Early and midterm results of thoracic endovascular aortic repair using a branched endograft for aortic arch pathologies: A retrospective single-center study

Abstract

Background: Zone 0 landing hybrid thoracic endovascular aortic repair (TEVAR) includes a few moderately invasive surgical procedures. To reduce invasiveness, TE-VAR with a branched aortic arch stent-graft can be considered. This study aimed to elucidate the effectiveness of performing TEVAR using a Bolton (Bolton Medical, Inc, Sunrise, Fla) branched endograft by analyzing early and midterm results.Methods: We enrolled 28 patients (mean age, 78.4 years) who underwent TEVAR with the Bolton branched endograft in Osaka University Hospital between October 2012 and June 2018 with a mean follow-up period of 4.0 years. Double-side and single-side branched devices were used in 24 (85.7%) and 4 (14.3%) patients, respectively.Results: All procedures were successful; no cases of endoleak or conversion to open repair were noted during the 30-day postoperative period. The perioperative stroke rate was 14.3% (4 out of 28); midterm stroke was not detected. All patients with perioperative stroke had atheroma grade !2 in the brachiocephalic artery. No type 1a endoleak was reported during the early or midterm results. The cumulative survival rate, aorta-related death-free rate, and aortic event-free survival rate at 5 years were 80.8%, 95.8%, and 81.6%, respectively. Conclusions:We achieved satisfactory early and midterm results by using a Bolton branched endograft for high-risk patients with arch pathologies except for high postoperative stroke. Although this treatment method is associated with postoperative stroke, performing strict evaluation of atheroma may prevent such complication. By preventing intraoperative stroke, TEVAR with this custom-made Bolton branched endograft may be considered a less-invasive treatment. (JTCVS Techniques 2020;4:17-25) Schematic of thoracic endovascular repair using the Bolton branched endograft. CENTRAL MESSAGEEarly and midterm results of thoracic endovascular aortic repair using a Bolton branched endograft show that preoperative strict atheroma evaluation is important for preventing postoperative stroke. PERSPECTIVEWhen using a custom-made Bolton branched endograft, it is essential to prevent perioperative stroke. The development of perioperative stroke may be prevented by performing a strict preoperative evaluation of atheroma. By preventing perioperative stroke, thoracic endovascular aortic repair using a custom-made Bolton branched endograft may become a less-invasive treatment.

Commentary: Zone 0 thoracic endovascular aortic repair stroke risk remains too high

“…At a mean follow-up of 4 years, the authors report procedural success in all patients and an 81% 5-year survival but a 14% (4/28) perioperative stroke rate. 1 The authors conclude that using this branched stent graft for zone 0 TAVR may provide a less-invasive treatment compared with open and hybrid approaches.…”

“…Kudo and colleagues 1 report mid-term results after zone 0 thoracic endovascular aortic repair (TEVAR) using the Bolton (Bolton Medical, Inc, Sunrise, Fla) branched endograft at their center between 2012 and 2018 in patients with degenerative thoracic aneurysm (22/28, 79%) or dissection (6/28, 21%). This study represents the largest series using the dual branched device system with relatively long follow-up data.…”

Total Endovascular Aortic Arch Repair: From Dream to Reality

“…A Japanese cohort of 28 patients (mean age 78 ± 7 years, 61% males, mean Logistic EUROscore 34%) treated with a double branched endograft reported a complete procedural success without any in hospital death [ 8 ]. Four patients (14%) had symptomatic strokes and two of these were disabling.…”

Comparison of the Outcomes of Total Endovascular Aortic Arch Repair Between Branched Endograft and Chimney Endograft Technique in Zone 0 Landing

“…[5][6][7] In addition, zone 0 landing hybrid TEVAR without median sternotomy has gained increasing attention to treat aortic arch diseases. 8,9 However, zone 0 landing hybrid TEVAR without median sternotomy was reportedly associated with a high rate of stroke and type 1a endoleak. [8][9][10] This study aimed to compare the outcomes of total endovascular aortic arch repair between branched TEVAR (bTE-VAR) and chimney TEVAR (cTEVAR) at the landing zone (LZ) 0 in the native aorta.…”