Outcome Comparison of Zone 1 to Zone 3 Thoracic Endovascular Aortic Repair Performed Outside Versus Inside 2-cm Proximal Landing Zone Recommendation

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

Journal of Vascular Surgery ◽

10.1016/j.jvs.2018.03.122 ◽

2018 ◽

Vol 67 (6) ◽

pp. e106-e107

Author(s):

Thomas J. Desmarais ◽

J. Westley Ohman ◽

Senthil N. Jayarajan ◽

Jeffrey Jim ◽

Luis A. Sanchez

Keyword(s):

Carotid Artery ◽

Common Carotid Artery ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Landing Zone ◽

Aortic Repair

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Zone 3 Versus Zone 2 Thoracic Endovascular Aortic Repair for Acute Type B Aortic Dissection: The Case for a More Proximal Landing Zone

Journal of Vascular Surgery ◽

10.1016/j.jvs.2019.10.035 ◽

2020 ◽

Vol 71 (1) ◽

pp. e19-e20

Author(s):

Tomaz Mesar ◽

Fanny Alie-Cusson ◽

Animesh Rathore ◽

David J. Dexter ◽

Gordon K. Stokes ◽

...

Keyword(s):

Aortic Dissection ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Acute Type ◽

Type B ◽

Type B Aortic Dissection ◽

Landing Zone ◽

Aortic Repair

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Chimney parallel grafts and thoracic endovascular aortic repair for blunt traumatic thoracic aortic injuries: A systematic review

Vascular ◽

10.1177/1708538118812548 ◽

2018 ◽

Vol 27 (2) ◽

pp. 204-212 ◽

Cited By ~ 3

Author(s):

Rebeca Carter ◽

Ian Jun Yan Wee ◽

Kyle Petrie ◽

Nicholas Syn ◽

Andrew MTL Choong

Keyword(s):

Systematic Review ◽

Aortic Injury ◽

Thoracic Endovascular Aortic Repair ◽

Small Sample ◽

Endovascular Aortic Repair ◽

Technical Success Rate ◽

Landing Zone ◽

Aortic Repair ◽

Thoracic Aortic Injury ◽

Chimney Graft

Background Whilst the management of blunt traumatic thoracic aortic injury has seen a paradigm shift to an ‘endovascular first’ approach, the limitations of thoracic endovascular aortic repair remain. An inadequate proximal landing zone limits the use of thoracic aortic stent grafts and in an emergent polytrauma setting, aortic arch debranching via open surgery may not be practical or feasible. A wholly endovascular approach to debranching utilising ‘off-the-shelf’ stents and parallel graft techniques may represent a possible solution. Hence, we sought to perform a systematic review investigating the use of chimney graft techniques alongside thoracic aortic stenting in blunt traumatic thoracic aortic injury. Methods We performed the systematic review in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on Medline (PubMed), Web of Science and Scopus to identify articles describing the use of chimney grafts in traumatic aortic transection (PROSPERO: CRD42017082549). Results The systematic search revealed 172 papers, of which 88 duplicates were removed resulting in 84 papers to screen. Based on title, abstract and full text review, six articles were included for final analysis. There were nine patients in total with an average age of 41 (three females, five males, one unspecified), all with significant polytrauma, secondary to the mechanism of injury. A variety of stents were used between centres, with techniques showing a predominance to stenting of the left subclavian artery (77%, n = 7). The technical success rate was 82%, with two (18%) cases of type 1 endoleaks, of which one resolved spontaneously. Conclusions Despite the encouraging results, this by no means provides for a firm conclusion given the small sample size. Patients should still be judiciously selected on a case-by-case basis when employing the chimney graft technique. Larger cohort studies are needed to establish these findings.

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Coil Embolization–Assisted Thoracic Endovascular Aortic Repair for Multiple Saccular Descending Aortic Aneurysms with Insufficient Landing Zone

Annals of Vascular Surgery ◽

10.1016/j.avsg.2016.07.093 ◽

2017 ◽

Vol 39 ◽

pp. 290.e17-290.e20

Author(s):

Akito Imai ◽

Tomomi Nakajima ◽

Masataka Sato ◽

Yasunori Watanabe ◽

Shunichi Kondo ◽

...

Keyword(s):

Coil Embolization ◽

Thoracic Endovascular Aortic Repair ◽

Aortic Aneurysms ◽

Endovascular Aortic Repair ◽

Landing Zone ◽

Aortic Repair

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Rebuttal: Should the distal landing zone be assessed in thoracic endovascular aortic repair?

Catheterization and Cardiovascular Interventions ◽

10.1002/ccd.25758 ◽

2014 ◽

Vol 85 (5) ◽

pp. 934-935 ◽

Cited By ~ 3

Author(s):

Rolf Alexander Jánosi ◽

Markus Bettin ◽

Philipp Kahlert ◽

Michael Horacek ◽

Fadi Al-Rashid ◽

...

Keyword(s):

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Landing Zone ◽

Aortic Repair

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Early outcomes after left subclavian artery revascularisation in association with thoracic endovascular aortic repair

Vascular ◽

10.1177/1708538116647631 ◽

2016 ◽

Vol 25 (1) ◽

pp. 74-79 ◽

Cited By ~ 4

Author(s):

Dare Oladokun ◽

Benjamin O Patterson ◽

Jack RW Brownrigg ◽

Jorg L deBruin ◽

Peter J Holt ◽

...

Keyword(s):

Subclavian Artery ◽

Left Subclavian Artery ◽

Tertiary Hospital ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Complication Rates ◽

Landing Zone ◽

Aortic Repair

Approximately 40–50% of patients undergoing thoracic endovascular aortic repair require left subclavian artery coverage for adequate proximal landing zone. Many of these patients undergo left subclavian artery revascularisation. However, outcomes data for left subclavian artery revascularisation in the context of thoracic endovascular aortic repair remain limited. In this study, 70 left subclavian artery revascularisation procedures, performed on thoracic endovascular aortic repair patients at a tertiary hospital, were retrospectively reviewed. Particular emphasis was placed on revascularisation-related outcomes during staging interval between revascularisation and thoracic endovascular aortic repair. Forty-six (66%) carotid-subclavian bypass, 17 (24%) carotid-carotid-subclavian bypass and 7 (10%) aorto-inominate-carotid-subclavian bypass procedures were performed. There were no strokes or mortalities following left subclavian artery revascularisation procedures alone. Three (10%) minor complications occurred including a seroma, a haematoma and a temporary neuropraxia. Separation of complications following left subclavian artery revascularisation from those of the associated thoracic endovascular aortic repair can be difficult. Early outcomes data from patients who underwent left subclavian artery revascularisation in isolation indicate that the procedure is safe with low complication rates.

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