysms and dissections still represents a significant challenge for vascular and cardiac surgeons. We focused on the design, evolution, implementation, and prospects of endovascular dual branch technology for treatment of pathologies in the aortic arch.

AREAS COVERED

The literature search was conducted in a non-systematic fashion through the PubMed and Scopus databases; articles deemed relevant to the scope of the work and fully published in English language from January 12,000 until December 2023 were considered for inclusion. Two companies so far have developed and launched in market a dedicated arch dual branch platform: Terumo Aortic and Cook Medical.

EXPERT OPINION

A common limitation to the available technology is represented by the fact that urgent cases (i.e. large or rapidly growing aneurysms, symptomatic patients) cannot be treated because the customization process generally takes between 6 and 8 weeks, and there is an inherent risk for aorta-related adverse events to happen during the waiting time. While the future holds much promise, several technical hurdles still exist and further developments (in device design, operators' skills, patients' selection, and outcomes assessment) are needed to establish the safety and effectiveness of treatment particularly over the long-run.

Aortic Arch Debranching and Thoracic Endovascular Aortic Repair (TEVAR) for Type B Aortic Dissection

BACKGROUND

Since its introduction, thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of type B aortic dissections (TBADs). However, the proximal aspect of the aortic pathology treated may infringe on the origin of the left subclavian artery or even more proximally. Hence, to ensure durable outcomes, the origin of these vessels needs to be covered, but an extra-anatomical bypass is required to perfuse vital branches, known as aortic arch debranching. This series aims to describe and delineate the disparities of aortic arch debranching during TEVAR for TBAD.

METHODS

A retrospective review and analysis of a multicenter international database was conducted to identify patients with TBAD treated with TEVAR between 2005 and 2021. Data analyzed included patient demographics, disease characteristics, operative characteristics, and postoperative outcomes with follow-up on mortality and reintervention. All statistical analyses were carried out using IBM SPSS 26. Patient survival was calculated using a Kaplan-Meier survival analysis, and a P value of less than 0.05 was considered statistically significant.

RESULTS

A total of 58 patients were included in the analysis, of which 27 (46.6%) presented with complicated disease and 31 were uncomplicated, of which 10 (17.2%) were classed as high risk and 21 (36.2%) low risk. Zone 2 was the most common proximal landing zone for the stent graft. Left subclavian artery bypass was performed selectively (26%), with 1 stroke occurring, likely due to embolic reasons. A further 6 underwent more proximal aortic debranching before TEVAR (10%) and was a significant risk factor for mortality and the number of stents deployed. The overall rates of reintervention and mortality were 17.2% (n = 10) and 29.3% (n = 17).

CONCLUSIONS

Aortic arch debranching and TEVAR for TBAD is associated with significant mortality. Future developments to treat aortic arch pathology could incorporate branched graft devices, eliminating the need for debranching, improving stroke rates, and reducing future reinterventions.

An early single-center experience with the Relay double inner-branch arch endograft

Background

Open surgery remains the gold standard technique for the treatment of aortic arch pathologies, although endovascular techniques offer a new opportunity for patients deemed unfit for open repair. This paper assesses the early outcomes of patients treated with a double inner-branched arch endograft in a single, tertiary-care institution.

Methods

All consecutive cases of elective endovascular arch repair from 2016 to 2022 were included in a prospective database. All procedures were performed using the custom-made Relay® (Terumo Aortic-Bolton Medical Inc., Sunrise, FL, USA) double inner-branched endograft; an extra-anatomical bypass was associated in all cases to preserve the patency of supra-aortic trunks. Comorbidities, periprocedural data, immediate results and follow-up complications were analyzed.

Results

Twelve patients were treated during the study period [mean age 74±7 years, 100% male, 58% American Society of Anesthesiologists (ASA) risk ≥3]. Treated conditions included aneurysms (n=9), one pseudoaneurysm, one aortic ulcer and a type IA endoleak. The technical success rate was 100%. Early complications included respiratory insufficiency (n=3; 25%), stroke (n=1; 8.3%), acute coronary syndrome needing coronary stenting (n=1; 8.3%), and one perioperative death (n=1; 8.3%) secondary to an intracranial bleeding after coronary stenting. One patient required early reintervention due to retroperitoneal iliac access bleeding (n=1; 8.3%). During a median follow-up of 15.5 (range, 0-44) months, four patients suffered neurological events (two of them of cardioembolic origin), one reintervention was needed (subclavian anastomosis pseudoaneurysm), and a type IB endoleak was diagnosed. Overall mortality was of 17% (n=2), with an 83% overall survival at 2 years. The aortic-related death-free survival was 100%.

Conclusions

Endovascular treatment of aortic arch pathology is feasible and shows promising early mortality and stroke rates in high-risk candidates. The main short and midterm goal should be minimizing neurological complications. A longer follow-up is mandatory to determine the effectiveness of the technique and to detect device related complications.

Endovascular aortic arch repair: A comparison of outcomes and current trends

OBJECTIVE

Application of thoracic endovascular aortic repair (TEVAR) to the aortic arch has been met with the development of purpose-made endoprostheses for on-label use in the aortic arch. An appraisal of the clinical efficacy of each major device is therefore useful towards informing clinical decision making for patients eligible for endovascular arch repair (EAR) rather than open surgical reconstruction.

METHODS

A literature review of publications outlining clinical experience with the RELAY™ Branched and Zenith™ devices was undertaken, and the results therefrom analysed to evaluate the clinical efficacies of each device.

RESULTS

Early- and long-term mortality rates associated with EAR appear favourable, especially compared against open surgical repair. EAR is also associated with good neurological outcomes and target vessel patency rates. However, EAR continues to be associated with substantial reintervention rates.

CONCLUSIONS

At the present stage, EAR represents a promising alternative option to open surgical reconstruction in patients that meet its eligibility criteria. Though there remains a substantial learning curve associated with EAR, its favourable outcome profile is likely to increase its applicability in the future.

Physician-Modified Endovascular Graft for Left Subclavian Artery Fenestration during Thoracic Endovascular Aortic Repair

BACKGROUND

This study aimed to evaluate the safety and efficacy of physician-modified endovascular graft for preservation of left subclavian artery during thoracic endovascular aortic repair.

METHODS

From June 2019 to October 2022, 66 patients with a variety of thoracic aortic pathologies were treated with thoracic endovascular aortic repair using physician-modified endovascular graft left subclavian artery fenestration to achieve adequate proximal landing zone. The details of surgical techniques were described. The perioperative morbidity, mortality, and the outcomes of mid-term follow-up were analyzed.

RESULTS

Of the 66 patients (men: women, 53:13; age, 55.18 [55.18 ± 10.62] years), 53 (80.30%) presented with type B aortic dissection, 10 (15.15%) with thoracic penetrating aortic ulcer, 2 (3.03%) with thoracic aortic aneurysm, and 1 (1.52%) with left subclavian artery aneurysm. All of them underwent thoracic endovascular aortic repair using physician-modified endovascular graft left subclavian artery fenestration on the sterile back table. The technique success rate was 96.97% (n = 64). Total operation time was 92 min (interquartile range, 86-118), graft modification time was 19 min (interquartile range, 17-21), fluoroscopy time was 49 min (interquartile range, 41-62), and contrast agent dosage was 165 mL (interquartile range, 155-185). 30-day perioperative morbidities were 3 (4.55%) strokes, 1 (1.52%) retrograde type A aortic dissection, 1 (1.52%) aortic intimal intussusception, 1 (1.52%) left arm ischemia, and 3 (4.55%) type Ia endoleaks. Postoperative 30-day mortality and reintervention rates were 1.52% and 4.55%, respectively. Among the 63 patients included in the follow-up of 17 months (interquartile range, 7.75-18.25), the primary patency of left subclavian artery fenestration stents was 100%. Late complications were 1 (1.59%) distal stent graft-induced new entry and 1 (1.59%) death due to retrograde type A aortic dissection during the follow-up. The stent graft-induced new entry patient was observed with stable false lumen.

CONCLUSIONS

Thoracic endovascular aortic repair with physician-modified endovascular graft for left subclavian artery revascularization is a safe, feasible, and efficacious technique associated with high success rate. Further study is needed for long-term outcome investigation.

Safety and Efficacy of Inner Branched Stent-Graft in the Treatment of Aortic Arch Disease: A Systematic Review

OBJECTIVE

To provide a descriptive overview on the contemporary outcomes of thoracic endovascular arch repair with inner branched endoprosthesis (bTEVAR) for the treatment of aortic arch pathologies.

METHODS

A comprehensive literature search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Pre-defined search terms were used to interrogate PubMed and OVID Medline databases from January 1999 to July 2022. Patient characteristics, indication for treatment, procedural data, mortality rates, postoperative complications, and reintervention rate during follow-up were evaluated.

RESULTS

Nineteen articles were included, encompassing a total of 618 patients who received bTEVAR, most of which were double-branched (63.9%, n=395). The main indication for treatment was aneurysm secondary to chronic aortic dissection (38.8%, n=240/618) with a mean maximum diameter of 58.3±11.4 mm. Pooled mean technical success rate was 97.4±4.4% (95% confidence interval [CI]=95.1%-99.5%); 2 and 3 patients required conversion to chimney technique and open repair, respectively. Among the pooled rates of early complications, postoperative stroke was the highest (10.5%; 95% CI=6.8%-14.3%). Thirty-day and in-hospital mortality rate was 5.5% (95% CI=2.6%-9.7%). Forty patients (6.5%; 95% CI=2.5%-9.5%) required early reintervention. During a mean follow-up of 20.7±13.5 months, the mortality rate was 18.2% (n=108/593; 95% CI=8.6%-20.6%) where 12 (11.1%) were aortic-related. Pooled late reintervention rate was 9.6% (95% CI=4.8%-14.3%). Comparison of demographics and outcomes found no significant difference between single and double bTEVAR.

CONCLUSION

Branched thoracic endovascular aortic repair is a promising approach for aortic arch pathologies with a high technical success rate despite a steep learning curve. However, contemporary outcomes reflect that postoperative stroke remains the predominant concern. Further experience and long-term follow-up are required to sufficiently elucidate the safety and durability of bTEVAR in the management of aortic pathologies for high-risk patients.

CLINICAL IMPACT

This systematic review summarized the contemporary outcomes of thoracic endovascular aortic repair with different inner branched stent-grafts for the management of aortic arch pathologies. Pooled results from nineteen studies with 618 patients demonstrated a high technical success rate and an acceptable mortality rate. However, postoperative stroke remains the major concern. Long-term follow-up is needed to evaluate its durability.

Uncomplicated Type B Aortic Dissection: Challenges in Diagnosis and Categorisation

BACKGROUND

Acute type B aortic dissection (TBAD) is a rare disease that is likely under-diagnosed in the UK. As a progressive, dynamic clinical entity, many patients initially diagnosed with uncomplicated TBAD deteriorate, developing end-organ malperfusion and aortic rupture (complicated TBAD). An evaluation of the binary approach to the diagnosis and categorisation of TBAD is needed.

METHODS

A narrative review of the risk factors predisposing patients to progression from unTBAD to coTBAD was undertaken.

RESULTS

Key high-risk features predispose the development of complicated TBAD, such as maximal aortic diameter > 40 mm and partial false lumen thrombosis.

CONCLUSION

An appreciation of the factors that predispose to complicated TBAD would aid clinical decision-making surrounding TBAD.

Driving Technology for Thoracic Endovascular Aortic Repair: An International Analysis of Single-versus Double-Branch RELAY Outcomes

BACKGROUND

The introduction of endovascular aortic arch repair (EAR) represents a paradigm shift in the management of complex arch pathologies usually treated with open surgical repair (OSR). This shift in treatment of aortic arch disease has also been accompanied with a rise in commercial interest in EAR resulting in the development of several endografts. However, the RELAY™ Branched by Terumo Aortic can be considered the prime endograft choice. In this international original study, a retrospective comparative analysis of international prospective outcomes data on the single- and double-branch RELAY stent grafts is provided.

METHODS

International data on EAR procedures carried out from January 2019 to January 2022 using the single- and double-branch RELAY endograft configurations were collected prospectively. Follow-up data were collected at 30 days, 6 months, 12 months, and 24 months postoperatively. Retrospective descriptive analysis, logistic regression, and Kaplan-Meier analysis were performed.

RESULTS

A total of 125 patients were included, out of which 17 (13.6%) received the single-branch RELAY and 108 the double-branch device. In the single-branch group, no mortalities, strokes, or reinterventions were recoded over 24 months of follow-up. The rates of these outcomes were higher in the other group; however, the differences did not reach significance. Target vessel patency was maintained at 100% throughout the study period with the single-branched RELAY. Overall, our Kaplan-Meier analyses proved that both configurations of RELAY Branched yield excellent short- and mid-term survival and freedom from reintervention.

CONCLUSIONS

Our series has clearly demonstrated that EAR using RELAY Branched is a highly efficacious strategy that yields very favorable results which can be considered superior to other EAR devices as well as OSR. Nevertheless, it seems that clinical outcomes with the single-branch RELAY are more optimal than with the double-branch device.

Cost analysis of thoracic endovascular aortic repair in type B aortic dissection: How much does quality cost?

BACKGROUND

Aortic dissection (AD) is a life-threatening medical emergency that affects an estimated 3-4 people per 100,000 annually, with 40% of cases classified as type B AD (TBAD). TBAD can be further classified as being complicated (co-TBAD) or uncomplicated (un-TBAD) based on the presence or absence of certain features such as malperfusion and rupture. TBAD can be managed conservatively with optimal medical therapy (OMT), or invasively with open surgical repair (OSR) or thoracic endovascular aortic repair (TEVAR), depending on several factors such as type of TBAD and its clinical acuity. The cost-effectiveness, or cost-benefit profile, of these strategies must be given equal consideration. However, TBAD studies featuring cost analyses are limited within the literature. This narrative review aims to address the gap in the literature on cost-effectiveness of TBAD treatments by providing an overview of cost analyses comparing OMT with TEVAR in un-TBAD and TEVAR with OSR in co-TBAD. Another aim is to provide a market analysis of the commercially available TEVAR devices.

METHODS

A comprehensive literature search was performed using several search engines including PubMed, Ovid, Google Scholar, Scopus, and Embase to identify and extract relevant studies.

RESULTS

Several TEVAR devices are available commercially on the global market costing $12,000-19,495. Nevertheless, the Terumo Aortic RELAY® stent graft seems to be the most cost-effective, yielding highly favourable clinical outcomes. Despite the higher initial cost of TEVAR, evidence in the literature strongly suggest that it is superior to OMT for un-TBAD on the long-term. In addition, TEVAR is well established in the literature as being gold-standard repair technique for co-TBAD, replacing OSR by offering a more optimal cost-benefit profile through lower costs and improved results.

CONCLUSIONS

The introduction of TEVAR has revolutionized the field of aortovascular surgery by offering a highly efficacious and long-term cost-effective treatment for TBAD.