Midterm Follow-up of Fenestrated and Scalloped Physician-Modified Endovascular Grafts for Zone 2 TEVAR

Abstract

Purpose: To investigate the midterm outcomes of scalloped or fenestrated physician-modified endovascular grafts (PMEGs) for zone 2 thoracic endovascular aortic repairs (TEVAR). Materials and Methods: Between November 2013 and May 2019, 54 consecutive patients (mean age 63 years; 41 men) were treated with thoracic PMEGs modified with 7 scallops or 47 fenestrations for the left subclavian artery (LSA). Indications for aortic repair were acute complicated type B aortic dissection (17, 31%), degenerative aneurysm (13, 24%), acute traumatic rupture of the aortic isthmus (9, 16%), post chronic dissection aneurysmal evolution (8, 15%), penetrating aortic ulcer (3, 6%), intramural hematoma (2, 4%), and floating thrombus (2, 4%). Results: Technical success was 94%; 3 (6%) LSAs were unintentionally covered. An intraoperative type Ia endoleak was treated during the index procedure. One (2%) patient suffered spinal cord ischemia, with irreversible bilateral paraplegia. Three (6%) patients experience postoperative minor strokes with full neurological recovery. Four (7%) patients died in the perioperative period; 2 (2%) were due to aneurysm rupture. Mean follow-up was 26±16 months; 15 (28%) patients had at least 3 years of follow-up. Two (4%) type II endoleaks were identified and successfully treated (4% reintervention rate); no other endoleaks were identified. All the LSAs remained clinically and radiologically patent. There were no conversions to open repair, ruptures, retrograde dissection, stent fracture, migrations, or other aortic complications. Conclusion: Scalloped or single-fenestrated PMEGs for the LSA appear to be durable and safe in the midterm. Combined with low periprocedural morbidity and mortality, these results suggest that this approach can be considered as an off-label alternative to extend proximal seal to zone 2 for TEVAR. Further studies with a larger number of patients and long-term outcomes are needed to fully validate this approach.

Self-Radiopaque Markers Guiding Physician-Modified Fenestration (S-Fenestration) in Aortic Arch Endovascular Repair

“…In our study, the endoleak events have a low rate of 5.6%, and it only persists in two patients who received a large fenestration stent for all of the three artery branches. In our experience, most endoleak happens in SF-TEVAR with multi-branch fenestration, which is not difficult to interpret since large and multiple fenestration brings higher chance of gap and fissure ( 29 ). However, the instant endoleak does not necessarily persist for a prolonged time.…”

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

“…In our series, no stent fractures were detected during routine radiologic follow-up examinations. The Montpellier group has previously reported a series of 15 patients with single fenestration PMEGs for zone 2 TEVAR with >3 years of follow-up, 19 with no stent fractures or endoleaks, and with all supra-aortic trunk vessels permeable. Further data are needed to establish durability.…”

“…Although the technique described is reproducible, the Montpellier group has extensive experience in physician modification of thoracic stent-grafts. Before the total endovascular aortic arch repair series described, the unit gained experience by performing experimental and clinical studies of proximal scalloped PMEGs, 20,21 followed by single fenestrated PMEGs for zone 2 TEVAR, 19 and, finally, single fenestrated PMEGs for TEVAR of zone 0 and zone 1 aortic lesions, combined with cervical debranching procedures. 22 After the initial experience with the double fenestrated technique, the group studied the incorporation of a preloaded guidewire using bench top cadaveric flow models.…”

Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review

“…Most of current publications, however, report the successful use of PMSG with either just one fenestration for the left subclavian artery [194,195] or preserving more or all supra-aortic branches [196][197][198][199][200][201]. Comparison to Chimney procedures found in situ fenestrations more favourable [202].…”