Aortic Arch Reconstruction by Transluminally Placed Endovascular Branched Stent Graft

Abstract

Background-Recently, thoracic aortic stent grafting has emerged as an alternative therapeutic modality for patients with thoracic aortic aneurysms and aortic dissections. However, its application has been limited to descending thoracic aortic aneurysms distal to the aortic arch. We report our initial clinical experience of endovascular branched stent graft repair for aortic arch aneurysms. Methods and Results-Endovascular grafting with Inoue branched stent grafts was attempted for 15 patients with thoracic aortic aneurysms and aortic dissections under local anesthesia (nϭ14) or general anesthesia (nϭ1). Single-branched stent grafts were used in 14 patients, and a triple-branched stent graft in one. The branched stent grafts were delivered through a 22F or a 24F sheath under fluoroscopic guidance and implanted across the aneurysmal aortic arch. In 2 patients, the single-branched stent graft did not pass through the 22F sheath used. Complete thrombosis of the aneurysm was ultimately achieved in 11 patients (73%). Of 4 persistent leaks, 1 minor leak spontaneously thrombosed and 1 major leak was successfully treated by additional straight stent graft placement. In 1 patient, the right external iliac artery ruptured during the withdrawal of the sheath and was successfully repaired by the implantation of a straight stent graft.One patient with severe stenosis of the aortic graft section was successfully managed by additional stent deployment. Peripheral microembolization to a toe occurred in 1 patient, and cerebral infarction occurred in 1 other patient. Two patients who had failed to receive endovascular stent grafts died during an average follow-up of 12.6 months, 1 of pneumonia and the other of rupture of a concomitant abdominal aortic aneurysm. Key Words: aneurysm Ⅲ vessels Ⅲ aorta Ⅲ stents Ⅲ grafting T he leading cause of death for patients with surgically untreated thoracic aortic aneurysms is ruptured aneurysm. [1][2][3] Currently, the standard treatment of thoracic aortic aneurysms is surgery with artificial graft replacement, for which perioperative mortality rates of 5% to 35% have been documented in multicenter reports. 4 -10 The surgical treatment has achieved remarkable advancement due to the introduction of deep hypothermic circulatory arrest and myocardial protection with cardioplegic solution. Despite recent progress of thoracic aortic surgery, complications are still prevalent in repair of aortic arch aneurysms, especially in patients with advanced age and coexisting morbid conditions. 4,11,12 Recently, catheter-based strategy for the treatment of coronary heart disease and valvular heart disease has progressed dramatically. 13 Therefore, the development of new, minimally invasive treatment for aortic aneurysms is desired. Conclusions-ThisTransluminal endovascular stent graft placement has recently been introduced as a promising alternative to surgical treatment of aortic aneurysms. For thoracic aortic aneurysms, Dake and colleagues first reported the clinical feasibility of endovascular repair with ...

Impact of Renal Chimney Grafts on Anatomical Suitability for Endovascular Repair in Ruptured Abdominal Aortic Aneurysm

“…Renal SGs are yet not deployed and the most proximal aortic part not fully deployed. Branched SGs were also developed and many prototypes tested both experimentally and in clinical cases (Inoue et al 1999, Chuter et al 2005, Andersen et al 2005. The main advantage of branched SGs is that they can be used in aneurysmatic parts of the aorta where there is no apposition between the main SG and the native aortic wall.…”

Endovascular Repair of Abdominal and Thoracic Aortic Aneurysms

“…69 For even more proximal thoracic aneurysms involving the aortic arch, branched and fenestrated stent grafts are being developed to accommodate perfusion through the great vessels. 99,100 Although feasibility has been demonstrated, it is already apparent that the required implantation techniques would have to be highly complex and demand considerable technical expertise. Some centers have thus been investigating techniques to create fenestrations intraoperatively after device deployment and coverage of critical branches.…”

Management of Left Subclavian Artery in Endovascular Stent-Grafting for Distal Aortic Arch Disease

“…According to reports of stent-grafting concomitant with bypass-grafting to head vessels, the technical success rate and the mortality rate are 87% and 7-17%, respectively, 1,14 which means there is no advantage compared with our results obtained using fenestrated stent grafts without bypass-grafting. Branched stent graft for aortic arch aneurysm was reported several years ago 15 and although the concept is promising, it has not been widely accepted because of the high mortality rate and high incidence of postoperative cerebral infarction. Saito et al recently reported improved results without any stroke complication using a single-branched stent graft for distal aortic arch aneurysm.…”