Endovascular treatment of the descending thoracic aorta.

OBJECTIVES: to report our initial experience with endovascular stent graft repair of a variety of thoracic aortic pathology. DESIGN: retrospective single center study. MATERIAL AND METHODS: between February 2000 and January 2002, endovascular stent graft repair was performed in 26 patients: traumatic aortic isthmus rupture (n=3), Type B dissection (n=11) and descending thoracic aortic aneurysm (n=12). The deployed stent graft systems were AneuRx-Medtronic (n=1), Talent-Medtronic (n=13) and Excluder-Gore (n=12). RESULTS: successful deployment of the stent grafts in the intended position was achieved in all patients. No hospital mortality neither paraplegia were observed. Late, non procedure related, death occurred in four patients (15%). Access artery complications with rupture of the iliac artery occurred in two patients and were managed by iliac-femoral bypass. The left subclavian artery was overstented in seven patients (27%). Only the first patient received a carotido-subclavian bypass. The mean maximal aortic diameter decreased significantly in patients treated for descending thoracic aneurysm. Only one patient had an endoleak type II after 6 months without enlargement of the aneurysm. Complete thrombosis of the thoracic false lumen occurred in all but one patient treated for Type B dissection 6 months postoperatively. Two patients underwent a consecutive stent graft placement, due to a large re-entry tear distal to the first stent graft. CONCLUSIONS: endovascular stent graft repair for Type B dissection, descending thoracic aneurysm and aortic isthmus rupture is a promising less-invasive alternative to surgical repair. Further studies are mandatory to determine its long-term efficacy.     

Early and mid-term results of endovascular treatment of thoracic aorta diseases: a single-center experience

We conducted an analysis to assess early and mid-term outcomes of patients after thoracic endovascular aortic repair (TEVAR) for type B thoracic aorta dissection, descending thoracic aneurysm, or traumatic aortic transection. From January 2016 through December 2018, twenty-seven patients (23 male, 4 female, mean age of 57 years) affected by type B dissection (n = 13 [48.2%]), thoracic aneurysm (n = 9 [33.3%]), and post-traumatic aortic isthmus rupture (n = 5 [18.5%]) were treated using TEVAR with and without left subclavian artery revascularization. All procedures were performed in a hybrid operating room using general (n = 12) or regional (n = 15) anesthesia. A combined brachial artery and bilateral femoral artery access was used in all patients. To achieve adequate proximal thoracic aorta landing zone length, coverage of the left subclavian artery with proximal endovascular plug occlusion was performed in 17 patients (62.9%); including 4 patients undergoing carotid–subclavian artery bypass before TEVAR stent-graft deployment. Primary procedural success rate was 96.3%; 1 patient had a Type Ib endoleak that was treated by distal stent graft extension. Four adverse outcomes occurred in the immediate postoperative period, including 2 cases of left upper arm acute ischemia (7.4%), ischemic stroke (3.7%), and asymptomatic iliac artery dissection (3.7%). During a mean follow-up of 18 months, no graft-related deaths or endoleak occurred. One patient developed symptomatic subclavian steal syndrome 1 month after operation and underwent a left carotid–subclavian artery bypass with symptom resolution. One patient died 6 months after TEVAR due to neoplasm. Our experience indicates TEVAR is a safe and less invasive alternative to open surgery for a spectrum of thoracic aorta diseases, especially for urgent conditions and in patients with high-risk surgical comorbidities.     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

Endovascular repair of a right-sided descending thoracic aortic aneurysm with a right-sided aortic arch and aberrant left subclavian artery

Aneurysms involving a right-sided aortic arch and a right-sided descending thoracic aorta with an aberrant origin of the left subclavian artery are rare. We describe the successful surgical repair of this vascular anomaly by the combined use of a left carotid to subclavian artery bypass followed by endovascular stent-graft placement to exclude the aortic aneurysm. We also review the literature associated with this particular anatomic presentation.     

Endovascular thoracic aortic aneurysm repair with concomitant myocardial and carotid revascularization

A 73-year-old woman presented with a large saccular aneurysm involving the distal aortic arch. Preoperative aortography and cardiac catheterization revealed left main coronary artery and left common carotid artery stenoses. Concomitant coronary artery bypass grafting to the left anterior descending and first diagonal arteries, ascending aorta-to-left common carotid artery bypass grafting, and endovascular thoracic aortic aneurysm repair with antegrade stent-graft deployment and intentional left subclavian artery coverage were performed.     

Acute Type A Dissection Treated with Combined Endovascular Repair of Arch and Surgical Bypass of Arch Vessels from Descending Aorta

We report a case of an endovascular repair of a recurrent dissecting aneurysm of the aortic arch and dissection of carotid vessels, 3 years after surgical repair of aortic valve and ascending aorta for a type A dissection. We performed a bypass from the descending aorta to right, left common carotid artery (CCA), to left subclavian artery with no cardiopulmonary bypass and thereafter, total ascending and aortic arch stent grafting. We suggest considering total aortic arch stent grafting with bypass of arch vessels in cases of complicated acute type A dissection. In cases where the ascending aorta cannot be used as donor site for bypass, we suggest the use of the descending aorta.     

Endovascular Repair of Thoracic Aortic Aneurysms: Stent-graft Fixation across the Aortic Arch Vessels

The close proximity of the arch vessels to the origin of many thoracic aortic aneurysms (TAA) may result in placement of the stent struts across the left subclavian or carotid ostia. The purpose of this study is to determine the incidence and impact of transaortic arch vessel fixation during thoracic aortic stent graft deployment for the treatment of descending TAA. From May 1997 to July 2000, 20 patients (10 men, 10 women, mean age 82 years) with descending TAA were treated in the operating room with endoluminally placed stent grafts secured proximally to the thoracic aorta with a long (15-mm) uncovered stent segment (Talent LPS). Pre- and postoperative angiograms and IV contrast-enhanced spiral CT scans were performed in all cases. Follow-up contrast CT scans were obtained at 1, 3, 6, and 12 months and yearly thereafter to assess the adequacy of repair and to determine stent position and arch vessel patency. We found that thoracic aortic endograft fixation across the left aortic arch vessels occurs frequently during device placement and is associated with no early morbidity. Long-term follow-up is necessary to ensure that there are no late sequelae.     

Pseudoaneurysm of the aortic arch after aortosubclavian bypass treated with endoluminal stent grafting--a case report

This paper describes a case of aortic arch pseudoaneurysm treated with stent graft 2 years after aortosubclavian bypass repair of a subclavian artery aneurysm. An 84-year-old man presented with back pain. Two years before, he had had a left subclavian artery aneurysm repaired with aortosubclavian bypass. Upon examination by computed tomography (CT) scan and angiography he was found to have a bovine arch configuration, a 7-centimeter pseudoaneurysm arising from the stump f the native subclavian artery, a patent aortosubclavian bypass, and a left hemothorax. A 37 mm by 10 mm Gore Excluder thoracic graft was introduced into the right femoral artery cutdown and deployed across the arch, excluding the pseudoaneurysm and preserving the brachiocephalic vessels. Follow up CT scan at 1 year shows exclusion of the pseudoaneurysm. The patient continues to do well 1 year after implantation without evidence of endoleak. In the presence of unusual anatomical characteristics, endoluminal stent graft repair can be successfully performed across the aortic arch.     

Staged hybrid treatment of complex ascending aortic and distal aortic arch pseudoaneurysm after repair of aortic coarctation

A 49-year-old operated for aortic coartaction patient presented with thoracic and ascending aortic aneurysm. He was asymptomatic. Angio-magnetic resonance nuclear scan and angiography revealed an ascending aortic aneurysm (5.2 cm), bicuspid aortic valve, 6-cm proximal descending aortic pseudoaneurysm at the site of the previous operation with involvement of the left subclavian artery. Restenosis at the original site of coarctation and aortic arch hypoplasia distally to the brachiocefalic trunk was also found. The operation performed was a "modified Bentall - De Bono". The pseudoaneurysm was not accessible through median sternotomy due to the massive lung adhesions following the previous surgery. The left common carotid artery was explanted from the aortic arch and connected with a graft to the ascending aortic conduit. A proximal neck suitable for landing zone of the endovascular stent-graft was then established. The postoperative course was uneventful. After two weeks, the patient was readmitted. The exclusion of the thoracic descending aortic pseudoaneurysm by endovascular implantation of the stent-graft prosthesis was performed. The left subclavian artery was excluded because left vertebral artery was closed. The patient did not develop hand claudicatio. The procedure was successful.     

Combined open and endovascular treatment of a right subclavian artery aneurysm: a case report

A 69-year-old man with previous ascending aortic repair combined with valve replacement for an ascending aortic aneurysm presented with a type 2 thoracoabdominal aneurysm and a 4.4-cm aneurysm of the right subclavian artery. Because of the anatomic location of the aneurysm and his previous operation, an innominate to carotid artery stent graft and a carotid-subclavian bypass and vertebral artery bypass were performed. Postoperative computed tomographic angiography confirmed good flow in the right carotid and vertebral artery, and the patient recovered without complication.     

Coverage of the left subclavian artery during thoracic endovascular aortic repair

BACKGROUND: Thoracic aortic stent grafts require proximal and distal landing zones of adequate length to effectively exclude thoracic aortic lesions. The origins of the left subclavian artery and other aortic arch branch vessels often impose limitations on the proximal landing zone, thereby disallowing endovascular repair of more proximal thoracic lesions. METHODS: Between October 2000 and November 2005, 112 patients received stent grafts to treat lesions involving the thoracic aorta. The proximal aspect of the stent graft partially or totally occluded the origin of at least one great vessel in 28 patients (25%). The proximal attachment site was in zone 0 in one patient (3.6%), zone 1 in three patients (10.7%), and zone 2 in 24 patients (85.7%). Patients with proximal implantation in zones 0 or 1 underwent debranching procedures of the supra-aortic vessels before stent graft repair. In one patient who underwent zone 1 deployment, the left subclavian artery was revascularized before stent graft deployment. Among patients who underwent zone 2 deployment with partial or complete occlusion of the left subclavian artery, none underwent prior revascularization. Patients were assessed postoperatively and at follow-up for development of neurologic symptoms as well as symptoms of left upper extremity claudication or ischemia. RESULTS: Mean follow-up was 7.3 months. Among the 24 patients with zone 2 implantation, 10 (42%) had partial left subclavian artery coverage at the time of their primary procedure. A total of 19 patients experienced complete cessation of antegrade flow through the origin of the left subclavian artery without revascularization at the time of the initial endograft repair as a result of a secondary procedure or as a consequence of left subclavian artery thrombosis. Left upper extremity symptoms developed in three (15.8%) patients that did not warrant intervention, and rest pain developed in one (5.3%), which was treated with the deployment of a left subclavian artery stent. Two primary (type IA and type III) endoleaks (7.1%) and one secondary endoleak (type IA) (3.6%) were observed in patients who underwent zone 2 deployment. Three cerebrovascular accidents were observed. Thoracic aortic lesions were successfully excluded in all patients who underwent supra-aortic debranching procedures. CONCLUSION: Intentional coverage of the origin of the left subclavian artery to obtain an adequate proximal landing zone during endovascular repair of thoracic aortic lesions is well tolerated and may be managed expectantly, with some exceptions.     

Transcarotid artery endovascular reconstruction of the aortic arch by modified bifurcated stent graft for Stanford type A dissection

A 40-year-old man with Stanford type B dissection underwent his first endovascular repair (EVAR) in April 2004 by Talent thoracic stent graft. He had an uncomplicated recovery and maintained good blood pressure control. However, a new retrograde dissection appeared in September 2004. The new dissection involved his aortic arch and ascending thoracic aorta to the opening of the coronary arteries. To reconstruct the aortic arch, bypasses between the right common carotid artery (RCCA), left common carotid artery and left subclavian artery were performed before endovascular repair. A modified bifurcated Talent stent graft was deployed from the RCCA to the ascending thoracic aorta with a long limb in the innominate artery and a short limb in the aortic arch. A further two pieces of graft were deployed via the common femoral artery. The ascending thoracic aorta and aortic arch were reconstructed completely by the bifurcated stent graft. The final angiography confirmed that there was good stent graft configuration, normal blood flow, and stable haemodynamics. No endoleak or other major complications were encountered. This result indicated that it is possible to reconstruct the aortic arch with a bifurcated stent graft and could be a new endovascular repair model for complex thoracic aortic aneurysm and dissection.     

Usefulness of intraoperative transesophageal echocardiography in stent graft implantation for thoracic descending aorta

BACKGROUND: Stent graft implantation for thoracic descending aorta is a promising alternative to open repair. Transesophageal echocardiography (TEE) is a sensitive imaging modality for aortic disease. We reviewed our experience with TEE in stent graft implantation for thoracic descending aorta. METHOD: Five patients underwent stent graft implantation for thoracic descending aorta under general anesthesia. Intraoperative angiography and TEE were used to identify the extent of the aneurysm and the placement of the stent. RESULTS: TEE showed stent graft configuration and presence of leakage in all cases. In three cases, additional stent graft placement or bypass was performed. CONCLUSIONS: Useful information was obtained by TEE in enhancing the accuracy of stent graft positioning potentially improving outcomes. TEE may facilitate repair by confirming aortic pathology, identifying endograft placement, and assessing the adequacy of aneurysm sack isolation, presence of leakage, as well as dynamic intraoperative cardiac performance.     

Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology

BACKGROUND: A rapidly increasing number of thoracic aortic lesions are now treated by endoluminal exclusion by using stent grafts. Many of these lesions abut the great vessels and limit the length of the proximal landing zone. Various methods have been used to address this issue. We report our experience with subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. METHODS: Thirty (43%) of 70 patients undergoing thoracic endovascular stent-graft placement from January 2001 to August 2005 had lesions adjacent to or involving the origin of the subclavian artery. The mean age was 62 years (range, 22-85 years; 63% were men, and 37% were women). This subgroup of 30 patients had indications for repair that included thoracic aortic aneurysm (n = 15), traumatic transection (n = 6), chronic dissection with pseudoaneurysm (n = 5), and acute dissection with intramural hematoma (n = 4). All 30 patients had the subclavian origin covered by the stent graft. In eight cases (27%), no effort was made to revascularize the subclavian artery before or during the endograft placement procedure. Twenty-three (77%) of 30 patients underwent subclavian to carotid artery transposition (n = 21) or bypass (n = 2) before (n = 12; average of 14 days before stent-graft placement), concomitant with (n = 10), or after (n = 1) the endovascular procedure. Physical examination and computed tomography scans were performed after surgery at 1, 6, and 12 months and annually thereafter. The mean follow-up was 18 months (range, 1-51 months). RESULTS: Five acute complications occurred in the eight patients (63%) who had the subclavian artery covered without pre-endograft revascularization and included four patients who experienced stroke (accounting for the only death) and one patient who developed symptomatic subclavian-vertebral steal that necessitated transposition 7 months later. Two (9%) of the 23 patients who had subclavian revascularization experienced left-sided vocal cord palsies, and 1 patient (4%) developed lower extremity paraparesis secondary to spinal cord ischemia. No late endoleaks related to retrograde sac perfusion from the most distal great vessel have been identified in any patient. CONCLUSIONS: Subclavian revascularization procedures can be performed with relatively low risk. Complications are rare, and patient recovery is rapid. Although this is not necessary in all cases, we advocate subclavian to carotid transposition when the aortic lesion is within 15 mm of the left subclavian orifice to prevent type II endoleak or perfusion of a dissected false lumen when the ipsilateral vertebral artery is patent and dominant or when coronary revascularization using an ipsilateral internal mammary artery is anticipated and in cases that necessitate extensive coverage of intercostals that contribute to spinal cord perfusion. Carotid to subclavian artery bypass should be reserved for patients with a patent internal mammary artery conduit perfusing a coronary vessel and should be combined with proximal subclavian ligation.     

Outcome after celiac artery coverage during endovascular thoracic aortic aneurysm repair: preliminary results

BACKGROUND: Endovascular repair of descending thoracic aortic aneurysms has emerged as an alternative to open repair. Coverage of the left subclavian origin has been reported to expand the proximal sealing zone. We report the planned coverage of the celiac artery origin with a thoracic stent graft to achieve an adequate distal sealing zone. METHODS: All patients undergoing endovascular aneurysm repair are prospectively entered into a computerized database. All patients who underwent thoracic endovascular aneurysm repair with coverage of the celiac artery origin were identified and retrospectively analyzed. End points for evaluation included indications for covering the celiac artery, anatomic features of the distal landing zone, demonstration of collateral circulation between the celiac artery and the superior mesenteric artery, technical success of the procedure, and presence of clinical ischemic symptoms after the procedure. RESULTS: Between March 2005 and May 2006, 46 patients underwent endovascular repair of descending thoracic aortic aneurysms. Seven patients had planned celiac artery coverage with a thoracic stent graft to secure an adequate distal sealing zone. Six patients demonstrated collateral circulation through the gastroduodenal artery between the celiac and superior mesenteric arteries before deployment of the stent graft. One patient had a distal type I endoleak at the conclusion of the procedure related to inadequate sealing at the superior mesenteric artery origin. No type II endoleaks were evident at the final intraoperative angiogram or 30-day computed tomography scan. There were no postoperative deaths, no ischemic abdominal complications, and no clinical spinal cord ischemia. Short-term follow-up (1 to 10 months) has demonstrated no additional endoleaks (type I not fully assessed), no aneurysm growth, and no aneurysm ruptures. CONCLUSION: This limited series supports the suitability, in selected patients, of covering the celiac artery origin for a distal landing zone when the distal sealing zone proximal to the celiac artery is inadequate. We recommend the angiographic evaluation of the collateral circulation between the celiac and superior mesenteric arteries when covering the celiac artery origin is being considered.     

When is safe to cover the left subclavian and celiac arteries. Part I: left subclavian artery

Over the last 15 years the endovascular repair of thoracic aortic pathologies has been developing as the treatment of choice, but it requires appropriate anatomy. Proximal and distal landing zones are essential for fixation and sealing. In order to extend the proximal landing zone for the stent-graft and achieve an adequate seal, the left subclavian artery (LSA) is often covered, with or without concomitant subclavian artery revascularization. In this article the authors review the LSA anatomy and consequences of LSA coverage as scenery for a discussion of the ramifications of LSA coverage during endovascular thoracic aortic repair (TEVAR). Summari-zing the currently available literature, the authors reveal that there is no consensus regarding a preparatory left carotid-subclavian bypass or a transposition of the left subclavian artery to the left common carotid artery. Various management strategies are offered.     

Left subclavian artery management in endovascular repair of thoracic aortic aneurysms and aortic dissections

PURPOSE: The purpose is to report our experience and revise our previously published results in endovascular repair of short-necked thoracic aortic aneurysms or aortic type B dissections, in which the left subclavian artery (LSA) was occluded by the stent graft intentionally.METHODS: Seven patients with an aortic type B dissection and three patients who had a thoracic aortic aneurysm were treated endovascularly with stent grafts. In all patients the ostium of the LSA was occluded by the stent graft, only in two patients a primary, prophylactic revascularization of the LSA was performed by transposition to the left common carotid artery (LCA). Two types of stent grafts were used: the Talent (Medtronic) and the Excluder (Gore) stent graft. RESULTS: In all patients the sealing of the entry tear in aortic dissections and the exclusion of existing thoracic aortic aneurysms were achieved. No immediate neurological deficit or left arm ischemia occurred. Nevertheless, during a mean follow-up of 18 months (2 to 31 months) in three patients a second surgical intervention had to be performed due to subclavian steal syndrome, left arm ischemia, or continuing perfusion of the dissected false aortic channel. CONCLUSION: Intentional occlusion of the LSA in stent-graft repair of thoracic aortic diseases seems to be a safe procedure. Close follow-up is needed due to arising subclavian steal syndrome, arm ischemia, or persistent perfusion of the false channel via LSA in aortic dissections after patients' discharge, requiring surgical intervention.     

合并严重冠心病的短锚定区主动脉弓降部疾病的腔内修复

目的:探讨合并严重冠心病,已经接受或近期可能接受冠状动脉旁路移植手术须保留左锁骨下动脉,且近端锚定区又不足的主动脉弓降部疾病患者腔内修复治疗的策略及注意事项。方法:回顾性分析2016年4月—2016年7月期间阜外医院血管外科中心收治的9例合并严重冠心病、近端锚定区不足的主动脉弓降部疾病患者资料,其中男7例,女2例,平均年龄60(37~76)岁,均行胸主动脉腔内修复术治疗,均需保留左锁骨下动脉,从而保留作为冠脉前降支桥血管最佳来源的左侧乳内动脉。结果:手术成功率100%,无手术死亡,所有患者左侧乳内动脉均保留成功。术后发生I型内漏1例(1/9),随访3个月后内漏消失;术后4个月因冠状动脉回旋支狭窄行经皮冠状动脉成形术1例(1/9)。所有患者均获得门诊或电话随访,随访时间6(4~7)个月,所有患者临床症状消失或明显减轻,生活质量改善,无随访死亡病例。结论:对于已经接受左侧乳内动脉-冠脉前降支搭桥或即将接受冠脉搭桥手术的主动脉弓降部疾病患者,在实施胸主动脉腔内修复手术时可采取个性化措施保留左锁骨下动脉,进而保留左乳内动脉,必要时可以采用"烟囱"等技术辅助。     

Two cases of stent graft repair for thoracic aortic dissection: usefulness of three-dimensional computed tomogram]

We carried out stent graft repair in two patients with Stanford type B thoracic aortic dissection. A 51-year-old male was admitted to our hospital because of thoracic aortic dissection. Chest CT revealed an aneurysm of the distal aortic arch. The entry was pointed out 1 cm distal from the take off of the left subclavian artery in three-dimensional CT (3 D-CT). He was treated with a Gianturco stent which was anchored into the 30 mm Hemashield graft under selective cerebral perfusion. Another case was a 72-year-old male with a descending aortic aneurysm. 3 D-CT showed that the entry existed 4 cm proximal to the celiac artery. We performed transluminal implantation of the spiral Z-stent covered with the woven Dacron graft. 3 D-CT was useful for the preoperative management and the surgical treatment of thoracic aortic dissection.     

Surgical treatment for cervical aortic arch with aneurysm formation

Cervical aortic arch is an unusual malformation. Cervical aortic arch with aneurysm formation is very rare. We report a case of cervical aortic arch associated with a saccular aneurysm in a 59-year-old Japanese man. The aneurysm protruded caudally and was located between the left common carotid and left subclavian arteries. Cardiopulmonary bypass and deep hypothermic circulatory arrest was applied as adjunct methods. A Dacron graft was sutured just distal to the left common carotid artery, with the patient in the Trendelenburg position. The proximal site was left open while oxygen-saturated venous blood was supplied in a retrograde manner to perfuse the lower body during occlusion of the descending aorta. Distal anastomosis to the descending aorta was performed during rewarming. The left subclavian artery was reconstructed by using a branch of the graft. This procedure is simple and useful for distal arch operations, especially in patients with Haughton D type aneurysms.