Abstract
Background
Preservation of supra-aortic branches in thoracic endovascular aortic repair plays a role in associated neurological outcomes, and the strategy varies.
Objectives
This study aimed to evaluate the safety and efficacy of a parallel graft technique to reconstruct the aortic arch.
Methods
From August 2014 to July 2018, a total of 25 patients with thoracic aortic pathologies requiring arch reconstruction were included. All patients underwent thoracic aortic endovascular repair (TEVAR) with a zone 1 landing aortic stent graft, a chimney graft to preserve the left common carotid artery, and a periscope graft to preserve the left subclavian artery. The associated outcomes and complications were reported.
Results
Eighteen patients presented with aortic dissection, 4 with a thoracic aortic aneurysm, 1 with a penetrating aortic ulcer, 1 with a traumatic aortic injury, and 1 case of re-TEVAR. The technical success rate was 96% (24/25), but the case of immediate failure died of retrograde type A dissection. Over a mean follow-up of 32.33 months, another retrograde type A aortic dissection was detected in 1 month, and a case of early failure (< 1 year) and 3 cases of late failure (> 1 year) whose primary aortic problems recurred were detected.
Conclusions
This study demonstrates a total endovascular approach to preserve supra-aortic branches with a parallel graft technique. However, the dilemma of excessive graft oversizing was disclosed due to the risk of retrograde type A dissections and an unsatisfactory durability in this small series.
Keywords: Aortic aneurysm, Aortic dissection, Chimney, Periscope, Thoracic endovascular aortic repair
INTRODUCTION
Thoracic endovascular aortic repair is becoming increasingly important in the treatment of thoracic aortic disease, and it can provide an alternative to open surgery.1 Preservation of supra-aortic branches plays a role in associated neurological outcomes2-4 and promotes the development of many endovascular strategies including parallel grafts and branch-fenestrated repair.5-7
In cases of thoracic aortic pathology that necessitates a zone 1 landing aortic stent graft, revascularization of both left common carotid artery (LCCA) and left subclavian artery (LSA) is required. The chimney graft technique, which was first described by Greenberg and his colleague,8 is used for visceral debranching as well as preservation of supra-aortic branches.9 A "periscope" or "reverse chimney" graft, combined with the sandwich technique, has also been reported to revascularize major branches.10 However, the increased number of chimney grafts raises concerns of gutter leakage and type Ia endoleak,9 while the periscope configuration may not be an ideal strategy to preserve the LCCA due to insufficient carotid flow in a retrograde fashion. A previous study reported a secure zone 2 landing with preservation of the LSA in thoracic aortic endovascular repair (TEVAR) with a periscope graft to the LSA.11 To extend this concept and achieve a secure zone 1 landing aortic stent graft, a combination of a chimney graft and a periscope graft to respectively preserve the LCCA and LSA has been designed. In this study, we aimed to evaluate the safety and efficacy of this technique and measure the associated outcomes.
METHODS
Patients
From August 2014 to July 2018, a total of 25 patients with various thoracic aortic pathologies who underwent TEVAR requiring a zone 1 landing were included. Acute pathology was defined as the onset of symptoms less than 14 days before the procedure, while a patient was considered to be a chronic case if the symptoms lasted for more than 90 days. A subacute case was defined if this interval was 14-90 days.10 The inclusion criteria were residual type B dissection after open repair for type A aortic dissection in which the procedure served as a part of a hybrid operation, acute or subacute complicated type B aortic dissection, chronic type B aortic dissection with a maximal diameter > 5 cm, thoracic aortic aneurysm with a maximal diameter > 5 cm, penetrating aortic ulcer of the thoracic aorta, and traumatic aortic injury. We also included cases of type A aortic dissection if the location of the pathologies was desirable for an endovascular approach. Patients who received re-TEVAR due to previous complications such as endoleak were also included. The exclusion criteria were severe calcifications or tortuosity of the iliac vessels or distal aorta prohibiting passage of an endograft. Before the procedure, the risks, benefits, process of the procedure, the off-label use of the device, and the need of follow-up were explained in detail to all of the patients and their families. Informed consent was obtained from all of the patients. The Institutional Review Board of our hospital approved the study.
Interventions
All of the patients underwent computed tomography angiography (CTA) before the procedure. Each patient was brought to the hybrid operation room and placed in the supine position. Under general anesthesia, bilateral common femoral arteries (CFAs) and left brachial artery (LBA) over the left elbow were punctured under ultrasound guidance. Thoracic aortography was performed to confirm and mark the course of the aorta. The intra-operative activated clotting time (ACT) was maintained at around 300 seconds.
The thoracic aortic stent grafts used in this technique were Zenith TX2 (Cook Medical, Inc.), GORE TAG (W. L. Gore & Associates, Flagstaff, AZ), and Valiant Captivia (Medtronic Vascular, Santa Rosa, CA). Under the support of a Lunderquist guidewire, the first aortic endograft was deployed over the thoracic aorta with its proximal end landing distal to the LSA. To form a through-and-through guidewire, a wire was snared from the LBA to the CFA with an Indy Vascular Retriever (Cook Medical, Inc.). A periscope endograft using Viabahn (W. L. Gore & Associates), sized 1-2 mm larger than the LSA at its intended landing site, was introduced from the CFA with the support of the through-and-through guidewire and positioned into the LSA with a minimum of 2 cm into the branch without covering the left vertebral artery (Figure 1A). Under ultrasound guidance, the LCCA was accessed through a left neck puncture, and a chimney Viabahn endoprosthesis (W. L. Gore & Associates) for the LCCA was introduced to the ascending aorta. Asecond aortic stent graft was then advanced to zone 1. Following deployment of the endografts to the LSA and LCCA, the second aortic stent graft was also deployed (Figure 1B). The LSA periscope endograft landed caudally to the distal edge of the proximal aortic stent graft with its proximal tip inside the lumen of the distal aortic stent graft in a sandwich configuration, as shown in postoperative CTA (Figure 1C, D, E).
Figure 1.
Deployment of parallel endografts. (A) Introduction of periscope endograft to left subclavian artery under the support of through-and-through wire which was snared from left brachial artery to common femoral artery. (B) The left common carotid chimney endograft deployment was followed by the second, proximal aortic stent graft deployment. (C, D, E) The postoperative computed tomography angiography disclosed a sandwich configuration of 2 aortic stent graft, encompassing the left subclavian artery periscope graft in sagittal (C), coronal (D), and reconstruction image from right posterior view (E).
The diameter oversizing of the aortic stent graft was measured both proximally at the zone 1 landing site and distally at the sandwich site, and was defined as [the diameter of the aortic stent graft – the diameter of the true lumen] / [the diameter of the true lumen]. After deployment, the aortic stent graft and 2 parallel endografts were than molded by the kissing balloon technique respectively using a Tri-Lobe Balloon Catheter (W. L. Gore & Associates) in the aortic stent graft and standard angioplasty balloon (EverCross; ev3 Endovascular, Inc., Plymouth, MN) in the Viabahn endografts. Additional bare aortic stents were placed down to the level of the compromised lumen. Completion aortography was performed to confirm the resolution of the aortic pathologies and absence of immediate complications. The puncture sites of the LBA and bilateral CFAs were closed using a preclose system (ProGlide, Abbott Vascular, Redwood City, CA) or repaired primarily. The puncture site of the LCCA was closed with an 8Fr Angio-Seal vascular closure device (St. Jude Medical Inc.).
After the operation, aspirin 100 mg was prescribed to all of the patients as stroke prevention if there were no contraindications, and postoperative CTA was done after 1 month to assess the outcomes. All patients were scheduled for follow-up assessments, including routine office visits and CTA at 6 and 12 months after the operation, and then annually every 3 years.
Study design and data collection
Technical success was defined as successful implantation of 2 aortic stent grafts into the thoracic aorta, a chimney graft into the LCCA and a periscope graft into the LSA with complete exclusion of aortic pathologies, resolution of mal-perfusion, patent blood flow of supra-aortic branches, and absence of immediate complications in the completion aortography. The outcomes including technical success, access complications, patency of endografts, resolution of primary aortic pathologies, procedure-related immediate, early (< 30 days) and late (> 30 days) mortality, were analyzed. The requirement of secondary endovascular treatment or surgical conversion to solve the primary aortic pathology or procedure-related complications were regarded as early (< 1 year) or late (> 1 year) procedural failure.
Statistical analysis
Continuous variables are presented as mean with range, and categorical data are presented as absolute numbers with percentage. Changes in the maximum thoracic aortic diameter of an aortic dissection or aneurysm were analyzed. A p value < 0.05 was considered to be statistically significant. Statistical analysis was performed using SPSS version 25.0 (SPSS, Inc., Chicago, IL, USA).
RESULTS
The patients’ demographic features and comorbidities are shown in Table 1, and the operative data are listed in Table 2. Eighteen patients presented with aortic dissection, 4 with a thoracic aortic aneurysm, 1 with a penetrating aortic ulcer, 1 with a traumatic aortic injury, and 1 patient received re-TEVAR to solve endoleak from previous TEVAR for a descending aortic dissecting aneurysm. Four of the patients with chronic type B aortic dissections and the re-TEVAR case had previously undergone open surgery for type A aortic dissection, and 2 patients with thoracic aortic aneurysms had previously undergone open surgery for ascending aortic aneurysms. Malperfusion developed prior to the operation in all of the 5 cases with acute complicated type B aortic dissections, 1 case with a subacute type A aortic dissection, and 3 cases with chronic type B aortic dissections. Except for the 5 patients with acute complicated type B aortic dissections and 1 case with a traumatic aortic injury, the procedures were done electively. The mean operative time was 197.60 ± 49.52 minutes (range 120 to 300 minutes) with a median of 180 minutes.
Table 1. Patient’s characteristics.
| Variables | n = 25 |
| Age | 51.2 (19-84) |
| Male | 20 (80.0) |
| Hypertension | 24 (96.0) |
| Diabetes mellitus | 4 (16.0) |
| Chronic kidney disease | 8 (32.0) |
| Hyperlipidemia | 10 (40.0) |
| Coronary artery disease | 3 (12.0) |
| Old cerebral vascular disease | 3 (12.0) |
Data are expressed as number (%) or mean (range).
Chronic kidney disease stage 3 or worse (glomerular filtration rate < 60 mL/min/1.73 m2).
Table 2. Operative data (n = 25).
| Aortic pathologies | |
| Aortic dissection | 18 (72.0) |
| Residual type aortic B dissection after open grafting of type A aortic dissection | 1 (0.4) |
| Acute complicated type B aortic dissection | 5 (2.0) |
| Subacute type A aortic dissection | 1 (0.4) |
| Chronic type B aortic dissection | 11 (44.0) |
| Thoracic aortic aneurysm | 4 (1.6) |
| Penetrating aortic ulcer, thoracic aorta | 1 (0.4) |
| Traumatic aortic injury | 1 (0.4) |
| Re-TEVAR* | 1 (0.4) |
| Previous open heart or thoracic aortic surgery | 7 (2.8) |
| Mal-perfusion prior to the operation | 9 (3.6) |
| Emergent operation | 6 (2.4) |
| Operative time (minute) | 197.6 (120-300) |
| Preoperative maximum thoracic aortic diameter (mm) (n = 25) | 56.7 (20.2-85.0) |
| Aortic dissection (n = 17)# | 56.1 (34.2-79.0) |
| Thoracic aortic aneurysm (n = 3)† | 74.8 (70.0-79.3) |
| Proximal aortic endograft oversizing at zone 1 (%) | 23.1 ± 5.7 (11.0-36.5) |
| Aortic endograft oversizing at sandwich site (%) | 25.4 ± 10.0 (10.0-57.1) |
Data are expressed as number (%) or mean (range).
* The procedure was done to solve endoleak from previous thoracic aortic endovascular repair (TEVAR) for descending aortic dissecting aneurysm. # Exclusion of an immediate mortality. † Exclusion of a patient who refused computed tomography angiography (CTA) follow-up.
The outcome data are listed in Table 3. Technical success was registered in 24 of the 25 patients and confirmed by completion aortography without immediate complications. Immediate failure of the procedure and mortality occurred in a 44-year-old male patient with a chronic type B aortic dissection. Retrograde type A aortic dissection occurred during the procedure and the procedure was converted to open surgery during cardiopulmonary resuscitation and setup of cardiopulmonary bypass. A complete circumferential intimal tear was found at the base of the innominate artery with retrograde telescoping of the intimal flap into the left ventricle (Figure 2A, B, C), causing left ventricle outflow tract obstruction and cardiogenic shock. The patient expired despite emergent open grafting and repair of the ascending aorta.
Table 3. Outcome data (n = 25).
| Variable | |
| Technical success | 24 (96.0) |
| 30-day mortality | 1 (4.0) |
| Late mortality | 2 (8.0) |
| Acute myocarditis | 1 |
| Intra-cranial hemorrhage | 1 |
| Access complications* | 3 (12.0) |
| Early failure (< 1 year)# | 1 (4.0) |
| Late failure (> 1 year)† | 3 (12.0) |
| Major endovascular complications | 6 (24.0) |
| Retrograde type A dissection | 2 |
| Immediate (intraoperative) | 1 |
| Delayed (postoperative 1 month) | 1 |
| Type Iaendoleak | 2 |
| Aneurysmal change | 1 |
| Prosthetic infection | 1 |
| Postoperative maximum thoracic aortic diameter (mm) (n = 23) | 48.9 (20.0-88.8) |
| Aortic dissection (n = 17)‡ | 47.2 (30.1-77.7) |
| Thoracic aortic aneurysm (n = 3)§ | 66.7 (37.2-88.8) |
Data are expressed as number (%) or mean (range).
* All access complications were pseudoaneurysm of left common carotid artery. # Intraoperative retrograde type A dissection. † Including 2 cases of type Ia endoleak and 1 case of aneurysmal change. ‡ Exclusion of an immediate mortality. § Exclusion of a patient who refused computed tomography angiography (CTA) follow-up.
Figure 2.
Iatrogenic retrograde type A dissection. (A) Emergent surgical conversion during thoracic aortic endovascular repair (TEVAR) in a 44-year-old male patient. The chimney graft in left common carotid artery was exposed (arrow). Circumferential intimal tear was noted at the base of innominate artery. (B) Retrograde telescoping of the intima into left ventricle. (C) Intraoperative trans-esophageal echocardiography showed left ventricle outflow tract obstruction due to intimal flap. (D) The other clinically silent retrograde type A aortic dissection in a 63-year-old male patient. An intimal tear was found over original landing site at greater curvature of aortic arch. The chimney graft in left common carotid artery was exposed (arrow).
Except for this 1 case of mortality, the other 24 patients were discharged after a median postoperative hospitalization of 5 days (range 3 to 111 days, average 14.39 days). Some patients had extended hospitalization for more than 14 days. A 61-year-old female patient was hospitalized for 30 days due to ischemic stroke with left side weakness, which developed on postoperative day 10 and was not regarded to be a procedure-related morbidity because no intervention was performed over the vascularity of the right cerebral hemisphere. A 41-year-old male patient suffered from acute kidney injury with anuria before the operation because of severe visceral organ malperfusion resulting from an acute complicated type B aortic dissection, but he had poor resolution of renal function after the operation that necessitated temporary hemodialysis. He was hospitalized for 111 days due to prolonged respiratory training and a dialysis catheter-related blood stream infection, however he was discharged without requiring ventilatory support or renal replacement therapy. This patient received surgical grafting to replace the endovascular device 6 months later due to an uncontrolled prosthesis infection.
After discharge from the hospital, no cases of 30-day mortality were registered in the 24 patients during a mean follow-up of 32.33 months (range 5.5-52 months), and all of the patients were scheduled to have CTA as follow-up in our hospital. The change in the maximum diameter of 17 cases with aortic dissections was from 56.14 mm (range 34.2-79.0 mm) to 47.22 mm (range 30.1-77.7 mm) (p = 0.003), excluding the case of immediate mortality. The change in the maximum diameter of 3 cases with aortic aneurysms was from 74.77 mm (range 70.0-79.3 mm) to 66.70 mm (range 37.2-88.8 mm) (p = 0.611). One patient who refused postoperative CTA was excluded from the analysis.
A clinically silent retrograde type A aortic dissection with dilated ascending aorta up to 6 cm was detected in 1-month postoperative CTA in a 63-year-old male patient with a chronic type B aortic dissection, and this was regarded to be a procedure-related major complication. He subsequently underwent surgical conversion. Intraoperatively, an intimal tear was found over the original landing site at a greater curvature of the aortic arch (Figure 2D), and it was solved with open partial arch grafting with reconstruction of the innominate artery and LCCA, without complications.
Early procedural failure was identified in a 33-year-old male patient with a type B aortic dissection, with rapid enlargement of a false lumen 10 months postoperatively. It was managed by re-TEVAR with a zone 0 landing, fenestrated stent graft to preserve the innominate artery and elongation of the LCCA chimney graft. Three patients were regarded as having late procedural failure. Three years after the primary procedure, a type Ia endoleak with persistent blood filling into the false lumen developed in a 47-year-old male patient with a chronic type B dissection, which was salvaged by embolization to the gutter. An 84-year-old male patient with a thoracic aortic aneurysm (Figure 3A) had a type Ia endoleak with progressive dilatation of the aneurysmal sac 2 years after the operation (Figure 3B). Although recurrent endoleak and aneurysm persisted despite secondary endografting, the patient hesitated to undergo a repeat intervention. An 81-year-old female patient with a thoracic aortic aneurysm refused postoperative CTA follow-up and any intervention, but progressive expansion of the aortic arch, which was revealed on a chest radiograph, disclosed failure to solve the aortic pathology.
Figure 3.
An 84-year-old male patient with thoracic aortic aneurysm. (A) Preoperative computed tomography angiography. (B) Two years after primary procedure, type Ia endoleak with progressive aneurysm sac expansion was found in computed tomography angiography.
A 44-year-old female patient died of acute myocarditis 3 months after the operation, and a 71-year-old male patient died due to intracranial hemorrhage, both of which were considered to be non-procedure-related late mortalities. Except for the patient with immediate procedure-related mortality, the 2 patients whose endovascular devices were surgically replaced (including 1 with a prosthesis infection and 1 with a retrograde type A dissection), and the patient who refused postoperative CTA, the graft patency and resolution of the primary aortic problems in the remaining 21 patients was confirmed according to clinical manifestation and CTA. During the follow-up period, no patient experienced a left cerebral vascular event or spinal ischemia.
DISCUSSION
While an endovascular approach is becoming increasingly popular to treat aortic disease involving the aortic arch, anatomical variations of supra-aortic branches and lesion involvement are regarded to be the major challenges of TEVAR and to influence the management of branch preservation. The chimney technique appears to be a viable option for a technically feasible aortic arch for both emergent and elective settings,5 but it is not without a major risk of complications.13
One of the most common complications is stroke, which was reported to occur in about 5% of 379 patients in a meta-analysis of 12 studies.14 In the current study, the LCCA was punctured under ultrasound guidance just after the first stent graft had been deployed below the LSA. The second stent graft was then advanced to zone 1 without deployment, and the sheath was removed immediately after balloon angioplasty in order to minimize the duration of manipulating the LCCA. We kept the intraoperative ACT to around 300 seconds, and initiated aspirin 100 mg postoperatively as stroke prevention. No patient had a left hemisphere or spinal ischemic stroke in this study. On the other hand, the access complication of LCCA pseudoaneurysm formation was probably due to unreliable withdrawal of the Angio-Seal closure device through the muscular layer. Such complications can be avoided by extending and dilating the extravascular tract of the device.
The main concern with the chimney graft technique is the risk of type I endoleak, especially Ia due to the direct antegrade flow entering the gutter, and the incidence of early type Ia endoleak has been reported to be 0-44% in thoracic chimney grafts.15 We defined this as a kind of procedural failure because it resulted in enlargement of the aneurysm sac or blood filling into the false lumen, indicating failure to solve the primary aortic pathologies. The gutter could be reduced by extending the overlapping area between 2 endografts. However, this application in a LCCA chimney graft is restricted by the innominate artery proximally. Stent graft oversizing is therefore essential.16 Mestres et al. reported a smaller gutter using 20-30% oversizing during 2 and 3 parallel graft techniques in a juxta-renal abdominal aortic aneurysmal neck model.17 Research on abdominal aortic aneurysm repair suggests that endograft oversizing up to 25% is associated with a decreased gutter size. However, the benefits of endograft oversizing on the incidence of type I endoleaks and re-intervention is controversial,18,19 and optimal oversizing of the thoracic aorta has yet to be standardized.
The aortic diameter is usually smaller at the sandwiched site than that at zone 1, especially in cases of aortic dissection. By using a non-tapered proximal aortic stent graft, we reached a mean oversizing of 25.42 ± 10.01% at the sandwiched site, however extreme oversizing of up to 57.1% was encountered in a case of re-TEVAR with the distal landing on the previous device. The resulting intimal injury directed by local forces against the descending aorta was avoided by the sandwich technique. Such oversizing reduces the risk of type Ib endoleak and strengthens the sealing at the sandwiched site without compromising the patency of the periscope grafts.
Oversizing at zone 1 is therefore worth discussing in our series because of the coexisting LCCA chimney graft, which may have been the major source of the type Ia endoleaks. We had a mean oversizing of 23.07 ± 5.69% at zone 1 and sometimes up to 30% rather than the general consensus of 10-20%, to ensure adequate sealing of the endografts, prevent graft migration and minimize the gutter. Nevertheless, as endovascular manipulation including wire, sheath and balloon dilatation device can produce localized intimal injuries to an unhealthy aortic wall resulting in a new dissection,16 an increasing oversizing ratio at the proximal arch as well as the kissing technique increase the risk of a retrograde type A aortic dissection. In a meta-analysis of 8969 patients, the incidence of retrograde type A dissections was 2.5% and the mortality rate was 37.1%.20 However, a definite cut-off value of the oversizing ratio has yet to be determined, and the effect of oversizing on retrograde type A dissections is still under debate, and such complications appear to be better correlated with proximal landing in zone 1 and 2.21,22 We experienced such a catastrophic complication in 1 patient who died and a clinically asymptomatic case whose complication was detected 1 month postoperatively, which we attributed to the increased stent graft oversizing that potentiated the intimal injury, and the chimney technique on zone 1 which gave rise to intraluminal interference which affected the ascending aorta. It is worth noting that the primary aortic pathologies of these 2 cases of iatrogenic retrograde type A dissections were also aortic dissection. In our opinion, the subsequent procedural failure due to endoleaks was rare in cases of dissection with a compromised true lumen, however the intimal injury indicates the negative effect of excessive oversizing. For cases with dissection with predominately aneurysmal changes or cases with aortic aneurysms, stent graft oversizing to nearly 30% is well tolerated, however the endograft sealing is not reliable and migration will probably occur in a dilated aortic lumen. Procedural failure with type Ia endoleaks occurred in a short postoperative period despite technical success, indicating the unsatisfactory durability and efficacy of this procedure in selective cases.
Despite the aforementioned problems, this technique serves as a total endovascular solution to preserve supra-aortic branches if a zone 1 landing device is required. Compared with conventional extra-anatomical bypass surgery, the surgical wound is minimal. Compared with a branch-fenestrated aortic device, it features simple passage and deployment of the aortic stent graft without graft axis adjustment and an off-the-shelf device that can be applied to both emergent and elective procedures and fit each aortic anatomy. For patients who have high anesthetic and surgical risks for open heart surgery, this technique may still be considered when there are few other treatment choices, however the ideal oversizing ratio should be based on each aortic pathology. Intensive monitoring and imaging follow-up are essential postoperatively for the early detection of potential endovascular complications.
This study has some limitations. It is a small series of experience from a single surgeon, and the patients’ preoperative status was heterogenous. Larger studies with long-term follow-up are needed to evaluate this technique, however the technical advancement may justify the preliminary results and be a guide for practical instruction.
CONCLUSIONS
Our experience of using a combination of a chimney graft to the LCCA and a periscope graft to the LSA in TEVAR demonstrates a total endovascular solution for aortic disease that requires zone 1 landing. However, the dilemma of graft oversizing was shown due to the risk of retrograde type A dissections and an unsatisfactory durability in this small series. However, for a patient with high surgical risk, this technique can be considered under prudent assessment when other treatment choices are lacking. Further technical improvements may justify this approach.
Acknowledgments
The authors would like to thank all patients who participated in the study, colleagues and medical staffs who took part in the care of patients indicated above, and reviewers and the editor for their comments.
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
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