Thoracic endovascular repair (TEVAR) in the management of aortic arch pathology

Abstract

Background: Conventional repair of aortic arch pathology is associated with significant mortality and stroke rates of 6-20% and 12%, respectively. Because endografting has excellent results for descending thoracic aortic disease, extension of thoracic endovascular repair (TEVAR) to the arch is a consideration.

Methods: Records of patients with aortic arch pathology treated with TEVAR were reviewed. Branch vessels were (1) covered without revascularization, (2) surgically bypassed, (3) stented, or (4) fenestrated. Technical success was defined both by accurate endograft deployment with disease exclusion and by target vessel revascularization. Patient postoperative outcomes, complications, and follow-up are reported.

Results: Between March 2006 and January 2010, 58 patients with arch pathology were treated with TEVAR. Indications included aneurysm (n = 19, 32.8%), dissection (type A: n = 3, 5.2%; type B: n = 18, 31.0%), transection (n = 8, 13.8%), pseudoaneurysm (n = 6, 10.3%), or other (n = 4, 6.9%). Pathology was zone 0 (n = 1, 1.7%), zone 1 (n = 10, 17.2%), zone 2 (n = 45, 77.6%), or zone 3 (n = 2, 3.4%). Interventions were emergent in 44.8% and elective in 55.2%. The left subclavian (LSA) was covered in all and revascularized (n = 23, 39.7%) via bypass (n = 13, 22.4%), stenting (n = 4, 6.9%), or fenestration (n = 6, 10.3%). The carotid was revascularized (n = 11, 19.0%) with bypass (n = 7, 12.1%) or stenting (n = 4, 6.9%). One patient (1.7%) underwent innominate revascularization with a homemade branched endograft. Technical success was 100% for endograft deployment and 97.1% for revascularization. Thirty-day mortality was 3.4% (2 of 58). ICU and hospital stays were 5.8 ± 6.8 (range: 0-34; median 4) and 10.9 ± 8.0 (range: 1-40; median: 9) days, respectively. Morbidities included renal failure (n = 3, 5.2%), respiratory (n = 2, 3.4%), myocardial infarction (n = 1, 1.7%), stroke (n = 6, 10.3%), and spinal cord ischemia (SCI) (n = 2, 3.4%). SCI (p < 0.001), but not stroke (p = 0.33), was associated with LSA sacrifice. Stroke was associated with underlying pathology and graft selection (p = 0.01). During follow-up of 10.6 ± 9.1 (range: 0-43) months, 17 patients (29.3%) required 20 reinterventions for endoleak (n = 8, 13.8%), disease extension (n = 5, 8.6%), steal (n = 4, 6.9%), or other reasons (n = 3, 5.2%). Dissection patients had a higher rate of reintervention (p = 0.01). All patients with steal had LSA sacrifice and were left-hand dominant.

Conclusions: TEVAR can effectively treat aortic arch pathology in high-risk patients with low morbidity and mortality. TEVAR and branch vessel revascularization techniques may be extended to the more proximal arch without increased complications compared with patients with subclavian only involvement. Stroke remains the most significant drawback of arch interventions. Indications for intervention, graft selection, and revascularization choices may all affect outcome. LSA sacrifice is associated with increased SCI and may predispose left-handed patients to symptomatic weakness.