Cerebral embolic protection during endovascular arch replacement

Abstract

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.

Cerebral Protection Using Percutaneous Normothermic Bilateral Antegrade Cerebral Perfusion During Total Arch TEVAR in a Patient With Shaggy Aorta

“…6 Placement of these filters in the internal carotid artery via direct access of the supra-aortic vessels is awkward because of their long delivery systems and has the potential for displacement and kinking. 6 These filters do not protect against gaseous embolism, and even with bilateral use in the carotid arteries, the posterior cerebral circulation remains unprotected and prone to embolization. 15 Clearly, effective, procedure-specific techniques that provide global CEP during TEVAR are required; our endeavor in the present case was to fill this void and improve the safety of such procedures in patients at high-risk for embolization.…”

“…CEP systems designed for use in transcatheter aortic valve replacement or in carotid artery stenting are inappropriate for use in aortic arch TEVAR as they are likely to interfere with the deployment of the aortic endograft or could get entrapped by it. 6 Placement of these filters in the internal carotid artery via direct access of the supra-aortic vessels is awkward because of their long delivery systems and has the potential for displacement and kinking. 6 These filters do not protect against gaseous embolism, and even with bilateral use in the carotid arteries, the posterior cerebral circulation remains unprotected and prone to embolization.…”

“…5 Similarly, distal embolic protection filters used in carotid artery stenting could interfere with arch hardware and therefore need to be inserted by direct access of the supra-aortic vessels, which is cumbersome and runs the risk of inadvertent displacement and kinking. 6 In open arch repair under hypothermic circulatory arrest, antegrade cerebral perfusion (ACP) has been found to significantly reduce neurological deficits. 7 This report presents a global CEP system designed by a multidisciplinary team specifically for use in arch TEVAR.…”

Pre-fenestration endovascular repair of aortic diseases in patients with zone 2 segment: A single-center experience

“…Some of these risks are the presence of atherosclerosis, ulcers of the aortic arch, or angulation of the aortic arch, as well as the excessive use of guidewires and catheters through the arch, air embolisms caused by introducer systems, the partial covering of arch branches, and the insufficiency of technical familiarity. 16,20 Unlike single LSA pre-fenestration TEVAR therapy, inaccurate alignment of the fenestration with the orifices of the branch vessels can cause a severe deficiency of blood supply to the brain. This can cause death within a short period.…”

Successful concomitant open surgical repair of aortic arch pseudoaneurysm and percutaneous myocardial revascularization in a high risk patient: A case report

“…It has been stated that patients with degenerative aortic arch pseudoaneurysm (AAP) often have associated coronary artery disease (CAD) and also that aortic arch atherosclerosis is commonly found in the population over the age of 55 years [ 1 ]. Severe aortic arch atheroma is defined as the presence of an over 4 mm thick, ulcerated or mobile plaque, with prevalence increases with advancing age and is found in patients over 75 years in 20% [ 2 ]. Coronary artery disease is also commonly found in the population; in adults, there is a progressive rise with age.…”