Fenestrated Physician Modified Endografts for Endovascular Aortic Arch Repair in Zone 0

OBJECTIVE

This multicentre study aimed to assess the early and midterm outcomes of fenestrated physician modified endografts (PMEGs) for endovascular aortic arch repair in zone 0.

METHODS

Between 2018 and 2022, a retrospective study was conducted in three centres of consecutive patients undergoing endovascular aortic arch repair in zone 0 with PMEGs. Endpoints included technical success, 30 day mortality, major adverse events, secondary interventions, stent stability, target vessel patency, and overall survival.

RESULTS

A total of 54 patients (mean age 63 years; 45 males) with aortic arch pathology were included, comprising aortic dissections (n = 32; 59%) and aortic arch aneurysms (n = 22; 41%). Technical success was 98%, and one patient died from stroke within 30 days. Major adverse events included stroke (n = 4; 7%), retrograde type A dissection (RTAD) (n = 3; 6%), and acute kidney injury (n = 2; 4%). During a median follow up of 12 months, there were two deaths (4%) of unknown cause at 1 month and 1.5 months, and no aortic related death. Type Ia, type Ic, and type IIIc endoleaks were observed in 2 (4%), 3 (6%), and 2 (4%) patients, respectively. No vessel stenosis was observed. Re-intervention was required in 10 patients (19%). Estimates of overall survival, freedom from secondary intervention, and freedom from target vessel instability at 1 year were 94.2% (standard error [SE] 3.3%), 81.8% (SE 6.0%), and 92.0% (SE 4.5%), respectively.

CONCLUSION

This study demonstrated the efficacy of PMEGs for zone 0 endovascular aortic arch repair, with acceptable technical success and mortality rate. Stroke, RTAD, and re-intervention rates remain a concern for endovascular therapy. A larger population and long term outcomes are required to assess the safety and durability of this technique as a beneficial choice for endovascular aortic arch repair in specialised centres.

Differences of mid-term outcomes in debranching thoracic endovascular aortic repair between zone 0 and zone 1-2 landing

OBJECTIVE

Debranching thoracic endovascular aortic repair (d-TEVAR) for zone 0 landing (Z0-TEVAR) remained challenging in aortic arch aneurysms. This study aimed to compare the mid-term outcomes between Z0-TEVAR and Z1/2-TEVAR to assess the appropriateness of Z0-TEVAR as the first-line therapy for aortic arch aneurysms in high-risk patients.

METHODS

Medical records of 200 patients who underwent d-TEVAR from 2007 to 2019 were retrospectively reviewed. Of these, 40 patients who underwent Z0-TEVAR (70% males; the median age of 82 years) and 160 Z1/2-TEVAR (78% males; the median age of 77 years) were compared. In each group, 39 patients were matched using propensity scores (PS) to adjust for differences in patient backgrounds.

RESULTS

Freedom from all-cause mortality (p < 0.001), aorta-related mortality (p < 0.001), and stroke (p = 0.001) were significantly lower in Z0-TEVAR than in Z1/2-TEVAR. Freedom from reintervention was similar between the two groups (p = 0.326). Type A dissection post-TEVAR was observed in 3 (7.5%) of Z0-TEVAR, but none in Z1/2-TEVAR (p = 0.006). Pneumonia was also more frequent in Z0-TEVAR (n = 8, 30%) than Z1/2-TEVAR (n = 4, 2.5%) (p < 0.001). PS matching also yielded worse outcomes (all-cause mortality, p = 0.017; aorta-related mortality, p = 0.046; and stroke, p = 0.027) in Z0-TEVAR than Z1/2-TEVAR.

CONCLUSIONS

Higher mid-term mortality and stroke rates after Z0-TEVAR were confirmed by PS matching. Z0-TEVAR would be an alternative for high-risk patients with arch aneurysms requiring zone 0 landing but not a reliable method.

New anatomical frozen elephant trunk graft for zone 0: endovascular technology reduces invasiveness of open surgery to the max

The first-in-man implant of a custom-made branched frozen elephant trunk graft designed for an anastomosis in aortic arch zone 0 is reported. Combining endovascular technology with open surgical techniques has allowed for simplification of the open procedure with substantial reduction in circulatory arrest time and in the extent of the surgical preparations.

Aortic proximalization-Zone 0 versus Zone 2: A concept or true challenge?

BACKGROUND

The use of the Frozen Elephant Trunk (FET) device to manage complex surgical pathologies of the aorta (such as acute type A aortic dissection) has gained popularity since its introduction in the early 2000s. Though the distal anastomosis was traditionally performed at aortic Zone 3 (Z-3-FET), preference gradually shifted towards Zone 2 (Z-2-FET) in favor of improved surgical access and clinical outcomes. This review seeks to elucidate whether proximalization of arch repair to Zone 0 (Z-0-FET) would further improve postoperative outcomes.

METHODS

We performed a review of available literature to evaluate the comparative efficacies of Z-2-FET versus Z-0-FET, in terms of surgical technique, clinical outcomes, and incidence of adverse events.

RESULTS

Z-0-FET seems to be associated with a more accessible surgical approach, and shorter cardiopulmonary bypass, antegrade cerebral perfusion, and cardioplegia durations than Z-2-FET. Further, Z-0-FET is could potentially be associated with a lower incidence of neurological, renal, and recurrent laryngeal nerve injury, as well as mortality and reintervention rates than Z-2-FET. This said, Z-0-FET is itself associated with significant challenges, and efficacy in terms of postoperative true lumen integrity and false lumen thrombosis is mixed.

CONCLUSION

Current literature seems to suggest that Z-0-FET procedures are more straightforward and associated with lower rates of certain adverse events, however, the majority of data reviewed is retrospective. This review, therefore, recommends prospective research into the comparative strengths and limitations of Z-0-FET and Z-2-FET to better substantiate whether proximalization of arch repair represents a concept, or a true challenge to advance surgical intervention for arch pathologies.

Midterm Outcomes of Zone 0 Antegrade Endograft Implantation During Type I Hybrid Aortic Arch Repair

OBJECTIVE

Type I hybrid arch repair has become popular as a procedure that is less invasive than total arch replacement. The major advantage of this technique is that antegrade endograft implantation can be performed during the procedure, thereby avoiding the complications of introducing the endograft from the groin. The aim of this study was to assess the midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation.

METHODS

Thirty consecutive patients who underwent type I hybrid repair with antegrade endograft implantation from 2009 to 2015 were reviewed retrospectively. Patient demographics, and peri-operative and late results were collected from a prospective database and analysed.

RESULTS

Four patients (13%) were female and the median age was 78 years. Median aneurysm size was 64 mm. Six patients (20%) developed stroke, and the 30 day mortality rate was 3%. Two patients suffered aortic dissection at the site of debranching anastomosis. The median follow up was 5.2 years. All aneurysms remained stable or had decreased in size at three years, and 82% were stable at five years. Overall survival was 79% at three years and 71% at five years. The rates of freedom from aorta related death were 86% at three and five years, respectively. During the follow up period, three additional left subclavian artery embolisations and one endograft relining due to type IIIb endoleak were required.

CONCLUSION

Midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation for aortic arch aneurysms are reported. Although the incidence of peri-operative stroke was high, late sac behaviour was acceptable.

Total debranching thoracic endovascular aortic repair with elephant trunk insertion technique

We report successful total debranching thoracic endovascular aortic repair using the elephant trunk insertion technique without hypothermic circulatory arrest for a 56-year-old man who developed aortic arch dissection and ascending aortic aneurysm. In the first step, an elephant trunk graft was inserted into the ascending aorta under cardiopulmonary bypass, and a branched prosthetic graft was attached to the ascending aorta. The left common carotid artery and brachiocephalic artery were sequentially anastomosed to the branched graft. The second step was thoracic endovascular aortic repair covering the elephant trunk to the distal arch. Postprocedure digital subtraction angiography showed no endoleaks or false lumen.

Deployment of proximal thoracic endograft in zone 0 of the ascending aorta: treatment options and early outcomes for aortic arch aneurysms in a high-risk population

OBJECTIVES

Open repair of aortic arch aneurysms can be technically challenging. Hybrid approaches have been developed to facilitate arch repairs and improve their clinical outcomes in high-risk patients. We examined treatment options and early outcomes in patients whose thoracic endografts were deployed to include Zone 0.

METHODS

Between 2005 and 2011, a hybrid approach in which the endograft was deployed in the ascending aorta was used in 29 patients (median age 67 years, range 32-85 years). The indication for surgery was saccular arch aneurysm in 11 patients (37.9%), fusiform arch aneurysm with or without involvement of the proximal descending aorta in 10 (34.5%), proximal Type I endoleak after endovascular repair of the descending aorta in 5 (17.2%), chronic Type III (Type B) aortic dissection with aneurysmal arch formation in 2 (6.9%) and acute Type I (Type A) dissection with prior repair of an extent I thoracoabdominal aneurysm in 1 (3.4%). Six patients (20.7%) had previously undergone a sternotomy. One-, two- or three-branch aortobrachiocephalic de-branching, with or without concomitant heart surgery, was performed in 28 patients and extra-anatomic bypass in 1.

RESULTS

Two patients (6.9%) died during postoperative hospitalization. Overall survival during the follow-up period (median 411 days) was 79.3%. Five neurological events occurred: one extensive stroke, two minor strokes (10.3%) and two episodes of paraparesis (6.9%), one with partial recovery and one with full recovery.

CONCLUSIONS

The hybrid approach enables the treatment of aortic arch disease in high-risk individuals. Long-term follow-up data are needed.