The use of EndoAnchors in endovascular repair of abdominal aortic aneurysms with challenging proximal neck: Single-centre experience

Objectives The aim of this study was to present a single-centre experience with EndoAnchors in patients who underwent endovascular repair for abdominal aortic aneurysms with challenging proximal neck, both in the prevention and treatment of endograft migration and type Ia endoleaks. Methods We retrospectively analysed 17 consecutive patients treated with EndoAnchors between June 2015 and May 2018 at our institution. EndoAnchors were applied during the initial endovascular aneurysm repair procedure (primary implant) to prevent proximal neck complications in difficult anatomies (nine patients), and in the follow-up after aneurysm exclusion (secondary implant) to correct type Ia endoleak and/or stent-graft migration (eight patients). Results Mean time for anchors implant was 23 min (range 12–41), with a mean of 5 EndoAnchors deployed per patient. Six patients in the secondary implant group required a proximal cuff due to stent-graft migration ≥10 mm. Technical success was achieved in all cases, with no complications related to deployment of the anchors. At a median follow-up of 13 months (range 4–39, interquartile range 9–20), there were no aneurysm-related deaths or aneurysm ruptures, and all patients were free from reinterventions. CT-scan surveillance showed no evidence of type Ia endoleak, anchors dislodgement or stent-graft migration, with a mean reduction of aneurysm diameter of 0.4 mm (range 0–19); there was no sac growth or aortic neck enlargement in any case. Conclusions EndoAnchors can be safely used in the prevention and treatment of type Ia endoleaks in patients with challenging aortic necks, with good results in terms of sac exclusion and diameter reduction in the mid-term follow-up

Aortic arch debranching and thoracic endovascular repair

Objective: Currently, the best approach to the aortic arch remains unsupported by robust evidence. Most of the available data rely on small sample numbers, heterogeneous settings, and limited follow-up. The objective of this study was to evaluate early and midterm results of arch debranching and endovascular procedures.Methods: From 2005 through 2013, 104 consecutive patients underwent elective arch treatment with debranching and thoracic endovascular aortic repair. Rates of perioperative (30-day) mortality and neurological complications, and mortality, endoleak, supra-aortic vessel patency, and arch diameter changes at 5 years were analyzed.Results: Patients' mean age was 69.8 years, and 90 were males. Twenty arches were repaired for dissection. Nineteen patients required total debranching for diseases extended to zone 0. In 59, debranching and thoracic endovascular aortic repair procedures were staged. At 30 days, death, stroke, and spinal cord ischemia occurred in six, four, and three patients, respectively. Extension to ascending aorta (zone 0 landing) was the only multivariate independent predictor for perioperative mortality (odds ratio, 9.6; 95% confidence interval, 1.54-59.90; P = .015), but not for stroke. Four retrograde dissections, two fatal, occurred during the perioperative period. At 1, 3, and 5 years, Kaplan-Meier survival rates were 89.0%, 82.8%, and 70.9%, and freedom from persistent endoleak rates were 96.1%, 92.5%, and 88.3%, respectively. Over 5-year follow-up, 34 aneurysms shrank >= 5 mm, and four grew. Five reinterventions were required. Two supra-aortic vessel occlusions and no late aorta-related mortalities were recorded.Conclusions: Despite the perioperative mortality risk, the late outcome of endovascular arch repair presents a low rate of aorta-related deaths and reinterventions and acceptable midterm survival. Furthermore, more than one-third of the aneurysms' diameters decrease over 5 years as a measure of the long-term efficacy of treatment. Retrograde type A dissection remains a major concern in the perioperative period and careful arch approach is required. (J Vasc Surg 2014; 59: 107-14.

Contemporary comparison of aortic arch repair by endovascular and open surgical reconstructions

Objective: This study analyzed total aortic arch reconstruction in a contemporary comparison of current open and endovascular repair.Methods: Endovascular (group 1) and open arch procedures (group 2) performed during 2007 to 2013 were entered in a prospective database and retrospectively analyzed. Endovascular repair (proximal landing zones 0-1), with or without a hybrid adjunct, was selected for patients with a high comorbidity profile and fit anatomy. Operations involving coverage of left subclavian artery only (zone 2 proximal landing: n = 41) and open hemiarch replacement (n = 434) were excluded. Early and midterm mortality and major complications were assessed.Results: Overall, 100 (78 men; mean age, 68 years) consecutive procedures were analyzed: 29 patients in group 2 and 71 in group 1. Seven group 1 patients were treated with branched or chimney stent graft, and 64 with partial or total debranching and straight stent graft. The 29 patients in group 2 were younger (mean age, 61.9 vs 70.3; P = .005), more frequently females (48.2% vs 11.3; P < .001) with less cardiac (6.9% vs 38.2%; P = .001), hypertensive (58.5% vs 88.4%; P =. 002), and peripheral artery (0% vs 16.2%; P = .031) disease. At 30 days, there were six deaths in group 1 and four in group 2 (8.5% vs 13.8%; odds ratio, 1.7; 95% confidence interval, 0.45-6.66; P = .47), and four strokes in group 1 and one in group 2 (odds ratio, 0.59; 95% confidence interval, 0.06-5.59; P = 1). Spinal cord ischemia occurred in two group 1 patients and in no group 2 patients. Three retrograde dissections (1 fatal) were detected in group 1. During a mean follow-up of 26.2 months, two type I endoleaks and three reinterventions were recorded in group 1 (all for persistent endoleak), and one reintervention was performed in group 2. According to Kaplan Meier estimates, survival at 4 years was 79.8% in group 1 and 69.8% in group 2 (P = .62), and freedom from late reintervention was 94.6% and 95.5%, respectively (P = .82).Conclusions: Despite the older age and a higher comorbidity profile in patients with challenging aortic arch disease suitable and selected for endovascular arch repair, no significant differences were detected in perioperative and 4-year outcomes compared with the younger patients undergoing open arch total repair. An endovascular approach might also be a valid alternative to open surgery in average-risk patients with aortic arch diseases requiring 0 to 1 landing zones, when morphologically feasible. However, larger concurrent comparison and longer follow-up are needed to confirm this hypothesis

TAA 8. Hybrid Repair Techniques for Kommerell Diverticulum, New Aortic Arch Classification, Early and Late Results

Objective: The aim of this study was to evaluate early and late results of hybrid repair techniques for Kommerell diverticulum (KD). Methods: All patients undergoing hybrid repair (thoracic endovascular aortic repair + supra-aortic debranching) for KD between 2009 and 2018 were included in this retrospective multicenter study (three Italian cen- ters). A proximal landing zone (PLZ) of at least 2 cm of healthy aorta was considered adequate for the deployment of a standard thoracic stent graft. The early end points were technical success, in-hospital mor- tality, and cerebrovascular events. Late outcomes included survival, rein- tervention, and patency of supra-aortic debranching. We proposed an embryogenetic anomaly-based aortic arch classification for PLZ evalua- tion to choose the most appropriate hybrid adjunct (Fig). Results: Sixteen patients with KD were included. According to the aforementioned classification, six patients (37.5%) required stent graft deployment in PLZ 0, nine (56.3%) in PLZ 1, and one (6.3%) in PLZ 2. Tech- nical success was achieved in all patients. One patient (6.3%) died in the hospital of posterior cerebral hemorrhage after a total debranching (PLZ 0). No other cerebrovascular event was registered. One patient (6.3%) re- ported an asymptomatic right subclavian artery-left subclavian artery bypass occlusion and required an early reintervention. The 30-day pri- mary assisted patency of supra-aortic debranching was 100% (Table I). Two type II endoleaks (12.5%) were detected at 1-month computed to- mography angiography. Further transient complications were registered in three cases: hemidiaphragm paralysis in one patient and recurrent laryngeal nerve paralysis in two patients. At a mean follow-up of 48 months, four patients died of non-aorta-related reasons and one right common carotid artery-right subclavian artery bypass lost its patency. Ten patients (62.5%) presented with aneurysmal sac shrinkage of at least 5 mm (Table II). Conclusions: Hybrid repair has been confirmed to be a safe and effec- tive approach for KD. Operative risk is mostly related to the invasiveness of the hybrid adjunct

iTalian RegIstry of doUble inner branch stent graft for arch PatHology (the TRIUmPH Registry)

Objective: The objective of this study was to assess early and midterm results after endovascular aortic arch repair using a double inner branch stent graft (DIBSG) in patients with aortic arch aneurysm or dissection unfit for open surgery. Methods: Between 2012 and 2018, there were 24 patients with aortic arch disease who were treated with a single model of a DIBSG (Terumo Aortic, Glasgow, United Kingdom) in nine Italian cardiovascular centers. We investigated technical success, mortality, occurrence of major complications, and need for reintervention in a multicenter, nonrandomized, retrospective fashion. Results: The in-hospital mortality rate was 16.7%. Cerebrovascular events occurred in 25% of patients and major strokes in 12.5%. Two patients experienced a retrograde dissection (8.3%), whereas none reported any type I or type III endoleak. During a mean follow-up of 18 months (range, 1-60 months), one patient died of a nonaortic cause and one reported a nonarch-related major stroke. No late secondary intervention was needed during the follow-up. Excluding from the analysis the first six patients treated until 2014 as part of the learning curve, in-hospital mortality, major stroke, and retrograde dissection rates were 11.1%, 11.1%, and 5.6%, respectively. Conclusions: Endovascular aortic arch repair using this model of DIBSG is feasible, and results are acceptable for a new technique in a high-risk subset of patients. Operative mortality suffers the effect of a learning curve, whereas midterm aorta-related survival is promising. Endovascular repair of aortic arch disease with a DIBSG should always be considered to give high-risk patients a chance of repair. Large-scale studies are needed to assess the long-term durability of this technique