Outcomes of thoracic endovascular aortic repair using aortic arch chimney stents in high-risk patients

Abstract

Introduction Aortic arch disease is a challenging clinical problem, especially in high-risk patients where open repair can have morbidity and mortality rates of 30–40% and 2–20%, respectively. Aortic arch “chimney”(AAC) stents used during thoracic endovascular aortic repair(TEVAR) are a less invasive treatment strategy than open repair, but the current literature is inconclusive about the role of this technology. The focus of this analysis is to describe our experience with TEVAR and AAC stent(s). Methods All TEVAR procedures performed from 2002–15 were reviewed to identify those with AAC stents. Primary end-points were technical success, as well as 30-day and 1-year mortality. Secondary end-points included complications, reintervention, and endoleak. Technical success was defined as a patient surviving the index operation with deployment of the AAC stent(s) at the intended treatment zone with no evidence of type 1 or 3 endoleak on initial postoperative imaging. The Kaplan-Meier method was used to estimate survival. Results Twenty-seven patients(age:69±12 years[male 70%]) were identified, and all were described as prohibitive risk for open repair by the treating team. Relevant comorbidity rates were: coronary artery disease/myocardial infarction(59%), O2-dependent emphysema(30%), preoperative creatinine>1.8mg/dL(19%), and congestive heart failure(15%). Presentations included: elective-67%(n=18), symptomatic-26%(n=7), and ruptured-7%(n= 2). Eleven(41%) had prior endovascular and/or open arch/descending thoracic repair. Indications were: degenerative aneurysm(49%), chronic residual type A dissection with aneurysm(15%), type 1a endoleak after TEVAR(11%), post-surgical pseudoaneurysm(11%), penetrating ulcer(7%), and acute type B dissection(7%). 32 BC vessels were treated: innominate, n=7; left common carotid artery(LCCA), n=24; left subclavian artery(LSA), n=1. Five patients(19%) had simultaneous innominate-LCCA chimneys. BCC stents were planned in 75%(n=24) with the remainder placed for either LCCA or innominate artery encroachment(n=8). Overall technical success was 89%(1-intraoperative death, 2-persistent type 1a endoleaks in follow-up). 30-day mortality was 4%(n=1; intraoperative in a patient with a ruptured arch aneurysm) and median LOS was 6[IQR 4, 9] days. Seven(26%) patients experienced a major complication(stroke-3[all with unplanned BCC], respiratory failure-3, and death-1). Nine(33%) patients underwent aorta-related reintervention, and no chimney occlusion events occurred during follow-up(median follow-up:9[IQR 1,23] months). One and 3-year survival is estimated to be 88±6% and 69±9%, respectively. Conclusions TEVAR with AAC can be performed with high technical success and acceptable morbidity and mortality in high-risk patients. Unplanned AAC placement during TEVAR results in an elevated stroke risk, which may be related to the branch vessel coverage necessitating AAC placement. Acceptable mid-term survival can be anticipated, but aorta-related reintervention is not uncommon, and diligent follow-u...

A case report of a hybrid procedure (visceral and partial aortic arch debranching) in the treatment of a challenging aneurysm of the thoracoabdominal aorta in the endovascular era

“…Despite encouraging initial results, further studies are required to standardize this technique [19,20,21]. Chimney technique to extend the proximal landing zone in TEVAR is feasible in the majority of vascular centers, with satisfied midterm outcomes, but not without a risk of major complications [22][23][24][25]. Zhao et al [26] compared the outcomes of the chimney and hybrid technique for the reconstruction of a single arch branch and found that type Ia endoleak rate was significantly higher in the chimney group.…”

Complications and Management of the Thoracic Endovascular Aortic Repair

“… 41 New devices, such as fenestrated grafts, appear to be promising solutions to prevent occluding branches of the aortic arch, but more studies are needed to support the benefit of these devices. 42 43 …”

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“…41 New devices, such as fenestrated grafts, appear to be promising solutions to prevent occluding branches of the aortic arch, but more studies are needed to support the benefit of these devices. 42,43 When proximal endograft coverage is needed and causes occlusion to the great vessels branching off of the aorta (►Fig. 3B), pre-TEVAR revascularization, in this case, a series of extra-anatomical bypasses, is required to maintain cerebral blood flow.…”