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. 2022 Feb;10(1):13-19.
doi: 10.1055/s-0042-1742696. Epub 2022 May 31.

Physician-Modified Endovascular Grafts for Zone-2 Thoracic Endovascular Aortic Repair

André B Queiroz  1   2 , Jackson B Lopes  1 , Vanessa P Santos  2 , Pedro B A F Cruz  1 , Ronald J R Fidelis  2 , José S Araújo Filho  1   2 , Luiz C S Passos  1
Affiliations

Physician-Modified Endovascular Grafts for Zone-2 Thoracic Endovascular Aortic Repair

André B Queiroz et al. Aorta (Stamford). 2022 Feb.

Abstract

Objective: This study aims to describe our technique and early experience with physician-modified endovascular grafts (PMEGs) for aortic arch diseases in zone 2. We used a total endovascular technique based on a single fenestrated endograft to preserve left subclavian artery (LSA) patency.

Methods: From December 2019 to August 2020, six consecutive patients with a variety of thoracic aortic diseases were treated with handmade fenestrated thoracic aortic grafts: four aortic dissections, one penetrating aortic ulcer, and one intramural hematoma. The planning, endograft modification, surgical technique, and follow-up of the patients were described. We evaluated immediate technical success and after 30 days, the LSA patency, Type-1 endoleak, and postoperative complications.

Results: Thoracic endovascular aortic repair (TEVAR) was performed for zone 2 in all cases. Immediate technical success, defined as successful alignment of the LSA with a covered stent and no Type-1 endoleak, was achieved in all cases. Patients had a 30-day follow-up computed tomography, which demonstrated LSA patency and no Type-I endoleaks. To date, no strokes, left arm ischemia, paraplegia, or conversions to open surgery have been reported; one patient operated for acute Type B dissection died during the early follow-up.

Conclusion: TEVAR for zone 2 with a PMEG to maintain LSA patency achieved technical success and early durability. It is expected that with longer follow-up and a larger number of cases, these results will be confirmed.

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Conflict of interest statement

The authors declare no conflict of interest related to this article.

Figures

Fig. 1
Fig. 1
Sequential images show the endograft fully unsheathed on the back table and the fenestration site marked with a sterile pen ( A ). The fenestration for the left subclavian artery was made using thermal cautery ( B ). The edge of the fenestration was reinforced using a radiopaque wire ( C ). A 0.035 guidewire was passed through the sheath ( D ) and exited the endograft through the fenestration ( E ). The endograft was resheathed using umbilical tapes ( F ) and a small groove was made in the tip of the introducer sheath ( G ) to better accommodate the guidewire ( H ).
Fig. 2
Fig. 2
Intraoperative images demonstrate the radiopaque marks in the resheathed endograft in anterior ( A ) and lateral ( B ) views. Aortography demonstrates the aortic arch anatomy ( C ). The endograft partially unsheathed and placement of an angioplasty balloon trough the fenestration ( D ). Angiography demonstrates the vertebral artery ( E ) and a completion aortography shows the endograft positioning, the covered stent patency, and no endoleak ( F ).
Fig. 3
Fig. 3
Three-dimensional computed tomography reconstructions show the preoperative image of a Type B aortic dissection beginning close to the left subclavian artery ( A ), and the postoperative image with the physician-modified endograft well positioned in the distal arch, with patency of left subclavian artery, and no endoleak ( B ).
See this image and copyright information in PMC

References

    1. Gloviczki P. ESVS Volodos lecture: innovations and the Hippocratic oath. Eur J Vasc Endovasc Surg. 2018;55(05):605–613. - PubMed
    1. Gutsche J T, Cheung A T, McGarvey M L.Risk factors for perioperative stroke after thoracic endovascular aortic repair Ann Thorac Surg 200784041195–1200., discussion 1200 - PubMed
    1. Delafontaine J L, Hu B, Tan T W. Outcome comparison of TEVAR with and without left subclavian artery revascularization from analysis of nationwide inpatient sample database. Ann Vasc Surg. 2019;58:174–179. - PubMed
    1. Bradshaw R J, Ahanchi S S, Powell O. Left subclavian artery revascularization in zone 2 thoracic endovascular aortic repair is associated with lower stroke risk across all aortic diseases. J Vasc Surg. 2017;65(05):1270–1279. - PubMed
    1. Society for Vascular Surgery . Matsumura J S, Lee W A, Mitchell R S. The Society for Vascular Surgery practice guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg. 2009;50(05):1155–1158. - PubMed