Multicenter global early feasibility study to evaluate total endovascular arch repair using three-vessel inner branch stent-grafts for aneurysms and dissections

Abstract

Objective: We evaluated the outcomes of total endovascular aortic arch repair using three-vessel inner branch stentgrafts for aneurysms and chronic dissections.Methods: We reviewed the clinical data and outcomes of consecutive patients treated by total endovascular aortic arch repair at eight academic centers using three-vessel inner branch stent-grafts (William Cook Europe, Bjaeverskov, Denmark) from 2016 to 2019. All patients received three-vessel designs with two antegrade and one retrograde inner branch, which was used to incorporate the innominate, left common carotid, and left subclavian arteries. The antegrade inner branches were accessed via a carotid or an upper extremity approach. A preloaded catheter was used for access to the retrograde left subclavian artery branch via a transfemoral approach. The endpoints were technical success, mortality, major adverse events, any stroke (minor or major) or transient ischemia attack, secondary interventions, target vessel patency, target vessel instability, aneurysm-related mortality, and patient survival.Results: A total of 39 patients (31 men [79%]; mean age, 70 6 7 years) had undergone treatment of 14 degenerative (36%) and 25 chronic (64%) postdissection arch aneurysms. The clinical characteristics included American Society of Anesthesiologists class $III in 28 patients (95%) and previous median sternotomy for ascending aortic repair in 28 patients (72%). The technical success rate was 100%. Two patients had died in-hospital or within 30 days (5%), and two patients had experienced a stroke (one minor). The combined mortality and any stroke rate was 8% (n ¼ 3). Major adverse events occurred in 10 patients (26%), including respiratory failure in 4 (10%) and estimated blood loss >1 L, myocardial infarction, and acute kidney injury in 2 patients each (5%). The median follow-up was 3.2 months (interquartile range, 1-14 months). Of the 39 patients, 12 (31%) required secondary interventions to treat vascular access complications in 5, endoleak in 6 (three type II, one type Ic, one type Ia/Ib, one type IIIa), and target vessel stenosis in 1 patient. At 1 year, the primary and secondary patency rates and freedom from target vessel instability were 95% 6 5%, 100%, and 91% 6 5%, respectively. Freedom from aortic-related mortality and patient survival was 94% 6 4% and 90% 6 6%, respectively. Conclusions:The findings from the present multicenter global experience have demonstrated the technical feasibility and safety of total endovascular aortic arch repair for aneurysms and chronic dissections using three-vessel inner branch stent-grafts. The mortality and stroke rates compare favorably with those after open surgical repair in a higher risk group From the Department of cardiothoracic and vascular surgery, McGovern Med-

Crushing of a bridging stent during follow-up of endovascular branched aortic arch repair: A novel mode of failure

“…The forces and movements on endografts in the ascending aorta and aortic arch are not extensively researched, although it has been suggested they are more pronounced compared with more distal and static portions of the aorta, 10 where these compressions had been seen. 4 These forces may have been accentuated by the tortuous course of the branch owing to the slight misalignment during initial placement and the very fast remodeling evident on the significant shrinkage of the aneurysm in the early follow-up period. The latter, combined with the small diameter of the false lumen and misalignment between the branch and the ostium, may have led to an external compression of the branch by the dissection flap that tends to become less pliable after the first months after an acute dissection.…”

“…This complication seems to be rare, given the good results after the endovascular repair of post type A dissection. 4 However, given its potential consequences, in cases of misalignment and difficulties in catheterizing branches, it may be prudent to liberally reinforce the branches with several high-radial force stents and have a more vigorous follow-up until the remodeling of the aneurysm is verified.…”

“… 3 In recent years total endovascular arch techniques have matured, showing particularly favorable result in residual dissection following an open ascending repair. 4 …”

One-Stage Hybrid Total Aortic Arch and Descending Thoracic Aortic Repair is a Safe and Secure Procedure With Less Postoperative Complications for Extended Aortic Arch Aneurysms

“…Recent studies reported quite low rates of neurological complications after total endovascular arch repair. 17,18 However, the freedom from secondary intervention at 1 year was relatively high (60%-75%), despite being successful. Hence, these TEVAR-related complications should be the focus of future improvements of these less invasive procedures including HAR and total endovascular aortic arch repair.…”

“First in Man” Total Percutaneous Aortic Arch Repair With 3-Inner-branch Endografts

“…4 In experienced hands, arch-branched graft technology has proved an alternative to open surgery 3 but it has its problems-not least neck swelling and haematoma as complications of carotid artery cut-down while ACT exceeds 350 second. 5 To mitigate this, we have developed this total percutaneous approach described in incremental steps, with rerouting of the preloaded LSCA/LCCA branch catheter and a modification of the previously described percutaneous axillary artery access technique. 6 The TAT route allows reliable advancement of an 8Fr sheath into the LCCA branch, which provides a stable platform for LCCA catheterization and stenting from femoral access.…”