Fenestrated and Scalloped Endovascular Grafts in Zone 0 and Zone 1 for Aortic Arch Disease.

BACKGROUND: The aim of this study is to present midterm results of thoracic endovascular aortic repair (TEVAR) using scalloped or fenestrated custom-made endovascular grafts (CMEGs) in aortic arch Zones 0 and 1. METHODS: A retrospective review of prospectively collected data involving consecutive patients with aortic arch disease treated by scalloped or fenestrated Relay Plus stent grafts (Terumo Aortic, Sunrise, FL) landed in Zones 0 and 1. Patient demographics, operative details, clinical outcomes, and complications were analyzed. RESULTS: Between February 2014 and February 2020, 14 patients (9 male and 5 female) with a median age of 66 years (range 48-84) underwent scalloped or fenestrated TEVAR to preserve flow to the supra-aortic trunks (SATs). In 6 cases the landing zone was Zone 0 and in 8, Zone 1. Target vessels for the scallops were left common carotid artery in 8 cases (Zone 1) and innominate artery (IA) in 1 (Zone 0). All 5 fenestrations were designed to preserve the IA (Zone 0). Technical success was 100% with no endoleaks on completion angiography. One fatal perioperative stroke (7%) occurred in a patient with a fenestration for the IA and atherosclerotic plaques in the arch. During median follow-up of 37.5 (3-72) months, no other patient died, and all the target vessels and cervical revascularizations remained patent. There was no paraplegia, no retrograde dissection, and no other complication. Two patients (14%) with scallops in Zone 1 developed late endoleak: 1 type Ib at 6 months and 1 type Ia endoleak at 12 months. There were no endoleaks at all in the group of fenestrated endografts (Zone 0). CONCLUSIONS: When anatomy allows, endovascular treatment using scalloped or fenestrated CMEGs in Zones 0 and 1 is a feasible technique to treat patients with aortic arch disease involving the SATs.

Technique for planning and implantation of a branched endograft as a proximal extension of a previous fenestrated endovascular aneurysm repair.

Our patient had undergone a previous three-fenestration Anaconda (Terumo Medical Corp, Tokyo, Japan) fenestrated endovascular aneurysm repair (EVAR) to treat a juxtarenal aortic aneurysm. At 10 years postoperatively, distal migration of the prosthesis, a proximal type I endoleak, and aortic sac enlargement of 10 mm in 6 months was observed. Because of the short length of the Anaconda's bifurcated body, we chose to use a Zenith custom-made endograft with four branches and a bifurcated body with an inverted contralateral limb. We have also described the issues that can arise during branched EVAR after fenestrated EVAR and some of the bailout techniques we performed to successfully perform the treatment.

Endovascular Treatment of Aortic Arch Lesions Using Scalloped Endografts.

OBJECTIVE: To present our early and midterm results using thoracic endovascular aortic repair (TEVAR) with a custom-made proximal scalloped stent graft to accommodate left common carotid artery (LCCA) and innominate artery (IA) in treating aortic lesions involving the arch. MATERIALS AND METHODS: Between February 2014 and April 2017, select patients presenting with aortic arch lesions and short proximal landing zone were treated by proximal scalloped Relay Plus stent grafts. Patient demographics, operative details, clinical outcomes, and complications were analyzed. RESULTS: Six patients (50% male) with a median age of 71 years (range, 60-82) underwent scalloped TEVAR using thoracic custom-made Relay Plus stent graft to preserve flow in the proximal supra-aortic trunks. Target vessels for the scallop were LCCA in 5 cases and IA in 1 case. The technical success rate was 100%, and proximal seal was achieved in all cases with no type I endoleaks on completion angiography. The median follow-up period was 20 (7-32) months. No conversion to open surgical repair and no aortic rupture occurred. One patient had a distal type I endoleak on the 6-month computed tomography (CT) scan, and 1 patient had a proximal type I endoleak on the 12-month CT scan. There was no stroke, paraplegia, retrograde type A dissection, or other aortic-related complication. We routinely used temporary rapid right ventricular pacing to obtain a near-zero blood pressure level during the graft deployment. No complications were observed related to the use of rapid pacing. CONCLUSION: When anatomy allows, proximal scalloped stent graft to accommodate LCCA and IA is a viable therapeutic option in treating aortic lesions involving the arch with short proximal landing zones. In addition, these findings represent a strong argument for the use of temporary rapid pacing during graft deployment.

Pseudooclusión carotídea sintomática: tratamiento quirúrgico y resultados / Symptomatic pseudo-occlusion of the carotid artery: surgical treatment and outcomes

Introducción. Estudios multicéntricos recientes sugieren un dudoso beneficio de la endarterectomía carotídea (EC) en pacientes con pseudooclusión carotídea (POC). Objetivo. Evaluar el resultado clínico y hemodinámico de la EC en las POC sintomáticas. Pacientes y métodos. Entre 1999 y 2005 se intervinieron 13 pacientes con POC interna (3,96% de la cirugía carotídea) sintomáticas: siete con infarto cerebral (53,8%), tres con accidente isquémico transitorio (23,1%), dos con amaurosis fugaz (15,4%) y uno con síncopes de repetición (7,7%). En todos se realizó eco-Doppler y angiografía. Criterios diagnósticos del eco-Doppler: oclusión origen carótida interna, flujo en goteo o señal distal amortiguada. Criterios diagnósticos de la angiografía: obstrucción origen carótida interna con relleno filiforme distal. Se indicó la revascularización quirúrgica en todos ellos. Resultados. En 12 pacientes se pudo revascularizar la carótida interna (92,3%) y en uno se hizo su ligadura (7,7%). Técnica de revascularización: 11 EC y un bypass a carótida interna distal. Morbimortalidad quirúrgica del 0%. Control clínico: 3-69 meses (media: 31,6 meses) mediante eco-Doppler de troncos supraaórticos y transcraneal, encontrándose todos vivos, asintomáticos y con permeabilidad de la carótida interna. La reserva hemodinámica homolateral postoperatoria se ha encontrado normalizada en la mayoría de los pacientes. Conclusiones. Se considera indicada la intervención quirúrgica en casos sintomáticos de POC, ya que logra la repermeabilización de la carótida y la normalización de la reserva hemodinámica en un alto porcentaje, previniendo además la aparición de nueva sintomatología a largo plazo

Introduction. Recent multicentre studies suggest dubious benefits for carotid endarterectomy (CE) in patients with pseudo-occlusion of the carotid artery (POC). Aim. To evaluate the clinical and haemodynamic outcomes of CE in cases of symptomatic POC. Patients and methods. Between 1999 and 2005 interventions were carried out on 13 patients with symptomatic pseudo-occlusion of the internal carotid artery (3.96% of the carotid surgery conducted): seven with cerebral infarction (53.8%), three with transient ischemic attack (23.1%), two with amaurosis fugax (15.4%) and one with recurring syncopes (7.7%). Doppler ultrasonography and angiography recordings were performed in all cases. Diagnostic criteria for Doppler ultrasonography were occlusion with its origin in the internal carotid artery, a drip flow or attenuated distal signals. Diagnostic criteria for angiography were occlusion with its origin in the internal carotid artery with filiform distal filling. Surgical revascularisation was indicated in all cases. Results. The internal carotid artery was revascularised in 12 patients (92.3%) and ligation was performed in one of them (7.7%). Revascularisation technique: 11 CE and one distal internal carotid artery bypass. Surgical morbidity and mortality rates of 0%. Clinical monitoring: 3-69 months (mean: 31.6 months) using transcranial and supra-aortic trunk Doppler ultrasonography; all patients were alive, asymptomatic and with patency of the internal carotid artery. The post-operative homolateral haemodynamic reserve was found to be at normal levels in most of the patients. Conclusions. Surgical intervention is considered to be indicated in symptomatic cases of POC, as it achieves repatency of the carotid artery and normalises the haemodynamic reserve in a high percentage of cases; it also prevents the appearance of new symptoms in the long term