Thoracic Endovascular Aortic Repair for Challenging Aortic Arch Diseases Using Fenestrated Stent Grafts From Zone 0

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...

Section: Discussionmentioning

confidence: 99%

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

Voskresensky

Scali

Feezor

et al. 2017

“…The incidence of additional TEVAR and surgical conversion was not as high compared with other studies 2 and was better than TEVAR with fenestrated stent grafts. 25 The patients in this study did not experience late-phase aortic dissection at the edge of the ISG because the extra-flexible nickel titanium ring is supposed to help minimize potential damage to the aortic intima. Occlusion of the branched section occurred in only one patient at the LSCA graft.…”

Section: Branch Occlusionmentioning

confidence: 98%

Thoracic endovascular aortic repair with branched Inoue Stent Graft for arch aortic aneurysms

Tazaki

Inoue²,

Higami

et al. 2017

“…7,8 Similar to endovascular abdominal aortic repair, a challenging TEVAR landing zone, which could consist of a short proximal neck, curvature, or severe angulation, is also associated with an increased risk of adverse events and endoleaks. [9][10][11] The latest versions of thoracic stent grafts seek to overcome the limitations of previous generation devices by using smaller profile delivery systems and having improved stent graft apposition to the aortic wall for varied patient anatomies.…”

mentioning

confidence: 99%

Pivotal results for the Valiant Navion stent graft system in the Valiant EVO global clinical trial

Azizzadeh

Desai

Arko

et al. 2019

Objective: The Valiant Navion stent graft system (Medtronic, Santa Rosa, Calif) is a new iteration of a thoracic endograft for the treatment of descending thoracic aortic aneurysms. Herein, the 30-day primary safety and efficacy outcomes and secondary end points are presented. Methods:The Valiant EVO global clinical trial is a prospective, nonrandomized, single-arm trial. Patient enrollment occurred from April 2016 to October 2017. The primary end point was defined as access and/or deployment failure and/or a major device effect (MDE), including device-related secondary procedures, device-related mortality, conversion to open surgery, or thoracic aortic aneurysm rupture within 30 days of the index procedure. Other measures of stent graft performance including procedural data, rates of secondary procedures, and frequency of endoleaks are also reported.Results: Of the 87 consecutive patients undergoing thoracic endovascular aneurysm repair who were enrolled, 33 (37.9%) were female with 61 (70.9%) presenting with severe access artery tortuosity and 66 (85.7%) with high thoracic aortic tortuosity per core laboratory evaluation. The mean procedure duration was 88.7 6 53.4 minutes and geographical differences existed such as percutaneous access (37/52 [71.2%]) in the United States and surgical cut down in the outside of the U.S. sites (28/35 [80.0%]). There were no access or deployment failures and only 2.3% of the patients (2/87; P < .0001; performance goal of 16%) experienced a MDE within 30 days of the index procedure. Two secondary procedures (n ¼ 1 retrograde type A dissection; n ¼ 1 aortic arch rupture) were required, and in the first 30 days, two patients died leading to a freedom from all-cause mortality of 97.7%. Endoleaks at 1 month were reported in 2.5% of patients (n ¼ 1 type Ia; n ¼ 1 type II).Conclusions: Access/deployment failures, MDEs, and endoleaks were rare in the first 30 days of the Valiant Evo clinical trial. The Valiant Navion thoracic stent graft system has shown encouraging 30-day results in this challenging cohort and trial patients will continue to be followed through 5 years. (J Vasc Surg 2019;70:1399-408.)