IP065. Five-Year Experience With Common Carotid Artery Chimney Grafts to Extend Proximal Landing Zone for Thoracic Endovascular Aortic Repair

Background: Adequate seal for thoracic endovascular aortic repair (TEVAR) commonly requires landing in zone 2, but can prove to be challenging due to the tortuous and angulated anatomy of the region. Objectives: Our objective was to determine the proximal landing accuracy of zone 2-targeted TEVARs following carotid-subclavian revascularization (CSR) and its impact on clinical outcomes. Methods: Retrospective review of patients that underwent CSR for zone 2 endograft delivery at a tertiary institute between January 2008 and March 2018 was conducted. Technical outcomes were assessed by examining the incidence of intraoperative corrective maneuvers, 1a endoleaks and reinterventions. Distance to target and incidence of LSA stump filling were examined as radiographic markers of landing accuracy. Results: Zone 2-targeted TEVAR with CSR was performed in 53 patients for treatment of dissections (49%), aneurysms (30%) or trauma (21%). Nine (17%) cases required intraoperative corrective procedures: 5 (9%) proximal cuffs due to type 1a endoleak and 4 (8%) left common carotid artery (LCCA) stenting due to inadvertent coverage. Cases performed using higher resolution hybrid fluoroscopy machine compared to mobile C-arm were associated with increased proximal cuff use (OR 8.8; 95% CI 1.2-62.4). Average distance between the proximal edge of the covered graft to LCCA was 8 ± 1 mm and larger distances were not associated with higher rates of 1a endoleak. Twenty-eight (53%) cases of antegrade LSA stump filling were noted on follow-up imaging, but were not associated with higher rates of reinterventions (OR 0.8, 95% CI [0.2-4.6]). Three (6%) patients had a stroke within 30 days and 4 (8%) patients expired within 1 month. Intraoperative corrective maneuvers, post-operative 1a endoleak and reinterventions were not associated with higher rates of stroke or mortality. Conclusion: Using current endografts and imaging modalities, zone 2-targeted TEVARs have suboptimal technical accuracy.

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Complete Fracture of a Chimney Stent in the Left Common Carotid Artery after Thoracic Endovascular Aortic Repair for Thoracic Aneurysm

Chinese Medical Journal ◽

10.4103/0366-6999.170271 ◽

2015 ◽

Vol 128 (23) ◽

pp. 3264-3265 ◽

Cited By ~ 1

Author(s):

Bao-Lei Guo ◽

Wei-Guo Fu ◽

Da-Qiao Guo ◽

Zhen-Yu Shi

Keyword(s):

Carotid Artery ◽

Common Carotid Artery ◽

Thoracic Endovascular Aortic Repair ◽

Left Common Carotid Artery ◽

Endovascular Aortic Repair ◽

Thoracic Aneurysm ◽

Aortic Repair ◽

Complete Fracture

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“Kissing Stents” as an Adjunct to Thoracic Endovascular Aortic Repair Warts and All

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e31826e03b9 ◽

2012 ◽

Vol 7 (4) ◽

pp. 295-299

Author(s):

Riyad Karmy-Jones ◽

Stephen C. Nicholls

Keyword(s):

Carotid Artery ◽

Subclavian Artery ◽

Common Carotid Artery ◽

Open Repair ◽

Left Subclavian Artery ◽

Thoracic Endovascular Aortic Repair ◽

Left Common Carotid Artery ◽

Endovascular Aortic Repair ◽

Thoracic Aneurysm ◽

Landing Zone

A 75-year-old man presented with symptomatic thoracic aneurysm involving the origin of the left subclavian artery. To obtain an adequate landing zone, a simultaneous stent was placed in the left common carotid artery. Until fenestrated and branch graft technology is more available, snorkel approaches may be an acceptable approach for patients with contraindications to open repair.

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Geometric Deformations of the Thoracic Aorta and Supra-Aortic Arch Branch Vessels Following Thoracic Endovascular Aortic Repair

Vascular and Endovascular Surgery ◽

10.1177/1538574417753452 ◽

2018 ◽

Vol 52 (3) ◽

pp. 173-180 ◽

Cited By ~ 5

Author(s):

Brant W. Ullery ◽

Ga-Young Suh ◽

Kelsey Hirotsu ◽

David Zhu ◽

Jason T. Lee ◽

...

Keyword(s):

Carotid Artery ◽

Aortic Arch ◽

Thoracic Aorta ◽

Common Carotid Artery ◽

Ascending Aorta ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Branch Angle ◽

Aortic Repair ◽

Aortic Branch

Objective: To utilize 3-D modeling techniques to better characterize geometric deformations of the supra-aortic arch branch vessels and descending thoracic aorta after thoracic endovascular aortic repair. Methods: Eighteen patients underwent endovascular repair of either type B aortic dissection (n = 10) or thoracic aortic aneurysm (n = 8). Computed tomography angiography was obtained pre- and postprocedure, and 3-D geometric models of the aorta and supra-aortic branch vessels were constructed. Branch angle of the supra-aortic branch vessels and curvature metrics of the ascending aorta, aortic arch, and stented thoracic aortic lumen were calculated both at pre- and postintervention. Results: The left common carotid artery branch angle was lower than the left subclavian artery angles preintervention ( P < .005) and lower than both the left subclavian and brachiocephalic branch angles postintervention ( P < .05). From pre- to postoperative, no significant change in branch angle was found in any of the great vessels. Maximum curvature change of the stented lumen from pre- to postprocedure was greater than those of the ascending aorta and aortic arch ( P < .05). Conclusion: Thoracic endovascular aortic repair results in relative straightening of the stented aortic region and also accentuates the native curvature of the ascending aorta when the endograft has a more proximal landing zone. Supra-aortic branch vessel angulation remains relatively static when proximal landing zones are distal to the left common carotid artery.

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Safety and Effectiveness of TEVAR in Native Proximal Landing Zone 2 for Chronic Type B Aortic Dissection in Patients With Genetic Aortic Syndrome

Journal of Endovascular Therapy ◽

10.1177/15266028211061276 ◽

2021 ◽

pp. 152660282110612

Author(s):

Ahmed Eleshra ◽

Giuseppe Panuccio ◽

Konstantinos Spanos ◽

Fiona Rohlffs ◽

Yskert von Kodolitsch ◽

...

Keyword(s):

Aortic Dissection ◽

False Lumen ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Type B ◽

Type B Aortic Dissection ◽

Chronic Type ◽

Ehlers Danlos Syndrome ◽

Landing Zone ◽

Aortic Repair

Objectives The aim of this study is to report the safety and effectiveness of thoracic endovascular aortic repair (TEVAR) in a native proximal landing zone (PLZ) 2 for chronic type B aortic dissection (TBAD) patients with genetic aortic syndrome (GAS). Methods A retrospective review of a single center database to identify patients with GAS treated with TEVAR in native PLZ 2 for chronic TBAD and thoracic false lumen aneurysm between February 2012 and February 2018 was undertaken. Results In total, 31 patients with GAS (24 Marfan syndrome [MFS], 5 Loeys-Dietz syndrome [LDS], and 2 vascular Ehlers-Danlos syndrome [vEDS]) were treated by endovascular repair. Nineteen patients were treated by TEVAR as index procedures with 8 patients (5 females, mean age = 55, range = 36–79 years old) receiving TEVAR in native PLZ 2. Left subclavian artery (LSA) perfusion was preserved in all 8 patients: by left common carotid artery-LSA bypass in 6 patients, chimney stenting of the LSA in 1 patient, and partial coverage of LSA ostium in 1 patient. Technical success was achieved in all patients (100%). There was no 30 day mortality (0%). The 30 day morbidity (0%) was free from major complications. The median follow-up was 40 months (range = 7–79). One patient died due to non-aortic-related cause. Native PLZ 2 was free from complications in MFS patients (5/8). Two patients with LDS developed type Ia endoleak with aneurysmal progression. One patient was treated by proximal extension with a double inner branched arch stent-graft landing in the replaced ascending aorta. The other one was treated with frozen elephant trunk. Conclusion Thoracic endovascular aortic repair in native PLZ 2 was safe and effective with no early or midterm PLZ complications in patients with MFS with chronic TBAD in this limited series. Native PLZ 2 is not safe in patients with LDS and should only be used in emergencies as a bridging to open repair.

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Surgical bypass from the left common carotid artery to the left subclavian artery: Central approach

10.1510/mmcts.2021.023 ◽

2021 ◽

Keyword(s):

Carotid Artery ◽

Subclavian Artery ◽

Common Carotid Artery ◽

Left Subclavian Artery ◽

Thoracic Endovascular Aortic Repair ◽

Left Common Carotid Artery ◽

Aortic Diseases ◽

Landing Zone ◽

Surgical Bypass ◽

Aneurysm Dissection

To create an optimal landing zone (zone 2) in the aortic arch for concomitant or subsequent thoracic endovascular aortic repair of aortic diseases (aneurysm, dissection), surgeons frequently need to debranch the supra-aortic vessels. We present a surgical debranching of the left subclavian artery by performing a centrally located bypass from the left common carotid artery to the left subclavian artery.

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Handmade stent graft fenestration to preserve left subclavian artery in thoracic endovascular aortic repair†

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezz049 ◽

2019 ◽

Vol 56 (3) ◽

pp. 587-594 ◽

Cited By ~ 5

Author(s):

Huey-Shiuan Kuo ◽

Jih-Hsin Huang ◽

Jer-Shen Chen

Keyword(s):

Carotid Artery ◽

Stent Graft ◽

Subclavian Artery ◽

Common Carotid Artery ◽

Left Subclavian Artery ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Technical Success ◽

Aortic Stent Graft ◽

Aortic Pathologies

Abstract OBJECTIVES This study aimed to evaluate the efficacy and safety of a handmade fenestrated stent graft over an aortic stent graft for preserving the left subclavian artery (LSA) in thoracic endovascular aortic repair (TEVAR). METHODS From July 2015 to October 2018, a total of 32 consecutive patients with various thoracic aortic pathologies who underwent TEVAR in which handmade fenestration over a thoracic aortic stent graft was used for LSA were included. Outcomes including technical success, procedure-related complications, perioperative mortality and morbidity and graft patency were analysed. RESULTS Twenty-four patients (75.00%) presented with aortic dissection, 5 patients (15.63%) with thoracic aortic aneurysm and 2 patients (6.25%) with penetrating aortic ulcer; 1 patient (3.13%) required re-TEVAR due to endoleak and sac expansion from previous TEVAR for thoraco-abdominal aneurysm. TEVAR was performed in a zone 2 landing with single fenestration for LSA (26 patients, 81.25%), zone 1 landing with double fenestration for both LSA and left common carotid artery (5 patients, 15.63%) or zone 1 landing with single fenestration for LSA and a chimney graft for left common carotid artery (1 patient, 3.13%). The technical success rate, defined as the successful alignment of fenestration to LSA, was 93.75%. At a mean follow-up of 17.3 months, 4 cases of endoleak and 2 cases of stent graft-induced new entry were noted, 3 of which were treated endovascularly. CONCLUSIONS Our preliminary results demonstrate the viability of preserving LSA blood flow in TEVAR using a handmade stent graft fenestration to treat various aortic pathologies in various clinical situations and the technical feasibility and short-term results that may justify the use of this method in emergency cases.

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Methods and clinical outcomes of in situ fenestration for aortic arch revascularization during thoracic endovascular aortic repair

Vascular ◽

10.1177/1708538120902650 ◽

2020 ◽

Vol 28 (4) ◽

pp. 333-341 ◽

Cited By ~ 1

Author(s):

HL Li ◽

YC Chan ◽

HY Jia ◽

SW Cheng

Keyword(s):

Stent Graft ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Current Evidence ◽

Type Ii ◽

Technical Success ◽

Landing Zone ◽

Short Term Result ◽

Aortic Repair

Objective Despite endovascular advances in fenestrated and branched devices, thoracic endovascular aortic repair (TEVAR) for arch pathologies remains challenging. The aim of this study was to provide a contemporary review on the current evidence for in situ fenestration during TEVAR and to evaluate its short- and mid-term clinical outcome in the management of arch pathology. Methods A systematic literature review on in situ fenestration of thoracic aortic stent-graft from January 2003 to September 2018 was performed under the instruction of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. Results Our initial search yielded 169 studies, of which 21 articles were relevant to the topic and were finally included. One hundred and forty-five in situ fenestration procedures in 99 patients were reviewed, involving 25 innominate arteries (17%), 33 left common carotid arteries (23%) and 87 left subclavian arteries (60%). Twelve patients (12/99, 12%) had two-vessel fenestration and three-vessel fenestration was performed in 17 patients (17/99, 17%). Technical success was achieved in 136 arteries (136/145, 93%). Talent/Valiant with monofilament twill woven polyester fabric was the most common (50/99, 51%) stent-graft used for fenestration. Three methods reported for in situ fenestration were needle, laser and radiofrequency. Needle was the most frequently used device for fenestration, which was performed in 60 patients (60/99, 61%). Three patients (3/99, 3%) died with 30 days, none were in situ fenestration TEVAR procedure-related. Perioperative complications including one (1%) retrograde type A aortic dissection, two (2%) type II endoleaks, and three (3%) strokes were reported. The pooled estimate for overall technical success, perioperative mortality and stroke was 88.3% (95% CI, 78.6%–93.9%), 5.9% (95% CI, 2.5%–13.4%) and 9.5% (95% CI, 4.1%–20.6%), respectively. Four patients (4/96, 4%) died during follow-up, none were aortic-related. All the fenestration bridging stents were reportedly patent, with only 1 (1/96, 1%) asymptomatic left subclavian stent stenosis. Two patients (2/96, 2%) with type II endoleak from left subclavian artery required secondary intervention. Conclusion In situ fenestration appeared to be a feasible and effective method to extend proximal landing zone during TEVAR. It had an acceptable short-term result with high technical success and low fenestration related morbidity. Long-term durability data were lacking, and there was no high level evidence to recommend the routine use of in situ fenestration TEVAR for the management of arch pathology.

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