Cervical Debranching in the Endovascular Era: A Single Centre Experience

Abstract

WHAT THIS PAPER ADDS With one of the largest series of cervical debranching operations with 211 cases, the results of a single centre's experience are presented. Focusing on post-operative complications and graft patency, attempts are made to identify factors that influence outcome and discuss the findings. It is concluded that cervical debranching has some relevant local complications but that long-term patency is exceptional. Objective/Background: Debranching of the supra-aortic arteries is a common practice either as part of a hybrid treatment of aortic arch pathology or owing to arterial occlusive disease. Results of the debranching techniques have not been reported frequently. Methods: This was a retrospective single centre study of all consecutive patients with cervical debranching procedures as part of hybrid aortic arch repair. Results: Between 2010 and 2017, 201 patients underwent 211 cervical debranching procedures in a tertiary centre. Mean AE SD patient age was 67.7 AE 10.7 years (70.6% males; n ¼ 142/201) and mean AE SD body mass index (BMI) was 26.3 AE 5. In 78.7% of the cases carotidesubclavian bypass was performed alone (n ¼ 166/211) followed by transposition of the subclavian artery to the ipsilateral carotid (n ¼ 17/211; 8.1%) and in 28 cases (13.3%) a combination of procedures was performed. Twenty-four cases (11.4%) were complicated with local bleeding and 21 cases required re-intervention (10.4%). Nineteen patients (9.5%) developed local peripheral neurological damage post-operatively. Eight patients (3.8%) developed a chylous fistula and five (2.4%) presented with a local wound infection. One patient (0.5%) developed a bypass graft infection. The thirty day mortality was 7.6% (n ¼ 16/211): one death occurred after isolated debranching without thoracic endovascular aneurysm repair (TEVAR; 0.5%). Whether the hybrid procedures were undertaken in a single stage (simultaneous TEVAR and cervical debranching) or two stage fashion appeared to have a significant impact on 30 day mortality (single stage n ¼ 9/60 [15%] vs. debranching alone or two stage hybrid procedures n ¼ 7/144 [4.9%]; p ¼ .018). The major stroke incidence was 4.3% (n ¼ 9/211); no strokes occurred after isolated debranching. Stroke was correlated with longer operating times (odds ratio [OR] 1.006; 95% confidence interval [CI] 1.000e1.011; p ¼ .045) and higher BMI (OR 1.195; 95% CI 1.009e1.415; p ¼ .039). Mean AE SD follow up was 15 AE 17 months (range 0e89 months). Primary cumulative graft patency during follow up was 98.1% (n ¼ 207/211) and secondary patency was 100%. Conclusion: The results of cervical debranching procedures showed not only excellent patency rates, but also a significant rate of local complications. Carotidesubclavian bypass appeared to be safer with significantly fewer post-operative complications. Staged hybrid procedures also seemed to be safer.

Off-the-Shelf Devices for Treatment of Thoracic Aortic Diseases: Midterm Follow-up of TEVAR With Chimneys or Physician-Made Fenestrations

“…The treatment of TAD and TAA involving the aortic arch are high-risk procedures, but with the evolution in endovascular techniques in recent years, a less invasive option with relatively satisfactory clinical outcomes is available for these patients. [2][3][4][5][6][7]11,14,15 Ten years ago, our team started to use endovascular procedures, such as physician-customized fenestrations and chimney techniques, in the aortic arch with satisfactory clinical efficacy. 10,11 ch-TEVAR and f-TEVAR were used for patients with aortic dissections or aneurysms involving the origin of the supra-aortic branches or if a TEVAR landing zone required coverage of a supra-aortic branch.…”

“…Thoracic aortic dissection (TAD) and thoracic aortic aneurysm (TAA) involving the aortic arch or its branches are not suitable for standard thoracic endovascular aortic repair (TEVAR), so the procedure is combined with debranching of the supra-aortic vessels 1 or fenestrated/ branched stent-grafts. 2 TEVAR has been widely used in China, [3][4][5][6][7] but no customized fenestrated stent-grafts are available. Thoracic aortic pathologies involving the arch have been treated mainly with chimney TEVAR (ch-TEVAR) or other parallel graft techniques 3,5,7 or on-site construction of fenestrations and branches in commercially available stent-grafts.…”

“…Thoracic aortic dissection (TAD) and thoracic aortic aneurysm (TAA) involving the aortic arch or its branches are not suitable for standard thoracic endovascular aortic repair (TEVAR), so the procedure is combined with debranching of the supra-aortic vessels 1 or fenestrated/branched stent-grafts. 2…”

Anatomical Suitability of the Aortic Arch Arteries for a 3-Inner-Branch Arch Endograft

“…This endovascular approach frequently requires LSA debranching, which may delay treatment and increase the morbidity of the procedure. 12 A 3-inner-branch aortic endograft (3-IBAE) has been introduced in previous studies 13,14 ; each branch of the device is used for the revascularization of a supra-aortic vessel. However, despite obvious advantages, the use of a 3-IBAE has not yet become a standard in some centers.…”

Neuroprotection and the Aorta: One System, One Artery, One Expectation, One Team

“…It follows that the teams of Vascular as well as Cardio-Thoracic Surgeons should strive to unite their approach retracing the steps of De Bakey, Cooley and other pioneers with a panaortic interest. A classic example of such a harmonious reunion is the concept of arterial debranching, manifest in left carotid bypass to protect the collateral arterial circulation to the spinal cord when a stent graft may obliterate the ostium of the ipsilateral subclavian artery in complex hybrid Thoracic Endovascular Aortic Repairs (TEVAR) 12,13. By the same token, the peripheral access (via the iliofemoral and axillobrachial arterial systems) for TEVAR require a fully integrated cardiothoracic and peripheral vascular service, vestiges of which were explored the previous decade.…”