Branched versus fenestrated endografts for endovascular repair of aortic arch lesions

TY - JOUR

T1 - Branched versus fenestrated endografts for endovascular repair of aortic arch lesions

AU - Tsilimparis, Nikolaos

AU - Debus, E Sebastian

AU - von Kodolitsch, Yskert

AU - Wipper, Sabine

AU - Rohlffs, Fiona

AU - Detter, Christian

AU - Roeder, Blayne

AU - Kölbel, Tilo

N1 - Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

PY - 2016/9

Y1 - 2016/9

N2 - OBJECTIVE: Endovascular repair of the aortic arch represents a formidable challenge because of aortic diameter, angulation, elasticity, and greater distance to the femoral access vessels. Whereas both fenestrated and branched endografts have been customized to accommodate complex pathologic processes of the arch, no data comparing the techniques are available. The aim of this study was to compare the outcomes of custom-made fenestrated vs branched thoracic endovascular aortic repair (fTEVAR vs bTEVAR).METHODS: This was a single-center, retrospective comparative study of all consecutive patients treated with fTEVAR and bTEVAR for aortic arch diseases. All patients were considered unsuitable for open surgical therapy and treated with customized stent grafts (Cook Medical, Bloomington, Ind).RESULTS: Within 42 months, 29 patients underwent fTEVAR and bTEVAR (66 ± 9 years; nine female patients). The fTEVAR patients (n = 15) had no differences in comorbidities compared with the bTEVAR patients (n = 14). Dissection or postdissection aneurysm was the indication in 6 of 15 fTEVARs and 5 of 14 bTEVARs (40% vs 36%; P = NS); the remaining procedures were performed for aneurysms. Six (40%) fTEVAR patients underwent previous cervical debranching compared with all bTEVAR patients. In all patients with bTEVAR, two arch vessels were targeted (innominate, 13; left carotid artery, 14; left subclavian artery, 1), whereas fTEVAR targeted 1.6 ± 0.5 arch vessels (bovine trunk, 4; innominate artery, 1; left carotid artery, 10; left subclavian artery, 9). Technical success was achieved in all but one case of a fenestrated endograft that was displaced, resulting in major stroke and death of the patient. Strokes occurred in two fTEVAR patients and one bTEVAR patient (P = NS). The 30-day mortality was 20% in the fTEVAR patients (n = 3) vs 0% in the bTEVAR patients (P = NS). The causes of early mortality were major stroke (n = 1), access complication (n = 1), and myocardial infarction (n = 1). Mean follow-up was 8 (1-35) and 10 (2-22) months for fTEVAR and bTEVAR, respectively. No branch occlusions occurred, and two patients underwent coil embolization for endoleaks (P = NS). One patient was readmitted with infected branched endograft 4 months after intervention and has so far been successfully treated with aneurysm sac drainage and antibiotics. There was one late nonaneurysm-related death in each group.CONCLUSIONS: Both fTEVAR and bTEVAR are feasible for the treatment of aortic arch diseases in high-risk patients. Results are promising, although fTEVAR was associated with higher mortality in this early experience. bTEVAR was more commonly used in Ishimaru zone 0.

AB - OBJECTIVE: Endovascular repair of the aortic arch represents a formidable challenge because of aortic diameter, angulation, elasticity, and greater distance to the femoral access vessels. Whereas both fenestrated and branched endografts have been customized to accommodate complex pathologic processes of the arch, no data comparing the techniques are available. The aim of this study was to compare the outcomes of custom-made fenestrated vs branched thoracic endovascular aortic repair (fTEVAR vs bTEVAR).METHODS: This was a single-center, retrospective comparative study of all consecutive patients treated with fTEVAR and bTEVAR for aortic arch diseases. All patients were considered unsuitable for open surgical therapy and treated with customized stent grafts (Cook Medical, Bloomington, Ind).RESULTS: Within 42 months, 29 patients underwent fTEVAR and bTEVAR (66 ± 9 years; nine female patients). The fTEVAR patients (n = 15) had no differences in comorbidities compared with the bTEVAR patients (n = 14). Dissection or postdissection aneurysm was the indication in 6 of 15 fTEVARs and 5 of 14 bTEVARs (40% vs 36%; P = NS); the remaining procedures were performed for aneurysms. Six (40%) fTEVAR patients underwent previous cervical debranching compared with all bTEVAR patients. In all patients with bTEVAR, two arch vessels were targeted (innominate, 13; left carotid artery, 14; left subclavian artery, 1), whereas fTEVAR targeted 1.6 ± 0.5 arch vessels (bovine trunk, 4; innominate artery, 1; left carotid artery, 10; left subclavian artery, 9). Technical success was achieved in all but one case of a fenestrated endograft that was displaced, resulting in major stroke and death of the patient. Strokes occurred in two fTEVAR patients and one bTEVAR patient (P = NS). The 30-day mortality was 20% in the fTEVAR patients (n = 3) vs 0% in the bTEVAR patients (P = NS). The causes of early mortality were major stroke (n = 1), access complication (n = 1), and myocardial infarction (n = 1). Mean follow-up was 8 (1-35) and 10 (2-22) months for fTEVAR and bTEVAR, respectively. No branch occlusions occurred, and two patients underwent coil embolization for endoleaks (P = NS). One patient was readmitted with infected branched endograft 4 months after intervention and has so far been successfully treated with aneurysm sac drainage and antibiotics. There was one late nonaneurysm-related death in each group.CONCLUSIONS: Both fTEVAR and bTEVAR are feasible for the treatment of aortic arch diseases in high-risk patients. Results are promising, although fTEVAR was associated with higher mortality in this early experience. bTEVAR was more commonly used in Ishimaru zone 0.

KW - Aged

KW - Aneurysm, Dissecting/diagnostic imaging

KW - Aorta, Thoracic/diagnostic imaging

KW - Aortic Aneurysm, Thoracic/diagnostic imaging

KW - Aortography/methods

KW - Blood Vessel Prosthesis

KW - Blood Vessel Prosthesis Implantation/adverse effects

KW - Computed Tomography Angiography

KW - Endovascular Procedures/adverse effects

KW - Female

KW - Germany

KW - Humans

KW - Male

KW - Middle Aged

KW - Postoperative Complications/etiology

KW - Prosthesis Design

KW - Retreatment

KW - Retrospective Studies

KW - Risk Assessment

KW - Risk Factors

KW - Stents

KW - Time Factors

KW - Treatment Outcome

U2 - 10.1016/j.jvs.2016.03.410

DO - 10.1016/j.jvs.2016.03.410

M3 - SCORING: Journal article

C2 - 27313087

VL - 64

SP - 592

EP - 599

JO - J VASC SURG

JF - J VASC SURG

SN - 0741-5214

IS - 3

ER -