Off-the-Shelf Devices for Treatment of Thoracic Aortic Diseases: Midterm Follow-up of TEVAR With Chimneys or Physician-Made Fenestrations.
Purpose: To evaluate the midterm outcomes of thoracic endovascular aortic repair (TEVAR) using chimney grafts (ch-TEVAR) or thoracic stent-grafts with fenestrations made on the back table (f-TEVAR) to treat thoracic aortic dissection (TAD) and thoracic aortic aneurysm (TAA). Materials and Methods: A retrospective analysis was conducted of 474 consecutive patients (mean age 62.3±10.7 years; 346 men) treated with either f-TEVAR (n=110) or ch-TEVAR (n=364) for 352 TADs (81 f-TEVAR and 271 ch-TEVAR) or 122 TAAs (29 f-TEVAR and 93 ch-TEVAR) from 2008 to 2016. The primary endpoints at 30 days and during follow-up were overall mortality, aorta-related mortality, and major complications. The secondary endpoints were endoleak and reintervention. The patency of the target branches, cost of hospitalization, and the use of antiplatelet drugs were also analyzed. Results: Intraoperative type I endoleaks were treated in 69 (14.6%) cases (4 f-TEVAR and 65 ch-TEVAR, p<0.01) to achieve 100% technical success. Four (0.8%) patients died within 30 days [1 (0.9%) f-TEVAR and 3 (0.8%) ch-TEVAR]. Perioperative cerebral ischemia (1 fatal stroke) occurred in 9 (1.9%) patients: (1 f-TEVAR and 8 ch-TEVAR, p=0.39). During the mean follow-up of 50.6±20.0 months (49.5±18.3 months in f-TEVAR and 50.9±20.6 months in ch-TEVAR), 11 (2.3%) patients died of an aorta-related event. Type I endoleak was present in 40 (8.4%) patients (1 f-TEVAR and 39 ch-TEVAR, p<0.01). Eleven (2.3%) patients experienced stent-graft migration and 13 (2.7%) had a retrograde dissection. One hundred (16.9%) of the 593 branch stents occluded (4/75 in the f-TEVAR group and 96/518 in the ch-TEVAR group, p<0.01). The branch reintervention rate was 7.2% (34/474). The f-TEVAR group had a significantly higher probability of freedom from branch occlusion (92%) than the ch-TEVAR group (83%, p=0.007). Conclusion: Off-the-shelf techniques employing chimney grafts and homemade fenestrations are both suitable options for TAD and TAA involving the supra-aortic branches, with a low incidence of reintervention. Fenestrated TEVAR seems to have more favorable short- and midterm outcomes. Further study of these off-the-shelf techniques for aortic arch repair is warranted.
['Zhang|Lei|L|', 'Wu|Meng-Tao|MT|0000-0002-1957-1829', 'Zhu|Guang-Lang|GL|', 'Feng|Jia-Xuan|JX|', 'Song|Chao|C|0000-0002-1170-2759', 'Li|Hai-Yan|HY|', 'Jing|Zai-Ping|ZP|', 'Yeung|Kak Khee|KK|', 'Lu|Qing-Sheng|QS|0000-0003-0262-7985']
D000368:Aged D000784:Aneurysm, Dissecting D001013:Aorta, Thoracic D017545:Aortic Aneurysm, Thoracic D001807:Blood Vessel Prosthesis D019917:Blood Vessel Prosthesis Implantation D057510:Endovascular Procedures D005260:Female D006801:Humans D008297:Male D008875:Middle Aged D011183:Postoperative Complications D011474:Prosthesis Design D012189:Retrospective Studies D012307:Risk Factors D015607:Stents D013997:Time Factors D016896:Treatment Outcome D014654:Vascular Patency
fenestration thoracic endovascular aortic repair chimney graft thoracic stent-graft aortic dissection aortic aneurysm stent aortic arch covered stent endograft physician-modified stent-graft surgeon-modified stent-graft