A systematic review and meta-analysis of hybrid aortic arch replacement

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.

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.

Evidence-based frozen elephant trunk practice: a narrative review

Background and Objective

The frozen elephant trunk (FET) allows a single-stage repair of complex arch pathologies due to its stented and non-stented hybrid prosthesis (HP) features. FET inherently has its own related complications including distal stent graft-induced new entry (dSINE), failure of aortic remodelling, endoleak, reintervention, and kinking of the stent. The aim of this narrative review is to discuss the latest evidence regarding the postoperative clinical outcomes of the FET procedure. Another aim is to provide an overview of results achieved using different FET devices on the global arch prostheses market.

Methods

A comprehensive literature search was conducted using multiple electronic databases to identify and extract the relevant data and information.

Key Content and Findings

This review found that the literature reported a 5-12% mortality rate post-FET, with varying figures depending on the prosthesis type. Between 0-18.2% of patients developed dSINE, while 0.1-28% developed endoleak. Reintervention occurred in 0-28% of patients and the incidence of kinking has been quoted between 0-8% in the literature. Reporting aortic remodelling rates was challenging due to the lack of standardisation and various measurements reported; however, all studies included in this review reported relative increase in true lumen diameter, reduction in the false lumen diameter, and/or false lumen thrombosis.

Conclusions

In conclusion, FET can achieve a favourable postoperative profile in terms of survival, complications and aortic remodelling, and remains the gold-standard treatment for thoracic aortic pathologies implicating the arch and descending thoracic aorta.

Multicenter Comparison of Aortic Arch Aneurysms and Dissections Zone 0 Hybrid and Total Endovascular Repair

PURPOSE

Comparison of hybrid and total endovascular aortic arch repair at two tertiary vascular surgery centers.

MATERIALS AND METHODS

Consecutive patients undergoing hybrid (HG) or total endovascular (TEG) total aortic arch repair for aneurysms or dissections were included (2008-2022). Primary outcome measure was 30-day mortality. Secondary outcomes were major complications, technical success (defined as absence of surgical conversion/mortality, high-flow endoleaks or branch/limb occlusion), clinical success (defined as absence of disabling clinical sequelae), late and aortic-related mortality/reinterventions, freedom from endoleaks, aortic diameter growth > 5 mm, graft migration and supra-aortic trunks (SAT) patency.

RESULTS

In total, 30 patients were included, 17 in HG and 13 in TEG. TEG presented shorter intervention time (240.5 vs 341 min, p = 0.01), median ICU stay (1 vs 4.5 days, p < 0.01) and median length of stay (8 vs 17.5 days, p < 0.01). No intraoperative deaths occurred. Technical success was 100%; clinical success was 70.6% in HG and 100% in TEG (p = 0.05). Thirty-day mortality was 13.3%, exclusively in HG (p = 0.11). Nine major complications occurred in 8 patients, 5 in HG and 3 in TEG (p = 0.99), among which five strokes, two in HG and three in TEG (p = 0.62). Late mortality was 38.5%, six patients in HG and four in TEG, p = 0.6. Two late aortic-related deaths occurred in HG (p = 0.9). Two aortic-related reinterventions, no graft migration or SAT occlusion was observed.

CONCLUSIONS

Total endovascular repair seems to shorten operative times and provide higher clinical success compared with hybrid solutions, without significant 30-day mortality differences. The most common major complication is stroke.

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

Even with increasing operator experience and a better understanding of the disease and the operation, intervention for aortic arch pathologies continues to struggle with relatively higher mortality, reintervention, and neurologic complications. The hybrid aortic arch repair was introduced to simplify the procedure and improve the outcome. With recent industry-driven advances, hybrid repairs are not only offered to poor surgical candidates but have become mainstream. This review discusses the evolution of hybrid repair, terminology pertinent to this technique, and results. In addition, we aim to provide a pervasive review of hybrid aortic arch repairs with reference to relevant literature for a detailed understanding. We have also discussed our institutional experience with hybrid repairs.

Current state of hybrid solutions for aortic arch aneurysms

Since its inception in the early 2000s, hybrid arch repair (HAR) has evolved from a novel approach to a well-established treatment modality for aortic arch pathology in appropriately selected patients. HAR procedures have been proposed as a means to circumvent the perioperative morbidity and mortality associated with open total arch replacement. These procedures, all of which remain off-label applications of approved endograft technology, combine more conventional open surgical techniques, to create endograft landing zones, with thoracic endovascular aortic repair to exclude the aortic pathology from the circulation. The current classification system for HAR was proposed in 2013 and consists of three types, designated by the Roman numerals I, II and III. The current system has become outdated, however, with the advent of newer technologies, and herein we propose a new, updated classification system that is more encompassing with regards to the broad array of options available to treat aortic arch disease. Likewise, an institutional algorithm to guide patient and operative selection for HAR is presented. Patients are considered for HAR if they have either high-risk comorbidities or high-risk anatomy, with an important feature of the algorithm being that any decisions about repair strategy should be made by a surgical team with expertise in both open and endovascular techniques. Despite being performed for nearly two decades, the evidence around HAR consists mainly of single center series (level B-C evidence) with no randomized controlled trials. The data suggest HAR to be a safe alternative to open repair with acceptable short and mid-term results. As we as aortic surgeons continue to move towards less invasive approaches, both conventional open and hybrid techniques will remain important tools in the toolbox for arch repair, although the advent of multi-branched arch endografts will almost certainly reduce the extent of open or hybrid repair in many patients and eliminate it altogether in others.

[Ascending Aorta and Aortic Arch - Endovascular Therapy Today and in the Future]

Pathologies in the region of the aortic arch may occur in isolation, but adjacent segments of the thoracic aorta - the ascending or descending aorta - are much more commonly affected. The first surgical procedures to treat the aortic arch were performed nearly six decades ago. Despite numerous improvements and innovations in the 20th and early 21st centuries, these procedures are still associated with relevant operative mortality and neurological complication rates. Endovascular techniques and modern hybrid procedures are increasingly expanding the therapeutic spectrum in the aortic arch, although the open surgical approach is currently still the gold standard. Endovascular treatment of aortic aneurysm was first performed in the early 1990s in the infrarenal abdominal aorta. It was not long before the first attempts at endovascular therapy were made for the treatment of the aortic arch. In 1996, Inoue et al. reported the use of the first commonly used endoprosthesis to treat aneurysms in the aortic arch. Continuous improvements and refinements in implantation techniques and also implanted material have resulted in endovascular therapy now being an increasingly important option compared to open surgical procedures in the descending thoracic and abdominal aorta and has partially replaced them as the gold standard. This review article aims to provide an overview of the prerequisites, results, but also limitations of endovascular surgery of the aortic arch.

National Outcomes of Elective Hybrid Arch Debranching with Endograft Exclusion versus Total Arch Replacement Procedures: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database

OBJECTIVE

 Hybrid arch procedures (arch vessel debranching with thoracic endovascular aneurysm repair [TEVAR] coverage of arch pathology) have been presented as an alternative to total arch replacement (TAR). But multicenter-based analyses of these two procedures are needed to benchmark the field and establish areas of improvement.

METHODS

 The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from July 2014 to December 2015 was queried for elective TAR and hybrid arch procedures. Demographics and operative characteristics were compared and stepwise variable selection was used to create a risk-set used for adjustment of all multivariable models.

RESULTS

 A total of 1,011 patients met inclusion criteria, 884 underwent TAR, and 127 had hybrid arch procedures. TAR patients were younger (mean age: 62.7 ± 13.3 vs. 66.7 ± 11.9 years; p = 0.001) and had less peripheral vascular disease (34.0 vs. 49.6%; p < 0.001) and preoperative dialysis (1.7 vs. 4.7%; p = 0.026), but similar history of stroke (p = 0.91)/cerebrovascular disease (p = 0.52). TAR patients had more concomitant procedures (60 vs. 34.6%; p < 0.0001). TAR patients had lower mortality (6.7 vs. 12.6%; p = 0.02), stroke (6.9 vs. 15%; p = 0.002), paralysis (1.8 vs. 7.1%; p = 0.002), renal failure (4.6 vs. 8.7%; p = 0.045), and STS morbidity (34.2 vs. 42.5%; p = 0.067). Composite mortality, stroke, and paralysis were significantly lower with TAR (11.5 vs. 25.2%; p = 0.0001). After risk adjustment, analysis showed hybrid arch procedures imparted an increased odds of mortality (odds ratio [OR] = 1.91, p = 0.046), stroke (OR = 2.3, p = 0.005), and composite endpoint of stroke or mortality (OR = 2.31, p = 0.0002).

CONCLUSION

 TAR remains the gold standard for elective aortic arch pathologies. Despite risk adjustment, hybrid arch procedures were associated with increased risk of mortality and stroke, advocating for careful adoption of these strategies.

Endovascular repair of the aorti arch

AIM

The study was aimed at assessing the in-hospital results of aortic arch endoprosthetic repair using different variants of endovascular supraaortic debranching.

PATIENTS AND METHODS

The analysis included 27 patients subjected within the framework of aortic arch endoprosthetic repair to various types of supraaortic endobranching, including the technique of parallel prostheses and implantation of fenestrated stent grafts. We analysed the clinical and morphological status of patients prior to operation, peculiarities of the intervention (type of debranching and Ishimaru's classification zones in which the reconstruction was performed) and in-hospital results of treatment.

RESULTS

The patients' mean age amounted to 66 years. The main nosology (70%) was an aortic aneurysm. Nearly in 30% of cases, the operation was performed emergently for acute aortic syndrome. The main causes of refusal from the traditional prosthetic repair included chronic kidney disease (22.5%), chronic obstructive pulmonary disease (11%), acute cerebral ischaemia within the previous 6 months (15%). The technical success rate of the operation was achieved in 100% of cases. The average duration of the intervention amounted to 226 min, with the mean blood loss equalling 355 ml. The majority of reconstructions were performed in zones 1 and 2 according to Ishimaru (59 and 33%, respectively), in 2 (7%) patients prosthetic repair was performed in zone 0. The total number of the aortic branches involved into reconstruction amounted to 45. Intervention-related complications included 3 (11%) cases of acute cerebral circulation impairment, 2 (7.4%) aortic branch occlusions, and 1 (3.7%) type II endoleak. The in-hospital and 30-day mortality rates amounted to 3.7 and 7.4%, respectively.

CONCLUSION

Aortic arch endoprosthetic repair using supraaortic endobranching is considered to be an effective alternative method of treatment for patients with various pathology of the aortic arch and contraindications to traditional prosthetic repair involving artificial blood circulation.

Hybrid repair versus conventional open repair for aortic arch dissection

BACKGROUND

A dissection of the aorta is a separation or tear of the intima from the media. This tear allows blood to flow not only through the original aortic flow channel (known as the true lumen), but also through a second channel between the intima and media (known as the false lumen). Aortic dissection is a life-threatening condition which can be rapidly fatal. There is debate on the optimal surgical approach for aortic arch dissection. People with ascending aortic dissection have poor rates of survival. Currently open surgical repair is regarded as the standard treatment for aortic arch dissection. We intend to review the role of hybrid and open repair in aortic arch dissection.

OBJECTIVES

To assess the effectiveness and safety of a hybrid technique of treatment over conventional open repair in the management of aortic arch dissection.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 8 February 2021. We also undertook reference checking for additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and clinical controlled trials (CCTs), which compared the effects of hybrid repair techniques versus open surgical repair of aortic arch dissection. Outcomes of interest were dissection-related mortality and all-cause mortality, neurological deficit, cardiac injury, respiratory compromise, renal ischaemia, false lumen thrombosis (defined by partial or complete thrombosis) and mesenteric ischaemia.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all records identified by the literature searches to identify those that met our inclusion criteria. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of the evidence using GRADE.

MAIN RESULTS

We identified one ongoing study and two unpublished studies that met the inclusion criteria for the review. Due to a lack of study data, we could not compare the outcomes of hybrid repair to conventional open repair for aortic arch dissection.

AUTHORS' CONCLUSIONS

This review revealed one ongoing RCT and two unpublished RCTs evaluating hybrid versus conventional open repair for aortic arch surgery. Observational data suggest that hybrid repair for aortic arch dissection could potentially be favourable, but conclusions can not be drawn from these studies, which are highly selective, and are based on the clinical status of the patient, the presence of comorbidities and the skills of the operators. However, a conclusion about its definitive benefit over conventional open surgical repair cannot be made from this review without published RCTs or CCTs. Future RCTs or CCTs need to have adequate sample sizes and follow-up, and assess clinically-relevant outcomes, in order to determine the optimal treatment for people with aortic arch dissection. It must be noted that this may not be feasible, due to the reasons mentioned.

Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms

BACKGROUND

Thoracic aortic arch aneurysms (TAAs) can be a life-threatening condition due to the potential risk of rupture. Treatment is recommended when the risk of rupture is greater than the risk of surgical complications. Depending on the cause, size and growth rate of the TAA, treatment may vary from close observation to emergency surgery. Aneurysms of the thoracic aorta can be managed by a number of surgical techniques. Open surgical repair (OSR) of aneurysms involves either partial or total replacement of the aorta, which is dependent on the extent of the diseased segment of the aorta. During OSR, the aneurysm is replaced with a synthetic graft. Hybrid repair (HR) involves a combination of open surgery with endovascular aortic stent graft placement. Hybrid repair requires varying degrees of invasiveness, depending on the number of supra-aortic branches that require debranching. The hybrid technique that combines supra-aortic vascular debranching with stent grafting of the aortic arch has been introduced as a therapeutic alternative. However, the short- and long-term outcomes of HR remain unclear, due to technical difficulties and complications as a result of the angulation of the aortic arch as well as handling of the arch during surgery.

OBJECTIVES

To assess the effectiveness and safety of HR versus conventional OSR for the treatment of TAAs.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 March 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations.

SELECTION CRITERIA

We considered for inclusion in the review all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing HR to OSR for TAAs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles and abstracts obtained from the literature search to identify those that met the inclusion criteria. We retrieved the full text of studies deemed as potentially relevant by at least one review author. The same review authors screened the full-text articles independently for inclusion or exclusion.

MAIN RESULTS

No RCTs or CCTs met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of HR compared to OSR in people with TAAs, and we are unable to provide high-certainty evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs are necessary, addressing the objective of this review.

One-stage hybrid procedure for distal aortic arch disease: mid-term experience at a single center

Background

This study analyzes the outcomes of a one-stage hybrid procedure combining thoracic endovascular aortic repair (TEVAR) with extra-anatomic bypass in patients with distal aortic arch disease.

Methods

This retrospective study collected 103 hybrid procedures combining TEVAR with extra-anatomic bypass (mean age, 62.2±9.3 years; 90 males) performed from January 2009 to January 2019 at Beijing Anzhen Hospital. We analyzed 30-day and mid-term outcomes including survival rate and the incidence of stroke, spinal cord injury (SCI), and endoleak.

Results

Five deaths (4.6%) occurred within 30 days, including type I endoleak in Zone 1 (n=1), hemorrhagic shock (n=1), stroke (n=2), and stent migration (n=1). Two patients developed SCI. The median follow-up time was 39.5 (interquartile range, 13.6-69.0) months. In all, 14 late deaths occurred; these were due to stroke (n=2), severe pneumonia (n=1), aortic rupture caused by type I endoleak (n=3), and sudden death (n=8). Six late endoleaks occurred including three type I and one type II in Zone 1 and two type I in Zone 2. In a competing risks analysis, the incidences of reintervention at 7 years, late death, and survival without reintervention were 8%, 22%, and 70%, respectively. In a Cox risk model, stroke (HR, 21.602; 95% CI: 2.798–166.796; P=0.003) was the only risk factor for 30-day mortality. Stroke (HR, 19.484; 95% CI: 5.245–72.380; P<0.001), SCI (HR, 15.548; 95% CI: 2.754–87.786; P=0.002), and endoleak (HR, 4.626; 95% CI: 1.068–20.040; P=0.041) were independent risk factors for long-term mortality.

Conclusions

The one-stage hybrid procedure provides acceptable mid-term results with good mid-term patency of extra-anatomic bypass. Strict selection of patients suitable for hybrid repair can effectively improve the survival rate and reduce the incidence of complications. At the same time, close follow-up patients should receive close long-term follow-up after hybrid procedure.

A hybrid clampless technique for aortic anastomoses

Background and Purpose

In various circumstances of aortic repairs (heavy circumferential calcifications or shaggy aorta with extensive thrombus), open and endovascular techniques are at high risk. In addition to a likelihood of emboli, aortic clamping can be complicated by rupture and endovascular techniques may not be successful. We here describe a simple and reproducible hybrid technique that allows performing an aortic anastomosis without clamping in these situations.

Methods

After a limited exposure of the anterior aortic wall in a healthy segment, a prosthetic graft is sutured without any arteriotomy or clamping (adventitial suture), mimicking the final aspect of an end-to-side anastomosis. The graft and the anastomosis site are punctured using a long needle, allowing a guidewire to be positioned in the aorta under fluoroscopic guidance. Protected covered stenting of the anastomosis site opens the anastomosis without aortic clamping. After tunneling the graft to the target artery, the distal anastomosis is performed in a usual fashion.

Results

This technique was successfully used in 10 challenging consecutive cases with a sustained patency.

Conclusions

This hybrid clampless technique for aortic anastomosis represents a useful alternative for challenging lesions unsuitable for a simple open or endovascular treatment.

Which is the Optimal Frozen Elephant Trunk? A Systematic Review and Meta-Analysis of Outcomes in 2161 Patients Undergoing Thoracic Aortic Aneurysm Surgery Using E-vita OPEN PLUS Hybrid Stent Graft versus Thoraflex™ Hybrid Prosthesis

Objective

To systematically review the rate of morbidity and mortality associated with the use of E-vita hybrid stent graft and ThoraflexTM in patients undergoing complex aortic surgery.

Methods

A comprehensive search was undertaken among the four major databases to identify published data about E-vita or Thoraflex™ in patients undergoing repair of thoracic aortic aneurysms.

Results

In total, 28 papers were included in the study, encompassing a total of 2,161 patients (1,919 E-vita and 242 Thoraflex™). Patients undergoing surgery with E-vita or Thoraflex™ were of similar age and sex. The number of patients undergoing non-elective repair with Thoraflex™ was higher than with E-vita (35.2% vs. 28.7%, respectively). Cardiopulmonary bypass time was associated with increasing mortality in E-vita patients, however a meta-analysis of proportions showed higher 30-day mortality, permanent neurological deficit, and one-year mortality for Thoraflex™ patients. Direct statistical comparisons between E-vita and Thoraflex™ was not possible due to heterogeneity of studies.

Conclusion

Although there are limited studies available, the available data suggests that mortality and morbidity are lower for the E-vita device in thoracic aortic aneurysm surgery than for Thoraflex™. Long-term data of comparative studies do not yet exist to assess viability of these procedures.

Endovascular aortic repairs combined with looping-chimney technique for repairing aortic arch lesions and reconstructing left common carotid artery

Background

The aim of this retrospective study was to evaluate the feasibility and efficacy of thoracic endovascular aortic repairs (TEVAR) combined with looping chimney technique (LCT) for repairing aortic arch lesions and reconstructing left common carotid artery.

Methods

Total of 14 patients (mean age 52.86±14.46 years; range, 27–79; 10 men, 4 women) were included in the study from December 2016 to December 2018. Aortic arch pathologies of all patients with insufficient proximal landing zone (PLZ) were repaired by TEVAR under local anesthesia, before TEVAR, the left common carotid artery (LCCA) was protected by the guiding sheath from the retrograde brachial access, after aortic stent graft deployed, chimney graft was implanted to restore LCCA by LCT if necessary. All patients underwent computed tomography angiograph (CTA) 2 weeks, 3 months, 6 months and 1 year after surgery.

Results

Pathology results of 14 patients included: type B aortic dissection (n=8), penetrating aortic ulcers (n=1), retrograde type A aortic dissection (n=1), thoracic aortic aneurysm (TAA) (n=2), and thoracic aortic pseudoaneurysm (n=2). In all patients, aortic arch lesions were repaired by TEVAR; while LCCA were successfully reconstructed by the LCT. In one case, the innominate artery (IA) was simultaneously reconstructed through the same percutaneous right brachial artery (RBA) access. Coiling eliminated type Ia endoleak in 3 patients, and type II endoleak vanished by plugging left subclavian artery (LSA) in 2 patients. In four patients, the chimney stent (CG) of LCCA was partially compressed and then another bare stent was implanted to restore patency rate. The mean follow-up duration was 9.77±6.64 months (range, 0–24) and no combinations were observed in 13 patients; except in one patient who died of cerebral hemorrhage due to abnormal coagulation function.

Conclusions

TEVAR combined with LCT has shown to be suitable surgical approach for aortic arch lesions. Either covered intentionally or inadvertently, the LCCA could be safely and effectively reconstructed via percutaneous RBA access. Short-term follow-up demonstrated satisfactory morbidity and mortality in high-risk patients; however, longer follow-up is required to assess the effectiveness and durability of this innovative endovascular procedure.

Endovascular treatment for aortic arch pathologies: chimney, on-the-table fenestration, and in-situ fenestration techniques

Background

Revascularization of the supra-aortic major branches in thoracic endovascular aortic repair (TEVAR) is challenging owing to the complex anatomic configuration of aortic arch pathologies. This study aims to evaluate the feasibility, effectiveness, and safety of three major techniques—chimney, fenestrated, and in-situ fenestration—for patients with aortic arch pathologies.

Methods

A retrospective analysis was performed involving 234 patients with aortic arch lesions, who underwent TEVAR with adaptations in technique (chimney, fenestrated, or in-situ fenestration) between January 2016 and December 2017.

Results

One hundred and twenty-six patients underwent the chimney technique (98 single chimneys, 24 double chimneys, and four triple chimneys); one hundred and two patients (102/234) were treated with on-the-table fenestration technique (92 single fenestrations, nine double fenestrations, and one double fenestration plus innominate artery chimney); and the remaining six patients underwent in-situ needle fenestration technique. Overall, indications included aortic dissections (99/234), aortic arch aneurysms (60/234), penetrating aortic ulcers (72/234), and re-interventions (3/234). The technical success rates were 99.6%. There were five cases of early all-cause mortality. The patency rates of overall branches were 99.6%. There were 15 cases with type Ia endoleak—14 in the chimney group (11.1%) and one in the on-the-table fenestration group (1%). Five patients underwent re-interventions. The median follow-up time for all patients was 28 (range, 16–41) months.

Conclusions

Our experience suggests that chimney, on-the-table fenestration, and in-situ needle fenestration techniques are feasible, effective, and safe treatment options for aortic arch pathologies with encouraging mid-term results. Long-term durability concerns require further evaluation.

A Clampless Aortoprosthetic End to Side Anastomotic Device with Large Diameter Aortic Puncher

Introduction

To facilitate safe anastomosis of a vascular prosthesis onto the proximal ascending aorta without side clamping, a clampless anastomotic device with large diameter aortic puncher was developed.

Report

First, a vascular prosthesis is anastomosed onto the aorta without making a hole, then the aortic wall within the prosthesis is punched out using the device.

Discussion

After further refinement of the present device, endovascular surgery with debranching could be performed more safely and quickly.

Long-Term Outcomes of Open Surgery and Stent Graft Treatment in Patients Undergoing Repeat Thoracic Aortic Aneurysm Repair from Previous Anastomosis Site

Objective: The purpose of this study was to compare the long-term outcomes of open surgery and thoracic endovascular aortic repair (TEVAR) in patients undergoing repeat thoracic aortic repair from previous anastomosis site.

Methods: From January 2009 to December 2017, 68 patients needed repeat aortic surgery from previous anastomosis site. Twenty-three patients had dissected distal aorta and 45 patients had non-dissected distal aorta. Early and long-term outcomes of open surgery and TEVAR were compared in both groups.

Results: There were no significant differences in patient background between the two treatments in both groups. Open surgery was associated with longer intensive care unit stay, but there was no significant difference in in-hospital mortality in both groups. In patients with dissected distal aorta, there was no significant difference in long-term mortality (p=0.73). However, TEVAR was associated with higher risk of reintervention (p=0.038). In non-dissected distal aorta patients, acute kidney injury (p=0.002) and prolonged ventilation (p=0.032) were more often observed in open surgery. However, there were no significant differences in long-term mortality (p=0.23) and freedom from reintervention (p=0.13).

Conclusions: Long-term outcomes were similar between open surgery and TEVAR in both groups. However, TEVAR in patients with dissected distal aorta was associated with higher risk, for reintervention.

Risk factors for spinal cord injury in patients undergoing frozen elephant trunk technique for acute aortic dissection

BACKGROUND

The purpose of this study was to evaluate the risk factors for spinal cord injury (SCI) in patients with acute aortic dissection undergoing surgery with frozen elephant trunk technique (FET).

METHODS

From December 2014 to February 2018, 17 patients with acute aortic dissection underwent surgical treatment of the aortic arch with FET. SCI occurred in 3 patients. Risk factors for SCI were evaluated.

RESULTS

Mean age of the patients was 56 years and 88.2% were male. The ratio of true lumen to total aortic diameter at the level of carina (before: 0.48 vs. after: 0.75, P < 0.001), aortic valve (before: 0.47 vs. after: 0.67, P = 0.001), and celiac artery (before: 0.48 vs. after: 0.68, P = 0.003) increased after surgery. There were no significant differences in perioperative minimum hemoglobin level and postoperative mean arterial pressure between patients with and without SCI. However, patients with SCI had higher creatinine level before surgery (SCI: 1.32 mg/dL vs. no SCI: 0.81 mg/dL, P = 0.023). Although there was no difference in number of patent intercostal arteries before surgery, those originating from the true lumen were fewer in patients with SCI (SCI: 2.7 vs. no SCI: 8.6, P = 0.021). Furthermore, with entry closure, significant decrease in patency was observed in intercostal arteries originating from the false lumen (before: 3.1 vs. after: 1.0, P < 0.001).

CONCLUSION

FET was useful in entry closure. However, FET in patients with higher creatinine level and those who may have significant spinal cord perfusion from the false lumen could be a risk factor for postoperative SCI.

Off pump hybrid extra-anatomic techniques for aortic arch repair-own experience

Background

Treatment of the aortic arch pathologies is technically challenging. In this study we assess early and late outcomes of hybrid aortic arch repairs that comprise extra-anatomic surgical procedures completed by thoracic endovascular interventions [thoracic endovascular aortic repair (TEVAR)].

Methods

Since 2007, 21 patients (8 women and 13 men) with a median age of 48 years have undergone hybrid procedures for aortic arch pathologies. All of them were treated without cardio-pulmonary bypass. All survivors were followed up regularly and imaging examination were performed. A technical success, procedural complications as well as the early and late mortality and morbidity rates were evaluated.

Results

All patients survived surgery and TEVAR was technically successful in all of them. However, 2 individuals died (in-hospital mortality rate 9.5%) during in-hospital stay, both due to multi-organ failure (MOF). Additionally, one patient developed symptoms of cerebral stroke, another one of spinal cord ischemia. During the follow-up that ranged from 6 to 118 months and was completed by 100% of the survivors, one patient died 3 years after procedure because of sepsis (aorto-oesophageal fistula prior to intervention) and late vascular graft occlusions were noted in three cases.

Conclusions

Hybrid procedures on the aortic arch that comprise surgical and endovascular interventions has become an attractive and safe therapeutic option with acceptable mortality and morbidity rate. They may be considered as a method of choice in treatment of the elderly and high-risk patients.

Long-term outcomes of balloon-expandable bare stent as chimney stent in thoracic endovascular aortic repair for supra-aortic branches reconstruction

Background

To report the long-term outcomes of balloon-expandable bare stent (BEBS) as chimney stent (CS) in thoracic endovascular aortic repair (TEVAR) for supra-aortic branches reconstruction.

Methods

A total of 33 patients with thoracic aortic diseases underwent TEVAR using BEBSs as CSs for supra-aortic branches reconstruction in our center from 2010 to 2015. The demographics and procedural details were prospectively collected and retrospectively reviewed. All patients were followed up at 1, 3, 6 months and every 1 year thereafter. Postoperative complications and long-term outcomes were recorded.

Results

The technical success rate was 100%. A total of 36 BEBSs were utilized as CSs to reconstruct the supra-aortic branches during TEVAR. The rate of immediate endoleak was 42.4% (14/33), including 12 (36.4%) type Ia endoleaks and 2 (6.1%) type II endoleaks. Two of type Ia endoleaks were managed by balloon dilation and disappeared, while the rest were left with close follow-up. Two type II endoleaks were embolized by coils and excluded by a plug, respectively. One patient (3.0%) died 2 days after the procedure due to the acute rupture of aortic dissection. The mean follow-up time was 61.8 (ranged from 12 to 102) months. The unmanaged 10 type Ia endoleaks were closely observed during the follow-up, of which 7 disappeared at 1 year and 1 disappeared at 2 years. The rest 2 type Ia endoleaks existed without further dilation of the aorta. One patient (3.0%) was re-intervened for the increased false lumen due to the distal residual tears. The long-term mortality was 9.1% (3/33). All CSs kept patent till the end of follow-up. No other complications were found.

Conclusions

The balloon-expandable stent (BES) is a feasible choice as CS for supra-aortic branches reconstruction with long-term patency during TEVAR. However, BEBS may be related to a higher rate of early endoleak.

Open aortic arch surgery: the gold standard method

Aortic arch pathologies are complex and treating them requires close team collaboration and technical skills to provide safe outcomes with low morbidity and mortality rates. Such challenges are facing both aortic and vascular surgeons. Open aortic arch repair has been the standard method of practice in all cases of aortic arch pathologies for the last four decades since the very first successful published case series by Griepp et al. during 1975. However, since then, repair of multi-segmented thoracic aortic pathologies has been explored through endovascular techniques; this is with or without open repair as a one-stage procedure especially in high-risk and elderly patients. Although the role of endovascular techniques in thoracoabdominal aorta is well established, its utilization as solo technique in aortic arch pathologies remains debatable. In this review, we highlight current evidences behind using open, endovascular, and hybrid procedures in aortic arch surgery.

Aortic arch aneurysms and dissection-open repair is the gold standard

The aortic arch repair is one of the most complex surgeries and carries a high risk of complications as well as mortality. Since 1975, when the arch repair was first done by Randall B. Griepp using hypothermic circulatory arrest, many new technologies were introduced. But even with the use of antegrade and retrograde perfusion techniques and improvement of surgical techniques and grafts, the rate of mortality, cerebral, spinal, and visceral damage was much higher as compared to any other cardiac surgeries. With further developments aimed at less invasive approaches, thoracic endovascular aortic repair (TEVAR) along with de-branching of supra-aortic vessels or the frozen elephant trunk was introduced. Here, in this article, we review the myriad of approaches to the aortic arch and have come to a conclusion that while traditional open surgery is considered as the gold standard for treatment of extensive aortic arch pathologies, one school of thought suggests hybrid techniques such as the frozen elephant trunk and aortic arch vessel de-branching as more appropriate procedures for high-risk patients, where co-morbidities may contraindicate cardiopulmonary bypass and longer operative times required for traditional repair. No randomized trials are present to compare between open and hybrid or endovascular procedure in normal or high-risk patients. The meta-analysis of most of the studies defines open surgery as the gold standard for arch pathology because the hybrid procedures did not provide any proven survival benefits or decrease in stroke rate and spinal ischemia when compared to open surgery in early, mid, or long-term results.

Use of 3D Printing in Preoperative Planning and Training for Aortic Endovascular Repair and Aortic Valve Disease

Introduction

Three-dimensional (3D) printing has become an affordable tool for assisting heart surgeons in the aorta endovascular field, both in surgical planning, education and training of residents and students. This technique permits the construction of physical prototypes from conventional medical images by converting the anatomical information into computer aided design (CAD) files.

Objective

To present the 3D printing feature on developing prototypes leading to improved aortic endovascular surgical planning, as well as transcatheter aortic valve implantation, and mainly enabling training of the surgical procedure to be performed on patient's specific condition.

Methods

Six 3D printed real scale prototypes were built representing different aortic diseases, taken from real patients, to simulate the correction of the disease with endoprosthesis deployment.

Results

In the hybrid room, the 3D prototypes were examined under fluoroscopy, making it possible to obtain images that clearly delimited the walls of the aorta and its details. The endovascular simulation was then able to be performed, by correctly positioning the endoprosthesis, followed by its deployment.

Conclusion

The 3D printing allowed the construction of aortic diseases realistic prototypes, offering a 3D view from the two-dimensional image of computed tomography (CT) angiography, allowing better surgical planning and surgeon training in the specific case beforehand.

[Elimination of late endoleak after endovascular repair of a dissecting thoracoabdominal aortic aneurysm]

Described herein is a clinical case report regarding treatment of a 70-year-old male patient presenting with a late complication following endoprosthetic repair for a Stanford type B dissecting thoracic aortic aneurysm. The man was admitted to our hospital for persistent type IIb endoleak and an increased diameter of the aorta in its thoracic and thoracoabdominal portions. Two years previously, he had endured endoprosthetic repair of the thoracic aorta. The findings of computed tomography revealed negative dynamics manifesting as an increase in the diameter of the false channel of the arch and descending thoracic aorta with persistent type IIb endoleak. He was subjected to elimination of abdominal aortic dissection and type IIb endoleak with partial prosthetic repair of the descending thoracic portion of the aorta by means of prosthetic repair of the lower thoracic portion of the aorta between the stent graft and linear vascular Dacron prosthesis. The postoperative period was complicated by transient acute renal failure and paraparesis of the lower limbs. The patient was discharged on POD 14, with no endoleaks revealed on control computed tomography 3 months thereafter.

Frozen elephant trunk with modified en bloc arch reconstruction and left subclavian transposition for chronic type A dissection

Background

Several methods of arch vessel reconstruction, such as en bloc (island) and branched graft techniques, have been proposed to treat aortic arch pathologies during total arch replacement (TAR). We seek to review our experience with modified en bloc technique and left subclavian (LSCA)-left carotid artery (LCCA) transposition in TAR and frozen elephant trunk (FET) procedure for chronic type A aortic dissection (CTAAD).

Methods

From September 2010 to September 2016, 35 consecutive patients with CTAAD underwent modified en bloc arch reconstruction with LSCA-LCCA transposition during TAR and FET procedure. Computed tomographic angiography (CTA) was performed during follow-up.

Results

In-hospital mortality was 5.7% (2/35). No neurological deficit or spinal cord injury occurred. Re-exploration for bleeding and continuous renal replacement therapy were required in 2 patients each (5.7%). Follow-up was complete in 100% for a mean duration of 4.1±1.8 years (range, 0.5-6.7 years). One patient experienced a transient stroke and thoracoabdominal aortic replacement was performed in 1. There were 2 late non-cardiac deaths. Survival was 87.9% (95% CI, 70.7-95.3%) at 6 years. At 6 years, the incidence was 3% for reoperation, 12% for late death, and 85% of patients were alive without reoperation. The anastomosis between the LSCA and LCCA was patent in 100%.

Conclusions

Acceptable early and mid-term outcomes were achieved for patients with chronic type A dissection using en bloc technique with LSCA-LCCA transposition during TAR and FET procedure. This technique may be an alternative approach to chronic type A dissection in selected patients.

Comparison of open surgical versus hybrid endovascular repair for descending thoracic aortic aneurysms with distal arch involvement

Background

Our aim was to compare the efficacies of conventional open thoracotomy and hybrid endovascular technique in patients with descending thoracic aortic aneurysms involving the distal arch.

Methods

Between January 2005 and December 2015, 125 consecutive patients with descending aneurysms involving distal arch underwent open repair via thoracotomy (n=79) or zone 1/2 hybrid endovascular repair (n=46). Surgeries entailing total arch replacement by elephant trunk technique (with sternotomy) and Zone 0 hybrid arch repairs were excluded. Early and late outcomes were compared using propensity scores and inverse-probability-of-treatment weighting (IPTW).

Results

In-hospital mortality rates for open repair (10.1%) and hybrid repair (6.5%) did not differ significantly (P=0.49). Major adverse outcomes included stroke (11.4% vs. 8.7%), paraplegia (2.5% vs. 0.0%) and lung complications (19.0% vs. 6.5%). Once adjusted by IPTW, hospital mortality risk for conventional open repair (OR =4.396; P=0.086) tended to be higher, and there was significant risk of lung complications (OR =4.372; P=0.025). However, both techniques were similar in terms of 30-day mortality (OR =2.745; P=0.257), stroke (OR =2.134; P=0.217), paraplegia (OR =3.639; P=0.407), and midterm survival (OR =1.05; P=0.90). Freedom from reintervention at 10 years was significantly better for open repair (85.2%±7.1%) compared with the hybrid approach (46.3%±11.0%; OR =0.13; P<0.01).

Conclusions

Hybrid arch repair conferred a significantly lower incidence of pulmonary complications, without benefitting perioperative mortality and stroke. However, open repair proved more reliable, showing greater durability. Long-term investigations are needed to confirm the viability and safety of hybrid repair as an alternative treatment in this setting.

Salvage Procedure Using a Chimney Endograft for Early Cerebral Ischaemia after Hybrid Aortic Arch Repair of a Primary Aorto-bronchial Fistula

Introduction

Hybrid aortic arch repair for the treatment of aorto-bronchial fistulas has been suggested as a safe alternative to open repair. However, surgical morbidity and mortality are still significant and re-intervention is sometimes inevitable.

Report

Successful rescue by a hybrid approach is reported in a 76 year old woman who was transferred from another centre with recurrent episodes of left hemiplegia shortly after debranching of the supra-aortic vessels and thoracic aortic stent grafting for an aorto-bronchial fistula associated with a true aneurysm at the level of origin of the left subclavian artery. Investigation revealed partial coverage of the ostium of the brachiocephalic artery and Type Ib and II endoleaks. In the first stage a chimney graft was put into the brachiocephalic trunk, and in the second stage the left subclavian artery was plugged and the thoracic stent graft was extended distally. Completion angiography showed restoration of the supra-aortic blood flow and no residual endoleaks. After 1 year follow up the patient was doing well with no recurrent neurological events and no signs of infection.

Discussion

Procedure related problems should be suspected first when early post-operative complications occur after a hybrid aortic arch repair. The chimney graft technique is a valuable option for unintentional covering of a critical supra-aortic branch. Nevertheless, the importance of precise positioning during initial thoracic stent graft placement should be emphasised.

Cerebral embolic protection during endovascular arch replacement

Despite excellent results in high volume centers, open repair of aortic arch pathology is highly invasive, and can result in significant morbidity and mortality in high risk patients. Near-total and hybrid approaches to aortic arch disease states have emerged as an alternative for patients deemed moderate to high risk for conventional repair. Advantages of these approaches include avoidance of extracorporeal circulation and hypothermic circulatory arrest as well as avoidance of cross clamping, all of which are not well tolerated in high risk patients. Anatomically high-risk patients with anastomotic aneurysms from previous arch reconstruction may also benefit from these less invasive approaches. Medical devices designed specifically for the aortic arch are developing at a rapid pace and continue to evolve. Dedicated devices for zone 0-2 aortic arch repair are currently available under special access or being studied in clinical trials. Unfortunately, stroke continues to be the Achilles heel of endovascular approaches to the aortic arch, with cerebral embolism being the culprit in the majority of such cases. This perspective article describes the epidemiology, procedures, and mitigation strategies for current near-total and hybrid approaches to aortic arch pathology, and specifically addresses current means of embolic protection and future direction.

Open repair techniques in the aortic arch are still superior

Conventional arch replacement can be carried out in a great majority of patients. Hybrid procedures are often as invasive and technically difficult as conventional ones. Moreover, their immediate results are, in many reported experiences, not better and their long-term results less favourable than the ones observed with conventional methods. So, yes, the open conventional arch replacement is still "the gold standard".

Hybrid Treatment with Complete Transposition of Supra-Aortic Trunks versus Conventional Surgery for the Treatment of Aortic Arch Aneurysm

OBJECTIVE

The disease of the aortic arch is traditionally approached by open surgical repair requiring cardiopulmonary bypass and circulatory arrest. This study performed a retrospective analysis comparing outcomes through primary hybrid patients submitted to aortic arch surgery without cardiopulmonary bypass with patients submitted to conventional open surgery.

METHODS

25 patients submitted to the aortic arch surgery were selected in the period 2003-2012 at the Madre Teresa Hospital in the city of Belo Horizonte, Brazil; 13 of these underwent hybrid technique without cardiopulmonary bypass and 12 underwent conventional open surgery.

RESULTS

The mortality rate for the hybrid group was 23% and for the conventional surgery group was 17% (P=0.248). The postoperative complication rate was also similar in both groups, with no significant difference.

CONCLUSION

Both techniques proved to be similar in mortality and morbidity. However, due to the small sample, more analytical studies with larger samples and long-term follow-up are needed to clarify this issue.

Minimally Invasive Techniques for Total Aortic Arch Reconstruction

The cumulative experience with endovascular aortic repair in the descending thoracic and infrarenal aorta has led to increased interest in endovascular aortic arch reconstruction. Open total arch replacement is a robust operation that can be performed with excellent results. However, it requires cardiopulmonary bypass and circulatory arrest and, therefore, may not be tolerated by all patients. Minimally invasive techniques have been considered as an alternative and include hybrid arch debranching, parallel stent graft deployment in the chimney and snorkel configurations, and complete endovascular branched reconstruction with multi-branched devices. This review discusses the evolving use of endovascular techniques in the management of aortic arch pathology and considers their relevance in an era of safe and durable open aortic arch reconstruction.

One-stage hybrid surgery for acute Stanford type A aortic dissection with David operation, aortic arch debranching, and endovascular graft: a case report

Acute Stanford type A aortic dissection requires an extremely complex surgical strategy and presents high risk of complications. Although many different procedures were reported to treat this aortic dissection, high mortality rate and incidences of complications still exist. This study presents a 59-year-old lady with acute Stanford type A aortic dissection, which originated from the aortic root to proximal part of right external iliac artery and involved the brachiocephalic trunk, left carotid artery, celiac trunk, and left renal artery. The patient underwent one-stage hybrid surgery of David procedures, debranching, and endovascular aortic repair under ultrasound-guided aortic arch cannulation cardiopulmonary bypass (CPB). The surgery was successfully performed, and the patient showed no post-operative complication. The one-staged hybrid surgery of David procedures, debranching, and endovascular aortic repair provides novel and well-designed combined techniques for treating complex acute Stanford type A aortic dissection. Our techniques significantly lowered the risks, thereby expanding the indications of surgical intervention for acute Stanford type A aortic dissection.

Evolving practice pattern changes and outcomes in the era of hybrid aortic arch repair

OBJECTIVE

The role of hybrid repair in the management of aortic arch pathology, and long-term outcomes with these techniques, remains uncertain. We report a decade of experience with hybrid arch repair (HAR) and assess institutional practice patterns with regard to the use of hybrid and open techniques.

METHODS

Hybrid and open total and distal arch procedures performed between July 2005 and January 2015 were identified from a prospectively maintained, institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term survival were calculated. Hybrid and open procedural volumes over the study period were assessed to evaluate for potential practice pattern changes.

RESULTS

During the study period 148 consecutive procedures were performed for repair of transverse and distal aortic arch pathology, including 101 hybrid repairs and 47 open total or distal arch repairs. Patients in the hybrid repair group were significantly older with a greater incidence of chronic kidney disease, peripheral vascular disease, and chronic lung disease. Perioperative mortality and outcomes were not significantly different between the hybrid and open groups, aside from decreased median length of stay after hybrid repair. Need for subsequent reintervention was significantly greater after hybrid repair. Unadjusted long-term survival was superior after open repair (70% 5-year survival open vs 47% hybrid; P = .03), although aorta-specific survival was similar (98% 5-year aorta-specific survival open vs 93% hybrid; P = .59). Institutional use of HAR decreased over the final 3 years of the study, with an associated increased use of open total or distal arch repairs. This was primarily the result of decreased use of native zone 0 hybrid procedures. Concurrent with this apparent increased stringency around patient selection for HAR, perioperative morbidity and mortality was reduced, including avoidance of retrograde type A dissection.

CONCLUSIONS

HAR remains a viable option for higher-risk patients with transverse arch pathology with perioperative outcomes and long-term aorta-specific survival similar to open repair, albeit at a cost of increased reintervention. This observational single-institution study would suggest decreased use in more recent years in favor of open repair due to avoidance of native zone 0 hybrid procedures. This decline in the institutional use of native zone 0 hybrid repairs was associated with improved perioperative outcomes.

Hybrid treatment of aortic arch disease

Introduction

The management of thoracic aortic disease involving the ascending aorta, aortic arch and descending thoracic aorta are technically challenging and is an area in constant development and innovation.

Objective

To analyze early and midterm results of hybrid treatment of arch aortic disease.

Methods

Retrospective study of procedures performed from January 2010 to December 2012. The end points were the technical success, therapeutic success, morbidity and mortality, neurologic outcomes, the rate of endoleaks and reinterventions.

Results

A total of 95 patients treated for thoracic aortic diseases in this period, 18 underwent hybrid treatment and entered in this study. The average ages were 62.3 years. The male was present in 66.7%. The technical and therapeutic success was 94.5% e 83.3%. The perioperative mortality rate of 11.1%. There is any death during one-year follow- up. The reoperation rates were 16.6% due 2 cases of endoleak Ia and one case of endoleak II. There is any occlusion of anatomic or extra anatomic bypass during follow up.

Conclusion

In our study, the hybrid treatment of aortic arch disease proved to be a feasible alternative of conventional surgery. The therapeutic success rates and re- interventions obtained demonstrate the necessity of thorough clinical follow-up of these patients in a long time.

One-stage hybrid procedure without sternotomy for treating thoracic aortic pathologies that involve distal aortic arch: a single-center preliminary study

OBJECTIVE

This study aims to evaluate the initial results of a hybrid procedure without sternotomy for treating descending thoracic aortic disease that involves distal aortic arch. It also intends to report our initial experience in performing this procedure.

METHODS

A total of 45 patients (35 males and 10 females) with descending thoracic aortic disease underwent a hybrid procedure, namely, thoracic endovascular aortic repair (TEVAR) combined with supra-arch branch vessel bypass, in our center from April 2009 to August 2014. Right axillary artery to left axillary artery bypass (n=20) or right axillary artery to left common carotid artery (LCCA) and left axillary artery bypass (n=25) were performed. The conditions of all patients were followed up from the 2(nd) month to the 65(th) month postoperative (mean, 26.0±17.1). Mortality within 30 days, complications such as endoleak after the hybrid procedure, and stenosis or blockage of the bypass graft during the follow-up period was assessed.

RESULTS

All the patients underwent a one-stage procedure. One case of death and one case of cerebral infarction were reported within 30 days. One patient died of the sudden drop in blood pressure during the 2(nd) day of operation. Meanwhile, another patient suffered from cerebral infarction. Two patients underwent open surgery, and one of them had to undergo a second TEVAR during the follow-up period. Moreover, endoleak occurred in two patients and a newly formed intimal tear was observed in one patient. Overall, 93.2% of the patients survived without any complication related to the hybrid procedure.

CONCLUSIONS

Initial results suggest that the one-stage hybrid procedure is a suitable therapeutic option for thoracic aortic pathologies that involve distal aortic arch. However, this procedure is not recommended for type-B aortic dissection, in which a tear is located in the greater curvature or near the left subclavian artery (LSA), because of the high possibility of endoleak occurrence.

Outcome of frozen elephant trunk technique for acute type A aortic dissection: as systematic review and meta-analysis

Acute aortic dissections of Stanford type A require emergency surgery repair and present challenges to surgeons. The frozen elephant technique is one of several approaches used to treat aortic arch dissection. The purpose of this meta-analysis was to investigate the clinical effectiveness of the frozen elephant technique for treating acute type A aortic dissection.Medline, Cochrane, Google Scholar, and ClinicalTrials.gov databases were searched up to March 31, 2014, for studies that assessed the use of frozen elephant trunk technique for treating acute type A aortic dissection. The primary outcome was in-hospital mortality. Secondary outcomes included rate of stroke, spinal cord injury, renal failure, and reoperations for bleeding.Eleven studies were included in the analysis that encompassed 881 patients. The mean age ranged from 45.4 to 66.8 years, and the proportion of the population that was male ranged from 45 to 85%. The overall in-hospital mortality rate was 8%. The rate of stroke, spinal cord injury, renal failure, and frequency of reoperations for bleeding were 3, 4, 5, and 5, respectively. Sensitivity analysis indicates that the findings are robust and there was no publication bias.These findings indicate that the frozen elephant techniques does not bring unacceptable mortality or morbidity risk for treating acute type A aortic dissection.

Application of the Bolton Relay Device for Thoracic Endografting In or Near the Aortic Arch

Endovascular correction of aortic arch pathology remains a challenge, with a variety of techniques proposed over the years to minimize complications and enhance the probability of a successful result. A variety of approaches have been developed in order to deal with the aortic arch pathology and its idiosyncrasies. We review potential interventional techniques for the repair of aortic arch pathologies, beginning with conventional aortic arch surgery, followed by hybrid treatments and those along the endovascular spectrum (parallel and fenestrated endografts, scalloped endografts, and ascending and new branched endografts). We finish with an overview of all the Bolton Medical (Barcelona, Spain and Sunrise, FL, USA) thoracic platforms. Endovascular techniques show acceptable results in selected cases. Both proximal Bolton Relay configurations (with and without a bare stent) offer conformability and accuracy on deployment with very low rates of stroke. Fenestrated and scalloped designs are also useful for selected cases. Ascending and branched Bolton devices are very promising platforms for a serious, full endovascular approach to the aorta.

Mycotic thoracic aortic arch aneurysm from haematogenous spread of Clostridium septicum due to metastatic colorectal cancer: a survival guide

We report the case of a 78-year-old female who was found to have a mycotic thoracic aortic arch aneurysm caused by Clostridium septicum. Subsequent investigations demonstrated adenocarcinoma of the caecum with two liver metastases. The patient underwent a hybrid procedure involving endovascular repair of the aneurysm with a right-to-left carotid crossover bypass and a left carotid to left subclavian bypass to protect the cerebral and left subclavian blood flow. The caecal tumour was later completely excised by laparoscopic right hemicolectomy. The patient then underwent resection for the liver metastases. There was no evidence of tumour recurrence 2 years after her right hemicolectomy. This case emphasizes the importance of the association of C. septicum infection with colorectal malignancy. To our knowledge, this is the first case of a mycotic aortic arch aneurysm caused by C. septicum being successfully treated with a hybrid endovascular repair procedure.