Branched endografts in the aortic arch following open repair for DeBakey Type I aortic dissection

Branched endografts in the aortic arch following open repair for DeBakey Type I aortic dissection Abstract OBJECTIVES DeBakey Type I aortic dissections are frequently treated by an ascending aortic tube graft or hemiarch replacement with the residual dissection remaining untreated. We investigated the outcomes of branched thoracic endovascular repair for post-dissection aneurysms of the aortic arch. METHODS We conducted a retrospective, single-centre evaluation of 20 consecutive patients with a false-lumen aneurysm after a DeBakey I aortic dissection treated with branched thoracic endovascular repair. The indication for endovascular repair was agreed on in an interdisciplinary case conference. Study end points were technical success, 30-day mortality rate, complications and late complications and reinterventions. RESULTS Between 2012 and 2016, 20 patients (14 men, age 65 ± 9 years) were treated for false-lumen aneurysm formation after a DeBakey Type I aortic dissection. All patients had undergone open ascending aortic repair either isolated (n = 16) or with partial arch repair (n = 4). Technical success was achieved in 19 of 20 cases. The 30-day mortality rate and incidence of stroke were each 5% (1/20). Simultaneous procedures to exclude false-lumen perfusion included implantation of a Knickerbocker graft in 3 (15%) patients and a candy-plug graft in 7 (35%) patients. Early postoperative computed tomography angiography revealed persistent false-lumen perfusion in 10 cases that required secondary interventions in 6 cases. During 17 ± 14 months of mean follow-up, there was 1 aortic-related death and 2 deaths of non-aortic reasons. The estimated overall survival was 89 ± 7% and 75 ± 15% at 12 and 36 months, respectively. CONCLUSIONS Treatment of residual aortic arch dissections with branched thoracic endovascular repair appears feasible and safe with few deaths and low stroke rates. A high rate of secondary procedures is required to achieve thoracic false-lumen occlusion. DeBakey Type I aortic dissection, Endovascular repair, Branched thoracic endograft, Post-dissection aneurysm INTRODUCTION Acute aortic dissection DeBakey Type I is a potentially fatal clinical condition with a high mortality rate if left untreated. According to the International Registry of Aortic Dissection, 86% of these patients are treated with open surgery with mortality rates ranging from 18% to 5% [1]. Repair of the ascending aorta and/or the hemiarch disease is common whereas only 20% undergo total aortic arch replacement [2]. The late survival rate after surgical repair for DeBakey Type I dissection is satisfactory with survival rates of 80% and 65% at 5 and 10 years, respectively. However, approximately 70% of early survivors have persisting false-lumen perfusion due to the extension of the dissection into the downstream aorta, and a significant proportion of those patients, estimated at 20%, require late reintervention for chronic false-lumen aneurysm [3, 4]. Treatment of this entity is difficult, because it usually requires a reoperation at the site of the aortic arch. However, extension of the false lumen into the descending aorta makes open surgical approaches more challenging. Redo surgery of the aortic arch has been reported to be associated with increased morbidity and mortality rates [5]. Progress in endovascular techniques have allowed the use of stent grafts in such complex cases. Recent studies have reported encouraging results following endovascular treatment of complex aortic aneurysms in the thoraco-abdominal aorta treated with branched and fenestrated endografts [6, 7]. Endovascular therapy of the aortic arch has also been shown to be feasible and safe with branched devices over the past years, although these reports included all disease states and more frequently aneurysms [8, 9]. Specific endovascular strategies, such as staged procedures and the use of fenestrated and branched endografts, have been proposed for the treatment of post-dissection aortic aneurysms, but so far, apart from isolated case reports or small cohorts with mixed diseases, no articles have addressed branched endovascular repair in post-dissection aortic arch aneurysms as an individual entity. The aim of the present study was to investigate the feasibility and safety of an endovascular approach with branched thoracic endovascular repair (b-TEVAR) to treat false-lumen aneurysms after DeBakey Type I aortic dissection (Fig. 1). Figure 1: View largeDownload slide (A) Three-dimensional computed tomography angiography reconstruction; (B) axial computed tomography image of the aortic arch of a patient with residual Type I dissection after ascending interposition; (C) Three-dimensional computed tomography angiography reconstruction after implantation of an arch branched device. Figure 1: View largeDownload slide (A) Three-dimensional computed tomography angiography reconstruction; (B) axial computed tomography image of the aortic arch of a patient with residual Type I dissection after ascending interposition; (C) Three-dimensional computed tomography angiography reconstruction after implantation of an arch branched device. METHODS Study design A retrospective, single-centre study was undertaken including consecutive patients with residual DeBakey Type I aortic arch dissection treated with b-TEVAR in our institution from 2012 to 2016. End points were technical success, 30-day mortality rate, complications and late complications and reinterventions. This study involved collecting existing data and imaging tests that were recorded in such a manner that subjects could not be identified, either directly or through identifiers linked to the subject. In Hamburg Germany, local state regulation does not require physicians to acquire ethical committee approval when only using file data to perform clinical research. Patient selection Patients who were included in our study were not suitable for open surgical therapy due to co-morbidities, previous repair or personal choice. Cases were discussed by members of an interdisciplinary aortic board comprising vascular surgeons, cardiologists and cardiovascular surgeons [10]. Indications for treatment with endovascular repair included complex prior open cardiothoracic surgery, advanced age and/or relevant comorbidities rendering them at high risk for open repair with hypothermic circulatory arrest and refusal of open repair due to previous personal experience. Type of endograft All patients were treated with custom-made devices manufactured by Cook Medical (Bloomington, IN, USA) [11]. Arch branch graft design The endograft used was the arch branched endograft (Cook Medical, Bloomington, IN, USA), which comprises 2 internal funnels (Fig. 2). The graft is designed to land proximally in the ascending aorta distal to the orifices of the coronary arteries with 1 or 2 sealing stents and active barb fixation. The delivery system is precurved, so that the funnels for the target vessels self-align with the supra-aortic vessels. Distally, the graft can seal in the proximal descending aorta or further distally if extended with other thoracic endografts. The graft has a sequential deployment mechanism with constraining wires to allow precise deployment of the proximal portion of the graft. Figure 2: View largeDownload slide (Top) Branched arch endograft with 2 inner funnels for the supra-aortic vessels (Cook Medical, Bloomington, IN, USA). (Bottom) A drawing of the stent graft. Figure 2: View largeDownload slide (Top) Branched arch endograft with 2 inner funnels for the supra-aortic vessels (Cook Medical, Bloomington, IN, USA). (Bottom) A drawing of the stent graft. In a first session, a left-sided carotid-subclavian bypass is placed between the proximal extrathoracic common carotid artery and the subclavian artery. In the second session (typically a few weeks later), the main procedure is performed with a cutdown of 1 femoral artery for insertion of the main graft [12]. Femoral puncture of the contralateral groin is performed to insert an angiographic catheter in the ascending aorta. Access from the surgically exposed right common carotid artery (RCCA) and percutaneous access from the left brachial artery (after crossing the carotid-subclavian bypass) are required to complete the procedure by implanting the bridging stents into the target vessels, which are typically the innominate artery (IA) and the left common carotid artery (LCCA). The IA is bridged with a dedicated stent graft in a 12–14 Fr profile in a design similar to that of the iliac limb extensions, whereas the LCCA is typically bridged with a self-expandable stent graft, usually the Fluency (Bard Inc., Covington, GA, USA). On 1 side (preferably the right side), the deep femoral vein is accessed with a 14 Fr sheath to introduce a Coda balloon catheter (Cook Medical, Bloomington, IN, USA) in the inferior vena cava to be used for the occlusion manoeuver during deployment of the branched endograft. The custom-made candy-plug (Cook Medical, Bloomington, IN, USA) device was also used in some cases to occlude backflow to the false lumen [11]. The candy-plug device is a double tapered, tubular stent graft constructed of woven polyester fabric sewn to self-expanding nitinol stents with braided polyester and monofilament polypropylene sutures. The narrow 18-mm central midsection allows for retrieval of the dilator tip after deployment and is occluded using either a 22-mm AVP II (St. Jude Medical, St. Paul, MN, USA) or a 20-mm Iliac ZIP occluder (Cook Medical, Bjaeverskov, Denmark). The procedure has been described previously in Ref. [11]. The Knickerbocker technique has also been used in some cases to occlude backflow to the false lumen [13]. The concept is based on the dilation of a large-diameter prebulged part of a stent graft that is placed in the true lumen. This short segment of the stent graft is forcefully dilated using a compliant balloon, the goal being to rupture the dissection membrane and extend the stent graft to the false lumen. The procedure has been described in detail elsewhere [13]. Suitability for endovascular arch branched repair Table 1 demonstrates the anatomical criteria for the use of the arch branched device. Table 1: Anatomical requirements to perform branched thoracic endovascular repair in residual DeBakey Type I aortic dissections • Proximal landing zone in ascending graft >20 mm  • Proximal landing zone diameter <39 mm  • Minimum length of 50 mm in the outer curvature in the ascending aorta from the coronary arteries to the innominate artery  • Lack of severe kinking of the ascending prosthetic graft with angulation >90 grad  • Proximal landing zone in ascending graft >20 mm  • Proximal landing zone diameter <39 mm  • Minimum length of 50 mm in the outer curvature in the ascending aorta from the coronary arteries to the innominate artery  • Lack of severe kinking of the ascending prosthetic graft with angulation >90 grad  Table 1: Anatomical requirements to perform branched thoracic endovascular repair in residual DeBakey Type I aortic dissections • Proximal landing zone in ascending graft >20 mm  • Proximal landing zone diameter <39 mm  • Minimum length of 50 mm in the outer curvature in the ascending aorta from the coronary arteries to the innominate artery  • Lack of severe kinking of the ascending prosthetic graft with angulation >90 grad  • Proximal landing zone in ascending graft >20 mm  • Proximal landing zone diameter <39 mm  • Minimum length of 50 mm in the outer curvature in the ascending aorta from the coronary arteries to the innominate artery  • Lack of severe kinking of the ascending prosthetic graft with angulation >90 grad  RESULTS Between 2012 and 2016, 44 patients were treated with b-TEVAR of the aortic arch for all types of arch diseases. Among these patients, 20 were treated for chronic false-lumen aneurysm after DeBakey Type I aortic dissection following prior open repair of the ascending aorta. The prior open interventions included supracoronary replacement of the ascending aorta in 16 (80%) cases and partial or hemiarch replacement in 4 (20%) cases. The mean interval between open ascending repair and endovascular arch repair was 5 years (0–12 years). The indication for treatment was chronic false-lumen aneurysmal dilatation of the arch and the thoraco-abdominal aorta in 19 cases and aneurysm and persistent malperfusion syndrome post open repair in 1 patient. Dissection of any supra-aortic vessel was present in 13 patients; dissection of the IA was present in 10 patients, dissection of the RCCA in 5 patients, dissection of the LCCA in 6 and of the left subclavian artery in 8 patients. The characteristics of the 20 patients are presented in Table 2. Table 2: Demographic and anatomical characteristics of patients with branched arch endografts treated for residual DeBakey Type I aortic dissections   b-TEVAR (n = 20)  Age (years), mean ± SD  65 ± 9  Diameter of the post-dissection aneurysms (mm), mean ± SD  63 ± 12  Male gender, n (%)  14 (70)  Coronary disease, n (%)  12 (60)  Arrhythmia, n (%)  9 (45)  Prior myocardial infarction, n (%)  2 (10)  Hypertension, n (%)  17 (85)  Hyperlipidaemia, n (%)  9 (45)  Smoking, n (%)  7 (35)  Chronic obstructive pulmonary disease, n (%)  4 (20)  Renal insufficiency, n (%)  5 (25)  Connective tissue disorder, n (%)  2 (10)  Previous open aortic repair, n (%)  20 (100)  Extent of previous ascending repair, n (%)   Ascending repair  16 (80)   Partial arch repair  4 (20)  Extent of previous valve involvement, n (%)   Supracoronary repair  15 (75)   David operation  3 (15)   Prior valve replacement  2 (10)  Cervical debranching, n (%)  20 (100)    b-TEVAR (n = 20)  Age (years), mean ± SD  65 ± 9  Diameter of the post-dissection aneurysms (mm), mean ± SD  63 ± 12  Male gender, n (%)  14 (70)  Coronary disease, n (%)  12 (60)  Arrhythmia, n (%)  9 (45)  Prior myocardial infarction, n (%)  2 (10)  Hypertension, n (%)  17 (85)  Hyperlipidaemia, n (%)  9 (45)  Smoking, n (%)  7 (35)  Chronic obstructive pulmonary disease, n (%)  4 (20)  Renal insufficiency, n (%)  5 (25)  Connective tissue disorder, n (%)  2 (10)  Previous open aortic repair, n (%)  20 (100)  Extent of previous ascending repair, n (%)   Ascending repair  16 (80)   Partial arch repair  4 (20)  Extent of previous valve involvement, n (%)   Supracoronary repair  15 (75)   David operation  3 (15)   Prior valve replacement  2 (10)  Cervical debranching, n (%)  20 (100)  b-TEVAR: branched thoracic endovascular repair; SD: standard deviation. Table 2: Demographic and anatomical characteristics of patients with branched arch endografts treated for residual DeBakey Type I aortic dissections   b-TEVAR (n = 20)  Age (years), mean ± SD  65 ± 9  Diameter of the post-dissection aneurysms (mm), mean ± SD  63 ± 12  Male gender, n (%)  14 (70)  Coronary disease, n (%)  12 (60)  Arrhythmia, n (%)  9 (45)  Prior myocardial infarction, n (%)  2 (10)  Hypertension, n (%)  17 (85)  Hyperlipidaemia, n (%)  9 (45)  Smoking, n (%)  7 (35)  Chronic obstructive pulmonary disease, n (%)  4 (20)  Renal insufficiency, n (%)  5 (25)  Connective tissue disorder, n (%)  2 (10)  Previous open aortic repair, n (%)  20 (100)  Extent of previous ascending repair, n (%)   Ascending repair  16 (80)   Partial arch repair  4 (20)  Extent of previous valve involvement, n (%)   Supracoronary repair  15 (75)   David operation  3 (15)   Prior valve replacement  2 (10)  Cervical debranching, n (%)  20 (100)    b-TEVAR (n = 20)  Age (years), mean ± SD  65 ± 9  Diameter of the post-dissection aneurysms (mm), mean ± SD  63 ± 12  Male gender, n (%)  14 (70)  Coronary disease, n (%)  12 (60)  Arrhythmia, n (%)  9 (45)  Prior myocardial infarction, n (%)  2 (10)  Hypertension, n (%)  17 (85)  Hyperlipidaemia, n (%)  9 (45)  Smoking, n (%)  7 (35)  Chronic obstructive pulmonary disease, n (%)  4 (20)  Renal insufficiency, n (%)  5 (25)  Connective tissue disorder, n (%)  2 (10)  Previous open aortic repair, n (%)  20 (100)  Extent of previous ascending repair, n (%)   Ascending repair  16 (80)   Partial arch repair  4 (20)  Extent of previous valve involvement, n (%)   Supracoronary repair  15 (75)   David operation  3 (15)   Prior valve replacement  2 (10)  Cervical debranching, n (%)  20 (100)  b-TEVAR: branched thoracic endovascular repair; SD: standard deviation. Preoperative cervical debranching was performed in all cases. A left-sided carotid-subclavian bypass or subclavian transposition was performed in 19 (95%) patients. One patient underwent axilloaxillary bypass instead of carotid-subclavian bypass to allow occlusion of the IA and preserve flow in the supra-aortic vessels over the LCCA and the left subclavian artery through the axilloaxillary bypass. In this specific case, the proximal landing zone was too short to allow connection to the IA and the LCCA, so this specific debranching technique was used to achieve a longer proximal landing zone. Additionally, 2 patients underwent carotid-subclavian bypass on the right side due to dissection extending in the IA to achieve a better seal in the RCCA. Due to dissection involving the supra-aortic vessels, 2 patients underwent interposition grafting of the common carotid artery to improve the landing zone (Fig. 3). Figure 3: View largeDownload slide Preoperative cervical debranching with a left-sided carotid-subclavian bypass and additional graft interposition of the common carotid artery to improve the distal landing zone of the bridging stents in dissected arteries. Figure 3: View largeDownload slide Preoperative cervical debranching with a left-sided carotid-subclavian bypass and additional graft interposition of the common carotid artery to improve the distal landing zone of the bridging stents in dissected arteries. The main procedure involved implantation of an arch branched endograft in all cases. There was no case of a triple arch branch device. Among the patients treated with the arch branched device, a Knickerbocker endograft [13] was implanted at the same session in 3 cases and a custom-made candy-plug endograft in 7 cases [11, 14]. Technical success in implantation and connection of the funnels to the target vessels was achieved in all cases. Mean fluoroscopy time was 52 ± 30 min and the mean amount of contrast agent used was 168 ± 42 ml. Total operative time was 264 ± 74 min. There was 1 early perioperative death attributed to a major stroke. This death occurred following liquid embolization of the false lumen at the level of a proximal seal for Type Ia endoleak, resulting in distribution of the liquid embolization material into the supra-aortic circulation resulting in a stroke. The embolization was performed transfemorally over the false lumen using Histoacryl (TissueSeal, Ann Arbor, MI, USA) at the proximal landing zone of the stent graft. Due to the haemodynamic relations and the possible formation of vortexes, Histoacryl moved beyond the proximal edge of the graft, thus landing in the main circulation and causing the stroke. No further minor or major strokes were observed within 30 days. No spinal cord ischaemia was diagnosed in any patient. There were 2 minor access complications including an occlusion of the left brachial artery requiring thrombectomy and local dissection of the RCCA requiring local patch angioplasty and 1 local haematoma in the groin requiring evacuation. Two patients developed respiratory complications; however, they did not require reintubation or tracheotomy. No renal failure was observed. A pericardial effusion was detected in 1 patient and was treated with percutaneous drainage. Proximal entry tear occlusion was achieved in all cases whereas early distal persisting false-lumen perfusion was observed in 10 cases. Eighteen of 19 survivors were discharged to home and 1 patient was moved to a rehabilitation centre and discharged home from there. The mean hospital stay was 9 ± 3 days. All patients were given long-term single antiplatelet therapy, either aspirin or clopidogrel, at discharge. The mean follow-up period was 17 ± 14 (range 1–54) months. Secondary interventions to complete false-lumen occlusion were performed in 6 cases, including 2 patients with coil- or plug embolization of the false lumen at the level of the supra-aortic vessels, 1 patient with a candy-plug endograft occlusion of the thoracic false lumen, 1 patient with extension of the graft distally with a Knickerbocker endograft and 1 patient with a fenestrated branched abdominal endograft [13, 14]. In 1 patient, an undetermined endoleak was interpreted as potentially Type Ia; therefore, after accessing the false lumen, the proximal sealing zone was embolized with coils. No other type of endoleak was identified. The false lumen was regressive in 4 (33%) cases and stable in the remaining 16. No aneurysm expansion was observed during the 17 ± 14 months of follow-up. During the follow-up period, 2 late deaths occurred of causes unrelated to the aortic repair or the arch. One patient had a fever of unknown origin and an increase of his infection markers 6 months post repair without evident infection focus. A fluorodeoxyglucose-positron emission tomography-computed tomography scan revealed uptake of fluorodeoxyglucose at the level of the ascending conduit without involvement of the arch branched endograft. He was given long-term antibiotic therapy and remained asymptomatic on further follow-up. He died 37 months after the surgery of severe cardiac insufficiency and exacerbation of chronic obstructive pulmonary disease. Additionally, during the follow-up period, all patients were free of transient ischaemic attacks or a stroke episode. Additionally, all carotid-subclavian bypasses or subclavian transpositions and branches remained patent during the follow-up period, and no endoleak Type II was identified. No stent fracture or graft migration was recorded during the follow-up period in available patients. The estimated 12-, 24- and 36-month survival rates were 89 ± 7%, 89 ± 7% and 75 ± 15%, respectively. DISCUSSION Although several registries focus on early outcomes and optimal therapy of patients with Type I DeBakey aortic dissection, only limited data exist regarding the long-term remodelling of the aortic arch and the thoraco-abdominal aorta [15, 16]. Anastomotic aneurysms and continuous expansion are frequently observed in these patients with fragile aortic tissue. It is well documented that the remaining distal false lumen of the aorta often exhibits persisting false lumen flow with the consequence of a frequent need for reoperation. Unfortunately, not all patients with post-surgical DeBakey I dissection receive follow-up tomographic imaging [17]. In the acute setting of Type A dissection, a complete repair of the aortic arch with or without the frozen elephant trunk procedure is a complex process with a relevant risk of postoperative morbidity and mortality [18–20]. A totally endovascular approach with the combination of tubular ascending endografts and multibranched arch endografts to address acute Type A dissection has been also reported [21]. Given the surgical challenge of total open arch surgery, avoidance of such a complex procedure may spare patients higher perioperative morbidity and mortality from the risk of persistent false-lumen perfusion in the aortic arch and descending aorta. Fenestrated-branched endovascular repair has been successfully introduced in the treatment of thoraco-abdominal aneurysms and of abdominal chronic post-dissection aneurysms [22, 23]. In addition, a preliminary series published promising results of b-TEVAR for the endovascular reconstruction of chronic residual arch and descending thoracic aortic dissections [22–24]. Spear et al. [8] recently published the cumulative experience from 3 centres with no perioperative deaths and a major stroke rate of 7% among 27 patients treated with b-TEVAR for various diseases. Within this context, in our study, only 1 patient had a stroke during the first 30 postoperative days (5%). Lu et al. [25] also recently reported no stroke event in 51 patients with aortic dissections involving the aortic arch who were treated by endovascular branched stent grafts. The incidence of stroke in such complex endovascular procedures including those involving the aortic arch may be less common than we previously feared. Patients with chronic dissection of the aortic arch represent a more challenging cohort since a number of additional issues need to be addressed: The suitability of the proximal landing zone depends on the length and configuration of the proximal open ascending repair. Severe kinks of the ascending graft or interposition grafts that are too short could potentially make an endovascular arch branched repair impossible. Dissection of the supra-aortic vessels as well as the distal thoracic aorta compromise the distal landing zone, thus making aneurysm exclusion more challenging. Transfemoral navigation of access wires and the graft though true and false lumens and cannulation of the endograft funnels from dissected supra-aortic vessels could also be an additional challenge. With ongoing experience on chronic aortic arch dissections and the thoraco-abdominal aorta, we have established several techniques to deal with anticipated difficulties. Regarding the kinked proximal landing zone, we plan the sealing stents of the stent grafts to land either proximally or distally to the kink but not in the kink to avoid Type Ia endoleaks. In case of dissected supra-aortic vessels, we choose to extend the repair to the carotid vessels bilaterally and perform carotid-subclavian bypass with simultaneous graft interposition of the common carotid arteries to achieve a safe landing zone (Fig. 3). Simultaneous or staged false-lumen occlusion, whether in the supra-aortic vessels or in the distal thoracic aorta, is relevant for the final outcome. Techniques such as coil embolization, the Knickerbocker technique or the candy-plug occlusion technique could play an important role [11, 13, 14]. Additionally, the current device with antegrade arch branches demonstrates some advantages in comparison to other devices on the market with retrograde arch branched configuration: From a haemodynamic point of view, it offers a more physiological approach with antegrade perfusion vs. retrograde. Experience with hybrid procedures in the abdomen has shown that retrograde branches are more prone to occlusion. In contrast, the Gore feasibility study [26] provided preliminary data with good outcome including branches with retrograde orientation with a precannulated system, although the patients were carefully selected in a Food and Drug Administration study. There is still a concern about the mid- and long-term patency rates of reversed branches, especially in the setting of high angulations at the level of the supra-aortic vessels. Access from above for coronary interventions is not an issue. It is almost impossible with retrograde branches. Cannulation is easier. Less kinking of the bridging stent grafts occurs because they do not have to take an extra curve. Milne et al. [27] recently highlighted the applicability of inner branched devices and demonstrated that approximately 70% of patients with arch aneurysm formation after open ascending aortic replacement for Type A dissection are anatomically suitable for treatment with an aortic arch inner-branched device. A main disadvantage is access to the thoraco-abdominal aorta from above; for example, accessing the visceral vessels for a future branched thoraco-abdominal repair is more difficult than with antegrade branches. The introduction of preoperative CO2 flushing for arch endografts could be one of the decisive factors achieving reduction of stroke rates in complex arch repair because complex endografts may contain a significant amount of trapped air [28, 29]. Limitations The main limitations of our study were its retrospective nature and the small number of patients. However, the main focus of the study was to determine the technical feasibility and safety of the endovascular treatment using branched devices in patients with prior open ascending repair and chronic false-lumen aneurysm after DeBakey Type I aortic dissection and to evaluate the short-term outcomes in terms of mortality and morbidity. The endovascular approach is currently neither the gold standard nor superior to open repair for arch repair in patients with prior ascending repair and a chronic false-lumen aneurysm after a DeBakey Type I aortic dissection. Endovascular therapy is associated with a number of reinterventions to complete aneurysm exclusion. However, in our study the included patients were not candidates for open repair. Long-term results are awaited in order to clarify this issue. However, our early results demonstrate that the branched endovascular arch repair is feasible and safe for patients with prior ascending repair and chronic false-lumen aneurysm after DeBakey Type I aortic dissection. The long-term results of this technique are needed, and prospective comparative studies with redo open arch repair in patients with prior ascending repair would more precisely define the role of this technique. CONCLUSION Treatment of residual aortic arch dissections with b-TEVAR appears feasible and safe with low mortality and stroke rates. A high rate of secondary procedures is required to achieve thoracic false-lumen occlusion. 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Branched endografts in the aortic arch following open repair for DeBakey Type I aortic dissection

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1010-7940
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1873-734X
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10.1093/ejcts/ezy133
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Abstract

Abstract OBJECTIVES DeBakey Type I aortic dissections are frequently treated by an ascending aortic tube graft or hemiarch replacement with the residual dissection remaining untreated. We investigated the outcomes of branched thoracic endovascular repair for post-dissection aneurysms of the aortic arch. METHODS We conducted a retrospective, single-centre evaluation of 20 consecutive patients with a false-lumen aneurysm after a DeBakey I aortic dissection treated with branched thoracic endovascular repair. The indication for endovascular repair was agreed on in an interdisciplinary case conference. Study end points were technical success, 30-day mortality rate, complications and late complications and reinterventions. RESULTS Between 2012 and 2016, 20 patients (14 men, age 65 ± 9 years) were treated for false-lumen aneurysm formation after a DeBakey Type I aortic dissection. All patients had undergone open ascending aortic repair either isolated (n = 16) or with partial arch repair (n = 4). Technical success was achieved in 19 of 20 cases. The 30-day mortality rate and incidence of stroke were each 5% (1/20). Simultaneous procedures to exclude false-lumen perfusion included implantation of a Knickerbocker graft in 3 (15%) patients and a candy-plug graft in 7 (35%) patients. Early postoperative computed tomography angiography revealed persistent false-lumen perfusion in 10 cases that required secondary interventions in 6 cases. During 17 ± 14 months of mean follow-up, there was 1 aortic-related death and 2 deaths of non-aortic reasons. The estimated overall survival was 89 ± 7% and 75 ± 15% at 12 and 36 months, respectively. CONCLUSIONS Treatment of residual aortic arch dissections with branched thoracic endovascular repair appears feasible and safe with few deaths and low stroke rates. A high rate of secondary procedures is required to achieve thoracic false-lumen occlusion. DeBakey Type I aortic dissection, Endovascular repair, Branched thoracic endograft, Post-dissection aneurysm INTRODUCTION Acute aortic dissection DeBakey Type I is a potentially fatal clinical condition with a high mortality rate if left untreated. According to the International Registry of Aortic Dissection, 86% of these patients are treated with open surgery with mortality rates ranging from 18% to 5% [1]. Repair of the ascending aorta and/or the hemiarch disease is common whereas only 20% undergo total aortic arch replacement [2]. The late survival rate after surgical repair for DeBakey Type I dissection is satisfactory with survival rates of 80% and 65% at 5 and 10 years, respectively. However, approximately 70% of early survivors have persisting false-lumen perfusion due to the extension of the dissection into the downstream aorta, and a significant proportion of those patients, estimated at 20%, require late reintervention for chronic false-lumen aneurysm [3, 4]. Treatment of this entity is difficult, because it usually requires a reoperation at the site of the aortic arch. However, extension of the false lumen into the descending aorta makes open surgical approaches more challenging. Redo surgery of the aortic arch has been reported to be associated with increased morbidity and mortality rates [5]. Progress in endovascular techniques have allowed the use of stent grafts in such complex cases. Recent studies have reported encouraging results following endovascular treatment of complex aortic aneurysms in the thoraco-abdominal aorta treated with branched and fenestrated endografts [6, 7]. Endovascular therapy of the aortic arch has also been shown to be feasible and safe with branched devices over the past years, although these reports included all disease states and more frequently aneurysms [8, 9]. Specific endovascular strategies, such as staged procedures and the use of fenestrated and branched endografts, have been proposed for the treatment of post-dissection aortic aneurysms, but so far, apart from isolated case reports or small cohorts with mixed diseases, no articles have addressed branched endovascular repair in post-dissection aortic arch aneurysms as an individual entity. The aim of the present study was to investigate the feasibility and safety of an endovascular approach with branched thoracic endovascular repair (b-TEVAR) to treat false-lumen aneurysms after DeBakey Type I aortic dissection (Fig. 1). Figure 1: View largeDownload slide (A) Three-dimensional computed tomography angiography reconstruction; (B) axial computed tomography image of the aortic arch of a patient with residual Type I dissection after ascending interposition; (C) Three-dimensional computed tomography angiography reconstruction after implantation of an arch branched device. Figure 1: View largeDownload slide (A) Three-dimensional computed tomography angiography reconstruction; (B) axial computed tomography image of the aortic arch of a patient with residual Type I dissection after ascending interposition; (C) Three-dimensional computed tomography angiography reconstruction after implantation of an arch branched device. METHODS Study design A retrospective, single-centre study was undertaken including consecutive patients with residual DeBakey Type I aortic arch dissection treated with b-TEVAR in our institution from 2012 to 2016. End points were technical success, 30-day mortality rate, complications and late complications and reinterventions. This study involved collecting existing data and imaging tests that were recorded in such a manner that subjects could not be identified, either directly or through identifiers linked to the subject. In Hamburg Germany, local state regulation does not require physicians to acquire ethical committee approval when only using file data to perform clinical research. Patient selection Patients who were included in our study were not suitable for open surgical therapy due to co-morbidities, previous repair or personal choice. Cases were discussed by members of an interdisciplinary aortic board comprising vascular surgeons, cardiologists and cardiovascular surgeons [10]. Indications for treatment with endovascular repair included complex prior open cardiothoracic surgery, advanced age and/or relevant comorbidities rendering them at high risk for open repair with hypothermic circulatory arrest and refusal of open repair due to previous personal experience. Type of endograft All patients were treated with custom-made devices manufactured by Cook Medical (Bloomington, IN, USA) [11]. Arch branch graft design The endograft used was the arch branched endograft (Cook Medical, Bloomington, IN, USA), which comprises 2 internal funnels (Fig. 2). The graft is designed to land proximally in the ascending aorta distal to the orifices of the coronary arteries with 1 or 2 sealing stents and active barb fixation. The delivery system is precurved, so that the funnels for the target vessels self-align with the supra-aortic vessels. Distally, the graft can seal in the proximal descending aorta or further distally if extended with other thoracic endografts. The graft has a sequential deployment mechanism with constraining wires to allow precise deployment of the proximal portion of the graft. Figure 2: View largeDownload slide (Top) Branched arch endograft with 2 inner funnels for the supra-aortic vessels (Cook Medical, Bloomington, IN, USA). (Bottom) A drawing of the stent graft. Figure 2: View largeDownload slide (Top) Branched arch endograft with 2 inner funnels for the supra-aortic vessels (Cook Medical, Bloomington, IN, USA). (Bottom) A drawing of the stent graft. In a first session, a left-sided carotid-subclavian bypass is placed between the proximal extrathoracic common carotid artery and the subclavian artery. In the second session (typically a few weeks later), the main procedure is performed with a cutdown of 1 femoral artery for insertion of the main graft [12]. Femoral puncture of the contralateral groin is performed to insert an angiographic catheter in the ascending aorta. Access from the surgically exposed right common carotid artery (RCCA) and percutaneous access from the left brachial artery (after crossing the carotid-subclavian bypass) are required to complete the procedure by implanting the bridging stents into the target vessels, which are typically the innominate artery (IA) and the left common carotid artery (LCCA). The IA is bridged with a dedicated stent graft in a 12–14 Fr profile in a design similar to that of the iliac limb extensions, whereas the LCCA is typically bridged with a self-expandable stent graft, usually the Fluency (Bard Inc., Covington, GA, USA). On 1 side (preferably the right side), the deep femoral vein is accessed with a 14 Fr sheath to introduce a Coda balloon catheter (Cook Medical, Bloomington, IN, USA) in the inferior vena cava to be used for the occlusion manoeuver during deployment of the branched endograft. The custom-made candy-plug (Cook Medical, Bloomington, IN, USA) device was also used in some cases to occlude backflow to the false lumen [11]. The candy-plug device is a double tapered, tubular stent graft constructed of woven polyester fabric sewn to self-expanding nitinol stents with braided polyester and monofilament polypropylene sutures. The narrow 18-mm central midsection allows for retrieval of the dilator tip after deployment and is occluded using either a 22-mm AVP II (St. Jude Medical, St. Paul, MN, USA) or a 20-mm Iliac ZIP occluder (Cook Medical, Bjaeverskov, Denmark). The procedure has been described previously in Ref. [11]. The Knickerbocker technique has also been used in some cases to occlude backflow to the false lumen [13]. The concept is based on the dilation of a large-diameter prebulged part of a stent graft that is placed in the true lumen. This short segment of the stent graft is forcefully dilated using a compliant balloon, the goal being to rupture the dissection membrane and extend the stent graft to the false lumen. The procedure has been described in detail elsewhere [13]. Suitability for endovascular arch branched repair Table 1 demonstrates the anatomical criteria for the use of the arch branched device. Table 1: Anatomical requirements to perform branched thoracic endovascular repair in residual DeBakey Type I aortic dissections • Proximal landing zone in ascending graft >20 mm  • Proximal landing zone diameter <39 mm  • Minimum length of 50 mm in the outer curvature in the ascending aorta from the coronary arteries to the innominate artery  • Lack of severe kinking of the ascending prosthetic graft with angulation >90 grad  • Proximal landing zone in ascending graft >20 mm  • Proximal landing zone diameter <39 mm  • Minimum length of 50 mm in the outer curvature in the ascending aorta from the coronary arteries to the innominate artery  • Lack of severe kinking of the ascending prosthetic graft with angulation >90 grad  Table 1: Anatomical requirements to perform branched thoracic endovascular repair in residual DeBakey Type I aortic dissections • Proximal landing zone in ascending graft >20 mm  • Proximal landing zone diameter <39 mm  • Minimum length of 50 mm in the outer curvature in the ascending aorta from the coronary arteries to the innominate artery  • Lack of severe kinking of the ascending prosthetic graft with angulation >90 grad  • Proximal landing zone in ascending graft >20 mm  • Proximal landing zone diameter <39 mm  • Minimum length of 50 mm in the outer curvature in the ascending aorta from the coronary arteries to the innominate artery  • Lack of severe kinking of the ascending prosthetic graft with angulation >90 grad  RESULTS Between 2012 and 2016, 44 patients were treated with b-TEVAR of the aortic arch for all types of arch diseases. Among these patients, 20 were treated for chronic false-lumen aneurysm after DeBakey Type I aortic dissection following prior open repair of the ascending aorta. The prior open interventions included supracoronary replacement of the ascending aorta in 16 (80%) cases and partial or hemiarch replacement in 4 (20%) cases. The mean interval between open ascending repair and endovascular arch repair was 5 years (0–12 years). The indication for treatment was chronic false-lumen aneurysmal dilatation of the arch and the thoraco-abdominal aorta in 19 cases and aneurysm and persistent malperfusion syndrome post open repair in 1 patient. Dissection of any supra-aortic vessel was present in 13 patients; dissection of the IA was present in 10 patients, dissection of the RCCA in 5 patients, dissection of the LCCA in 6 and of the left subclavian artery in 8 patients. The characteristics of the 20 patients are presented in Table 2. Table 2: Demographic and anatomical characteristics of patients with branched arch endografts treated for residual DeBakey Type I aortic dissections   b-TEVAR (n = 20)  Age (years), mean ± SD  65 ± 9  Diameter of the post-dissection aneurysms (mm), mean ± SD  63 ± 12  Male gender, n (%)  14 (70)  Coronary disease, n (%)  12 (60)  Arrhythmia, n (%)  9 (45)  Prior myocardial infarction, n (%)  2 (10)  Hypertension, n (%)  17 (85)  Hyperlipidaemia, n (%)  9 (45)  Smoking, n (%)  7 (35)  Chronic obstructive pulmonary disease, n (%)  4 (20)  Renal insufficiency, n (%)  5 (25)  Connective tissue disorder, n (%)  2 (10)  Previous open aortic repair, n (%)  20 (100)  Extent of previous ascending repair, n (%)   Ascending repair  16 (80)   Partial arch repair  4 (20)  Extent of previous valve involvement, n (%)   Supracoronary repair  15 (75)   David operation  3 (15)   Prior valve replacement  2 (10)  Cervical debranching, n (%)  20 (100)    b-TEVAR (n = 20)  Age (years), mean ± SD  65 ± 9  Diameter of the post-dissection aneurysms (mm), mean ± SD  63 ± 12  Male gender, n (%)  14 (70)  Coronary disease, n (%)  12 (60)  Arrhythmia, n (%)  9 (45)  Prior myocardial infarction, n (%)  2 (10)  Hypertension, n (%)  17 (85)  Hyperlipidaemia, n (%)  9 (45)  Smoking, n (%)  7 (35)  Chronic obstructive pulmonary disease, n (%)  4 (20)  Renal insufficiency, n (%)  5 (25)  Connective tissue disorder, n (%)  2 (10)  Previous open aortic repair, n (%)  20 (100)  Extent of previous ascending repair, n (%)   Ascending repair  16 (80)   Partial arch repair  4 (20)  Extent of previous valve involvement, n (%)   Supracoronary repair  15 (75)   David operation  3 (15)   Prior valve replacement  2 (10)  Cervical debranching, n (%)  20 (100)  b-TEVAR: branched thoracic endovascular repair; SD: standard deviation. Table 2: Demographic and anatomical characteristics of patients with branched arch endografts treated for residual DeBakey Type I aortic dissections   b-TEVAR (n = 20)  Age (years), mean ± SD  65 ± 9  Diameter of the post-dissection aneurysms (mm), mean ± SD  63 ± 12  Male gender, n (%)  14 (70)  Coronary disease, n (%)  12 (60)  Arrhythmia, n (%)  9 (45)  Prior myocardial infarction, n (%)  2 (10)  Hypertension, n (%)  17 (85)  Hyperlipidaemia, n (%)  9 (45)  Smoking, n (%)  7 (35)  Chronic obstructive pulmonary disease, n (%)  4 (20)  Renal insufficiency, n (%)  5 (25)  Connective tissue disorder, n (%)  2 (10)  Previous open aortic repair, n (%)  20 (100)  Extent of previous ascending repair, n (%)   Ascending repair  16 (80)   Partial arch repair  4 (20)  Extent of previous valve involvement, n (%)   Supracoronary repair  15 (75)   David operation  3 (15)   Prior valve replacement  2 (10)  Cervical debranching, n (%)  20 (100)    b-TEVAR (n = 20)  Age (years), mean ± SD  65 ± 9  Diameter of the post-dissection aneurysms (mm), mean ± SD  63 ± 12  Male gender, n (%)  14 (70)  Coronary disease, n (%)  12 (60)  Arrhythmia, n (%)  9 (45)  Prior myocardial infarction, n (%)  2 (10)  Hypertension, n (%)  17 (85)  Hyperlipidaemia, n (%)  9 (45)  Smoking, n (%)  7 (35)  Chronic obstructive pulmonary disease, n (%)  4 (20)  Renal insufficiency, n (%)  5 (25)  Connective tissue disorder, n (%)  2 (10)  Previous open aortic repair, n (%)  20 (100)  Extent of previous ascending repair, n (%)   Ascending repair  16 (80)   Partial arch repair  4 (20)  Extent of previous valve involvement, n (%)   Supracoronary repair  15 (75)   David operation  3 (15)   Prior valve replacement  2 (10)  Cervical debranching, n (%)  20 (100)  b-TEVAR: branched thoracic endovascular repair; SD: standard deviation. Preoperative cervical debranching was performed in all cases. A left-sided carotid-subclavian bypass or subclavian transposition was performed in 19 (95%) patients. One patient underwent axilloaxillary bypass instead of carotid-subclavian bypass to allow occlusion of the IA and preserve flow in the supra-aortic vessels over the LCCA and the left subclavian artery through the axilloaxillary bypass. In this specific case, the proximal landing zone was too short to allow connection to the IA and the LCCA, so this specific debranching technique was used to achieve a longer proximal landing zone. Additionally, 2 patients underwent carotid-subclavian bypass on the right side due to dissection extending in the IA to achieve a better seal in the RCCA. Due to dissection involving the supra-aortic vessels, 2 patients underwent interposition grafting of the common carotid artery to improve the landing zone (Fig. 3). Figure 3: View largeDownload slide Preoperative cervical debranching with a left-sided carotid-subclavian bypass and additional graft interposition of the common carotid artery to improve the distal landing zone of the bridging stents in dissected arteries. Figure 3: View largeDownload slide Preoperative cervical debranching with a left-sided carotid-subclavian bypass and additional graft interposition of the common carotid artery to improve the distal landing zone of the bridging stents in dissected arteries. The main procedure involved implantation of an arch branched endograft in all cases. There was no case of a triple arch branch device. Among the patients treated with the arch branched device, a Knickerbocker endograft [13] was implanted at the same session in 3 cases and a custom-made candy-plug endograft in 7 cases [11, 14]. Technical success in implantation and connection of the funnels to the target vessels was achieved in all cases. Mean fluoroscopy time was 52 ± 30 min and the mean amount of contrast agent used was 168 ± 42 ml. Total operative time was 264 ± 74 min. There was 1 early perioperative death attributed to a major stroke. This death occurred following liquid embolization of the false lumen at the level of a proximal seal for Type Ia endoleak, resulting in distribution of the liquid embolization material into the supra-aortic circulation resulting in a stroke. The embolization was performed transfemorally over the false lumen using Histoacryl (TissueSeal, Ann Arbor, MI, USA) at the proximal landing zone of the stent graft. Due to the haemodynamic relations and the possible formation of vortexes, Histoacryl moved beyond the proximal edge of the graft, thus landing in the main circulation and causing the stroke. No further minor or major strokes were observed within 30 days. No spinal cord ischaemia was diagnosed in any patient. There were 2 minor access complications including an occlusion of the left brachial artery requiring thrombectomy and local dissection of the RCCA requiring local patch angioplasty and 1 local haematoma in the groin requiring evacuation. Two patients developed respiratory complications; however, they did not require reintubation or tracheotomy. No renal failure was observed. A pericardial effusion was detected in 1 patient and was treated with percutaneous drainage. Proximal entry tear occlusion was achieved in all cases whereas early distal persisting false-lumen perfusion was observed in 10 cases. Eighteen of 19 survivors were discharged to home and 1 patient was moved to a rehabilitation centre and discharged home from there. The mean hospital stay was 9 ± 3 days. All patients were given long-term single antiplatelet therapy, either aspirin or clopidogrel, at discharge. The mean follow-up period was 17 ± 14 (range 1–54) months. Secondary interventions to complete false-lumen occlusion were performed in 6 cases, including 2 patients with coil- or plug embolization of the false lumen at the level of the supra-aortic vessels, 1 patient with a candy-plug endograft occlusion of the thoracic false lumen, 1 patient with extension of the graft distally with a Knickerbocker endograft and 1 patient with a fenestrated branched abdominal endograft [13, 14]. In 1 patient, an undetermined endoleak was interpreted as potentially Type Ia; therefore, after accessing the false lumen, the proximal sealing zone was embolized with coils. No other type of endoleak was identified. The false lumen was regressive in 4 (33%) cases and stable in the remaining 16. No aneurysm expansion was observed during the 17 ± 14 months of follow-up. During the follow-up period, 2 late deaths occurred of causes unrelated to the aortic repair or the arch. One patient had a fever of unknown origin and an increase of his infection markers 6 months post repair without evident infection focus. A fluorodeoxyglucose-positron emission tomography-computed tomography scan revealed uptake of fluorodeoxyglucose at the level of the ascending conduit without involvement of the arch branched endograft. He was given long-term antibiotic therapy and remained asymptomatic on further follow-up. He died 37 months after the surgery of severe cardiac insufficiency and exacerbation of chronic obstructive pulmonary disease. Additionally, during the follow-up period, all patients were free of transient ischaemic attacks or a stroke episode. Additionally, all carotid-subclavian bypasses or subclavian transpositions and branches remained patent during the follow-up period, and no endoleak Type II was identified. No stent fracture or graft migration was recorded during the follow-up period in available patients. The estimated 12-, 24- and 36-month survival rates were 89 ± 7%, 89 ± 7% and 75 ± 15%, respectively. DISCUSSION Although several registries focus on early outcomes and optimal therapy of patients with Type I DeBakey aortic dissection, only limited data exist regarding the long-term remodelling of the aortic arch and the thoraco-abdominal aorta [15, 16]. Anastomotic aneurysms and continuous expansion are frequently observed in these patients with fragile aortic tissue. It is well documented that the remaining distal false lumen of the aorta often exhibits persisting false lumen flow with the consequence of a frequent need for reoperation. Unfortunately, not all patients with post-surgical DeBakey I dissection receive follow-up tomographic imaging [17]. In the acute setting of Type A dissection, a complete repair of the aortic arch with or without the frozen elephant trunk procedure is a complex process with a relevant risk of postoperative morbidity and mortality [18–20]. A totally endovascular approach with the combination of tubular ascending endografts and multibranched arch endografts to address acute Type A dissection has been also reported [21]. Given the surgical challenge of total open arch surgery, avoidance of such a complex procedure may spare patients higher perioperative morbidity and mortality from the risk of persistent false-lumen perfusion in the aortic arch and descending aorta. Fenestrated-branched endovascular repair has been successfully introduced in the treatment of thoraco-abdominal aneurysms and of abdominal chronic post-dissection aneurysms [22, 23]. In addition, a preliminary series published promising results of b-TEVAR for the endovascular reconstruction of chronic residual arch and descending thoracic aortic dissections [22–24]. Spear et al. [8] recently published the cumulative experience from 3 centres with no perioperative deaths and a major stroke rate of 7% among 27 patients treated with b-TEVAR for various diseases. Within this context, in our study, only 1 patient had a stroke during the first 30 postoperative days (5%). Lu et al. [25] also recently reported no stroke event in 51 patients with aortic dissections involving the aortic arch who were treated by endovascular branched stent grafts. The incidence of stroke in such complex endovascular procedures including those involving the aortic arch may be less common than we previously feared. Patients with chronic dissection of the aortic arch represent a more challenging cohort since a number of additional issues need to be addressed: The suitability of the proximal landing zone depends on the length and configuration of the proximal open ascending repair. Severe kinks of the ascending graft or interposition grafts that are too short could potentially make an endovascular arch branched repair impossible. Dissection of the supra-aortic vessels as well as the distal thoracic aorta compromise the distal landing zone, thus making aneurysm exclusion more challenging. Transfemoral navigation of access wires and the graft though true and false lumens and cannulation of the endograft funnels from dissected supra-aortic vessels could also be an additional challenge. With ongoing experience on chronic aortic arch dissections and the thoraco-abdominal aorta, we have established several techniques to deal with anticipated difficulties. Regarding the kinked proximal landing zone, we plan the sealing stents of the stent grafts to land either proximally or distally to the kink but not in the kink to avoid Type Ia endoleaks. In case of dissected supra-aortic vessels, we choose to extend the repair to the carotid vessels bilaterally and perform carotid-subclavian bypass with simultaneous graft interposition of the common carotid arteries to achieve a safe landing zone (Fig. 3). Simultaneous or staged false-lumen occlusion, whether in the supra-aortic vessels or in the distal thoracic aorta, is relevant for the final outcome. Techniques such as coil embolization, the Knickerbocker technique or the candy-plug occlusion technique could play an important role [11, 13, 14]. Additionally, the current device with antegrade arch branches demonstrates some advantages in comparison to other devices on the market with retrograde arch branched configuration: From a haemodynamic point of view, it offers a more physiological approach with antegrade perfusion vs. retrograde. Experience with hybrid procedures in the abdomen has shown that retrograde branches are more prone to occlusion. In contrast, the Gore feasibility study [26] provided preliminary data with good outcome including branches with retrograde orientation with a precannulated system, although the patients were carefully selected in a Food and Drug Administration study. There is still a concern about the mid- and long-term patency rates of reversed branches, especially in the setting of high angulations at the level of the supra-aortic vessels. Access from above for coronary interventions is not an issue. It is almost impossible with retrograde branches. Cannulation is easier. Less kinking of the bridging stent grafts occurs because they do not have to take an extra curve. Milne et al. [27] recently highlighted the applicability of inner branched devices and demonstrated that approximately 70% of patients with arch aneurysm formation after open ascending aortic replacement for Type A dissection are anatomically suitable for treatment with an aortic arch inner-branched device. A main disadvantage is access to the thoraco-abdominal aorta from above; for example, accessing the visceral vessels for a future branched thoraco-abdominal repair is more difficult than with antegrade branches. The introduction of preoperative CO2 flushing for arch endografts could be one of the decisive factors achieving reduction of stroke rates in complex arch repair because complex endografts may contain a significant amount of trapped air [28, 29]. Limitations The main limitations of our study were its retrospective nature and the small number of patients. However, the main focus of the study was to determine the technical feasibility and safety of the endovascular treatment using branched devices in patients with prior open ascending repair and chronic false-lumen aneurysm after DeBakey Type I aortic dissection and to evaluate the short-term outcomes in terms of mortality and morbidity. The endovascular approach is currently neither the gold standard nor superior to open repair for arch repair in patients with prior ascending repair and a chronic false-lumen aneurysm after a DeBakey Type I aortic dissection. Endovascular therapy is associated with a number of reinterventions to complete aneurysm exclusion. However, in our study the included patients were not candidates for open repair. Long-term results are awaited in order to clarify this issue. However, our early results demonstrate that the branched endovascular arch repair is feasible and safe for patients with prior ascending repair and chronic false-lumen aneurysm after DeBakey Type I aortic dissection. The long-term results of this technique are needed, and prospective comparative studies with redo open arch repair in patients with prior ascending repair would more precisely define the role of this technique. CONCLUSION Treatment of residual aortic arch dissections with b-TEVAR appears feasible and safe with low mortality and stroke rates. A high rate of secondary procedures is required to achieve thoracic false-lumen occlusion. 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European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Mar 28, 2018

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