Physician-Modified Thoracic Stent-Grafts for the Treatment of Aortic Arch Lesions

Canaud, Ludovic; Baba, Tsuyoshi; Gandet, Thomas; Narayama, Kouhei; Ozdemir, Baris Ata; Shiina, Tsuyoshi; Alric, Pierre; Morishita, Kiyofumi

doi:10.1177/1526602817714206

Cited by 45 publications

(36 citation statements)

References 16 publications

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“…These aspects have already been described in detail for both scalloped and fenestrated TEVAR in our previous publications. [12][13][14][15] In summary, procedure planning and device sizing were performed using a dedicated 3-dimensional vascular imaging workstation [either Aquarius WS (Terarecon Inc., San Mateo, CA, USA) or OsiriX Imaging Software (OsiriX, Geneva, Switzerland) until 2017, when the EndoSize 3D vascular imaging workstation (Therenva, Nanjing, France) became available. Center lumen line reconstruction was used to determine aortic diameter at the landing zones and measure lengths.…”

Section: Planning Sizing and Device Preparationmentioning

confidence: 99%

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

Chassin-Trubert

Mandelli²,

Ozdemir

et al. 2019

J Endovasc Ther

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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.

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Section: Planning Sizing and Device Preparationmentioning

confidence: 99%

“…The world experience with these strategies is both limited and without long-term follow-up. We have reported our experience [12][13][14][15] in the use of PMEGs for TEVAR with proximal landing in zones 0, 1, and 2. This retrospective analysis reviews the midterm outcomes of those TEVAR patients treated with PMEGs in zone 2.…”

Section: Introductionmentioning

confidence: 99%

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

Chassin-Trubert

Mandelli²,

Ozdemir

et al. 2019

J Endovasc Ther

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“…In order to resolve this issue, we ensure that the lateral size of the fenestration is wider than the arch branch. 8) In particular, in the case of tortuous aorta, the stent graft twists through the aorta, making it impossible to predict where the fenestrated part of the stent graft lands on the aortic arch. Therefore, in tortuous aorta, the width should be especially more so that the fenestration is one-third of the stent-graft circumference.…”

Section: Techniques To Secure Cerebral Blood Flowmentioning

confidence: 99%

Hybrid Aortic Arch Repairs

Morishita

2019

Annals of Vascular Diseases

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Hybrid aortic arch repair (HAAR) consists of thoracic stent-graft repair and procedures to maintain cerebral blood flow. Several hybrid techniques have been used, including arch artery debranching, parallel graft technique, fenestration or branching of endograft, or a combination of these. We provided an overview of HAAR by presenting literature reviews as well as our clinical experience. The experience consisted of 172 patients who had undergone HAAR. The 30-day mortality was 3% (5/172). Persistent neurologic deficits occurred in 7 patients (4%), respiratory failure in 5 (3%), de novo aortic dissection in 3 and spinal cord injury in 2. 17% of the patients experienced type Ia endoleak. Seventeen patients required redo thoracic endovascular aortic repair. Fifty-six late deaths occurred during the follow-up period, including aortic-related death in 9 patients. In conclusion, hybrid arch debranching repair should be performed for elderly or high-surgical-risk patients. However, refining techniques and device technology is likely to reduce late endograft-related events. (This is a translation of Jpn J Vasc Surg 2018; 27: 385–391.)

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“…It is generally utilized in patients who are otherwise not candidates for open surgery and did not have a proximal landing zone for endovascular treatment, especially in the urgent scenario. [1][2][3][4][5][6] Fenestrations are added to a standard commercial stent-graft to accommodate patient-specific vessel origins, thereby extending the landing zone proximally. Total endovascular arch repair can be achieved without compromise of the blood supply to the upper extremities, head, and neck using these physicianmodified endovascular grafts (PMEGs).…”

Section: Introductionmentioning

confidence: 99%

Aortic Arch Anatomy Pattern in Patients Treated Using Double Homemade Fenestrated Stent-Grafts for Total Endovascular Aortic Arch Repair

et al. 2020

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Purpose: To analyze the structural variation of the aortic arch and the supra-aortic arteries and establish an average spatial configuration that would be a pattern for a “universal double fenestration” design for physician-modified endovascular grafts (PMEGs) used in total thoracic endovascular aortic repair (TEVAR). Materials and Methods: Aortic arch morphology was retrospectively analyzed by reviewing the preoperative thoracic computed tomography angiography scans in 33 consecutive patients (mean age 68 years; 27 men) treated between January 2017 and March 2019 using double-fenestrated PMEGs for zone 0 TEVAR. Image analysis was completed according to a standardized technique on a vascular workstation with center lumen line reconstruction for all measurements. Variations in branching pattern of the aortic arch were classified into 8 types. Results: The arch trunk configuration was type I in 26 patients (79%), type II in 5 (15%), type III in 1, and type IV in 1. Mean aortic diameters at the level of mid ascending aorta, innominate artery (IA), left common carotid artery (LCCA), and left subclavian artery (LSA) were 35.7±3.7, 34.2±4.5, 33.3±6.7, and 33.7±4.7 mm, respectively. Mean diameters of the trunk were 12.2±1.7, 7.5±1.4, and 8.0±0.8 mm, respectively. Mean longitudinal center to center lengths were 15.9±2.5 mm between the LSA and LCCA and 12.1±3.0 mm between the LCCA and IA. Mean clock positions using the LSA as reference were 12:50 for the IA and 12:05 for the LCCA. In 32 patients (97%) all the supra-aortic branch vessels fit perfectly inside two delimited areas defined by a proximal common square area of 30×30 mm for the IA and LCCA and a second distal 8-mm-diameter circle for the LSA. Conclusion: Variations of the aortic arch anatomy are numerous and common. A general morphological pattern is described that delimits the aortic area where these variations occur. This information can be utilized for the design of an off-the-shelf double-fenestrated stent-graft for zone 0 TEVAR.

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Physician-Modified Thoracic Stent-Grafts for the Treatment of Aortic Arch Lesions

Abstract: Our experience suggests that physician-modified thoracic stent-grafts are feasible for aortic arch lesions and provide encouraging results in the short term. Durability concerns will need to be assessed.

Cited by 45 publications

References 16 publications

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

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

Hybrid Aortic Arch Repairs

Aortic Arch Anatomy Pattern in Patients Treated Using Double Homemade Fenestrated Stent-Grafts for Total Endovascular Aortic Arch Repair

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