The Initial Experience on Branched and Fenestrated Endografts in the Aortic Arch. A Systematic Review.

OBJECTIVE: Branched and fenestrated endografts (fEVAR/bEVAR) are complex techniques used to treat thoracic aorta pathologies involving the aortic arch. This systematic review aims to determine all the reported results regarding these techniques in the aortic arch, in order to describe their clinical outcomes. METHODS: A systematic review of the literature was performed, considering all articles published until October 2019. PubMed, Cochrane database resources were used. The protocol of the study was previously registered in the Prospero database (CRD42020147037). Primary exclusion criteria included opinion articles, merely technique descriptions, articles without the follow-up of at least 1 month, studies conducted on animals, mixed treatments, and ongoing trials without published data. Included variables were study design, aortic pathology, type of endovascular technique (fEVAR/bEVAR), endograft manufacturing, number of fenestrations/branches and type of bridge stents. Technical success, complications during surgery and follow-up were also described. RESULTS: From a total of 164 articles, 29 (28 retrospective, 1 prospective) were analyzed with a total of 693 cases (341 fEVAR and 352 bEVAR). The most common indications for repair were aneurysm (54.8%) and dissection (40%). Only fEVAR and bEVAR were considered, but different endograft materials and techniques were used and, therefore, reported upon in the current review. Zenith Alpha Thoracic Endovascular Graft was the most representative (24% of cases). Custom made, off-the-shelf, physician modified and in situ fenestrated endografts were also used in 39%, 22.4%, 18.6% and 18.9% of cases, respectively. Bridge stents were implanted in the 50.5% of cases. Technical success rate was 96%. The main intraoperative complication was the endoleak (5.2%) followed by stroke (4.8%). The in-hospital mortality was 2.5%. The mean follow-up was 18.5 months. The mortality related to the main operation during follow-up was 3.2% and not directly related to the main operation was 11.3%. During the follow-up, 92 cases (13.3%) in total had to undergo through a reintervention, 46.7% with endovascular repair and 26.1% with open surgical repair (the rest were not specified). CONCLUSION: published experience with bEVAR and fEVAR in the aortic arch showed acceptable short-term effectiveness and safety. More well-conducted prospective clinical studies with long term follow-up, combined with comparative meta-analysis, are needed to elucidate the real benefit of those endovascular techniques in the aortic arch pathology.

FEVAR/BEVAR have limitations and do not always represent the preferred option for juxtarenal reconstruction.

Following the definition given by the recent ESVS guidelines, juxtarenal abdominal aortic aneurysm (JAAA) is defined as an aneurysm extending up to but not involving the renal arteries, necessitating suprarenal aortic clamping for open surgery, i.e. a short neck (<10 mm). JAAA repair always represents a challenge intervention, either by open or endovascular means, mostly related to the renal arteries involvement. Concerning endovascular repair, different options can be considered. Among them, fenestrated endografts (FEVAR) should be considered as a first option1, due to their reported safety and efficacy. However, when the anatomy is not favorable or when FEVAR devices are not available in an emergency setting for instance, other alternatives can be considered like parallel graft or chimney technique (ChEVAR). Do nothing is the last alternative when medical and anatomical circumstances are absolutely poor. In the following pages, we will review the limitations of FEVAR and branched endografts, the better indications and anatomical conditions for a successful repair with ChEVAR technique and its current clinical results reported in the literature.

The most relevant unmet needs in endovascular management of descending thoracic aorta.

Endovascular repair of descending thoracic aorta (DTA) is considered as first interventional option for most part of the aortic disorders. However, many unmet needs and issues are still limiting its applicability. One of the major limitations is related to the existing gaps in evidence. Clear and robust evidence is still needed in many aspects of the management of DTA pathologies. In numerous clinical scenarios, adequate trials are lacking. Besides those gaps in evidence, it is well recognized that thoracic endografting (TEVAR) is technically evolving in order to overcome technical and device-related complications and limitations. We can deploy endografts in any aortic segment: in the descending, in the ascending, in the arch, even preserving aortic branches. Nevertheless, from the pure technical point of view, current generations of endografts still need more development and improvement. Durability remains the major concern for any endovascular treatment, and thoracic endografting is not an exception. As Galenus said, the physician is only nature's assistant, thoracic endograft should also follow the natural anatomy instead of fighting against it. We will focus the following pages on the graft conformability and compliance, both related to durability and safety of thoracic endografting. We will review the current knowledge and concerns associated with the anatomical and hemodynamic modifications induced by the thoracic endograft strength, stiffness and straightness and their implications for the future thoracic endograft designs.

Mycotic Abdominal Aortic Aneurysm Secondary to Septic Embolism of a Thoracic Aorta Graft Infection.

Mycotic aneurysms account for 1% of abdominal aortic aneurysms. There are very few cases published that describe the formation of mycotic aneurysms after septic embolism due to graft infection. We present the first case to our knowledge to be described in the literature of a mycotic aneurysm caused by septic embolism derived from a thoracic aorta graft infection, treated with conventional surgery leading to a successful outcome and evolution.