Abstract
Purpose
To evaluate the outcomes of fenestrated thoracic endovascular aortic repair (f-TEVAR) using physician-modified stent grafts (PMSGs) in zone 0 and zone 1 for aortic arch diseases.
Methods
f-TEVAR using PMSGs in Z0 and Z1 was performed on ten high-risk patients for open surgery from November 2015 to September 2017. Indications were complicated acute type B dissection (ABAD) with retrograde dissection involving the mid-arch (n = 1), distal arch aneurysms (n = 3), mid-arch aneurysms of the inner arch curvature (n = 3) and penetrating aortic ulcer located in the mid- or proximal arch (n = 3). Pre-, intra- and postoperative clinical data were recorded.
Results
The median patient age was 61 (range 45–81) years, and 9 (90%) patients were men. Ten PMSGs (Medtronic Valiant stent grafts, n = 1; Relay thoracic stent grafts, n = 4; Cook TX2 device, n = 5) were deployed. PMSGs were deployed from Z0 and Z1 in 5 and 5 patients, respectively. Double small fenestrations for the left subclavian artery (LSA) and the left common carotid artery (LCCA), respectively, were created in 3 patients. Triple small fenestrations for the innominate artery (IA), the LCCA and the LSA, respectively, were created in 2 patients. One large fenestration for both the IA and the LCCA combined with one small fenestration for the LSA was created in 3 patients. One large fenestration for the LCCA combined with one small fenestration for the LSA was created in 2 patients. Posterior diameter-reducing ties were added to all the devices except to one Valiant stent graft. All but 2 patients underwent elective procedure. Median duration for stent graft modifications was 105 (range 90–125) min. The technical success rate was 90%. Overall mortality was 10% (1/10). One patient died of sudden cardiac arrest intraoperatively after the deployment of the PMSG and all the supra-aortic branch stents. Mean operative time was 106.0 ± 43.0 min, and fluoroscopy time was 30.6 ± 22.9 min. There were no type I or type III endoleaks, perioperative neurological complications or spinal cord ischemia. Median length of stay was 8 (range 4–35) days. Nine patients survived at mean 13.3 (range 6.0–19.0) months follow-up. Retrograde dissection occurred in one patient of Z0 group 40 days post-f-TEVAR and resolved after open repair. During follow-up, all target vessels remained patent without fenestration-related type I or III endoleaks.
Conclusions
f-TEVAR using PMSGs in Z0 and Z1 for the treatment of aortic arch diseases in high-risk patients is feasible in the hands of experienced operators.
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Abbreviations
- f-TEVAR:
-
Fenestrated thoracic endovascular aortic repair
- PMSG:
-
Physician-modified stent graft
- ABAD:
-
Acute type B dissection
- CTA:
-
Computed tomography angiography
- IA:
-
Innominate artery
- LCCA:
-
Left common carotid artery
- LSA:
-
Left subclavian artery
- ASA:
-
American Society of Anesthesiologists
- RTAD:
-
Retrograde type A aortic dissections
- RAO:
-
Right anterior oblique
- LAO:
-
Left anterior oblique
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Zhu, J., Dai, X., Noiniyom, P. et al. Fenestrated Thoracic Endovascular Aortic Repair Using Physician-Modified Stent Grafts (PMSGs) in Zone 0 and Zone 1 for Aortic Arch Diseases. Cardiovasc Intervent Radiol 42, 19–27 (2019). https://doi.org/10.1007/s00270-018-2079-9
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DOI: https://doi.org/10.1007/s00270-018-2079-9