Physician-modified fenestration or in situ fenestration for preservation of isolated left vertebral artery in thoracic endovascular aortic repair

Reconstruction of the isolated left vertebral artery in total aortic arch replacement for type A aortic dissection via a single upper right hemisternotomy approach

OBJECTIVES

The isolated left vertebral artery (ILVA) is a rare congenital abnormality of the branches of the aortic arch. Its presence can influence both the surgical procedure and the prognosis of total aortic arch replacement. The goal of this study was to assess the early postoperative outcomes of ILVA reconstruction performed during total aortic arch replacement via a single upper right hemisternotomy approach.

METHODS

From October 2018 to March 2024, patients diagnosed with type A aortic dissection who underwent total aortic arch replacement via a single upper right hemisternotomy at the General Hospital of the Northern Theater Command were included. Based on the presence of ILVA, the patients were divided into the ILVA group and the control group. Patients in the ILVA group underwent intraoperative ILVA reconstruction, and relevant perioperative clinical data were collected and analysed. Inverse probability of treatment weighting was applied to balance the preoperative baseline data.

RESULTS

A total of 516 patients were included in the study. Of these, 34 patients were in the ILVA group, which included 27 males (79.4%) with a mean age of 48.9 ± 12.9 years; the remaining 482 patients were assigned to the control group, which included 360 males (74.7%) with a mean age of 50.5 ± 10.9 years. Following adjustment using the inverse probability of treatment weighting, the incidence of paraplegia was significantly lower in the ILVA group than in the control group (0% vs 2.14%, P = 0.003). Furthermore, the incidence of stroke (3.38% vs 6.55%, P = 0.354) and of in-hospital death (3.23% vs 5.58%, P = 0.454) was similar in both groups.

CONCLUSIONS

The research indicates that ILVA reconstruction during total aortic arch replacement via a single upper right hemisternotomy effectively preserved ILVA patency and resulted in excellent early outcomes. Statistically, the incidence of postoperative paraplegia was significantly lower compared to the that in the control group, and no significant differences were observed in deaths or other complications between the 2 groups.

CLINICAL REGISTRATION NUMBER

The study was approved by the Ethics Committee of the General Hospital of the Northern Theater Command, Shenyang City, China [Y(2024)188].

Antegrade In Situ Fenestration During Thoracic Endovascular Aortic Repair for Preserving Isolated Left Vertebral Artery

Introduction

An isolated left vertebral artery (ILVA) on the aortic arch with aortic arch pathologies is common, but how to preserve the ILVA blood flow during endovascular repair remains challenging. Several strategies have been reported but there is still no consensus on the best treatment. This case report presents a novel totally endovascular technique for ILVA revascularisation using antegrade in situ needle assisted fenestration without neck surgical procedures.

Report

A 72 year old man with an ILVA and an incomplete circle of Willis underwent endovascular repair of an aortic arch dissection aneurysm. A 30-26 x 160 mm polytetrafluoroethylene aortic stent graft (Ankura; Lifetech, Shenzhen, China) was deployed proximally in zone 2 of the aortic arch covering the primary tear together with the ILVA and left subclavian artery (LSA). A 6F steerable sheath was placed in the LSA through brachial access, and another 6F long sheath with an adjustable puncture needle was introduced through the right femoral access and placed against the ILVA ostium with the guidance of LSA angiography. Antegrade ILVA fenestration was successfully performed using a needle, and a 0.018 inch guidewire was introduced through the puncture hole, followed by balloon dilation and implantation of a 4.5 × 12 mm balloon expandable bare stent (Dynamic; Biotronik, Bulach, Switzerland). The LSA was reconstructed using a retrograde in situ needle fenestration technique through the steerable sheath from left brachial access, and a 9 × 50 mm Viabahn stent graft was deployed. Post-operatively, the patient recovered uneventfully without neurological deficit. One year follow up imaging confirmed patent ILVA and LSA, and favourable aortic remodelling without any leakage.

Conclusion

This case suggests that the totally endovascular technique of antegrade in situ fenestration is feasible and effective for preserving an ILVA.

Utilizing Single-Branched Stent in Combination With Fenestration or Chimney for Endovascular Repair of Aortic Arch Lesions With Aberrant Subclavian Artery

OBJECTIVE

The study was to figure out the feasibility, efficacy, and safety of a single-branched stent graft, namely Castor, in combination with fenestration or chimney in the context of aortic arch lesions presenting with aberrant subclavian artery (ASA) and/or Kommerell's diverticulum (KD).

METHODS

All consecutive patients with aortic arch lesions and ASA and/or KD receiving Castor from June 2018 to June 2023 were investigated.

RESULTS

Incorporating 18 patients, the study encompassed 11 cases with KD, 3 cases with dysphagia; 2 cases of right-sided aortic arch with left-sided aberrant left subclavian artery (ALSA), and 16 cases of left-sided aortic arch with right-sided aberrant right subclavian artery (ARSA). The mean operation time was 132±23 minutes. The mean measured proximal aortic diameter was 30.9±1.6 mm, and proximal diameter of Castor stent was 34 (32, 34.5) mm, with oversize of 9.1±1.6%; the mean measured branch diameter was 8.8±0.97 mm, and branch diameter of Castor stent was 10 (8, 10) mm, with oversize of 0.86±0.57 mm. Technical success rate was 100%, and no in-hospital mortality, no stroke, and no endoleak were identified. One (5.6%) case with spinal cord ischemia and one (5.6%) case with poor healing of operative site were identified. During the follow-up period, no aortic-related death or secondary intervention was recorded. The maximal aortic diameter was significantly reduced at the sixth postoperative month (padj=0.031); KD diameter was significantly reduced at the third (padj=0.001) and sixth (padj<0.001) postoperative month.

CONCLUSION

Totally endovascular repair of aortic arch lesions with ASA and KD via Castor stent in combination with fenestration or chimney is feasible, effective, and safe, which can achieve an encouraging medium-term outcome and provide excellent remodeling at the lesions.

CLINICAL IMPACT

Single branched stent in combination with fenestration or chimney achieved a sufficient proximal landing zone and provided an encouraging medium-term outcome in this retrospective review of 18 patients receiving endovascular treatment of pathological aortic arch with aberrant subclavian artery and/or Kommerell's diverticulum. The authors suggest this time-saving and efficient technique to establish systematic experience for the treatment in this kind of patients.

Utilizing physician modified fenestration on the castor branched stent technique for reconstruction of an isolated left vertebral artery on the aortic arch

The study aimed to provide physician modified fenestration (PMF) on a single-branched stent for the aortic arch (Castor) to protect the isolated left vertebral artery (ILVA) during thoracic endovascular aortic repair (TEVAR). Patients who underwent TEVAR involving ILVA reconstruction through PMF performing on the Castor branched stent were included in a retrospective, multi-centre study from June 2018 to December 2022. In these patients, all proximal landing zones of "Castor" were positioned in Ishimaru zone 2a. A total of twenty-five patients met the inclusion criteria and the achievement rate showed 25/25 (100%) success in them. The twenty-five patients had a median follow-up length of 28.5 ± 14.6 months. One patient (4.0%) suffered from postoperative ischemic stroke before discharge. One patient (4.0%) died from a hemodialysis-related brain hemorrhage before discharge on the 29th day after the procedure. One patient died of advanced liver cancer in the 33th month after discharge. Aortic rupture, stroke or spinal cord injury did not occur throughout the follow-up period after discharge. Two patients (8.0%) experienced endoleak at the fenestration, however, resulting in only one's necessity for reintervention. Notably, the procedure effectively maintained ILVAs patency for all patients during follow up. According to our preliminary findings, performing a TEVAR under local anaesthesia using PMF on a Castor branched stent for ILVA preservation appeared practical, secure, and effective.