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

  • Clinical Investigation
  • Arterial Interventions
  • Published:
CardioVascular and Interventional Radiology Aims and scope Submit manuscript

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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Authors and Affiliations

  1. Department of Vascular Surgery, General Hospital of Tianjin Medical University, Tianjin, 300052, People’s Republic of China

    Jiechang Zhu, Xiangchen Dai, Yudong Luo, Hailun Fan, Zhou Feng, Yiwei Zhang & Fanguo Hu

  2. Department of Vascular Surgery, Yala Medical Center Hospital, Yala, 95000, Thailand

    Phasakorn Noiniyom

Authors
  1. Jiechang Zhu
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  2. Xiangchen Dai
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  3. Phasakorn Noiniyom
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  4. Yudong Luo
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  5. Hailun Fan
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  6. Zhou Feng
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  7. Yiwei Zhang
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  8. Fanguo Hu
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Correspondence to Xiangchen Dai.

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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

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