Total aortic arch repair with double-fenestrated physician-modified endografts, at least 3-year follow-up.

OBJECTIVE: This study aims to report the efficacy and safety of double-fenestrated physician-modified endovascular grafts (PMEGs) for total aortic arch repair with at least 3 years of follow-up. METHODS: All consecutive patients with a pathological aortic arch who underwent aortic arch repair combined with a homemade double-fenestrated stent graft from 2017 to 2020 were reviewed. RESULTS: 74 patients were treated for pathological arch conditions with a double-fenestrated PMEG. Of these, 81% were male, the mean age was 69.9 years, and 59% were classified as American Society of Anesthesiology 3 or 4. Thirty-five percent were treated for a postdissection aneurysm, 36% for a degenerative aneurysm, and 14% for acute type B dissection. Fifteen percent had supra-aortic trunk dissection. Fenestration on the subclavian artery was performed in 96%; if not, a carotid-subclavian bypass was carried out. Technical success was 100%. The proximal landing zone is consistently in zone 0. Early outcomes revealed a 3% occurrence of type 1 endoleak, which was successfully treated by prompt reintervention. One retrograde dissection occurred, and one patient died from hemorrhage on an iliac conduit. A 5% stroke rate was reported. During long-term follow-up (mean time 40.7 months), one type 1 endoleak appeared and was successfully treated; no type 2 or type 3 endoleak requiring intervention occurred. No stent fractures or migrations were reported. Four percent of patients required reintervention, but no surgical conversion to open surgical repair was needed on the aortic arch. No patient died from a cause related to the main procedure. CONCLUSIONS: Total aortic arch repair with double-fenestrated PMEGs is associated with acceptable early and midterm major morbidity and mortality. It is suitable for the main aortic pathologies. Moreover, it is easily available for emergency situations.

Zone 2 Aortic Arch Repair With Single-Fenestrated Physician-Modified Endografts, at Least 3 Years of Follow-up.

OBJECTIVE: The aim of this study is to report the efficiency and safety of single-fenestrated physician-modified endografts (PMEGs) in zone 2 aortic arch pathologies with at least 3 years of follow-up. METHODS: All consecutive patients with a pathological aortic arch who underwent aortic repair combined with homemade single-fenestrated stent-graft from 2015 to 2020 were reviewed. The patients with a target vessel different from the left subclavian artery (LSA) were excluded. RESULTS: A total of 63 patients were treated for a pathological arch in zone 2 with a single-fenestrated PMEG. 73% were male, and the mean age was 65 years old. 25% were treated for a degenerative aneurysm, 19% for a post dissection aneurysm and 24% for an acute type B dissection. 52% of the patients were treated as an emergency and half of those for an aortic rupture. The LSA fenestration was stented in 70%. During 30 days of follow-up, 2 strokes (3%) were reported, 6 patients (10%) died with 4 of those treated for aortic rupture and 1 had a retrograde aortic dissection. During at least 3 years of follow-up (median 49 months), no reintervention was needed for endoleaks, there was no stent fracture or stent migration. No patient died from an aortic cause. Subgroup analysis comparing the endovascular treatment for various aortic pathologies did not find significant differences in death rate or comorbidity including stroke. When comparing emergent and elective aortic repair, operating time was similar (64 vs 65 minutes), and the LSA fenestration was less frequently stented (52%) in the emergency group. There was no difference in stroke frequency. There was a higher rate of death in the emergency group at 30 days of follow-up, but no patient died from aortic cause in the long-term follow-up. CONCLUSIONS: Aortic arch repair with single-fenestrated PMEGs for zone 2 pathological arch disease is associated with acceptable early and midterm major morbidity and mortality. It is suitable for emergency situations. CLINICAL IMPACT: Single-fenestrated PMEG for the left subclavian artery is a safe and efficient option in the short and medium term for the treatment of the aortic arch in zone 2 with 98% technical success. It allows for aortic repair and subclavian artery revascularization in a single step for all patients. It is suitable for a range of main pathologies, including degenerative, dissection-related, isthmus rupture, and embolic pathologies. Additionally, it is always available and easily utilized in emergency cases.

Fenestrated Physician-Modified Endovascular Grafts for Aberrant Right Subclavian Artery and/or Kommerell's diverticulum.

OBJECTIVE: The aim of this case series is to report feasibility, efficiency, and safety of fenestrated physician-modified endografts (PMEGs) in aortic arch pathologies with aberrant right subclavian artery (ARSA) and/or Kommerell's diverticulum (KD). METHODS: All consecutive patients with ARSA and/or KD who underwent hybrid aortic arch repair combined with homemade fenestrated stent-graft from 2018 to 2022 were reviewed. RESULTS: Six patients with ARSA and/or KD underwent hybrid surgery for aortic repair, 4 of whom were men, with a mean age of 49 years. Furthermore, 2 of them were symptomatic with dysphagia, 1 was taken in emergency, 1 had a bovine arch and a KD, and 2 had right descending thoracic aortas. The mean operation time was 138 (111-216) minutes. In addition, 83% of the homemade grafts were double fenestrated. All the proximal landings were in zone 0; the mean proximal aortic diameter was 29 (23-34) mm. The range of diameters for the endografts were 24 to 38 mm. There was a 100% technical success, with 0% 30 days mortality, no stroke, and no endoleak. During the follow-up, no aortic-related death or secondary intervention was required and all supra-aortic vessels remain patent. CONCLUSION: Hybrid aortic arch repair, with fenestrated PMEGs for ARSA and/or KD, is associated with acceptable early and midterm major morbidity and mortality. CLINICAL IMPACT: This retrospective case series analyzed outcomes in 6 patients with an aberrant right subclavian artery and/or Kommerell's diverticulum treated with fenestrated PMEGs during an average 16 month follow-up. The case series suggests that the use of these fenestrated PMEGs for the management of patients with an aberrant right subclavian artery is a safe, effective and durable method in the medium-term.