Double fenestrated physician-modified stent-grafts for total aortic arch repair in 50 patients

Abstract

Objective: Our aim was to evaluate the early-and medium-term outcomes of using double fenestrated physicianmodified endovascular grafts (PMEGs) for total endovascular aortic arch repair.Methods: The present single-center retrospective analysis of prospectively collected data included 50 patients from January 2017 through October 2019, who had undergone thoracic endovascular aortic repair (TEVAR). The fenestrations were a proximal larger fenestration that incorporated the brachiocephalic trunk and left common carotid artery and a distal smaller fenestration for the left subclavian artery (LSA). Only the LSA fenestration was stented.Results: The median duration for stent graft modification was 26 6 6 minutes. Of the 50 patients, 41 were men. The mean patient age was 68 6 11.5 years. The indications for treatment included degenerative aortic arch aneurysm (n ¼ 17), dissecting aortic arch aneurysm after type A dissection (n ¼ 13), type B dissection (n ¼ 13), aortic ulcer (n ¼ 3), and other pathologies (n ¼ 4). The technical success rate was 94% (47 of 50) overall, and 100% (28 of 28) after a technical modification incorporating a preloaded guide wire for the LSA fenestration (P < .05). The 30-day mortality was 2% (n ¼ 1). Two patients (4%) had a minor stroke with full recovery. One patient (2%) had a type IB and two patients (4%) had a type II endoleak from the LSA. Four patients (8%) required reintervention: one because of a type IB endoleak and three because of access-related complications. All supra-aortic trunks were patent. During a mean follow-up of 16 6 8.3 months, no conversions to open surgical repair were required and no aortic rupture, paraplegia, or retrograde dissection occurred.Conclusions: Using double fenestrated PMEGs for TEVAR is both feasible and effective for total endovascular aortic arch repair, avoiding the need for anatomic and extra-anatomic surgical revascularization. The absence of brachiocephalic trunk stenting was not associated with endoleaks or treatment failure and resulted in a lower stroke risk than alternative strategies. The midterm results suggest that stenting of the brachiocephalic trunk and right common carotid artery might not be necessary for a large proportion of patients undergoing total endovascular aortic arch repair. The persistence of the seal and ongoing durability require assessment in studies with long-term follow-up data available.

Endovascular Management of Aortic Arch Diseases: Current Status and Future Trends

“…The same research team recently reported on a series of 50 patients receiving double-fenestrated physician-modified stent grafts to preserve all supra-aortic branches. [43] The outcomes were similarly satisfactory: the prevalence of technical success was 94%, type-II endoleak was 4%, 30-day mortality was 2%, and reintervention was 8%. Zhang et al [44] conducted a comparative study of physician-modified fenestration (110 cases) and chimney technique (364 cases).…”

Outcomes of thoracic endovascular aortic repair with fenestrated surgeon-modified stent-graft for type B aortic dissections involving the aortic arch

“…A pre-loaded guidewire has been recommended to assist in overcoming the migration ( 21 ). Chassin-Trubert et al reported improvement in the success rate after applying the pre-loaded guidewire [from 94% (19/22) to 100% (28/28)], all of which were total endovascular aortic arch repair, revascularizing all supra-aortic trunks ( 22 ). Additionally, the alignment could be simplified and reassured with a pre-loaded guidewire, thus shortening the learning curve ( 23 ).…”

Safety and efficacy of physician-modified thoracic endovascular aortic repair using a low-profile device for aortic arch lesions

“…Although there are many technical challenges to endovascular repair in the aortic arch (i.e., curvature, angulation, short distance of the landing neck, hemodynamics, and respiratory motion), bifurcated custom SGs have gained acceptance over the past decade. 14…”