Endovascular exclusion of the entire aortic arch with branched stent-grafts after surgery for acute type A aortic dissection

Abstract

Background: The treatment of residual pathology of the aortic arch after surgical repair for type A acute dissection (AAD) represents a therapeutic challenge. Recently, new branched endovascular devices have expanded the possibility of aortic arch stent-grafting (ASG) with proximal landing in zone 0. The aim of this retrospective, single-center study was to evaluate outcomes of patients with a history of surgical repair for AAD undergoing ASG with branched devices.

Methods: We analyzed patients undergoing ASG after treatment for type AAD with 2 different branched devices: Nexus (dual-module, single branch, off-the-shelf) and RelayBranch (single-module, dual branch, custom-made). Before ASG, surgical bypass of supra-aortic vessels was performed according to patient's anatomy and to the selected device. All patients underwent clinical and computed tomography scan evaluation before hospital discharge, at 6 months, and on a yearly basis thereafter.

Results: From March 2017 to April 2019, 4 consecutive patients underwent ASG after surgery for AAD at our institution. Mean time from surgery for AAD to ASG was 20 months. Mean age at the time of ASG was 72 years. Nexus and Relay were implanted in 2 patients each. All patients survived and were successfully discharged. Mean intensive care unit stay and hospital stay were 3 and 19 days, respectively. We did not observe any major adverse events. At a mean follow-up of 28 months, all patients are alive and computed tomography scans showed good anatomic results with no endoleaks.

Conclusions: This preliminary experience shows that ASG after surgery for AAD is feasible and provides encouraging clinical and anatomic early results.

Keywords: AAD, type A acute aortic dissection; ASG, aortic arch stent-grafting; BCT, brachiocephalic trunk; CT, computed tomography; LCCA, left common carotid artery; LSA, left subclavian artery; RCCA, right common carotid artery; aortic arch; endovascular therapy.

Graphical abstract

Results of ASG after surgery for type A AAD with 2 different branched devices.

Figure 1

Nexus stent graft system. This device has 2 modules. The ascending module (A) is curved and connects to the main module (B) through a side-facing self-projecting sleeve (arrow). The assembled device is shown in panel C.

Figure 2

RelayBranch system. This device has a main body with a window that hosts 2 inner tunnels for retrograde positioning of the supra-aortic branches.

Figure 3

A, Aortic arch stent-grating with double-branch device (RelayBranch). The 2-supra-aortic branches are positioned in the innominate artery and in the left common carotid artery. The left subclavian artery is reperfused through a carotid-subclavian bypass. B, Aortic arch stent-grafting with single-branch device (Nexus). In this case, the side-branch is positioned in the left subclavian artery and supra-aortic vessels are reperfused through a subclavian-left carotid-right carotid bypass; a vascular plug is positioned in the innominate artery. C, In this case, the side branch is positioned in the innominate artery and supra-aortic vessels are reperfused through a right carotid–left carotid–left subclavian bypass; a vascular plug is positioned in the left subclavian artery.

Figure 4

Results of aortic arch stent grafting after surgery for type A acute aortic dissection with 2 different branched devices: the custom-made, double-branch RelayBranch and the single-branch, bi-modular, off-the-shelf Nexus. Each device was implanted in 2 patients. We observed 100% technical success, no major complications, and all patients were alive and in good clinical conditions after a mean follow-up of 28 months.