Rockley Mark, Rommens Kenton L, McClure R Scott, Herget Eric J, Smith Holly N, Moore Randy D
Division of Vascular Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada.
Division of Cardiac Surgery, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada.
J Vasc Surg Cases Innov Tech. 2023 Jul 27;9(4):101274. doi: 10.1016/j.jvscit.2023.101274. eCollection 2023 Dec.
The objective is to describe the initial Canadian experience using novel aortic arch branched endograft technologies.
We performed a retrospective consecutive case series of all patients undergoing aortic arch branched repair with newly available endograft technology since 2020 at our site. We describe the patient characteristics, treatment characteristics, and postoperative outcomes.
Eleven patients received arch branched endografts, indicated for penetrating aortic ulcer in seven patients (64%), arch degeneration after prior aortic dissection repair in three (27%), and acute aortobronchial fistula in one patient (9%). Their average age was 72 ± 7 years. Complete arch repair from zone 0 to 4 was performed in six cases (55%); the remaining repairs landed proximally in zones 1 or 2. Seven repairs used a single retrograde facing inner branch (thoracic branch endoprosthesis; W.L. Gore & Associates), three used double antegrade inner branch (Bolton Relay; Terumo Interventional Systems), and one emergent case used double in situ fenestrations. Seven repairs (64%) used an adjunctive extra-anatomic bypass to complete great vessel perfusion, two of which were created during a prior aortic repair. Inferior vena cava balloon inflow occlusion during deployment was used in all cases. No mortalities, transient or permanent spinal cord paralysis, myocardial infarction, dialysis dependence, venous thromboembolism, or bleeding requiring reintervention occurred. No patient undergoing elective arch branch repair experienced a stroke. The one patient undergoing emergent repair did suffer a stroke. The median length of stay was 5 days (interquartile range, 2-8 days). Two endoleaks developed: a type Ia endoleak successfully treated with a Palmaz stent (Cordis) during the index admission, and a type II endoleak with ongoing sac regression on postoperative follow-up. Postoperatively, one patient suffered a suspected aortic graft infection that was treated with lifelong antibiotics. During a mean radiographic follow-up of 7.2 months, no cases of branch vessel instability (ie, no migration, reintervention, arterial rupture, intraluminal thrombus, occlusion, stenosis, or kinking of the branch grafts) developed. Three patients experienced sac regression of >5 mm, and no patient experienced continued postoperative dilation.
To the best of our knowledge, this is the largest reported Canadian volume of aortic arch repair using novel branched or fenestrated technology. The series demonstrates that a multidisciplinary program and properly selected patients can yield excellent results using endovascular repair for complex aortic arch pathology.
描述加拿大首次使用新型主动脉弓分支型血管内移植物技术的经验。
我们对2020年以来在我院接受新型血管内移植物技术进行主动脉弓分支修复的所有患者进行了回顾性连续病例系列研究。我们描述了患者特征、治疗特征和术后结果。
11例患者接受了主动脉弓分支型血管内移植物，其中7例（64%）因穿透性主动脉溃疡，3例（27%）因既往主动脉夹层修复术后弓部退变，1例（9%）因急性主动脉支气管瘘。他们的平均年龄为72±7岁。6例（55%）完成了从0区到4区的全弓修复；其余修复近端位于1区或2区。7例修复使用单个逆行面对内分支（胸部分支血管内假体；W.L. Gore & Associates），3例使用双顺行内分支（Bolton Relay；Terumo介入系统），1例急诊病例使用双原位开窗。7例修复（64%）使用辅助解剖外旁路完成大血管灌注，其中2例是在先前的主动脉修复术中创建的。所有病例在植入过程中均使用下腔静脉球囊流入道闭塞。未发生死亡、短暂或永久性脊髓麻痹、心肌梗死、透析依赖、静脉血栓栓塞或需要再次干预的出血。接受择期弓部分支修复的患者均未发生卒中。1例接受急诊修复的患者确实发生了卒中。中位住院时间为5天（四分位间距，2 - 8天）。出现了2例内漏：1例Ia型内漏在初次住院期间用Palmaz支架（Cordis）成功治疗，1例II型内漏在术后随访中瘤腔持续缩小。术后，1例患者疑似发生主动脉移植物感染，接受了终身抗生素治疗。在平均7.2个月的影像学随访期间，未发生分支血管不稳定的情况（即分支移植物无迁移、再次干预、动脉破裂、腔内血栓形成、闭塞、狭窄或扭结）。3例患者瘤腔缩小>5 mm，无患者术后持续扩张。
据我们所知，这是加拿大报道的使用新型分支或开窗技术进行主动脉弓修复的最大病例数。该系列研究表明，多学科方案和恰当选择的患者使用血管内修复治疗复杂主动脉弓病变可取得优异结果。
