Pre-fenestration endovascular repair of aortic diseases in patients with zone 2 segment: A single-center experience

Abstract

Objective

The present study aims to analyze the outcomes of three cases of pre-fenestration and branch stent-graft endovascular repair of aortic disease with zone 2 aortic lesions.

Methods

From August 2017 to June 2018, three patients with zone 2 aortic lesions underwent thoracic endovascular repair with innominate artery, left common carotid artery, and left subclavian artery recannulation using pre-fenestration and branched stent-grafts to preserve the patency of the aortic arch branches.

Results

The technical success rate was 100%. One patient had a proximal type I endoleak with no need for additional treatment. The overall mortality was 0%. All branches were patent. The follow-up period lasted for 2–15 months, with one patient lost to follow-up. There were no conversions to open surgical repair, aortic rupture, paraplegia, or retrograde type A aortic dissection.

Conclusion

The use of a pre-fenestration and branch stent-graft for the thoracic endovascular repair of zone 2 aortic lesions is a feasible and effective method for aortic arch branch revascularization. The risk of this surgical procedure is high, requiring significant expertise. The procedure should be conducted only in experienced centers. Durability concerns should be assessed in future studies with long-term follow-up.

Keywords

Aortic dissection endovascular repair pre-fenestration branch stent graft

Introduction

Aortic dissection or pseudoaneurysm in zone 2 is a hazardous condition. Open surgery is the gold standard for treating aortic disease, though mortality and complication rates are high.^1–4 Endovascular treatment is minimally invasive. It can avoid sternotomy and hypothermic cardiopulmonary bypass and may reduce perioperative mortality. The proximal landing zone should be at least 15 mm, according to recent guidelines.⁵ In the present study, three patients with aortic dissection and aortic arch pseudoaneurysm in zone 2 were treated with triple pre-fenestration, and three covered stent-grafts were deployed in the branch vessels based on the experience of a previous study on single left subclavian artery (LSA) pre-fenestration and recannulation in our center.⁶ The short- to middle-term follow-up results were optimistic, and the details are as follows.

Materials and methods

The clinical data of the three patients are presented in Table 1. The study was conducted with approval from the Ethics Committee of the General Hospital of Ningxia Medical University. All participants provided written informed consent.

Table 1.

The clinical data of the three patients.

Item	Patient 1	Patient 2	Patient 3
Gender	Female	Male	Male
Age (years)	71	68	41
Hypertension	Y	Y	Y
Coronary heart disease	N	N	N
Diabetes	N	N	N
Marfan syndrome	N	N	N
Chronic obstructive pulmonary disease	N	Y	N
Time of onset (Day)		1	1

All three patients underwent computed tomography angiography (CTA) to assess the aortic lesions prior to surgery. CTA revealed that Patient 1 had an aortic arch pseudoaneurysm in the anterior wall at the lessor curve, while Patients 2 and 3 had acute aortic dissection with the entry tear located in zone 2 (Equipment model: Brilliance iCT, PHILIPS; Philips Extended Brilliance Workspace 4.5). CTA measurement data are presented in Table 2. The standard thoracic endovascular repair (TEVAR) procedure (Table 2, Figure 1) was not suitable for all the patients.

Table 2.

The data of the CTA measurements of the three patients.

Item	Patient 1	Patient 2	Patient 3
Location of laceration	Between LCCA and LSA	Between LCCA and LSA	The beginning of LSA
Vascular diameter (mm)
Near-end ascending aorta	30	34	36
Brachiocephalic trunk	13	12	13
LCCA	8	10	8
LSA	11	10	11
Distance between branches (mm)
Brachiocephalic trunk–LCCA	7	3	3
LCCA–LSA	18	3	5

LCCA: left common carotid artery; LSA: left subclavian artery.

Figure 1.

Preoperative aortic CTA. The aortic dissection involved the posterior wall of the aorta at the opening of the left subclavian artery (a). An entry tear was located at the opening of the left subclavian artery (c). The distance between the opening of the left subclavian artery and the opening of the left common carotid artery was 5 mm, while the distance between the opening of the left common carotid artery and the opening of the brachiocephalic trunk was 3 mm (b and d).

Figure 2.

CTA measurements: the aortic diameter of proximal and distal landing zone, the aortic diameter of opening of IA, LCCA, and LSA; the diameter of the original and distal of arch branches; the distance between the orifice of branches, the distance between the opening of the left subclavian artery and the left vertebral artery (a). Predict the angiographic angle (b). Determine the spatial relationships between the openings of arch branches (c).

CTA measurements（Figure 2）

Aortic diameter of the proximal and distal landing zone; aortic diameter of the opening of the innominate artery (IA), left common carotid artery (LCCA), and LSA.

Diameter of the original and distal of the arch branches.

Distance between the orifice of the branches; distance between the opening of the LSA and left vertebral artery.

Prediction of the angiographic angle.

Determination of the spatial relationships between the openings of the arch branches.

Stent modification

The fenestration position was selected according to preoperative CTA measurements, and a preoperative three-dimensional (3D) printed aortic arch solid model was used for assisted selection when necessary. In planning the operation, we developed our own criteria for measuring and selecting the stent-grafts. The key elements measured on the CTA arrays were demonstrated through a simple figure. Valiant aortic stents (Medtronic Inc., Santa Rosa, CA, USA) were partially deployed on the table during the procedure according to the opening position, and fenestrations were made at sites that corresponded to the results of the measurements. The metal components of the thoracic aortic stent-graft must be avoided during fenestration; otherwise, the branch stent-graft may not be deployed due to the metal skeleton. One or two markers were dislocated from the proximal part of the main body and re-located with 5–0 Prolene sutures next to the fenestration on the longitudinal centerline. The stent-graft was subsequently reloaded into the introducer system (Figure 3).

Figure 3.

The stent was modified according to the preoperative CTA and intraoperative angiography results. The stent was partly deployed, the fenestrations were made at the corresponding branches and the stent marker points were relocated.

Surgical procedure

The operations were performed under local anesthesia, and one side of the femoral artery and bilateral brachial arteries were punctured using the Seldinger method. Following aortography, the distal restrictive stent-graft was delivered to the distal segment of the descending aorta along the extra-stiff Lunderquist guidewire and deployed. The aortic stent was subsequently delivered to the arch. After ensuring the alignment of the opening position of fenestration with the orifices of the target branch vessels, the aortic stent was rapidly deployed.

The left brachial artery to the femoral artery guidewire route was established using a snare, and a branch stent-graft was guided from the femoral artery into the LSA opening and deployed. The route from the common femoral artery to the LCCA was subsequently established, and the branch stent-graft was guided into the LCA opening and deployed. Finally, the route from the right brachial artery to the common femoral artery was established with a snare, and a branch stent-graft was guided into the IA opening and deployed. The shape of the stent-graft was used to determine whether to introduce a balloon catheter. After deploying all the stent-grafts, ascending aortic angiography was performed to observe the immediate results (Table 3, Figure 4). If a type I endoleak was present, the possibility of resolving the endoleak was assessed. Based on our prior experience of fenestration TEVAR therapy, when the type I endoleak did not emerge immediately with the aortography but appeared after several cardiac circulations or the contrast agent was diffuse rather than fasciculate, it was considered a minor-moderate type I endoleak and was left for follow-up. After 6–12 months, a CTA scan was arranged to assess the endoleak and decide whether further intervention was needed.

Table 3.

The data of the three patients during the operation.

Item	Patient 1	Patient 2	Patient 3
The proximal landing zone (mm)	ZONE 0	ZONE 0	ZONE 0
The model number of aortic stent (mm)	34-34-200	38-38-200	40-40-200
Diameter of opening (mm)
Brachiocephalic trunk	11	11	11
LCCA	8	10	8
LSA	11	10	11
The model number of branched stent (mm)
Brachiocephalic trunk	13–50	13–50	13–50
LCCA	11–25	13–50	11–25
LSA	13–50	13–50	13–50

LCCA: left common carotid artery; LSA: left subclavian artery.

Figure 4.

Ascending aortic angiography before the stent modification (a). Ascending aortic angiography after all the stent grafts deployed, the entry tear disappeared and all of the branch stents were patent. There was no retrograde type A dissection and no type I endoleak revealed (b).

Postoperative treatment and follow-up

After the operation, the patients were treated with low molecular weight heparin anticoagulants. They gradually transitioned onto the oral use of aspirin tablets at 100 mg/day for anti-platelet therapy. Systolic blood pressure was maintained above 90 mmHg to ensure the blood supply to the spinal cord. At 1, 3, 6, and 12 months after the operation, a CTA scan was performed to evaluate the stent-graft and aortic remodeling.

Results

Postoperative angiography revealed that the aortic stents were deployed at the predicted positions in the three patients. Furthermore, the lesions were completely covered, the opening and branch were aligned, and the stents in the branch vessels were unobstructed. Patient 1 suffered a stroke after the operation, and craniocerebral magnetic resonance imaging (MRI) revealed multiple new bilateral cerebral infarcts. Unfortunately, Patient 1 was lost to follow-up after being discharged from hospital. Patient 2 did not present with type I endoleak, while Patient 3 had minor type I endoleak.

Fortunately, Patients 2 and 3 had no serious complications, such as cerebrovascular events, acute spinal cord ischemia, or paraplegia, during the perioperative period. These two patients were followed up for 2–15 months. At follow-up, all branches of the arch were unobstructed, and no branch stent-graft stenosis or occlusion was observed. No death or complications occurred during the follow-up period. The arch pseudoaneurysm was thrombotic, and in the aortic dissection, the proximal false lumen was also thrombosed, according to the postoperative CTA scan (Figure 5).

Figure 5.

At 1 month after the operation, the CTA was scanned. The entry tear disappeared and all of the branch stents were patent. There was no retrograde type A dissection and no type I endoleak revealed (a to C).

Discussion

Various techniques have been used to increase the proximal landing zone. The de-branching technique^7,8 increases the risk of retrograde dissection due to clamping of the ascending aorta and anastomosis suture.⁹ The gap between two parallel stents in the chimney technique increases the risk of type I endoleak.^10,11 In one study on a case of TEVAR, the incidence of type I endoleak was 57.14% (4/7) when the triple-branch chimney technique with C-TAG and Viabahn was used to treat arch lesions.¹² Branched or fenestrated stents have satisfactory short- and medium-term outcomes,^13–15 though customizing the stent is a lengthy process. Inner branched stents¹⁶ and semi-custom fenestrated stents¹⁵ have also been used to treat aortic arch diseases.

For the endovascular treatment of aortic arch pseudoaneurysm or dissection with entry tear in zone 2, the proximal landing zone may be located in zone 1. Retrograde type A aortic dissection (RTAD) may occur after the procedure due to the shear stress of the stent on the aorta and the continuous interactive forces between the proximal metal components and the aortic curve.^6,17 Prior research has shown that the incidence of RTAD can be reduced if the proximal landing zone is extended to the straight segment of the ascending aorta.^9,14,18 Therefore, triple pre-fenestration with branch vessel stent-graft recannulation was utilized in the present study, and the proximal landing zone was extended to the straight ascending aorta.

The measurements along the aortic centerline on multiplanar reconstruction (MPR) CTA images intuitively reflect the aortic anatomy and can locate the fenestration site for the arch branches. The suitable angiographic angle that can visualize the space between the orifices of LCA and LSA can also be identified by MPR images.¹⁹ 3 D printing can replicate a 1:1 geometric model of the aortic arch to intuitively reflect the relative spatial position of the openings of branches to assist in the selection of the fenestration on the aortic stent-graft.

The fenestration site should be selected to avoid the metal components in stent modification.¹⁹ In the present study, the fenestration diameter was 1 mm smaller than that of the opening of the target artery. The markers were re-positioned to ensure that the fenestration was accurately docked with the LSA, LCA, and IA openings under radiography. During the process of loading the stent back into the introducer sheath, the stent-graft must not be twisted, and the accumulated elastic force must be released to prevent the stent-graft from shifting during deployment and recannulation, which would make fenestration difficult or even impossible.

Stroke is a dangerous complication in the endovascular repair of arch diseases. The risk of stroke is related to the condition of the patient. Some of these risks are the presence of atherosclerosis, ulcers of the aortic arch, or angulation of the aortic arch, as well as the excessive use of guidewires and catheters through the arch, air embolisms caused by introducer systems, the partial covering of arch branches, and the insufficiency of technical familiarity.^16,20 Unlike single LSA pre-fenestration TEVAR therapy, inaccurate alignment of the fenestration with the orifices of the branch vessels can cause a severe deficiency of blood supply to the brain. This can cause death within a short period. Multi-angle observation and angiography can help determine the accuracy of the positioning. If a deviation is noted between the marker point position and the opening position of the branch when the stent-graft is delivered to the aortic arch, the aortic stent is brought back into the descending aorta.^14,19 It is almost impossible to make further adjustments when the stent-graft is deployed out, even if it is only partially deployed, and the final release lock is not open. Rotating stents in the aortic arch should be avoided, as doing so can induce stroke due to damage to the intima of the arch or the plaques falling off. In the present study, after the operation, Patient 1 suffered a stroke. Brain MRI non-enhanced and diffusion scans revealed that the patient had multiple new cerebral infarcts, which may have been due to plaques falling off in the aortic arch. The application of neuroprotective devices, which have been applied in transcatheter aortic valve replacement, may reduce stroke risk.²¹ However, the development of a new neuroprotective device for TEVAR for arch lesions is necessary.²⁰ Rapid and continuous stent release can avoid the distortion and displacement of stents due to forceful blood flow in the arch.

Branch stent-graft placement can increase the stability of the aortic stent, reduce the chance of the aortic stent migrating with the blood flow, and lower the risk of postoperative type I endoleak. Immediate angiography revealed that Patient 3 had a minor type I endoleak, which could have been because the aortic stent oversizing was small. One month after the operation, CTA revealed that the contrast agent density in the false lumen had significantly decreased. The patient remains under close observation without any further interventional treatment.

A covered stent with good flexibility must be selected for the branch vessels. In the present study, GORE Viabahn (W.L. Gore and Associates Inc., Flagstaff, AZ, USA) stents were the first choice, and the oversizing was 10%–15%. Stents of an appropriate length must be carefully selected. The proximal part of the stent was located in the thoracic aortic stent, and the length of the free segment was approximately 5 mm. The stent-graft must not cover the opening of the vertebral artery. In the present study, the diameter of the fenestration was smaller than the branched stent, so the stent was closely attached to the aortic stent. Branch stents were deployed via the femoral artery approach. The GORE Viabahn stent system is not protected by an introducer sheath; therefore, when the stent enters the target vessel through the fenestration, it must be maneuvered with care to avoid damage to the arterial wall.

The three patients were aged 68, 71, and 41 years, respectively. After considering the risk and mortality of total arch replacement, the two older patients chose TEVAR over open surgery. The younger patient refused open surgical treatment and required minimally invasive surgery. We have always argued that pre-fenestration TEVAR for such diseases should not become a routine operation and only offered as an alternative surgical treatment in experienced centers. Total arch replacement and the de-branching technique remain the gold standard treatment.

Conclusion

The treatment of aortic diseases in zone 2 using a pre-fenestrated aortic stent with a branch stent-graft can anatomically preserve the blood supply to the upper limbs and brain with low trauma and a short procedure time. However, this procedure is an off-label thoracic endovascular aortic repair technique. The potential risks involved in this endovascular procedure are high, and it should only be performed in experienced centers that conduct large volumes of TEVAR therapies. The long-term outcomes of the therapy should be assessed with further follow-up.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Science and Technology Department of Ningxia Province [No.2018BEG03029] and Natural Science Foundation of Ningxia province [No.2020AAC03367].

ORCID iD

Xiao-Dong Li

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