Aortic Arch Anatomy Pattern in Patients Treated Using Double Homemade Fenestrated Stent-Grafts for Total Endovascular Aortic Arch Repair

Abstract

Purpose: To analyze the structural variation of the aortic arch and the supra-aortic arteries and establish an average spatial configuration that would be a pattern for a “universal double fenestration” design for physician-modified endovascular grafts (PMEGs) used in total thoracic endovascular aortic repair (TEVAR). Materials and Methods: Aortic arch morphology was retrospectively analyzed by reviewing the preoperative thoracic computed tomography angiography scans in 33 consecutive patients (mean age 68 years; 27 men) treated between January 2017 and March 2019 using double-fenestrated PMEGs for zone 0 TEVAR. Image analysis was completed according to a standardized technique on a vascular workstation with center lumen line reconstruction for all measurements. Variations in branching pattern of the aortic arch were classified into 8 types. Results: The arch trunk configuration was type I in 26 patients (79%), type II in 5 (15%), type III in 1, and type IV in 1. Mean aortic diameters at the level of mid ascending aorta, innominate artery (IA), left common carotid artery (LCCA), and left subclavian artery (LSA) were 35.7±3.7, 34.2±4.5, 33.3±6.7, and 33.7±4.7 mm, respectively. Mean diameters of the trunk were 12.2±1.7, 7.5±1.4, and 8.0±0.8 mm, respectively. Mean longitudinal center to center lengths were 15.9±2.5 mm between the LSA and LCCA and 12.1±3.0 mm between the LCCA and IA. Mean clock positions using the LSA as reference were 12:50 for the IA and 12:05 for the LCCA. In 32 patients (97%) all the supra-aortic branch vessels fit perfectly inside two delimited areas defined by a proximal common square area of 30×30 mm for the IA and LCCA and a second distal 8-mm-diameter circle for the LSA. Conclusion: Variations of the aortic arch anatomy are numerous and common. A general morphological pattern is described that delimits the aortic area where these variations occur. This information can be utilized for the design of an off-the-shelf double-fenestrated stent-graft for zone 0 TEVAR.

Type 1A Endoleak after TEVAR in the Aortic Arch: A Review of the Literature

“…Out of the 48 studies selected: 10 [ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ] described outcomes in chimney procedures, 13 [ 1 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ] with the use of fenestrated devices, 9 [ 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ] focused on in situ fenestration outcomes, 14 [ 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ] on branched devices, one study compared fenestrated and branched devices [ 48 ], and one compared in situ fenestration and the chimney technique [ 49 ].…”

“…In a more recent experience, Zhu et al [ 24 ] described 58 fenestrated graft implants with 2 cases of type IA endoleaks, both linked to deployment failure. Chassin-Trubert et al [ 16 ] described 1 case of type IA endoleak in a sample of 50 patients. A total of 3 type IA endoleaks were reported among 32 procedures by Iwakoshi et al [ 17 ], while the highest endoleak incidence was reported by Kurimoto et al [ 18 ] with an incidence of 32% (12 patients out of 37).…”

“…In patients with aortic arch disease and short proximal landing zones, the use of fenestrated stent grafts increases sealing length and enables accurate deployment while maintaining supra-aortic trunk patency [ 13 ]. Fenestrated stent grafts can be associated with stenting or not, and while some authors stated that no statistically significant difference in endoleak rates was described [ 16 ], others [ 17 ] strongly advised supra-aortic stenting due to the way in which the aortic arch curvature could affect device positioning, reporting a significant success rate and a 97% 3-year patency rate. With fenestrated stent grafts, the rationale for stenting is not so much to achieve better sealing but to correct and or avoid misaligning between fenestrations and the ostia of the target vessels.…”

Anatomical Variations in Aortic Arch Branching Pattern: A Computed Tomography Angiography Study

“…Natsis et al's findings. The prevalence rates of the type 3b2 variation were 0.88% as reported by Açar et al, 1.2% by Karacan et al, 1.1% by Ergun et al 2% by Natsis, 1.2% by Berko et al, 1.9% by Budhiraja et al and 0.6% by Wang et al[2,6,7,11,13,15,17,21]. Trubert et al observed this variation in 1 out of 33 patients undergoing total thoracic aorta endovascular repair[2,6,7,11,13,15,17,21].…”

Technical details of thoracic endovascular aortic repair with fenestrations for thoracic aortic pathologies involving the aortic arch: A Chinese expert consensus

“…The surgeon manually squeezes the stent graft back into the sheath. It should be noted that the distance between each segment should not be compressed, and the stent graft should not rotate ( 28 – 30 ). During the procedure, the outer sheath should not push the stent graft forward.…”