Comprehensive review of hybrid aortic arch repair with focus on zone 0 TEVAR and our institutional experience

Anatomical Feasibility of the "Canaud Technique" for Physician-Modified Thoracic Endovascular Grafts for the Treatment of Aortic Arch Disease

PURPOSE

Thoracic endovascular aortic repair (TEVAR), originally conceived for deployment distal to the left subclavian artery (LSA), has been recently extended to more proximal landing zones. Among total endovascular solutions, the "Canaud technique" for Physician-Modified Thoracic Endovascular Grafts (C-PMEGs) has gained acceptance with good early results. The aim of this study is to report the proportion of patients with zone 0, 1, and 2 aortic arch lesions that could theoretically be treated with a C-PMEG.

MATERIALS AND METHODS

Computed tomography angiography (CTA) of all consecutive patient candidates to open, hybrid, or endovascular arch repair from January 2009 to July 2023 at our Institution were analyzed. The assessment of feasibility of C-PEMG was conducted following previously extensively described anatomical criteria.

RESULTS

During the study period, 209 consecutive patients were candidates for an open, hybrid, or endovascular aortic arch repair. Of them, 164 patients had a preoperative CTA scan eligible for analysis. One hundred twenty-six patients were male (76.8 %), with a mean age of 67 ± 10.8 years. Ninety-four patients (57.3%) were affected by atherosclerotic aneurysms, 48 post-dissecting aneurysms (29.3%) and 22 penetrating aortic ulcers (PAUs) (13.4%). Twenty patients (12.2%) were suitable for double-fenestrated C-PMEG, and 34 patients (20.7%) for single-fenestrated C-PMEG, totaling 32.9% of the entire cohort. The combination of supra-aortic trunks (SAT) bypass or the use of covered stent in IA or left common carotid artery (LCCA) as adjunctive maneuvers, would extend the C-PMEGs feasibility to 69 patients (42.1%). The use of an iliac graft conduit in 3 (1.8%) patients with inadequate ileo-femoral accesses would increase the C-PMEG suitability to 72 patients (43.9%). The main reason for exclusion was excessive ascending aortic diameter in 78 patients (47.6%).

CONCLUSIONS

The use of C-PMEG was shown to be theoretically feasible in a percentage of patients ranging from 32.9 to 43.9% affected by aortic arch aneurysms, dissections, and PAU. The main reason for exclusion was the dimension of the ascending aorta. The C-PMEG technique is a viable option in aortic arch lesions endovascular treatment. An off-the-shelf device with similar characteristics could also be used in emergency, avoiding the limitations of physician modifications (such as time for back-table procedure, sterility, off-label use).

CLINICAL IMPACT

Thoracic endovascular aortic repair (TEVAR) has been extended to more proximal landing zones for the treatment of aortic arch aneurysm, dissections, penetrating aortic ulcers. Among total endovascular solutions, the "Canaud technique" for Physician-Modified Thoracic Endovascular Grafts (C-PMEGs) has gained acceptance with good early results. The anatomical feasibility in 164 consecutive patients was 69 patients (42.1%), with the combination of supra-aortic trunks (SAT) bypass or the use of covered stent in IA or left common carotid artery (LCCA) as adjunctive maneuvers, showing that the C-PMEG technique is a viable option in aortic arch lesions endovascular treatment.

The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch

Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.

Aortic remodeling following hybrid arch repair with zone 0 to 5 thoracic endovascular aortic repairs for complex arch and descending thoracic aortic pathologies

Objective

For high-risk patients with aortic arch pathology, hybrid aortic arch repair with simultaneous or staged thoracic endovascular repair of the descending aorta may be a viable alternative to open repair. However, data on postintervention aortic remodeling remain limited. We report the short-term outcomes of remodeling of the thoracoabdominal aorta after hybrid arch repair + thoracic endovascular repair.

Methods

All patients undergoing hybrid arch repair with planned zones 0 to 5 thoracic endovascular repair from January 2020 to March 2022 were retrospectively reviewed. Computed tomography angiography scans preoperatively, after hybrid aortic arch repair, and on long-term follow-up were analyzed for thoracoabdominal aorta remodeling. Mean change in aortic true luminal diameter and full luminal diameter was calculated at every level, and paired-samples t test was used to compare means.

Results

Of 39 patients, 38 had follow-up data at a mean duration of 14.9 months. There were a total of 3 (7.7%) deaths, 0 (0.0%) strokes, and 0 (0.0%) paralysis. For the 35 patients undergoing thoracic endovascular repair for aortic dissection, at follow-up, there was a significant increase in the mean true luminal diameter at each level (P < .05), except at the aortic bifurcation and common iliac arteries. The largest increase in mean true luminal diameter (P < .01) was observed at the level of the left inferior pulmonary vein (mean difference +13.22 mm, 95% CI, 10.38-16.07), tracheal carina (mean difference +13.06 mm, 95% CI, 10.05-16.07), and inferior left atrium (mean difference +11.19 mm, 95% CI, 7.84-14.53).

Conclusions

Hybrid arch repair with zones 0 to 5 leads to improved true lumen augmentation in zones 0 to 8 with complete false lumen thrombosis down to zone 5 at short-term follow-up. Zones 9 to 11, if involved, may require adjunctive treatment strategies for total aortic remodeling and complete false lumen obliteration.