Single-center experience with an inner branched arch endograft

TY - JOUR

T1 - Single-center experience with an inner branched arch endograft

AU - Tsilimparis, Nikolaos

AU - Detter, Christian

AU - Law, Yuk

AU - Rohlffs, Fiona

AU - Heidemann, Franziska

AU - Brickwedel, Jens

AU - von Kodolitsch, Yskert

AU - Debus, E Sebastian

AU - Kölbel, Tilo

N1 - Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

PY - 2019/4

Y1 - 2019/4

N2 - OBJECTIVE: Whereas open repair is the "gold standard" for most aortic arch diseases, a subgroup of patients might benefit from an endovascular approach. The introduction of branched stent grafts with dedicated design to address the challenges of the ascending aorta and the aortic arch has opened an entirely new area of treatment for these patients. We investigated the early outcomes of branched thoracic endovascular aortic repair (b-TEVAR) in various types of disease of the aortic arch.METHODS: A retrospective analysis was conducted of prospectively collected data from a single center of all consecutive patients treated with b-TEVAR. The indication for elective endovascular repair was consented in an interdisciplinary case conference. All patients were treated with a custom-made inner branched arch endograft with two internal branches (Cook Medical, Bloomington, Ind) and left-sided carotid-subclavian bypass. Study end points were technical success, 30-day mortality, and complications as well as late complications and reinterventions.RESULTS: Between 2012 and 2017, there were 54 patients (38 male; median age, 71 years) treated with diseases of the aortic arch. Indications for therapy involved degenerative aortic arch or proximal descending aortic aneurysms requiring arch repair (n = 24), dissection with or without false lumen aneurysms (n = 26), and penetrating aortic ulcers (n = 4). Forty-three cases (80%) were performed electively and 11 urgently for contained ruptures (n = 3) or symptomatic aneurysms (n = 8) with endografts already available for the patient or with grafts of other patients with similar anatomy. Technical success was achieved in 53 cases (98%). The 30-day mortality and major stroke incidence were 5.5% (3/54) and 5.5% (3/54), respectively; in-hospital mortality was 7.4% (n = 4), and minor strokes (including asymptomatic new cerebral lesions) occurred in 5.5% (n = 3). There were two cases of transient spinal cord ischemia with complete recovery and one of paraplegia. No retrograde type A dissections or cardiac injuries were observed. Three early stent graft-related reinterventions were necessary to correct proximal endograft kinking with type IA endoleak in one patient, a bridging stent graft stenosis in another patient, and false lumen persistent perfusion from dissected supra-aortic vessels in the last patient. Mean in-hospital stay was 14 ± 8 days. During a mean follow-up of 12 ± 9 months, three nonaorta-related deaths and one aorta-related death distal to the arch repair were observed.CONCLUSIONS: Treatment of aortic arch diseases with b-TEVAR is feasible and safe with acceptable mortality and stroke rates.

AB - OBJECTIVE: Whereas open repair is the "gold standard" for most aortic arch diseases, a subgroup of patients might benefit from an endovascular approach. The introduction of branched stent grafts with dedicated design to address the challenges of the ascending aorta and the aortic arch has opened an entirely new area of treatment for these patients. We investigated the early outcomes of branched thoracic endovascular aortic repair (b-TEVAR) in various types of disease of the aortic arch.METHODS: A retrospective analysis was conducted of prospectively collected data from a single center of all consecutive patients treated with b-TEVAR. The indication for elective endovascular repair was consented in an interdisciplinary case conference. All patients were treated with a custom-made inner branched arch endograft with two internal branches (Cook Medical, Bloomington, Ind) and left-sided carotid-subclavian bypass. Study end points were technical success, 30-day mortality, and complications as well as late complications and reinterventions.RESULTS: Between 2012 and 2017, there were 54 patients (38 male; median age, 71 years) treated with diseases of the aortic arch. Indications for therapy involved degenerative aortic arch or proximal descending aortic aneurysms requiring arch repair (n = 24), dissection with or without false lumen aneurysms (n = 26), and penetrating aortic ulcers (n = 4). Forty-three cases (80%) were performed electively and 11 urgently for contained ruptures (n = 3) or symptomatic aneurysms (n = 8) with endografts already available for the patient or with grafts of other patients with similar anatomy. Technical success was achieved in 53 cases (98%). The 30-day mortality and major stroke incidence were 5.5% (3/54) and 5.5% (3/54), respectively; in-hospital mortality was 7.4% (n = 4), and minor strokes (including asymptomatic new cerebral lesions) occurred in 5.5% (n = 3). There were two cases of transient spinal cord ischemia with complete recovery and one of paraplegia. No retrograde type A dissections or cardiac injuries were observed. Three early stent graft-related reinterventions were necessary to correct proximal endograft kinking with type IA endoleak in one patient, a bridging stent graft stenosis in another patient, and false lumen persistent perfusion from dissected supra-aortic vessels in the last patient. Mean in-hospital stay was 14 ± 8 days. During a mean follow-up of 12 ± 9 months, three nonaorta-related deaths and one aorta-related death distal to the arch repair were observed.CONCLUSIONS: Treatment of aortic arch diseases with b-TEVAR is feasible and safe with acceptable mortality and stroke rates.

KW - Adult

KW - Aged

KW - Aged, 80 and over

KW - Aneurysm, Dissecting/diagnostic imaging

KW - Aorta, Thoracic/diagnostic imaging

KW - Aortic Aneurysm, Thoracic/diagnostic imaging

KW - Blood Vessel Prosthesis

KW - Blood Vessel Prosthesis Implantation/adverse effects

KW - Endovascular Procedures/adverse effects

KW - Female

KW - Hospital Mortality

KW - Humans

KW - Male

KW - Middle Aged

KW - Postoperative Complications/mortality

KW - Prosthesis Design

KW - Retrospective Studies

KW - Risk Factors

KW - Stents

KW - Time Factors

KW - Treatment Outcome

U2 - 10.1016/j.jvs.2018.07.076

DO - 10.1016/j.jvs.2018.07.076

M3 - SCORING: Journal article

C2 - 30477941

VL - 69

SP - 977-985.e1

JO - J VASC SURG

JF - J VASC SURG

SN - 0741-5214

IS - 4

ER -