Objectives Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have ...been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year. Methods The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB. Results Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation ( p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only ( p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group ( p < .001). The false lumen reduced in size in the BMT+TAG group ( p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG ( p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062). Conclusions Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.
Background Open repair is the gold standard for type A aortic dissection (TAAD). Endovascular option has been proposed in very limited and selected TAAD patients. We report our experience with ...endovascular TAAD repair. Methods Inclusion criteria were: (1) entry tear in the ascending aorta; (2) proximal landing zone of at least 2 cm; (3) distance between entry tear and brachio-cephalic trunk of at least 0.5 cm; (4) no signs of cardiac tamponade or severe aortic regurgitation and (5) no signs of aortic branches ischaemia. Patients with cardiac revascularisation from ascending aorta were excluded. Results From April 2009 to June 2012, 37 patients with TAAD were admitted to our hospital. As many as 28 underwent surgical repair and 9 were considered at high surgical risk in a multidisciplinary meeting. Four met our inclusion criteria for an endovascular approach. Two of them had previous ascending aortic repair for TAAD and one had aortic valve replacement. Technical success was achieved in 100% of the patients. No mortality was registered during a median follow-up of 15 months (range 4–39 months), no migration of the graft and complete false lumen thrombosis of the ascending aorta in three patients. Conclusion Endovascular treatment of TAAD is challenging but feasible in a selected subset of patients. Further research remains mandatory.
Objective To assess safety, effectiveness and clinical outcome of the conformable thoracic aortic endograft (CTAG) in the treatment of aortic arch pathologies. Methods Between October 2009 and ...December 2010, 100 consecutive patients (65 men; mean age 65 years) with aortic arch pathologies were treated with the CTAG device in five European centres. Indications were thoracic aortic aneurysm ( n = 57), Type B dissection ( n = 24), intramural haematoma ( n = 4), penetrating aortic ulcer ( n = 9), and traumatic transection ( n = 6). Emergency procedures were performed in 33%. The proximal landing zone (LZ) was LZ 0 in 7%, LZ 1 in14%, LZ 2 in 43%, and LZ 3 in 36%. Data were collected prospectively and analysed for technical and clinical success. Conformability and deployment accuracy were analysed on intra-operative angiography and post-operative computed tomography. Mean follow up was 24 ± 19 months (range, 0.3–36 months). Results The 30 day, 1 and 2 year survival rates were 90%, 81%, and 74% respectively. The 2 year survival was 80% in the elective and 62% in the emergency groups ( p = .20). The major 30 day complication rate was 34%: primary Type Ia endoleak affected 1%, retrograde dissection in 1%, and the paraplegia and stroke rates at 30 days were 4% and 11%. Age > 70 years was an independent predictor for mortality and complications. The primary technical success rate was 92%; device deployment was successful in 100% and accurate in 99%. Conformability to the aortic arch was achieved in 95%. Conclusion The CTAG stent graft shows high deployment accuracy, good conformability, and clinical effectiveness in the treatment of aortic arch pathologies. However, thoracic endovascular aortic repair in the arch is associated with a relatively high stroke rate. Further studies with more patients and longer follow up are needed to evaluate the long-term results.
The endovascular debranching with chimney stents provides a minimally invasive alternative to open surgery with readily available devices and has extended the option of endoluminal therapy into the ...realm of the aortic arch. But a critical observation at the use of this technique at the aortic arch is important and necessary because of the lack of long-term results and long term patency of the stents. Our study aims to review the results of chimney grafts to treat arch lesions.
A systematic health database search was performed in December 2014 according to the Prisma Guidelines. Papers were sought through a meticulous search of the MEDLINE database (National Library of Medicine, Bethesda, MA) using the Pubmed search engine.
Twenty-two articles were eligible for detailed analysis and data extraction. A total of 182 patients underwent chimney techniques during TEVAR (Thoracic Endovascular Aneurysm Repair). A total of 217 chimney grafts were implanted: 36 to the IA, 1 to the RCCA, 91 to the LCCA and 89 to the LSA. The type of stent-graft used for TEVAR was described in 132 patients. The type and name of chimney graft was described in 126 patients. In 53 patients information was limited to the type. Primary technical success, defined as a complete chimney procedure was achieved in 171 patients (98%). In 8 patients it was not clearly reported. The overall stroke rate was 5.3%. The overall endoleak rate, in those papers were it was clearly reported, was 18.4% (31 patients); 23(13,6%) patients developed a type IA endoleak, 1 patient (0.6%) developed type IB endoleak and 7 patients (4.1%) developed a type II endoleak
The total endovascular aortic arch debranching technique represent a good option to treat high-risk patients, because it dramatically reduces the aggressiveness of the procedure in the arch. Many concerns are still present, mainly related to durability and material interaction during time. Long-term follow-up is exceptionally important in light of the interactions of the stents, the thoracic endograft, the aortic arch, and every variation in systolic and diastolic pressure. Actually this technique has acceptable short and mid-term results. Long term data are available just from a very small number of patients and more data from a wider number are needed in order to embrace this method as a safe one.
This report describes an endovascular repair of a residual type A dissection using a medical device that is not marked by european conformity (CE) or Food and Drug Administration (FDA).The patient ...underwent ascending aortic surgery for acute type A dissection. The 2-year angio-computed tomography demonstrated patency of the residual false lumen with evolution into a 6 cm aneurysm, the extension of the dissection from the aortic arch to the aortic bifurcation with thrombosis of the right common iliac artery. There was no CE- or FDA-marked medical device indicated for this case or any other acceptable therapeutic alternative.We used the Najuta thoracic stent graft and successfully handled the pathology in a multiple-phase treatment.Technology is evolving with specific grafts for the ascending and fenestrated grafts for the aortic arch. In this single case the Najuta endograft, in spite of the periprocedural problems, was a valid therapeutic option.
To evaluate a recent approach for the endovascular repair of thoracic aortic aneurysms and dissections involving the aortic arch in high risk patients (HRP).
Amongst 102 thoracic aortic aneurysms and ...dissections, we treated 25 patients for aortic arch endovascular exclusion after transposition of the great vessels, of which 14 (56%) had thoracic aortic arch aneurysms and 11 type A and B chronic aortic dissections. Total transpositions were done in 15 cases (60%) and hemi-arch transpositions in 10. We then used Talent
®, Excluder
® and Zenith
® endografts in 12, seven and six cases, respectively.
Surgical transpositions were complicated by one minor stroke, which worsened to a major stroke (4%) after endovascular exclusion. After endovascular exclusions, two patients (8%) died from catheterization related complications. One patient had a delayed minor stroke (4%). The successful exclusion rate was 92%. During follow-up (15±5.8 months), one patient (4%) developed unilateral limb palsy, successfully treated by CSF drainage. The late exclusion rate remained 92%. No stent-related complications were seen.
Transposition of supra-aortic vessels allows the endovascular exclusion of the aortic arch in HRP. Aortic endografting after surgical transposition proved to be feasible and offers good mid-term results. Specialized surgical centers with both endovascular and surgical expertise are required to treat these patients.
Aim of the study was to report our single-center experience of the ultra-low profile OvationTM Abdominal Stent-Graft System with totally percutaneous endovascular aneurysm repair (PEVAR).
Between ...December 2010 and March 2013 we electively treated 35 patients (male: 89%, mean age: 73±7 years) with abdominal aortic aneurysm (AAA) using bilateral PEVAR with the OvationTM endograft. Most (77%) cases were characterized by challenging femoral artery anatomy. Patients returned for follow-up visits at 1, 3, 6 months and annually thereafter.
Technical success was 97.1%. One type Ia endoleak was identified on final angiography, which was treated with an extension cuff. No groin complications were observed, including lymphocele, hematoma, pseudoaneurysm, dehiscence, or wound infection. Mean follow-up was 10 months (range 1-24 months). No death was registered. One type Ia endoleak was identified at the 12-month follow-up, which resolved with placement of a Palmaz balloon-expandible stent. No type II, III, or IV endoleaks were identified. No migration, AAA enlargement, AAA rupture, or conversion to open surgery was reported. Two patients (5.7%) developed monolateral iliac limb occlusion at 58 and 72 days of follow-up, respectively. In one case a limb kinking was observed and treated with iliac kissing stent. The other limb occlusion was due to external iliac artery severe stenosis and was treated with thrombolysis and iliac artery stenting.
PEVAR with the OvationTM endograft is feasible and safe in patients with unfavorable anatomy.
We report an endovascular approach that used to treat a symptomatic extracranial vertebral artery aneurysm associated to an asymptomatic aberrant right subclavian artery aneurysm. A 54-year-old man ...presented with neck pain, vertigo and loss of balance. The computed tomography (CT) scan demonstrated a left extracranial vertebral artery aneurysm that compressed and eroded the C5 vertebra associated to an aberrant right subclavian artery aneurysm. Endovascular exclusion of the vertebral aneurysm using a covered stent and a hybrid treatment of the aberrant subclavian artery aneurysm were performed. The 13th month follow-up CT scan confirmed the stent-grafts and supra-aortic vessels patency. The endovascular treatment represents a good option for these complex pathologies with excellent immediate results, reduces the complication rate and the hospital stay if compared to open repair. Long-term follow-up is necessary. To our knowledge this is a unique case in the literature.
Extend thoraco-abdominal aortic aneurysms (TAAA) involving arch vessels and the visceral arteries remains a challenging operation when affecting high risk patients (HRP). Recently, hybrid surgery has ...gained popularity for HRP. The conventional surgical repair is the gold standard for low risk patients with previous mortality from 6% to 15% in thoracic aneurysms up to 30% in thoracic type B dissections. The risk of paraplegia is 3% to 15%. Without repair the outcome is poor with only 35% of patient's survival at two years after diagnosis. The total endovascular technique is not widespread used because of its very time-consuming, needs training, and procedure planning with high radiation exposure. Only few centers in the world perform it. In order to reduce the morbidity a novel approach is proposed, with an aortic debranching from the ascending aorta.
Nine patients (two females) aged between 53 and 81 years, with high risk factors for surgery, were offered this hybrid technique from March 2004 to July 2009. Eight patients presented with a TAAA and one type a B chronic dissection. A staged hybrid operation started by a debranching of the aorta from a median sternotomy to supra-aortic vessels and visceral arteries, followed by the second stage one-two weeks later, with an extended stent grafting. This attitude avoids CPB and aortic cross clamping. The surgical approach is a median sternotomy combined to mid upper laparotomy associated to pericardial and diaphragm division. It is well tolerated even in elderly patients and allows easy access to celiac axis (CA), superior mesenteric artery (SMA), right renal artery (RRA). Access to the left renal artery is more difficult and may be benefit from a combinated stent grafting and bypass according to the VORTEC technique described by Lachat M, or an extra-anatomic bypass. Rerouting the visceral arteries is done from the ascending aorta with a partial clamping on an undiseased implantation site, offering à good anterograde high flow. Combined bypass to supraaortic vessels is associated when needed.
There was no intraoperative mortality. One patient died during 30D period from cardiac failure and another on the early follow up from a pancreatic fistula. The complications: one stroke (11.1%); one cardiac failure (11.1%); one renal failure (11.1%), one pancreatic fistula (11.1%), one non-infected retrostrenal collection (11.1%). No paraplegia, limb ischemia or aortic fistula were detected. No stent-graft related complication was retrieved, the bypass patency was 77.7 at four-year survival.
Our early and mid term results are promising and similarly to other series. This new approach for rerouting the supraaortic and visceral arteries before stent grafting in extended TAAA, lowers the surgical injury and is particularly designed for HRP who cannot benefit from conventional surgery under CPB. Larger series and longer follow-up are needed.
PDF
