Anatomical Suitability of the Aortic Arch Arteries for a 3-Inner-Branch Arch Endograft

Purpose: To analyze aortic arch anatomy of patients who were already treated with a 2-inner-branch arch endograft (2-IBAE) in order to assess the anatomical suitability of the supra-aortic arteries as target vessels for a 3-IBAE. Materials and Methods: Three different configurations of the Cook Zenith Arch endograft were designed with distances of 110 mm (model 1), 90 mm (model 2), and 70 mm (model 3) between the orifices of the first and third inner branches. Preoperative measurements of the aortic arch anatomy from 104 consecutive patients treated electively with custom-made 2-IBAEs at 2 European centers between 2014 and 2019 were analyzed. A previously described standard methodology with a planning sheet was used. Data and measurements included the treatment indication for the aortic arch pathology, the type of landing zone, the type of arch, and the inner and outer lengths of the ascending aorta from the sinotubular junction to the innominate artery (IA). Additionally, the diameters and clock positions of the IA, left common carotid artery (LCCA), and left subclavian artery (LSA) were assessed, along with the distances between the IA and the LCCA, the IA and the LSA, and the distal landing zone. Results: Type I was the most common arch configuration (75/104, 72%). The mean clock positions were 12:30±00:28 for the IA, 12:00±00:23 for the LCCA, and 12:15±00:29 for the LSA. The mean diameters were 14.2±2.2 mm for the IA, 8.8±1.8 mm for the LCCA, and 10.5±2 mm for the LSA. The mean distances between the IA and LCCA and between the IA and LSA were 14.7±5.8 mm and 33±9.4 mm, respectively. Model 2 (branch distance 90 mm) had the highest suitability (79%), while models 1 and 3 showed suitability rates of 73% and 68%, respectively. The most frequent exclusion criterion in all models was the diameter of the LSA, followed by the IA to LSA distance. Conclusion: The suitability for a 3-IBAE among patients who had a 2-IBAE implanted is high, favoring a 90-mm distance between the retrograde LSA branch and baseline.

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A 3-Dimensional Printed Aortic Arch Template to Facilitate the Creation of Physician-Modified Stent-Grafts

Journal of Endovascular Therapy ◽

10.1177/1526602818792266 ◽

2018 ◽

Vol 25 (5) ◽

pp. 554-558 ◽

Cited By ~ 10

Author(s):

Pawel Rynio ◽

Arkadiusz Kazimierczak ◽

Tomasz Jedrzejczak ◽

Piotr Gutowski

Keyword(s):

Aortic Arch ◽

Stent Graft ◽

Left Subclavian Artery ◽

Thoracic Endovascular Aortic Repair ◽

Stent Grafts ◽

Landing Zone ◽

3 Dimensional ◽

Improve Accuracy ◽

3D Printed ◽

Radiopaque Markers

Purpose: To demonstrate the utility of a 3-dimensional (3D) printed template of the aortic arch in the construction of a fenestrated and scalloped physician-modified stent-graft (PMSG). Case Report: A 73-year-old woman with descending thoracic aneurysm was scheduled for thoracic endovascular aortic repair after being disqualified for open surgery. Computed tomography angiography (CTA) revealed no proximal landing zone as the aneurysm began from the level of the left subclavian artery, so a fenestrated/scalloped PMSG was planned. To facilitate accurate placement of the openings in the graft, a 3D printed aortic arch template was prepared from the CTA data and gas sterilized. In the operating room, a Valiant stent-graft was inserted into the 3D printed template and deployed. Using ophthalmic cautery, a fenestration and a scallop were created; radiopaque markers were added. The PMSG was successfully deployed with no discrepancy between the openings and the target vessels. Conclusion: A 3D printed aortic arch template facilitates handmade fenestrations and scallops in PMSGs and may improve accuracy and quality.

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Aortic Arch Anatomy Pattern in Patients Treated Using Double Homemade Fenestrated Stent-Grafts for Total Endovascular Aortic Arch Repair

Journal of Endovascular Therapy ◽

10.1177/1526602820931787 ◽

2020 ◽

Vol 27 (5) ◽

pp. 785-791

Author(s):

Lucien Chassin-Trubert ◽

Thomas Gandet ◽

Baris Ata Ozdemir ◽

Youcef Lounes ◽

Pierre Alric ◽

...

Keyword(s):

Aortic Arch ◽

Spatial Configuration ◽

Innominate Artery ◽

Type I ◽

Morphological Pattern ◽

Type Iv ◽

Thoracic Computed Tomography ◽

Endovascular Grafts ◽

Fenestrated Stent Graft ◽

Aortic Area

Purpose: To analyze the structural variation of the aortic arch and the supra-aortic arteries and establish an average spatial configuration that would be a pattern for a “universal double fenestration” design for physician-modified endovascular grafts (PMEGs) used in total thoracic endovascular aortic repair (TEVAR). Materials and Methods: Aortic arch morphology was retrospectively analyzed by reviewing the preoperative thoracic computed tomography angiography scans in 33 consecutive patients (mean age 68 years; 27 men) treated between January 2017 and March 2019 using double-fenestrated PMEGs for zone 0 TEVAR. Image analysis was completed according to a standardized technique on a vascular workstation with center lumen line reconstruction for all measurements. Variations in branching pattern of the aortic arch were classified into 8 types. Results: The arch trunk configuration was type I in 26 patients (79%), type II in 5 (15%), type III in 1, and type IV in 1. Mean aortic diameters at the level of mid ascending aorta, innominate artery (IA), left common carotid artery (LCCA), and left subclavian artery (LSA) were 35.7±3.7, 34.2±4.5, 33.3±6.7, and 33.7±4.7 mm, respectively. Mean diameters of the trunk were 12.2±1.7, 7.5±1.4, and 8.0±0.8 mm, respectively. Mean longitudinal center to center lengths were 15.9±2.5 mm between the LSA and LCCA and 12.1±3.0 mm between the LCCA and IA. Mean clock positions using the LSA as reference were 12:50 for the IA and 12:05 for the LCCA. In 32 patients (97%) all the supra-aortic branch vessels fit perfectly inside two delimited areas defined by a proximal common square area of 30×30 mm for the IA and LCCA and a second distal 8-mm-diameter circle for the LSA. Conclusion: Variations of the aortic arch anatomy are numerous and common. A general morphological pattern is described that delimits the aortic area where these variations occur. This information can be utilized for the design of an off-the-shelf double-fenestrated stent-graft for zone 0 TEVAR.

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Endovascular treatment of isolated iliac artery aneurysms using a custom-made stent graft with proximal barb fixation: early outcome

Vascular ◽

10.1177/1708538113478720 ◽

2013 ◽

Vol 21 (2) ◽

pp. 92-96 ◽

Cited By ~ 3

Author(s):

D L H Baird ◽

K Mani ◽

T Sabharwal ◽

P R Taylor ◽

H A Zayed

Keyword(s):

Stent Graft ◽

Iliac Artery ◽

Perioperative Complications ◽

External Iliac Artery ◽

Stent Grafts ◽

Landing Zone ◽

Custom Made ◽

Internal Iliac ◽

The Mean ◽

Isolated Iliac Artery Aneurysms

Current endovascular treatments for isolated iliac artery aneurysms (IIAAs) include the use of aortoiliac stent grafts with coverage of the distal aorta or stent grafts confined to the iliac artery without active proximal fixation. We report our experience in the use of custom-made Cook Zenith™ iliac limb stent grafts with proximal barb fixation. Patients treated from July 2009 to February 2011 were included. All imaging and patient records were assessed for perioperative and early outcomes. Nine IIAAs (seven patients) were treated. The mean patient age was 80 years (range 58-91 years). The mean aneurysm size was 48 mm (35-80 mm), and the mean length of the proximal landing zone (PLZ) was 29 mm (10-50 mm). The distal landing zone was in the external iliac artery after coil embolization of the internal iliac artery. The Mean diameter of the PLZ was 21 mm (20-24 mm). Technical success was achieved in eight cases. Perioperative complications included reoperation in one patient for groin bleeding and ischemia. On follow-up (mean 12 months, range 1-26), all aneurysms were successfully excluded from the circulation and there was no stent graft migration or thrombosis. Use of custom-made stent grafts with proximal barb fixation in treatment of IIAAs is a feasible option which may reduce the risk of migration when compared with stent grafts with lack of proximal fixation.

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Results From a Nationwide Registry on Scalloped Thoracic Stent-Grafts for Short Landing Zones

Journal of Endovascular Therapy ◽

10.1177/1526602816674942 ◽

2016 ◽

Vol 24 (1) ◽

pp. 97-106 ◽

Cited By ~ 14

Author(s):

Emma van der Weijde ◽

Olaf J. Bakker ◽

Ignace F. J. Tielliu ◽

Clark J. Zeebregts ◽

Robin H. Heijmen

Keyword(s):

Stent Graft ◽

Innominate Artery ◽

Celiac Trunk ◽

Stent Grafts ◽

Conversion To Open Surgery ◽

Landing Zone ◽

Early Results ◽

Aortic Pathology ◽

Custom Made

Purpose: To report the perioperative results and short-term follow-up of patients treated with scalloped thoracic stent-grafts. Methods: A multicenter registry in the Netherlands captured data on 30 patients (mean age 68 years; 17 men) with thoracic aortic pathology and a short (<20 mm) proximal or distal landing zone who received a custom-made scalloped stent-graft between January 2013 and February 2016. Patients were treated for saccular (n=13) aneurysms, fusiform (n=9) aneurysms, pseudoaneurysms (n=4), or chronic type B dissections (n=4). The scallop was used to preserve flow in the left subclavian artery (LSA) (n=17), left common carotid artery (n=5), innominate artery (n=1), and celiac trunk (n=7). In 7 (23%) patients, the scallop also included the adjacent artery. Results: Technical success was achieved in 28 (93%) patients. In 1 patient, a minor type Ia endoleak was observed intraoperatively, which was no longer visible on computed tomography angiography at 3 months. In another patient, the LSA was unintentionally obstructed due to migration of the stent-graft on deployment. Concomitant carotid-carotid or carotid-subclavian bypass was performed in 4 patients. There was no retrograde type A dissection or conversion to open surgery. In-hospital mortality was 3%, and the perioperative ischemic stroke rate was 3%. At a mean follow-up of 9.7 months (range <1 to 31), 29 of 30 target vessels were patent. Conclusion: The scalloped stent-graft appears to be a safe and relatively simple alternative for the treatment of thoracic aortic lesions with short landing zones. Larger patient series and long-term follow-up are required to confirm these early results.

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Morphology and morphometry of ramification of the aortic arch in domestic shorthair cats in the clinical aspect

Medycyna Weterynaryjna ◽

10.21521/mw.5692 ◽

2017 ◽

Vol 73 (5) ◽

pp. 295-298

Author(s):

Karolina Barszcz ◽

Joanna Klećkowska-Nawrot ◽

Karolina Goździewska-Harłajczuk ◽

Zbigniew Bełkot ◽

Norbert Czubaj ◽

...

Keyword(s):

Aortic Arch ◽

Surface Area ◽

Subclavian Artery ◽

Left Subclavian Artery ◽

Mean Values ◽

Brachiocephalic Trunk ◽

Males And Females ◽

The Mean ◽

Morphology And Morphometry ◽

Post Hoc

The aim of the study was to investigate the morphology and morphometry of ramifications of the aortic arch in domestic shorthair cats in relation to the sex of the animals. The morphological study was performed on 61 hearts of adult domestic shorthair cats of both sexes, preserved in the 10% solution of formalin. Measurements of the area of openings of basic branches and distances between them were performed. In cats we can observe a double type of direct ramification of the aortic arch: the brachiocephalic trunk and the left subclavian artery. In all studied cases, the surface area of the ostium of the brachiocephalic trunk (SABT) was greater 4.94 ± 1.35 mm2 than the surface area of the ostium of the left subclavian artery (SALSA) 2.38 ± 0.88 mm2. The average difference between the opening area of the above vessels (r) amounted to 2.56 mm2. In the studied group of cats, the distance between the openings (d) varied between 0.5 and 4.37 mm. In the post hoc comparison of the mean values no statistically significant differences were found between the population of males and females. Fundamental changes in the structure of openings were found in two females. The first one concerned a secondary division of the brachiocephalic trunk opening and the second one – a secondary division of the opening of the left subclavian artery in the area of their parting from the aortic arch. CT angiography or MRI angiography is the method of choice for diagnosis of vascular disorders or malformations. The knowledge of the aortic arch morphology in various species of animals is a prerequisite for a correct assessment of the results of imaging tests.

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An in vitro evaluation of a new cannula tip design compared with two clinically established cannula-tip designs regarding aortic arch vessel perfusion characteristics

Perfusion ◽

10.1177/026765910001500110 ◽

2000 ◽

Vol 15 (1) ◽

pp. 69-76 ◽

Cited By ~ 15

Author(s):

E Joubert-Huebner ◽

A Gerdes ◽

H-H Sievers

Keyword(s):

Aortic Arch ◽

Left Subclavian Artery ◽

Flow Distribution ◽

Innominate Artery ◽

Clinical Implications ◽

Jet Stream ◽

Normal Flow ◽

Systemic Level ◽

Aortic Cannula

We investigated in vitro aortic arch vessel perfusion characteristics of single and multiple jet-stream cannulae and a new dispersion stream tip aortic cannula. Pressures and flows of all arch vessels were measured while directing cannulae jets at the different arch vessels using 6 l/min pump flow. The highest increase in pressure above the set systemic level of 80 mmHg and increase in flow above the set normal flow distribution in the arch vessels occurred in the jet-streamed arch vessels with the single stream cannula. The values were as follows: 29 mmHg and 118 ml/min for the innominate artery, 28 mmHg and 42 ml/min for the left common carotid artery, and 25 mmHg and 54 ml/min for the left subclavian artery. The dispersion stream cannula showed increases in pressure and flow, followed by the multiple stream cannula. Aortic cannula tips and the orientation of jets are potential sources of imbalances of arch vessel perfusion with possible clinical implications regarding perfusion of arch vessels during extracorporeal circulation.

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A Case Series of a Hybrid Approach to Aortic Arch Disease

The Heart Surgery Forum ◽

10.1532/hsf98.20131022 ◽

2013 ◽

Vol 16 (4) ◽

pp. 225 ◽

Cited By ~ 3

Author(s):

Robert E. Michler ◽

Evan Lipsitz ◽

Siyamek Neragi-Miandoab

Keyword(s):

Aortic Arch ◽

Aortic Surgery ◽

Hybrid Approach ◽

Case Series ◽

Chronic Obstructive ◽

Type I ◽

Endovascular Stent ◽

Technical Success Rate ◽

The Mean

Objective: Debranching of the aortic arch and endovascular stent placement as a combination therapy for complex aortic arch pathology has emerged over the past few years as an alternative to traditional repair. This hybrid approach is a viable option for patients who would not tolerate conventional arch replacement, as well as for patients with a failed stent graft of the descending aorta and a subsequent type I endoleak.Methods: We retrospectively reviewed the preoperative characteristics and postoperative outcomes of 5 patients who underwent debranching of the aortic arch and implantation of an endovascular stent across the aortic arch between 2008 and 2011. Data were analyzed with the Student t test and the Kaplan-Meyer method.Results: The mean age was 70.6 � 18 years; 4 men and 1 woman were evaluated. One patient had previous aortic surgery for dissection. The preoperative morbidities included arrhythmia (1 patient), chronic obstructive pulmonary disease (2 patients), cerebrovascular accident (1 patient), diabetes mellitus (2 patients), coronary artery disease (2 patients), and active angina (1 patient). One patient had a myocardial infarction 3 weeks before surgery. The primary technical-success rate was 100%, and none of the patients died in the perioperative phase. The mean follow-up time was 22 � 18.4 months, and the median follow-up time was 13.8 months (range, 7.13-50.7 months). Two patients died during follow-up. The pathology of the aorta in the patients who died was arch aneurysm; the 3 remaining patients are alive and regularly followed at our institution.Conclusion: The combination of surgery and simultaneous endovascular stenting in the operating room is an alternative approach for patients who are poor candidates for traditional arch repair under circulatory arrest.

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Endovascular Treatment of Aortic Arch Lesions Using Scalloped Endografts

Vascular and Endovascular Surgery ◽

10.1177/1538574417740056 ◽

2017 ◽

Vol 52 (1) ◽

pp. 22-26 ◽

Cited By ~ 3

Author(s):

Leopoldo Fernández-Alonso ◽

Sebastián Fernández Alonso ◽

Esther Martínez Aguilar ◽

Estéfana Santamarta Fariña ◽

Jordi Alegret Solé ◽

...

Keyword(s):

Ct Scan ◽

Aortic Arch ◽

Stent Graft ◽

Blood Pressure Level ◽

Type I ◽

Strong Argument ◽

Custom Made ◽

Type I Endoleak ◽

Rapid Pacing ◽

Aortic Lesions

Objective: To present our early and midterm results using thoracic endovascular aortic repair (TEVAR) with a custom-made proximal scalloped stent graft to accommodate left common carotid artery (LCCA) and innominate artery (IA) in treating aortic lesions involving the arch. Materials and Methods: Between February 2014 and April 2017, select patients presenting with aortic arch lesions and short proximal landing zone were treated by proximal scalloped Relay Plus stent grafts. Patient demographics, operative details, clinical outcomes, and complications were analyzed. Results: Six patients (50% male) with a median age of 71 years (range, 60-82) underwent scalloped TEVAR using thoracic custom-made Relay Plus stent graft to preserve flow in the proximal supra-aortic trunks. Target vessels for the scallop were LCCA in 5 cases and IA in 1 case. The technical success rate was 100%, and proximal seal was achieved in all cases with no type I endoleaks on completion angiography. The median follow-up period was 20 (7-32) months. No conversion to open surgical repair and no aortic rupture occurred. One patient had a distal type I endoleak on the 6-month computed tomography (CT) scan, and 1 patient had a proximal type I endoleak on the 12-month CT scan. There was no stroke, paraplegia, retrograde type A dissection, or other aortic-related complication. We routinely used temporary rapid right ventricular pacing to obtain a near-zero blood pressure level during the graft deployment. No complications were observed related to the use of rapid pacing. Conclusion: When anatomy allows, proximal scalloped stent graft to accommodate LCCA and IA is a viable therapeutic option in treating aortic lesions involving the arch with short proximal landing zones. In addition, these findings represent a strong argument for the use of temporary rapid pacing during graft deployment.

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Early experience and technical aspects of physician-modified fenestration in thoracic endovascular aortic repair for aortic arch pathologies

Journal of International Medical Research ◽

10.1177/0300060519870903 ◽

2019 ◽

Vol 48 (2) ◽

pp. 030006051987090 ◽

Cited By ~ 1

Author(s):

Xin Li ◽

Quanming Li ◽

Weichang Zhang ◽

Ming Li ◽

Hao He ◽

...

Keyword(s):

Aortic Arch ◽

Left Subclavian Artery ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Stent Grafts ◽

Time Saving ◽

Middle Term ◽

Aortic Repair ◽

The Mean

Objective This study was performed to describe the treatment of aortic arch pathologies with a physician-modified fenestration (PMF) technique in thoracic endovascular aortic repair (TEVAR). Methods From August 2015 to August 2017, 32 patients with aortic arch pathologies underwent TEVAR with the PMF technique. All patients’ clinical data were analyzed with GraphPad Prism 7.0. Results Thirty-four aortic stent-grafts were implanted in 32 patients. The mean proximal diameter of the stent-graft was 32.4 ± 3.4 cm, and the mean length was 170.0 ± 25.2 cm. Twenty-nine PMF procedures were performed to preserve the left subclavian artery (LSA) and three to preserve both the LSA and left common carotid artery. The mean distance between the pathology and LSA was 8.4 ± 4.0 mm. The mean procedure time (from first to last digital subtraction angiography) was 22.8 ± 20.8 min. The mean follow-up time was 8.3 ± 5.3 months. During follow-up, the all-cause survival rate was 83.3% and the patency rate of the branch artery after PMF was 96.0%. Conclusion The PMF technique is a relatively safe, feasible, and time-saving method to preserve the branch artery in TEVAR for aortic arch pathologies. The short- to middle-term result of this technique is satisfactory.

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Distribution of Air Embolization During TEVAR Depends on Landing Zone: Insights From a Pulsatile Flow Model

Journal of Endovascular Therapy ◽

10.1177/1526602819849931 ◽

2019 ◽

Vol 26 (4) ◽

pp. 448-455 ◽

Cited By ~ 3

Author(s):

Vladimir Makaloski ◽

Fiona Rohlffs ◽

Constantin Trepte ◽

E. Sebastian Debus ◽

Bent Øhlenschlaeger ◽

...

Keyword(s):

Stent Graft ◽

Flow Model ◽

Aortic Flow ◽

Type I ◽

Stent Grafts ◽

Descending Aorta ◽

Landing Zone ◽

The Mean ◽

The Right ◽

Common Carotid Arteries

Purpose: To analyze the distribution of air bubbles in the supra-aortic vessels during thoracic stent-graft deployment in zones 2 and 3 in an aortic flow model. Materials and Methods: Ten identical, investigational, tubular, thoracic stent-grafts were deployed in a glass aortic flow model with a type I arch: 5 in zone 2 and 5 in zone 3. A pulsatile pump generated a flow of 5 L/min with systolic and diastolic pressures (±5%) of 105 and 70 mm Hg, respectively. The flow rates (±5%) were 300 mL/min in the subclavian arteries, 220 mL/min in the vertebral arteries, and 400 mL/min in the common carotid arteries (CCAs). The total amounts of air released in each supra-aortic branch and in the aorta were recorded. Results: The mean amounts of air measured were 0.82±0.23 mL in the zone-2 group and 0.94±0.28 mL in the zone-3 group (p=0.49). In the zone-2 group compared with zone 3, the amounts of released air were greater in the right subclavian artery (0.07±0.02 vs 0.02±0.02 mL, p<0.01) and right CCA (0.30±0.8 vs 0.18±07 mL, p=0.04). There were no differences between the groups concerning the mean amounts of air measured in the right vertebral and all left-side supra-aortic branches. The amount of air released in the descending aorta was significantly higher in the zone-3 group vs the zone-2 group (0.48±0.12 vs 0.13±0.08 mL, p<0.01). Small bubbles were observed continuously during deployment, whereas large bubbles appeared more commonly during deployment of the proximal stent-graft end and after proximal release of the stent-graft. Conclusion: Air is released into all supra-aortic branches and the descending aorta during deployment of tubular thoracic stent-grafts in zones 2 and 3 in an aortic flow model. Higher amounts of air were observed in right-side supra-aortic branches during deployment in zone 2, whereas significantly greater amounts of air were observed in the descending aorta during deployment in zone 3.

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