Outcomes of thoracic endovascular aortic repair using fenestrated stent grafts in patients with thoracic aortic distal arch aneurysms.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is challenging because of anatomical restrictions and the presence of cervical branches. Revascularization of the cervical branch is required when conventional commercial stent grafts are used. TEVAR using fenestrated stent grafts (FSG) often does not require additional procedures to revascularize cervical branches. This study aimed to evaluate the features and initial and midterm outcomes of TEVAR using fenestrated stent grafts. METHODS: From April 2007 to December 2016, 101 consecutive patients underwent TEVAR using fenestrated stent grafts for distal aortic arch aneurysms at a single centre. Technical success, complications, freedom from aneurysm-related death, secondary intervention and aneurysm progression were retrospectively investigated. RESULTS: All the patients underwent TEVAR using fenestrated stent grafts. The 30-day mortality rate was zero. Cerebral infarction, access route problems and spinal cord injury occurred in 4, 3 and 2 patients, respectively. Each type of endoleak was observed in 38 of the 101 patients during the course of the study; 20/38 patients had minor type 1 endoleaks at the time of discharge. The endoleak disappeared in 2 patients and showed no significant change in 8 patients; however, the aneurysm expanded over time in 10 patients. Additional treatment was performed in 8 of the 10 patients with type 1 endoleaks and dilatation of the aneurysm. The rate of freedom from aneurysm-related death during the observation period was 98%. CONCLUSIONS: TEVAR with FSG is a simple procedure, with few complications. Additional treatment has been observed to reduce aneurysm-related deaths, even in patients with endoleaks and enlarged aneurysms. Based on this study, the outcomes of endovascular repair of aortic arch aneurysms using a fenestrated stent graft seem acceptable.

Multibranched endovascular repair using a modified endograft with hydrogel-reinforced fenestrations.

OBJECTIVES: We devised a novel physician-modified endograft (PMEG) with hydrogel-reinforced fenestrations to provide a more secure connection with the bridging graft than fenestrations alone. We applied this novel PMEG in a clinical setting and evaluated the clinical and technical results. METHODS: In this study, patients with complex thoraco-abdominal aortic pathologies involving the renal, superior mesenteric or coeliac artery were included. However, patients with pararenal abdominal aneurysm were excluded. Regardless of anatomical suitability, all patients referred to our hospital were enrolled. All patients were treated via compassionate use of PMEG. All PMEGs were used following the same procedure using hydrogel-reinforced fenestrations. A retrospective analysis was conducted on consecutive patients who were treated between October 2018 and April 2021. RESULTS: Out of 40 patients, 29 and 11 were men and women, respectively. The median patient age was 73.6 (range: 49-87) years. Among the patients, 36 (90%) had true aneurysms, whereas the others had false lumen aneurysms and penetrating atherosclerotic ulcer. Despite anatomical challenges, all branches were successfully reconstructed. The mean operative time was 333 (standard deviation 98) min. Postoperative computed tomography angiography did not reveal type I and IIIc endoleaks from the hydrogel-reinforced fenestrations. The 30-day survival rate was 97.5%. One patient died due to brain haemorrhage on postoperative day 5. During follow-up, computed tomography revealed no migration of any bridging graft. CONCLUSIONS: We confirmed the effectiveness of the hydrogel as a sealing material and the secure connection between hydrogel-reinforced fenestrations and side branches in vivo. CLINICAL TRIAL REGISTRATION NUMBER: 5287.

Modified Candy-plug Device for Dilated False Lumen Occlusion: Is a Candle Better Than a Candy?

The AFX stent graft (Endologix) has an active seal mechanism that can conform to an irregular vascular lumen. We modified the candy-plug technique using an AFX VERA suprarenal extension with restricted purse-string sutures to shape it into a candle-like contraption. We treated 2 patients with patent, dilated false lumens (FLs) after central aortic repair using this technique. This plug was deployed into the FL to block retrograde blood flow proximally. Partial or complete thrombosis of the FL was observed in both patients 6 months after surgery. This technique was feasible for FL occlusion.

[Selective Branch Embolization and Thoracic Endovascular Aortic Repair for Asymptomatic Bronchial Artery Aneurysm:Report of a Case].

Bronchial artery aneurysm (BAA) is a rare disease, for which early treatment is recommended due to the risk of rupture often resulting in severe consequences. We report a case of successful treatment of an asymptomatic BAA by selective branch embolization combined with thoracic endovascular aortic repair (TEVAR). A 68-year-old man was accidentally found to have a bronchial artery aneurysm by computed tomography. The distance from the origin of the bronchial artery to the aneurysm was only 6 mm, at which branches were found. The BAA was completely excluded by selective branch coil embolization and deployment of a thoracic stent graft to cover the orifice of the BAA. Angiography confirmed that there was no endoleak. Selective branch embolization of BAA combined with TEVAR is effective to completely occlude the blood stream to BAA.

Safety and efficacy of the percutaneous thoracic endovascular repair with regional anesthesia.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) is typically performed with general anesthesia (GA) and surgical cutdown (G-TEVAR). As the latest generation of TEVAR delivery systems are smaller, we introduced percutaneous TEVAR with regional anesthesia (RA) (R-TEVAR) and an arteriotomy closure device. In this study, we compare the safety and efficacy of R-TEVAR to that of the G-TEVAR. METHODS: This single-center observational study included consecutive patients who underwent either G-TEVAR between January 2015 and October 2018 (33 patients) or R-TEVAR (41 patients) between January 2018 and April 2020. RA was achieved using an ultrasound-guided nerve block. RESULTS: The mean outer diameter of the delivery device was significantly smaller in R-TEVAR (18.5 vs. 22.7 Fr; p < 0.01) and the time from arriving into the operating room to beginning of surgery (34.1 vs. 68.5 min; p < 0.01), procedural time (46.4 vs. 103.6 min; p < 0.01), and operating room stay time (108.3 vs. 194.6 min; p < 0.01) were significantly shorter. The mean rate of change in blood pressure was significantly lower in the R-TEVAR group (7.7% vs. 32.2%; p < 0.01). One case of spinal cord ischemia occurred in the G-TEVAR group (0% vs. 3.0%; p = 0.262) and one case of inadequate hemostasis and conversion to surgical cutdown without GA occurred in the R-TEVAR group (2.4% vs. 0%; p = 0.366). CONCLUSIONS: The R-TEVAR is safe and minimally invasive. Further, RA may provide additional benefits of mean blood pressure stability and early recognition of neurologic complications.

Total endovascular repair of a mycotic thoracic aortic aneurysm in a patient with an aberrant right subclavian artery.

An aberrant right subclavian artery (ARSA) is a rare arterial anomaly. Although a few cases of total endovascular repair for the ARSA aneurysm have been previously reported, anatomical limitations and the possibility of endoleaks remained. In this case, we created 4 holes on the stent graft for each cervical branch, with reference to the preoperative computed tomography findings. This approach might enable us to repair all types of thoracic aortic aneurysms with ARSA with each anatomical feature.

The midterm results of thoracic endovascular aortic repair with a precurved fenestrated endograft in zone 0-1.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) for the treatment of aortic arch disease remains challenging due to certain anatomical and haemodynamic features. The purpose of this study was to evaluate the midterm results of TEVAR with a second-generation fenestrated endograft for aortic arch disease. METHODS: This non-randomized, interventional study was part of a multicentre clinical trial conducted between 2010 and 2011 and was designed to assess the effectiveness of a second-generation precurved fenestrated endograft for aortic arch disease. Midterm data collected during the fifth postoperative year from 205 patients treated with this endograft with the proximal landing of zone 0 or 1 were assessed regarding survival, reoperation and complications. RESULTS: The initial and technical success rates were 94% and 91%, respectively. Ninety-seven percent of patients were treated using zone 0. The rate of in-hospital deaths was 3%. Overall survival was 71% at 5 years; thoracic aorta-related death-free survival rates at 1 and 5 years after surgery were 99.5% and 97.8%, respectively. Aneurysm-related event-free survival rates at 1 and 5 years after surgery were 86.8% and 77.1%, respectively. Reoperation-free survival rates at 5 years were 86.6%. The most frequent reason for reoperation was type Ia endoleak (5%), followed by type II endoleak (2%). Incidences of cerebral infarction, device migration, spinal cord ischaemia and supra-aortic branch stenosis were 6%, 1%, 1% and 1%, respectively. CONCLUSIONS: The precurved fenestrated endograft provided appropriate conformability to the aortic arch and made zone 0 landing possible with simplified, less-invasive manipulations. The midterm results of TEVAR with this endograft suggest this method is a valuable endovascular treatment option for aortic arch disease. CLINICAL TRIAL REGISTRATION NUMBER: UMIN000007213.

Therapeutic Strategies for Infectious Multiple Aortic Aneurysms: Thoracoabdominal Aortic Aneurysm Treatment Using a Fenestrated Stent-Graft.

Recently, it has been reported that a fenestrated stent graft is an effective option in the treatment of pararenal artery abdominal aortic aneurysm. We report the case of a 72-year-old male patient with multiple aortic aneurysms in the distal arch, thoracoabdominal aorta, right common iliac artery, as well as a pararenal abdominal aortic aneurysm. The patient was found to have a mass with a tendency of rapid expansion within a month from its discovery. Because it was a saccular aneurysm with a tendency of rapid expansion and wide spread, the risk of rupture was judged to be high, and surgical treatment became necessary. One-stage treatment was desirable; therefore, endovascular treatment with a fenestrated stent graft was selected. Four fenestrations were made to a stent graft for the celiac artery, superior mesenteric artery, and bilateral renal arteries. The postoperative computed tomography (CT) showed no branch occlusion or endoleak, and the 2-year postoperative CT showed the shrinkage and subsequent disappearance of the aortic aneurysm at the treatment site. For extensive aortic aneurysm, including pararenal artery abdominal aortic aneurysms, one-stage treatment with fenestrated stent graft was considered to be effective as a treatment strategy. (This is a translation of Jpn J Vasc Surg 2020; 29: 9-13.).

Minimally invasive treatment for isolated internal iliac artery aneurysms preserving superior gluteal artery flow.

OBJECTIVES: To prevent buttock claudication, we performed endovascular aortic aneurysm repair (EVAR) for isolated internal iliac aneurysms (IIAAs) with selective preservation of the superior gluteal artery (SGA) flow. This study evaluates early clinical outcomes of this treatment. METHODS AND RESULTS: We retrospectively evaluated 6 patients with isolated IIAA who underwent EVAR under local anesthesia between October 2017 and July 2018 at Tokyo Women's Medical University Hospital. We used self-expanding stent grafts to exclude the IIAA while preserving SGA flow. If necessary, we occluded the inferior gluteal artery and other branches with vascular plugs to prevent type II endoleak. The mean proximal neck diameter and length of the IIAAs to be 9.4 ± 2.4 mm and 17.7 ± 11.3 mm. The mean diameter of the SGA was 6.5 ± 0.9 mm. There were no procedural complications, and the mean procedure time was 84 ± 24 min. All patients were free from buttock claudication at follow-up. Postoperative computed tomography demonstrated a 100% primary patency rate of the SGA stent graft: there was no case of migration or endoleak. CONCLUSION: EVAR for IIAAs with SGA flow preservation shows favorable early clinical outcomes. To prevent buttock claudication, SGA flow is necessary and sufficient. This novel approach is less invasive compared to conventional IIAA repair.

Use of stent-grafts for the ductus arteriosus and its related lesions.

Five cases of ductal lesions with various anatomies have been successfully treated by thoracic endovascular aortic replacement in recent years; 4 using mainly fenestrated stent-grafts, and one using a non-fenestrated stent-graft. Considering the invasive nature of open surgery and the anatomical limitations of the catheter technique for occluding a patent ductus in many adult cases, thoracic endovascular aortic replacement should be the first option because of its broad applicability for ductal lesions.

Stent-graft implantation for clinically diagnosed syphilitic aortic aneurysm in an HIV-infected patient.

We describe our experience with stent-graft placement in a patient with a clinically diagnosed syphilitic aortic aneurysm.The patient was a 43-year-old man with syphilitic and human immunodeficiency virus (HIV) co-infection. Computed tomography (CT) revealed an aortic aneurysm with 89 mm in maximum size which was located at distal aortic arch and was considered syphilis derived saccular aneurysm. The aneurysm was judged at high risk of rupture from its shape. We decided to perform stent-graft implantation. Before surgery, the patient was given antibacterial and anti-HIV agents. Hand-made fenestrated stent graft by Tokyo Medical University was implanted. The graft was placed from the ascending aorta to Th 9 level in the descending aorta. The aneurysm completely disappeared during follow-up, with no flare-up of syphilitic infection up to 2 years after surgery.The number of patients with syphilis and human immunodeficiency virus co-infection is now increasing. Stent-graft implantation may be an effective treatment in such immunocompromised patients.

The next generation of fenestrated endografts: results of a clinical trial to support an expanded indication for aortic arch aneurysm treatment.

OBJECTIVES: Short- and mid-term data regarding the use of precurved, fenestrated endografts have shown that these devices are both safe and effective in carefully selected patients. The first generation of the product was limited to patients with proximal landing zones (LZs) of >20 mm. The next generation of these endografts has been refined to enable the treatment of patients with shorter proximal seal zones (<20 mm), using smaller fenestrations and a greater diversity of skeletons. We reviewed the clinical studies involving the next-generation product and analysed the morphological characteristics of aortic arch aneurysms that were successfully treated. METHODS: Next-generation endografts were used to treat 393 patients with aortic arch aneurysms at 35 medical institutions during 2010 and 2011. There were 371 (94%) patients with sealing zones <20 mm and 244 (62%) with sealing zones <15 mm. The proximal sealing length was 2-35 (14.2 ± 5.1) mm. RESULTS: Technical success was achieved in 390 (99.2%) patients. Of the treated patient population, 6 patients died, 7 experienced strokes and 17 were subsequently identified to have Type I endoleaks. In cases with proximal LZs <15 mm, the aneurysm was more likely to develop an endoleak. The proximal sealing zones (11 ± 12 vs 9 ± 13 mm) were not significantly associated with the development of endoleaks, but the proximal aortic diameters were (34.0 ± 13.3 vs 36.6 ± 6.3 mm; P < 0.01), in the univariate analysis. In the discriminant analysis, the maximum length of the aneurysm was the only factor that was predictive of Type I endoleaks (73 ± 55 vs 97 ± 59 mm; P < 0.001). CONCLUSIONS: The next generation of precurved, fenestrated endografts shows promise as devices for aortic arch aneurysms with a <15-mm proximal sealing zone. These devices have a significant advantage in cases where the LZ has a short neck. However, more refinement is necessary to prevent Type I endoleaks, so that these devices can be used with aortic vessels with large proximal diameters and large aneurysms.

Usefulness of fenestrated stent grafts for thoracic aortic aneurysms.

OBJECTIVES: Endovascular stent grafts (SGs) comprise a novel therapeutic approach to repairing aortic aneurysms. However, endovascular repair of the aortic arch remains challenging. Generally, the repair of sites with SGs requires an extra-anatomical bypass. We introduced SG repair of the aortic arch with strategically positioned fenestrations for each arch branch in 2006. An extra-anatomical bypass is not required for this procedure. This study evaluates the early and mid-term outcomes of fenestrated SG treatment. METHODS: We retrospectively analysed the early and mid-term outcomes of 24 of 80 repairs with fenestrated SG among 383 single thoracic aortic aneurysm repairs that were undertaken at our department between January 2006 and March 2012. RESULTS: Technical success was obtained in 100% of the patients. However, there was a 30-day perioperative mortality rate of 4.1% (1 of 24) due to a shower embolism. One patient developed a Type 2 endoleak without aneurysm enlargement within a median follow-up time is 25.1 months. However, migrations or device-related complications requiring additional procedures did not arise. CONCLUSIONS: Treatment with fenestrated SGs does not require surgical transposition of the arch branches. The procedure is widely applicable and less invasive and outcomes are excellent.

Advantage of a precurved fenestrated endograft for aortic arch disease: simplified arch aneurysm treatment in Japan 2010 and 2011.

OBJECTIVE: We evaluated the results of our previous study investigating a precurved fenestrated endograft treatment for thoracic aortic aneurysms and aortic dissection extended to the aortic arch. METHODS: From February 2010 to December 2011 at 35 Japanese centers, 383 patients (mean age, 75.7 ± 9.4 years) who required stent-graft landing in the aortic arch were treated with a precurved fenestrated endograft. The device has 19 3-dimensional curved stent skeleton types similar to aortic arch configurations and 8 graft fenestration types and is 24 to 44 mm in diameter and 16 to 20 cm long. The endografts were fabricated according to preoperative 3-dimensional computed tomographic images. RESULTS: Technical and initial successes were achieved in 380 and 364 cases, respectively. Device proximal end was at zones 0 to 2 in 363, 15, and 2 patients, respectively. Lesions' proximal end ranged from zone 0 to 3 in 16, 125, 195, and 44 patients, respectively. The mean operative and fluoroscopic times were 161 ± 76 and 26 ± 13 min, respectively. The complications included stroke (7 patients), permanent paralysis (3), and perioperative death (6). No branch occlusion or proximal migration of the device occurred during follow-up. CONCLUSIONS: A precurved fenestrated endograft for endovascular repair in aortic arch disease rendered catheter manipulation simple and minimized operative complication risks. Although most patients had inadequate proximal landing zone and severely angled complex configuration, low mortality and morbidity and satisfactory clinical success were early outcomes, suggesting that this simplified treatment may be effective for aortic arch disease.

Perfect and least invasive sealing technique on the lesser curvature of the aortic arch: application of a novel stent graft to an aneurysm developing on a postoperative ductus arteriosus.

A 78-year-old woman who underwent an operation for a patent ductus arteriosus (PDA) about thirty years ago developed an aneurysm on the aortic side of the remnant ductal tissue. To avoid risky, open surgery, we performed endovascular aortic therapy using a novel stent graft (SG), which was pre-curved, fenestrated and custom-made type. This graft was designed to configure to the patient's whole aortic arch anatomy, and was capable of accurately adjusting its fenestrations to the arch branch orifices during the procedure. The operation was successful, and the patient was discharged uneventfully on 16th postoperative day. The advantage of this fenestrated SG is close sealing, especially over the lesser curvature of the arch. This device could be a simple and effective option to deal with an otherwise normal aortic arch with such a ductus-related localized lesion.

An innovative exclusion technique for ductus arteriosus with a novel stent graft.

A 72-year-old woman who had a patent ductus arteriosus that was anatomically unsuitable for catheter coiling was treated with a pre-curved fenestrated stent graft. This graft was custom-made to configure the patient's whole aortic arch, and was capable of accurately adjusting its fenestrations to the arch branch orifices. The advantage of this fenestrated stent graft is close sealing, especially on the lesser curvature of the arch. This device could be an excellent option to treat an otherwise normal aortic arch with such a localized lesion.

Surgical technique of total arch replacement for failed thoracic endovascular aortic repair.

Since its introduction in the 1990s, the number of thoracic endovascular aortic repairs is increasing rapidly. However, data on the operative method for reoperation after failed thoracic endovascular aortic repairs are still scanty. We describe the surgical technique of total arch replacement with partial stent removal and the elephant trunk procedure for failed thoracic endovascular aortic repair.

Endovascular repair of ascending aortic rupture: effectiveness of a fenestrated stent-graft.

PURPOSE: To present a technique for endovascular treatment using a fenestrated stent-graft in a patient with ascending aortic rupture in the setting of methicillin-resistant Staphylococcus aureus infection. CASE REPORT: A 62-year-old woman had undergone mastectomy and radiotherapy twice for breast cancer and then coronary artery bypass grafting (CABG). She developed sternal osteomyelitis 5 years after the CABG. Sternectomy and negative-pressure wound drainage were performed, but the infection did not resolve. Ascending aortic rupture occurred 5 months after sternectomy. Endovascular therapy was considered the only effective means of achieving hemostasis. A custom-designed fenestrated stent-graft was deployed from the ascending aorta to the proximal descending aorta via a femoral artery approach without transient cardiac arrest. Bleeding completely stopped after surgery. The postoperative course was uneventful, and the inflammatory activity subsided on antibiotic therapy. At 7 months after surgery, the patient's recovery has been uneventful. CONCLUSION: Rupture of the ascending aorta associated with infection was successfully treated by stent-graft repair. The use of a custom-made, fenestrated stent-graft was an effective, lifesaving procedure for the management of this ascending aortic lesion.

Successful treatment of multiple mycotic aortic aneurysms, using a hybrid procedure.

No generally accepted treatment of multiple mycotic aortic aneurysms of the thoracic and abdominal aorta has yet been established. We report a 67-year-old man with widespread mycotic aortic aneurysms previously treated for malignant lymphoma and interstitial pneumonia. He was successfully treated by a two-stage hybrid surgical procedure comprising open and endovascular methods. This is apparently the first report of repair of multiple mycotic aortic aneurysms using a hybrid procedure.