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Debranching solutions in endografting for complex thoracic aortic dissections.

Goksel OS, Guven K, Karatepe C, Gok E, Acunas B, Cinar B, Alpagut U - Arq. Bras. Cardiol. (2014)

Bottom Line: There were no early to midterm endoleaks.The median follow-up was 20 ± 8 months with patency rate of 100%.Various debranching solutions for different complex scenarios of the aortic arch serve as less invasive procedures than conventional open surgery enabling safe and effective treatment of this highly selected subgroup of patients with complex aortic pathologies.

View Article: PubMed Central - PubMed

Affiliation: Cardiovascular Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.

ABSTRACT

Background: Conventional surgical repair of thoracic aortic dissections is a challenge due to mortality and morbidity risks.

Objectives: We analyzed our experience in hybrid aortic arch repair for complex dissections of the aortic arch.

Methods: Between 2009 and 2013, 18 patients (the mean age of 67 ± 8 years-old) underwent hybrid aortic arch repair. The procedural strategy was determined on the individual patient.

Results: Thirteen patients had type I repair using trifurcation and another patient with bifurcation graft. Two patients had type II repair with replacement of the ascending aorta. Two patients received extra-anatomic bypass grafting to left carotid artery allowing covering of zone 1. Stent graft deployment rate was 100%. No patients experienced stroke. One patient with total debranching of the aortic arch following an acute dissection of the proximal arch expired 3 months after TEVAR due to heart failure. There were no early to midterm endoleaks. The median follow-up was 20 ± 8 months with patency rate of 100%.

Conclusion: Various debranching solutions for different complex scenarios of the aortic arch serve as less invasive procedures than conventional open surgery enabling safe and effective treatment of this highly selected subgroup of patients with complex aortic pathologies.

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Related in: MedlinePlus

Pre- TEVAR CAT scan of the patient with a history of ascending aortic repair anddebranching with a bifurcation graft for a type A aortic dissection (a).Periprocedural DSA of the patient with the patent debranching of the supra-aorticbranches and TEVAR covering both ascending aortic graft, aortic arch and thedescending aorta (b).
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f05: Pre- TEVAR CAT scan of the patient with a history of ascending aortic repair anddebranching with a bifurcation graft for a type A aortic dissection (a).Periprocedural DSA of the patient with the patent debranching of the supra-aorticbranches and TEVAR covering both ascending aortic graft, aortic arch and thedescending aorta (b).

Mentions: A complication unique to the hybrid aortic arch cohort of patients is the occurrence ofendoleaks. Data on endoleak rates with hybrid arch repair is not well defined, withlong-term follow-up data being virtually absent. Endoleak rates have ranged from 0% to15%1-3,8. Similar to TEVAR, hybridarch operations associated with Types I and III endoleak are associated with greatermorbidity than Type II endoleak. In a report by Kotelis et al9, patients undergoing hybrid arch repairwith zone 0 proximal landing had lower endoleak rates than zone 1 landing. In ouroverall experience with TEVAR as well as hybrid arch procedures, we have observedsimilar results mostly due atherosclerotic arch or the conic nature of the landing zonesdue to supraaortic branch ostia. Currently, we have adopted a type I repair strategy ifZ1 coverage is not deemed to be satisfactory (Figure5). Thus, atheromatous load on the landing zones inside the aortic arch is tobe avoided leading to more satisfactory results. Additionally, satisfactory sealing ofaorta with no resultant endoleaks allows the interventionist to cover shorter aorticsegments with this strategy possibly leading to more favorable neurological outcomes.Patient with right subclavian to left carotid artery bypass was initially treated withstraightforward TEVAR with coverage of left subclavian artery. He was referred to ourteam with proximal type I endoleak at the level of left carotid ostium. We managed thispatient with severe chronic lung disease adopting a practical approach to extend theendograft as proximal as the brachiocephalic trunk ostium as described above.


Debranching solutions in endografting for complex thoracic aortic dissections.

Goksel OS, Guven K, Karatepe C, Gok E, Acunas B, Cinar B, Alpagut U - Arq. Bras. Cardiol. (2014)

Pre- TEVAR CAT scan of the patient with a history of ascending aortic repair anddebranching with a bifurcation graft for a type A aortic dissection (a).Periprocedural DSA of the patient with the patent debranching of the supra-aorticbranches and TEVAR covering both ascending aortic graft, aortic arch and thedescending aorta (b).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4150667&req=5

f05: Pre- TEVAR CAT scan of the patient with a history of ascending aortic repair anddebranching with a bifurcation graft for a type A aortic dissection (a).Periprocedural DSA of the patient with the patent debranching of the supra-aorticbranches and TEVAR covering both ascending aortic graft, aortic arch and thedescending aorta (b).
Mentions: A complication unique to the hybrid aortic arch cohort of patients is the occurrence ofendoleaks. Data on endoleak rates with hybrid arch repair is not well defined, withlong-term follow-up data being virtually absent. Endoleak rates have ranged from 0% to15%1-3,8. Similar to TEVAR, hybridarch operations associated with Types I and III endoleak are associated with greatermorbidity than Type II endoleak. In a report by Kotelis et al9, patients undergoing hybrid arch repairwith zone 0 proximal landing had lower endoleak rates than zone 1 landing. In ouroverall experience with TEVAR as well as hybrid arch procedures, we have observedsimilar results mostly due atherosclerotic arch or the conic nature of the landing zonesdue to supraaortic branch ostia. Currently, we have adopted a type I repair strategy ifZ1 coverage is not deemed to be satisfactory (Figure5). Thus, atheromatous load on the landing zones inside the aortic arch is tobe avoided leading to more satisfactory results. Additionally, satisfactory sealing ofaorta with no resultant endoleaks allows the interventionist to cover shorter aorticsegments with this strategy possibly leading to more favorable neurological outcomes.Patient with right subclavian to left carotid artery bypass was initially treated withstraightforward TEVAR with coverage of left subclavian artery. He was referred to ourteam with proximal type I endoleak at the level of left carotid ostium. We managed thispatient with severe chronic lung disease adopting a practical approach to extend theendograft as proximal as the brachiocephalic trunk ostium as described above.

Bottom Line: There were no early to midterm endoleaks.The median follow-up was 20 ± 8 months with patency rate of 100%.Various debranching solutions for different complex scenarios of the aortic arch serve as less invasive procedures than conventional open surgery enabling safe and effective treatment of this highly selected subgroup of patients with complex aortic pathologies.

View Article: PubMed Central - PubMed

Affiliation: Cardiovascular Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.

ABSTRACT

Background: Conventional surgical repair of thoracic aortic dissections is a challenge due to mortality and morbidity risks.

Objectives: We analyzed our experience in hybrid aortic arch repair for complex dissections of the aortic arch.

Methods: Between 2009 and 2013, 18 patients (the mean age of 67 ± 8 years-old) underwent hybrid aortic arch repair. The procedural strategy was determined on the individual patient.

Results: Thirteen patients had type I repair using trifurcation and another patient with bifurcation graft. Two patients had type II repair with replacement of the ascending aorta. Two patients received extra-anatomic bypass grafting to left carotid artery allowing covering of zone 1. Stent graft deployment rate was 100%. No patients experienced stroke. One patient with total debranching of the aortic arch following an acute dissection of the proximal arch expired 3 months after TEVAR due to heart failure. There were no early to midterm endoleaks. The median follow-up was 20 ± 8 months with patency rate of 100%.

Conclusion: Various debranching solutions for different complex scenarios of the aortic arch serve as less invasive procedures than conventional open surgery enabling safe and effective treatment of this highly selected subgroup of patients with complex aortic pathologies.

Show MeSH
Related in: MedlinePlus