Advertisement

CardioVascular and Interventional Radiology

, Volume 42, Issue 1, pp 19–27 | Cite as

Fenestrated Thoracic Endovascular Aortic Repair Using Physician-Modified Stent Grafts (PMSGs) in Zone 0 and Zone 1 for Aortic Arch Diseases

  • Jiechang Zhu
  • Xiangchen Dai
  • Phasakorn Noiniyom
  • Yudong Luo
  • Hailun Fan
  • Zhou Feng
  • Yiwei Zhang
  • Fanguo Hu
Clinical Investigation Arterial Interventions
Part of the following topical collections:
  1. Arterial Interventions

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.

Keywords

Aortic arch disease Fenestration Thoracic endovascular aortic repair 

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

Notes

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

For this type of study formal consent is not required.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Consent for Publication

Consent for publication was obtained for every individual person’s data included in the study.

References

  1. 1.
    Estrera AL, Miller CC 3rd, Lee TY, Shah P, Safi HJ. Ascending and transverse aortic arch repair: the impact of retrograde cerebral perfusion. Circulation. 2008;118(Suppl):S160–6.CrossRefGoogle Scholar
  2. 2.
    Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor’s choice-management of descending thoracic aorta diseases: clinical practice guidelines of the European society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53(1):4–52.CrossRefGoogle Scholar
  3. 3.
    Redlinger RE Jr, Ahanchi SS, Panneton JM. In situ laser fenestration during emergent thoracic endovascular aortic repair is an effective method for left subclavian artery revascularization. J Vasc Surg. 2013;58(5):1171–7.CrossRefGoogle Scholar
  4. 4.
    Wang T, Shu C, Li QM, Li M, Li X, He H, et al. First experience with the double chimney technique in the treatment of aortic arch diseases. J Vasc Surg. 2017;66(4):1018–27.CrossRefGoogle Scholar
  5. 5.
    Kurimoto Y, Maruyama R, Ujihira K, Nishioka N, Hasegawa K, Iba Y, et al. Thoracic endovascular aortic repair for challenging aortic arch diseases using fenestrated stent grafts from zone 0. Ann Thorac Surg. 2015;100(1):24–32 discussion 32–33.CrossRefGoogle Scholar
  6. 6.
    Zhu J, Zhao L, Dai X, Luo Y, Fan H, Feng Z, Zhang Y, Hu F. Fenestrated thoracic endovascular aortic repair using physician modified stent grafts for acute type B aortic dissection with unfavourable landing zone. Eur J Vasc Endovasc Surg. 2018;55(2):170–6.CrossRefGoogle Scholar
  7. 7.
    Oderich GS. Technique of adding a diameter-reducing wire to the modified TX2 fenestrated stent graft. Vascular. 2010;18(6):350–5.CrossRefGoogle Scholar
  8. 8.
    Iba Y, Minatoya K, Matsuda H, Sasaki H, Tanaka H, Kobayashi J, et al. Contemporary open aortic arch repair with selective cerebral perfusion in the era of endovascular aortic repair. J Thorac Cardiovasc Surg. 2013;145(3 Suppl):S72–7.CrossRefGoogle Scholar
  9. 9.
    Kurazumi H, Mikamo A, Kudo T, Suzuki R, Takahashi M, Shirasawa B, et al. Aortic arch surgery in octogenarians: is it justified? Eur J Cardiothorac Surg. 2014;46(4):672–7.CrossRefGoogle Scholar
  10. 10.
    Geisbüsch P, Kotelis D, Müller-Eschner M, Hyhlik-Dürr A, Böckler D. Complications after aortic arch hybrid repair. J Vasc Surg. 2011;53(4):935–41.CrossRefGoogle Scholar
  11. 11.
    Spanos K, Tsilimparis N, Rohlffs F, Wipper S, Detter C, Behrendt CA, et al. Total endovascular arch repair is the procedure of the future. Part I. J Cardiovasc Surg (Torino). 2018.  https://doi.org/10.23736/s0021-9509.18.10412-5 Epub ahead of print.CrossRefGoogle Scholar
  12. 12.
    Cochennec F, Kobeiter H, Gohel M, Leopardi M, Raux M, Majewski M, et al. Early results of physician modified fenestrated stent grafts for the treatment of thoraco-abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2015;50(5):583–92.CrossRefGoogle Scholar
  13. 13.
    Haulon S, Greenberg RK, Spear R, Eagleton M, Abraham C, Lioupis C, et al. Global experience with an inner branched arch endograft. J Thorac Cardiovasc Surg. 2014;148(4):1709–16.CrossRefGoogle Scholar
  14. 14.
    Tsilimparis N, Debus ES, von Kodolitsch Y, Wipper S, Rohlffs F, Detter C, et al. Branched versus fenestrated endografts for endovascular repair of aortic arch lesions. J Vasc Surg. 2016;64(3):592–9.CrossRefGoogle Scholar
  15. 15.
    Iwakoshi S, Ichihashi S, Itoh H, Tabayashi N, Sakaguchi S, Yoshida T, et al. Clinical outcomes of thoracic endovascular aneurysm repair using commercially available fenestrated stent graft (Najuta endograft). J Vasc Surg. 2015;62(6):1473–8.CrossRefGoogle Scholar
  16. 16.
    Joseph G, Premkumar P, Thomson V, Varghese M, Selvaraj D, Sahajanandan R. Externalized guidewires to facilitate fenestrated endograft deployment in the Aortic Arch. J Endovasc Ther. 2016;23(1):160–71.CrossRefGoogle Scholar
  17. 17.
    Tshomba Y, Bertoglio L, Marone EM, Logaldo D, Maisano F, Chiesa R. Retrograde type A dissection after endovascular repair of a “zone 0” nondissecting aortic arch aneurysm. Ann Vasc Surg. 2010;24(952):e1–7.Google Scholar
  18. 18.
    Preventza O, Garcia A, Moeller K, Cooley DA, Gonzalez L, Cheong BY, et al. Retrograde ascending aortic dissection after thoracic endovascular aortic repair for distal aortic dissection or with zone 0 landing: association, risk factors, and true incidence. Ann Thorac Surg. 2015;100(2):509–15.CrossRefGoogle Scholar
  19. 19.
    Czerny M, Weigang E, Sodeck G, Schmidli J, Antona C, Gelpi G, et al. Targeting landing zone 0 by total arch rerouting and TEVAR: midterm results of a transcontinental registry. Ann Thorac Surg. 2012;94:84–9.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2018

Authors and Affiliations

  • Jiechang Zhu
    • 1
  • Xiangchen Dai
    • 1
  • Phasakorn Noiniyom
    • 2
  • Yudong Luo
    • 1
  • Hailun Fan
    • 1
  • Zhou Feng
    • 1
  • Yiwei Zhang
    • 1
  • Fanguo Hu
    • 1
  1. 1.Department of Vascular SurgeryGeneral Hospital of Tianjin Medical UniversityTianjinPeople’s Republic of China
  2. 2.Department of Vascular SurgeryYala Medical Center HospitalYalaThailand

Personalised recommendations