Anatomic Suitability for Branched Thoracic Endovascular Repair in Patients with Aortic Arch Pathological Features

Abstract

Background Endovascular repair has become a viable alternative for aortic pathological features, including those located within the aortic arch. We investigated the anatomic suitability for branched thoracic endovascular repair in patients previously treated with conventional open surgery for aortic arch pathological features. Methods and Results Patients who underwent open surgery for aortic arch pathological features at our institution between 2000 and 2018 were included. Anatomic suitability was determined by strict compliance with the anatomic criteria within manufacturers' instructions for use for each of the following branched thoracic stent grafts: Relay Plus Double-Branched (Terumo-Aortic), TAG Thoracic Branch Endoprosthesis (W.L. Gore & Associates), Zenith Arch Branched Device (Cook-Medical), and Nexus Stent Graft System (Endospan Ltd/Jotec GmbH). Computed tomography angiography images were analyzed with outer luminal line measurements. A total of 377 patients (mean age, 64±14 years; 64% men) were identified, 153 of whom had suitable computed tomography angiography images for measurements. In total, 59 patients (15.6% of the total cohort and 38.6% of the measured cohort) were eligible for endovascular repair using at least one of the devices. Device suitability was 30.9% for thoracic aneurysms, 4.6% for type A dissections, 62.5% for type B dissections, and 28.6% for other pathological features. Conclusions The anatomic suitability for endovascular repair of all aortic arch pathological features was modest. The highest suitability rates were observed for thoracic aneurysms and for type B dissections, of which repair included part of the aortic arch. We suggest endovascular repair of arch pathological features should be reserved for high-volume centers with experience in endovascular arch repair.

Keywords: anatomic suitability; aortic arch; branched stent grafts; cardiothoracic surgery; novel treatment; thoracic endovascular repair; vascular surgery.

Figure 1. Overview of the 4 aortic arch branched stent grafts reviewed.

Images are courtesy of Terumo Aortic, W.L. Gore & Associates, Cook Medical, and Endospan Ltd/Jotec.

Figure 2. Creation of the outer lumen line and diameter, length, and clock face.

Angle measurements at the left subclavian artery (A), left common carotid artery (B), and brachiocephalic trunk (C). BCA indicates brachiocephalic artery; cMPR, curved multiplanar reconstruction; and STJ, sinotubular junction.

Figure 3. Aortic arch zone distribution and Stanford classification of the ascending aorta and brachiocephalic artery (zone 0), left common carotid artery (zone 1), left subclavian artery (zone 2), and descending aorta (zone 3).

Type A dissections commence from the ascending aorta involving the arch arteries. Type B dissections commence distal to the left subclavian artery.

Figure 4. Flowchart of the patient selection and measurement outcome.

*Insufficient scan: supra‐aortic arteries outside field of view. IFU indicates instructions for use; and OR, operation report.